the treatm-ent of gunshot wounds by' packing ......reason given for removing a dressing, but if...

246

THE TREATM-ENT OF GUNSHOT WOUNDS BY' PACKING WITH. SALT SACS.,

By MAJOR ALFRED J. HULL. , Royal Army Medical Oorps.·

THE treatment of septic wounds by a pack which is allowed to remain in the wound for several days is so opposed to the usual teachings of surgery that at first sight its utility may be dou,bted. Nevertheless, SUCll treatment has proved one of the most effective methods of dealing with septic wounds during the present war. It has alt;lo peen found to be one o£'the most generally applicable procedures for the treatment" 6f secondary hffimorrhage. , It possesses the. great advantage of simplicity, an' important

factor when large nnmbersof cases require the attention of a limited staff. It also possesses the advantage of allowing transport ~d be undertaken without ,any anxiety regarding the dressing of the wound. . .

When it is necessary to ora'in a wound cavity, three methods are available, The ideal method would be ,to expose the whole of the interior of the wound so that its waqs become exposed and Ipore or less flat. There are anatomical and surgical objectionf;! to this as a rule, but it is occasionally employed, for example, when a

. rectal fistula is slit up, when an amputation is' performed by the guillotine method and in certaib cases of excision of woundR. . Very inferior to this ideal method is the drainage of every pocket and cavity of a wound by drains. The interior of the wound is often very irregular and it is sometim~~s impos~ible to ensure th-at every pocket is' drained. The third method, treatment by solid salt,

, imitates the first or open method, by draining every portion of the surface of the interior. ,

The treatment of septic wounds must fulfil certain requirements. The infecting microbes must be removed 'by some form of lavage: The outflow .of lymph must be increased. The bacterial growth must be repressed and the coagulation of the discharge must be prevented. The tissues of the wound must not I be damaged either by chemical or mechanical measures. It is common ground that free exposure of the infected tissues must be made in order that adequate' drainage be obtained, but many opinions are ,held as to the correct method" of dressing the wound.

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A Zfred ~J. Hull 247

These requirenie,nts. may be met by the use of hyperto~ic solution \ of common salt. ,

It can be demonstra~ed experimentally that phe higher.the ~on-, centration of salt the greater will be its power of attracting water

and albuminous substances. The" dra wing" power of salt has been known for many years. Sir A. E. Wright's original lymphagogic' f>olution consisted of, a'five per cent solution 6f common salt mixed with f per cent solution of sodium citrate .. Early in the pres~nt War, Sir A. E. Wright recommended the hypertonic solution of' salt for the purpose of lavage and repression of the bacterial organ-

· isms of septic wounds., Colonel C.B. Lawson invented -tablets of (il compressed salt vyhich he pl~ced in the lumen of drainage tubes ..

ColonelG. Gray"originateda modification of Sir A. E. Wright's hypertonic treatment by introducing the ~se of solid salt in the form of tablets. The tablets wrapped in gauze formed a solution of salt. .

Packing wounds with gauze' impregnated with,concen:t~ated\ salt solution must not be confused with the plugging of wouI?-ds' with ordinary dressings. Wound cavities are only potentialspaces, and in order to drain them the walls must be kept apart. -Ordipary drainage tubes rarely drain every recess· and 'elaborate methods are required to obtain dr~inage from every portion of th~ walls and, avoid the shutting off of pockets. A wound cavity filled with gauze

· and salt may be 'regarded as being just as effectively drained as if .the cavity were inverted and the waVs dressed like a' surface' wound. Every pc))::tion of' the sur~ace area, is drained by, the osmotic action of the salt, and the capillary actio'n of the gfLuzeand bandage ·are continually' removing the discharge', and producing a co.ntinuotis and automatic drainage: and lavage of every portiQn Of the interior of the wound. . ,.

The tablets of salt must'not come in contact with, the tissue or sloughing will oftep ensue. The ~all of the cavity must be well protected by gauze. '.

The solid ,'salt sac is an improvemynt upon the. tablets. It consists of a' two-walled sac of suitable size made ,of bandage, . between the layers of which four layers of gauze' are placed. The interior of the sac' is filled with salt and the tail of the. band'age forms a drain.. .

The sac is made by laying a strip of open woven bandage ab.out a foot in length flat on the table. On this strip, four layers of

· gauze .areplaced the same width as the bandage :but about four, . inches in length. On top of the gauze alwther strip Of bandage is'

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, 24$ ,'fheTreatment ol Gunshot Wounds

placed., The sid~s ,of the bandageistrips are ~hfm "Qrought together by doubling the ba,ndage .in its long diameter and sewing rto form a sac., The sacjs filledwith.salt, a few stitches are put in to close

'the mouth. ' ' ,These/sacs are made in several sizes, sterllized in an autoclave

and stored readv' for use. One or more of these sacs is used to, " ' , pack wounds, the spaces between the sacs being filled with, gauze. A tub~ of perforated zinc or rubber may be p'assed into the depth of the wound in case~ of large septic wounds."

, Long sleIfder sacs ar€kmade to f;ill bullet tracts. Small sacs are made for draining tracks .in thebra'in.: ,The free _ end' of the 'sacs are passed \nto a vessel eontaini:qg . saline solution and the wound then €i

'drains by capiilary drainage .. A -fine rubber, tube may be run in along each sac, and drip irrigation carried out i~ required. The salt remains, undissolved for several days and when the sacs are remoy,ed from a wound at the fmd' ora week undissolved salt still remains. '

The freqlJency with which. wounds are dressed often depends' upon ~mpirical convention rather than on a scientific or clinical reason .. The wounds are often dressed without any clear idea of the reason for removing the dressings. A dressing sticking to al wound is fre'gnently torn! off, tearing delicate granulationtissue,\ undoing the healing of the wound, and exposing raw surfaces for septic absorption. A more unscientific treatmentcaml0t be imagined., In some , cases,i,t is said, the wound is dre~sed in order to remove the djs- ' charge .. This is simply an admission that the dressing has been acting ,like.a cork in a bottle. A rise -of temperature is another" reason given for removing a dressing, but if the wound is being properly treated;,' changing the dressiIfg will not lower the tern pera,ture. '_'

There' are, (wo ways of dressing a wound -so that, no' harm is done by the' changing of dressing; one is to keep a light i~resrsing, continually moist so that its rerrfoval is not felt by the pati~nt and no tissue is damaged; the other is to leave, the dressing until it is quite moist and can be removed without pain.

The dressings of deep wounds is too often merely a ritual, the , dressings and drainage tubes ~re removed and replaced by clear't

ones, but the complicated series-of recesses which make up the interior of D;lost wounds' cannot be reached. They may be reached', by irrigatioq, but some por,tion of the wound will escape the dis- ' tending' effect of a drainage tube, and the 'walls will fall together and ,:1 pocket wjll result.

The effect of the salt sac' is to form a concentrated solution,of

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,1lfred J. Hull' 249

salt which promotes the resolution of inflammatory induration anq. aids the s"eparation of dead tissue by solution ~f coagulatedlyrnph. A powerful outgoing stream of healthy lymph is produced which carries mi9robes and debris out of' th,e wound and retards, the bacterial growth within it. It is unnecessary and undesirable to continue 'the action of this hypertonic, solu,tion of salt once the wound becomes clean. If the "\Yound is clean, the sacs are removed . .in {rom five to ten days and treatment by normal saline .inst~tuted. If the wound is foul it is either again packed with salt sacs or dressed every forty-eight hours with gauze soahi9 with twenty p~r cent salt solution., ,When the patient's temperature remains high' an!l his general conditiop. is unsatisfactory, it is fair to assume that a streptococcus is present. The presence 6f healthy lymph induced by the salt sacs does not aid in dealing with the streptococcus,' but

, it 'appe~rs probable that tb,e, most effective defence the body possesses against this organism is 'the white blood corpuscle. When normal ~aline is used the wound hitherto bright redbeeomes covered with a, grey film. This is caused by the protective layer' of lew,:locytes which act' as a barrier against further invasion until the healing is completed by the' ingrowth of epithelium. The hypertonic solution is therefore ehanged to norr;nal saline ,when streptoeoccal infection' appears probable. '

The advantages, of a dre~sing which does not require attention' for seven or eight days will be obvious. The patient is saved the pain and inconvenience ,6f frequent dressing, phere is a diminished risk of ,secondary' ihfeetion and there is an ~nornious saving in material. The salt sacs' have been found useful in' many special instances. ' They were first devised ':for, 'the drainage, of septie wounds of the brain. ,Excee9.ing~y septic wounds of ,the orbit ~ith destruction, to the eye have be~n treated by salt "sacs after removing the orbital contents and removal of loose septic fragments from the bony wall of the orbit, with uniformly satis-' factory results. ,Cases of ,secondary \hffimorrhage associated -with septic comminuted fractures of the upper part of the shaft of the femur have been packed with salt saes. No recurrence of hffimorrhage took place and when the sacs were removed eight days later, a clean granulating wound remained. The removal of a septic foreign body, whether bullet, shell' fragment, or shrapnel, is only the beginning of treatment; a septic cavity and track' remains which may prove ve:rY difficult to drain and dress effectively. Ithas become our routine tre~tment to silllply washout' the cavity

, and pack with salt sa~s: The soft nature of the sacs, if they are . I




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'250 The Treatment at Gunshot Wounds

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FIG.1.-A large 'salt sac, a section of a sac, and a 'small ,salt sac are shown in the figure. The wall of the sac' i~ composed of two layers of banda.ge between which four layers of gauze are placed. The action of a cigarette capillary drain is in this way combined with the hypertonic action of strong salt solution. The sacs are made in several sizes'and,when filled,' with salt are sterilized in the autoclave. '

FIG,. 2.-':A fiat'salt sac composed of the same material as the cartridge variety. These'sacs have been' found useful in dressing large flat wounds, such as amputation stumps., Q

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Alfred J., Hull, 251 I '

, dipped into water before insertion makes it very easy to completely pack a cavity. The sacs 'accommddate' themselves to the size and shape of a cavity and it is rarely necessary to add g?>uze to the packing. Large septic cavities ,associated with, fracture require a drai:t;tage-tube to be, inserted among the salt sacs.

The dressings become somewhat ,offensive at th~ end of a week hut the o,dour appears to be quite harmless.'l'he addition of the' powder eupad (bypochlorous acid) to the sacs would obviate the

'sm!3lI, but if tbe,f3rrlell oUhe drainage causes'the'patient tphe given what, is practically open-airtreatmen~~ its incop.veniE)lllce will be more than compensated for.' ,

I think it will be admitted that, a method of treatment which saves the patient the pain and inconvet;lience of frequent dressing, which forms an efficient method of preventing hremorrhage, and saves an enormous amount of labour and material is a good method

'provided its results are equal in all respect~ to otherinethods of treatment. ,I' consider that the results are not ,only equal, but better than any other knownmet4od; ,provided the technique is' properly carried' out.' It appears rational to add an antiseptic to the salt in foul cases and eupad appears to he' tbe most useful. Its additiQncertainly appears to ,do no harin in my experience and my only reason for not using it as a routine treatment is that tQe plain salt gives such excellent results that it appears unnecessary. The .offensive odour of the wound, may in a gre~t measure be, obviated byits use. ' , ",

Sacs filled with eupadand salt in the 'proportion of one to three are destroyed in the \1utoclave owing 'to the corrosive action of the ,hypochlorous acid upon the fabric. A convenient method of combining the eupad with salt is to pack the wound with ordinary salt sacs sterilized in the autoclave and introduce into the middle of the sacs without touching tbe wound 'an unsterilized sac filled, with eupad.

Six days may be said to be an average time for the sacs to remain. in the wound. 'The temperature usually falls to normal within that period and a rise of temperature is apt to follow- dressing the wouiId.- This rise of temperature can usually be ~voided by

, irrigating the wound for some hours before ,removing the salt sacs. The successful results of this, treatment' largely depend, as alL

treatment of septic wounds must, upon an early attack on the' sepsis and upon' the thoroughness with which ,it is possible to remove septic,"an1 necrosed tissue.'

This treatment has formed the routine treatment Ill, a large

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,252 The Treatment,oj Gtlnshot Wounds

series of cases; of patients to solutions :-

the following. charts demonstrate the reactipn the more concentrated and normal saline

M E M E' M E'M E M E M E M E M E M E M E M E FO "J)

" I~: : , " .", : ,,: : : .<0

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84 9& S& 84 eo 80 78 78 e& 8& ~& "

PULSE 68 100 96 92 eo 80 80 e4 6e 86

CASE '1.-Bullet wound left forearm. Very extensive comminution of ,radius and 'ulna. Extremely septic wo'un,d. The'wound measured eight inches by three. Packed with' salt sac and:dressed on the sixth day. The wound was healthy and granulating.

,Normal saline was !then employed. I,

M £ M E M'E!!! E :1\4£: M £ tII£ F

O '", : " . :16 .' , :

" 104°, :~.-: : : IIG-.~ . : : l>:'

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100° :- : <U'

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PULSE 8B 96 90 68 64 80 80 96 96 90 84 82 80

CASE 2,-Sh'rapnel wound' left axilla. ' Foreign body removedfrorn under pectoral . muscles, and cavity packed with salt. sacs. The te'mperature became normal four days

after the operation. , ,The sacs were removed on the, seventh day. ' When the sacs were removed, about two ounces of pus escaped. The retention of ,pus made no difference to the, patient's ,local or general condition. This accumulation of pus has very rarely been noticed an~ was pro?ably due to imperfect;packing of the whole wound.




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CASb: 1.

:b!xtensive commiuution of ra.dius I~ud ulna.

To illnst r::l.te "The Treatmcnt of Guushot Wound::; by Pn.ckiug with SaU Sacs," by Major ALFn ED J . HULL,

F.R. C.S., R.A.1l.C.

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JOc"Rl:;AL OF ' I' HE ROYAL AI-C\I\~ MEDICAL CORPS. li'.; u .• HH7.

CASJ:<.: ~.

T h ~ m isni le is Rhown in l be u.x illa lying upon I.he chest wall.

To illu:~ tra.te ., The Treatment o f Gun .';L o ~ \VoundR by P:"l.ckiug Y .. i~b Salt Sa.cs," by

Major .-\r.FT!.EO J. H ULL, ,I: '.H.C S., It.A.M. O.




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<, j

Alfred J: Hull 253

FO M E M E ME ME ME ME MEM'E'ME M E M E

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, 030 : I~: "', ", I "', I~: 102' ~: <u:

~A, ~~ "', "0 10 "':

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'J V' f1 <I); .' 99' .' :.

"'" J.'. f 1 96'

' . . PULSE 80 92 96 90 BD B4' Ba 80 8~"l 82 80 96 96 BB 'BO 80 BD 84

CA'SE 3.-Woun,Cl of left shoulder passing through' acromio-clavicular joint with fractures of the acromion process. _ Shrapnel removed at a' clearing station. On admission t~e wound was very septic. The wou!!:d was 'cleaned and packed with salt sacs. The temperature became normal on the day following the operation and remaiJ;ied normal, with' the exception of a rise due to aU,titetanic serum, until the sacs were removed on the sixth day. The wound was then clean and granulating.

M E M E M E NI El M E M E M E M,~E.j:1 M'-'c.':E+M~E=+"' M'-c"'EfM:.:..;E=-FM~E=+M":-,,EfM'7E+M:.,-=-EfM";-=t Ei'M",,;-,E'1

I : I : .~ , , :.,,~

.105°

100 100 106 90 80 84 100 98 - 66 . 64 96 96 98 96 ,94 88 PUL,SE so 92 118 100 92 96 106 100 90 90 .)00 100 108 ·96 '94 90 88

CASE 4.-Pte. F. Seven shrapri'el wounds of left buttock and thigh. The missiles had been removed at a clearing station. On admission the wounds were very septic and large drainage tubes had been iriserted. Under ether th~ wounds were irrigated and packed,with salt sacs. The packing w~s removed six "days later rhen the wou~ds were ,clean and granulating.· The wounds were not repacked, but were dressed wIth gauze soaked with 20.per cent saline solution every other day. Eight days . after the packing. the wounds were dressed with normal saline solution.

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254 The Treatment of Gunshot Wounds

"a M E M E M E M E M E 1\1 E M E M E M E M E : ! tJ': " " :

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CAim 5.-Shrapnel bullet embedded in thesacrum,bone cut ~way suffic!~ntly to allow its removal. ,The cavity packed with a salt ',sac containing one part eupad (b()~ic acid'and bleaching powder forming hypochlorous acid) and two parts salt. Retention of urfrie followed the operation but passed off three days later. The salt and eupad sac was removed on the sixth day. N.o sloughs ~vere present' and the wound was covered with clean granulations; The addition of eupad to the salt does not'-appear to make,

, any appreciable ,difference to the result. , ,

M E M,t M'E III E M E M E M t M E ME III E M E M E M E M E M E M E M E: ,M E M' E FO : : : ~: : "

: ; . 0 : : :

" : .. : ·107 " : : '. : : : "': : : : : :~ .' : : : 1::1 : : : ,,106'

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" : I~ : L"! I~. ~ : .A ;J! .-;... : 9 gO, : : : :v : : : : Iv. .I ~: : .. J : .L : : \: ' .

'. .. ," PULSE 110 92 96 104 100 92 98 88 80 88 92 88 84 88 80 90 96 ,

96 96 92 100 ' 1Q!l 100 96 B8 S8 84 ge 98 84 88 84 BO 80

CASE 6.-Pte. R. Shell wound, fragment lying over the neck of' the, femur. The fragment was removed seven days after the injury. The' wound was septic and caused a rise of temperature, in the eveni~g to about 102° F. The wound was packed with salt sacs and was re·dressed seven days after the operation. The removal of the'sacs caused a rise of. temperature. The' wound was not again packed with salt sacs, but was dressed every other day with gauze' soaked with ten per cent s~lt solution.

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JO C HNAL OF TH E HOYAL AH MY MEDICAL CO H P~ . F ,"~ h: . W 17 .

eMiK 5.

Sh r:l.pnd bull et embedded in t.h e Sfl.r rn m locil h zcd ... ix ccnLimcl ,'c;; in depth.

To illll>i trat (, "'1'h l,; 'f reatment. of Gun 'lh o ~ WounJ s by l 'ltCl,i ng wit h S:l.lt Sach, " uy

:'Jajur 1\LFRE 1J J. H U L L, F.R e.E . . R.A.) I .U.




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JOURNAL OF' 1'HE ROYAL AR}lY MEDICA~ CORPS. FIW., 1917.

CdSF. 7.

Dest ruction of th e olC('.f(\ llon proce~s.

To i ll u stra.te "'The T reatment of Gun shot \Youuus by Packin g \vith Salt Suc::;," by

11'Ja jor ALFRl: D J . H ULL, F.n. C.S. , R.A ,1\f.C,




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PULSE:

ME M E ; : : : : : "

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120 102 , lii4 96

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.M E M E M E M E M E Ni E ,M E M E M E M E M E M E M E M E

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1\ ~: 11 :, : : : : : : ::.: .. : ., : : : : : : :

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99° : It I : \I. : : : ; t :/\ : t : :

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., 128 96 100 96 96 100 96 92 96 100 ' 100 116 108 116 PULSj; 128 120 116 104 liD 96 96 92 100 111- 111- 114 96 86

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CASE' 7 . ....:....Shi:lll wound of 'right elbow. The upper half of 'the ulna was ~om~iuuted' ' and the soft parts were severely lacerated,and very septic. The dislocated'head of 'the radius I projected from. the wound .. The wouqd was treated by cutting a section across the point of the elbow, removing the comminuted upper' portion of the uina I and the, necrosed and septic tissue. Th\l' head of the radius was replaced. The flat wound which resulted was covered with flat salt sacs, The exten'sive nature of the injury and seveJ;e septic infection necessitated repeated packing of the wound. The continlfa,nce of pyrexia and'increased pulse rate after the wound was apparently clean was Idue to a streptococcal infection which reacted to' normal saline treatment.




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'256 The Treatment of Gunshot Wou1?ds

<0'

~ . .::::;. ,,. (~: to:

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11 : .... :~ : : : : : : ;

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". .,- v- L 9 8° : J ~: : 9 7" I : : : : ; : : : : : : : : - :

128 120 120 112 120 116 90 104 100 120 124 liS' 116 116 102 96 PULSE 112 116 110 119 120 110 100 128 1112 116 116 ,110 120 110 104 120

CASE S.-Pte. T. ~ Gumhot wound right knee. The chart illustrates the effect of change to normal saline solution. '




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Alfred J. Hull 257

M E M E MoE ME ME M E MEM E M°EtM E M E 1"0 ..,. I <>. '0 :'t::o : "'. "

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101° ",. :. :'" t:~ 'u\ :",

1°00° .~: :..., ~: i :~ ~V)

99° ;:; .. -". ~" 1\1 07 :\, ..... :I

98° IJo

/ i PULS ° 80 102 90 80 80 88 88 88 80 eo

E 100 90 10~ 96 B8 BD 9000BO 90 eo :

CASE B. - Shell wound, thigh. A septic;and lsloughing wound, four inches by three, was excised, and a missile removed, four daysOafter theil!jury. The wound was packed with salt sacs, which were removed:on the eighth day.

"

120 120 110 110 100 100 110 100 100 90 90' 100 120 100 104 110 100 90 BO PULSE 1:30 120 110 he ~-IO 'lOO 115 110 100 100 110 110 104 90 110 120 I 90 80 90

O~SEi lO.-Large'shrapnel wound of buttock with great 'destruction of muscle extending to dorsumlof ilium. Wound excised and necrosed tissue cut away.o Packed with

. salt sacs. The -sacs' were removed on the eighth, day. The wound was healthy and fairly discharging lymph. Dressing with five per cent saline was substituted. ° Seconqary hremorrhage occurred on the twelfth day after the operation. The wound was again I

, paeked with sacs which were ° left in° for six days. Streptococci were found in the wound. Thel dressing was change9- to normal saline, after which the temperature became normal.




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258 T<he Tnatment of Gunshot Wounds

.".-.. , , M E M E M E ME M E NU M E ME M E ME M E M E M E M E M E M,E M E M E

"I .0. : : ~: '" : : : :' ;, ~: : " Ill: ,. ; : : . loao : ~ : '. 'ili: ; ; ". :'~ " : Ill. : 1 ill: : : " '. 105" .",: , " ~:: I ,! , ~ ..

"l;,. ,

104° ~ ; : .,: : : : : I~:' : : : , : : : ~ : : : : ~: : : : :

I 03° : : .~: : : "l;,-\ : : : : : ~; :. : : " ~: : : :

"102° " .. : 1\ : ~: ~ : ", :' ) E!;. : : "

: I 0 1° : J' I : : : ~! : :

: I: " - : :. : :1 ,', : I 00° : \ 1-; "': Ill. ,.' Il U" I ~! : : :

: " : : : : 99° : : : '-': : : : 'F ! : I\t 'I' !JII : : ! ! !,

98° . : : ! " ., : r-r V ~ ~, " I"

- , : " : : , : t

PULSE 80 80 90 SO 80 100 eo 84 sg", 90 76. 70 70 " 90 90 90 100 90 110 86 88 94 94 80 70

CASE 11.- ·Pte. S. Shell wound left hand.. Severe laceration of the back of hand with extensive destruction of the extensor'tend~ns and very severe comminuticlll"of the first, second and third metacarpal bones. The wound was in a very septic condition at the time of operation. The septic tissue was as far as possible cut away and the wound packed with salt sacs. The wound was not dressed for seven days when the salt sacs were removed ... The wound· was found to be"'clean and covered with healthy .granulations. 'Normal saline'was substituted for the solid salt. The wound pecame covered with grey film. , The chart shows the fall in temperature when normal saline was suhstitut.ed for hypertdnic treatment.

CA,SE 12,-Frac'ture of ulna by shrapnel qullet. The wound, was in a very septic condition when the patient came under treatment. The wound was ,excised and the

';hrap'nel removed. Salt sacs,were inserted~nd the, case was not redressed for seven days. The wound was then healthy and was treated with nor-inal saline;,

; ,

•




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JO CRNAL O~' THE ROY,IL ARMY ~H:J)lCAL CORPS. E'EB., 1917,

Sh rapnel bullet lying 0 11 the !mct.urc<l u lna.

:.I'D ill llstrate .. The T re:1tment of GU ll~ h u L Wounds by Packiug wi th S:l.lt S IIoO;;; ," by !'Ifn.jor AI .. b'lWD J, H u f.L, F .R. O,S., RA.I\T,U,




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the treatm-ent of gunshot wounds by' packing ......reason given for removing a dressing, but if...

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