March, 1942] TREATMENT OF WOUNDS AND ULCERS : ANDREASEN 129

Original Articles

Magnesium sulphate powder in

the treatment of wounds and ULCERS

By A. T. ANDREASEN, f.r.c.s.

MAJOR, I.M.S.

The standard treatment of all wounds and Ulcers in India at present depends upon some orm 0f chlorine solution for its mainstay, with

frequent application of dressings. The wounds met with are often extensive and

almost always very, foul. Many are the result ?* neglect of abscesses, ulcers, and knife, axe

other wounds; others owe their foulness to

application of such village cures as plasters 9* leaves and mud, cow-dung plasters, etc.

ulcers are mainly chronic with consider- able fibrosis around the edges and bases; the

granulations, if visible, are pale, hard and c?arse. Large abscesses and septic joints are

Xery common in Indian practice. They are

generally treated along similar lines with chlorine solutions, irrigations, and daily or twice* daily dressings. In my experience, such wounds ^nd ulcers do not heal very rapidly with any of

chlorine antiseptics, no matter how frequent ttle dressings. , fn the chronic cases, I felt that no good was eing done, judging by the slow progress of the

cases, and that in all probability much harm as caused by the powerful action of chlorine Pon the growth of young tissue cells, making a eeble effort at repair. I have always felt that

J,.e(juent dressings, wet or dry, were more of a lru'rance to Nature than otherwise, in both

c^te and chronic cases. The fashion of washing ^ay a]i discharges as ' dirty ' has always caused jge to think that the old cult of

' laudable pus' I cleeply ingrained in many of us, certainly more hpGfly than any physiological principle of the ahng of tissue. However, this was mere con- ctiire. Hypothesis arose because nowhere

p d I find at that time (1931) any literature

^oncerned with the study of healing of wounds, ^le ra^e ce^ growth as an index of the

?acy and propriety of any method of treat-

ei- .' all workers had been concerned with the

j.j^mation of bacteria and the inhibition of :

eir growth. Because wounds heal whilst sub-

?^cl to treatment with this or that antiseptic / n? indication that the antiseptic in question baS.an.y particular specific destructive action on t c. .eria whilst exercising a stimulative or pro- n?c,1.Ye action upon the delicate growing and Prol'f .

UFU11 UVUVWH/ c*nv

^ 'iterating cells. Rather are these experi ^ents a demonstration of the extent of maltreat- the body will suffer and Nature overcome.

stujn ^e ?ne hand, we had been taught as

0r .ts that, in response to an invasion by an game irritant, Nature brings up a large and

remarkable force of combatants, specialized and general; that, allowed to go far enough, the fluid containing this army of Nature became an

opaque yellow colour and of a thick consistency, but that the fight went on continuously in this fluid. Given a reasonable chance, Nature would always win. We were taught that at the same time as the combatants, reconstruction units were marshalled, in the rear, and set to the work of repair immediately, and that certain

chemicals in the fluid medium in which these

reconstructive units moved, aided and stimulated their activities. On the other hand, having left the realms of

science and moved into the practical sphere we were taught that this day-dreaming was all very well but practical surgery required that the prac- titioner should '

get on with the job '. We were

taught to ' clean' the wounds daily, or more

often. It was a sign of neglect to have a pus stain on the gauze dressing. Wounds were irri-

gated, ' cleaned ' with swabs soaked in antiseptics

of all kinds, and all judged for their bacteri- cidal power rather than their growth-promoting properties. The two sides of our teaching did not meet. The practitioners were failing to

apply the advances of physiology, embryology and pathology to their daily work. Their work was becoming a mere meaningless ritual based on beliefs, having their origin in the dark ages. At precisely this point, when the writer was

realizing the presence of this gap in our applica- tion of knowledge to practice, he had the oppor- tunity of working under Dickson-Wright. To him I owe much. His stimulating and re-

actionary ideas on the treatment of varicose ulcer gave me much food for thought. In his

clinic I saw huge ulcers heal visibly under elasto- plast, where for months and years no signs of healing had been evoked by any other form of

dressing. The ulcers were put at rest, the cells allowed to grow quickly under the stimulus of the vital tissue juices, and elastic pressure necessary for all organized growth was exerted. At the same time as the part was put at rest, active exercise was possible for the limb without dis-

turbing the local condition, and so promotion of blood supply, with all the improvements attendant upon that vital requirement of life and healing, was invoked.

Now, elastoplast is not _

available to the poor of India, in or out of hospital, as it is too expen- sive; yet large sums of money are spent on a

variety of rather doubtful antiseptic. There

are, however, more rational methods, cheaper and easily available.

If a dry gauze dressing is placed over a clean ulcer for 12 hours, then removed and rinsed

continuously for 30 minutes in normal saline, and the resulting washings centrifuged, there will be found a small collection of white

material, which, when spread on a slide and stained with Leishman's stain, proves to be

nothing but millions of young fibroblasts. This is sufficient demonstration of the destruction of

130 THE INDIAN MEDICAL GAZETTE [March, 1942

Nature's reparative efforts caused at each single change of dressing alone. It would appear then to be rational to let the dressing stay in position as long as possible. How long ? Ideally until healing has occurred.

Next, take a little pus from the base of a foul

wound, place it in a vaseline ring under a cover- slip with a drop of saline to make it sufficiently dilute to transmit light. Place the slide on a warm stage and observe under a microscope what happens. Phagocytes will be seen moving about engulfing particles of debris and bacteria. Many other types of white cell can be seen; and when a smear of this pus is stained, there are certainly many dead cells, but many more are living cells, judged by their staining reactions. The bacteria present mostly show signs of

degeneration, let it be noted. If the pus was taken very close to the base of the ulcer then many living fibroblasts, few dead cells, and no bacteria are found.

It would, then, seem that inside this medium much of Nature's offensive, defensive, and

repair work is going on. Why disturb it with- out any knowledge of what good we are doing, and with much evidence to hand, that, by such action, we, at best, only retard the healing process ?

Every one knows the successful outcome of

proper application of the Winnett-Orr technique, both in osteomyelitis and in its recent appli- cation to compound fractures and war -wounds. All of us know the principle underlying the

technique. Thus, the requirements of a rational method

of treatment of wounds received in hospital after the lapse of the period where primary excision and suture, or excision and packing with vaseline, followed by complete immobili- zation of the part, could be safely carried out are :?

1. Some form of dressing which accelerates the transport to the part of Nature's forces, without offering any hindrance to their action.

2. This form of dressing must be capable of being renewed without disarranging the growing cells.

3. It must allow the part to remain perfectly immobilized.

4. It must be easily available and cheap; easily prepared.

5. It must be applicable to all types of

wound, however infected. 6. It must

' clean' the wound rapidly, i.e., bring it to a stage of healthy granulation where the vaseline technique of Winnett-Orr or the

elastoplast technique of Dickson-Wright may be used for the final stage of complete epithe- lialization.

In short, the primary treatment corresponds to the primary excision of the wound, plus the fact that it brings about an early stage of heal- ing, and finishes when healthy granulation has occurred. Searching for a substance to fulfil

these conditions, I hit upon magnesium sul- phate, thinking that its hygroscopic powers could be used to draw out the tissue fluids with their content of essentials for healing. I first used a saturated solution on gauze. This had the disadvantages in that the dressing was wet, required frequent changing if its power was to be maintained, and hence continually disturbed the wound and removed millions of fibroblasts at each change of gauze, even when left in place for 24 or 48 hours, for the cells grow rapidly along the cotton fibres. It was however a dis- tinct improvement on any other dressing I had used up till then.

Next, I used the crystalline salt, pure, on the wound. This is a slightly painful dressing on the first occasion, but after that there is little or no pain. The pain is always described as a '

drawing' sensation.

The disadvantage of this dressing was that it was difficult in a humid tropical climate to keep the salt dry. Unless absolutely dry, I believe that the effect of the dressing is reduced by at least 50 per cent, for I found that if the crystals are finely powdered and dried carefully before every application, the results were twice as rapidly attained with no more discomfort to the patient. My technique of dressing is as follows :? 1. Excess of pus and crusts is cleared

gently from the edges of the wound with gauze and forceps. Any thick crust or creamy pus is gently lifted away from the centre with the forceps or a spatula, without disturbing the essential layer covering the base of the wound or ulcer which contains all the growing cells.

2. The finely powdered, absolutely dry magnesium sulphate is then poured liberally directly into the wound so a^ to cover it com-

pletely. 3. Over this a light layer of gauze and wool

is placed and bandaged firmly with a small many-tail bandage. At the second dressing, which may be done in 12 hours, the many-tail bandage obviates the disturbance caused by undoing a roller bandage. A large amount of fluid will be found to have been drawn out, soaking the gauze and wool, at the first and second dressings.

Excess of wet salt is gently lifted off with a

spatula and fresh dry salt applied, without disturbing the underneath layer of salt now in contact with the base of the ulcer or wound. Fresh gauze and wool are bandaged in place as before.

Usually after the first dressing there is no

discomfort at the application of the salt, beyond a warm tingling sensation which lasts about 10 minutes.

After four such dressings, there is usually need of changing only once in 24 hours. At the end of 4 or 5 days, a large

ulcer, perhaps previously fouled with cow-dung and with a thick slough on the base, will be

March, 1942] PREPARATION & USES OF CELLULOID SPLINTS : DUNKERLEY 131

found covered by a thin crust of magnesium sulphate impregnated with serum, cells, etc. If ?ne edge of this is gently raised, a beautifully red-velvet bed of granulations will be seen

where before was foul slough; a pale bluish-

jvhite edge of growing epithelium is showing at the edges of the ulcer. I have seen diabetic carbuncles and diabetic ulcers respond quickly to this treatment; I have seen ulcers from which gas-forming organisms, tetanus, and viruljenti streptococci were grown, clear and become healing ulcers inside 8 to 10 days of such treat- ment. A limb with a large ulcer, or foul compound

jfacture, or septic joint, can be easily immobi- lized in a plaster case with a window during j^ls primary stage of treatment; such cases

transport well. The dressing need not be touched during transport. When the ulcer bed shows these healthy

granulations, the crust of salt is raised gently aild lifted off. A thick layer of sterile vaseline 18 laid over the ulcer bed and edges; over this a light layer of gauze and wool, and a firm r?ller bandage, or, if available, best of all a

complete plaster case. This dressing is left in P'ace for at least 10 days. In the hot damp feather of the Indian plains I found that five oays was a better period, as the smell in the heat Was practically unbearable. There is no breeze, and verandahs are too hot to put the patients ?n- In the cold season 10 days is easily operated. In the hills and cold parts the case

^n be left until healing is complete?about 20 ? 30 days, according to the size and depth and ^nation of the wound. Healing is rapid, scarring is minimum and

otten nearly absent. Scars are always pliable and freely movable over the underlying Parts. The method is cheap, easily carried out, iwayg available even in the remotest stations,

J1? Materials are easily carried in war, there eing no necessity for solutions and bottles, and ls the most efficient method I know of for

caning and healing foul, badly-infected wounds. ls far more effective than the solution of the

a Either magnesium or sodium sulphate ay be used; they are equally effective. Mag- num sulphate is more often available. *or over eight years now I have used this

^unique exclusively. The subdivisional hos-

j..1 als and dispensaries under my administra- .?n all use the.method and rely upon it exclu-

^ vely. Thus, annually, some 4,000 or 5,000 cptiG cases are treated by this technique, under y direction, and many under my personal

aiuf s*ay *n hospital of the average large T j grossly contaminated wounds has been

^ouced from 74 days to 21 days. By large, I

bvai* Wounds of a surface area of over 6 inches ^

o inches and a depth of 1 inch. Smaller ounds show a correspondingly shorter hospital ay- The method allows of earlier discharge

(Concluded at foot of next column)

(Continued from preirious column)

and early assumption of function, since the

patients can be discharged in plaster, and return for a change once or twice until healing is com- plete. Many of the smaller ones, of course, require no plaster, merely firm bandaging, a

sling, etc.

Many of my colleagues, having seen the method in operation, have adopted it for their own practice.

It will be seen that it fulfils all the require- ments of a good dressing as defined above. In

war, it should prove invaluable, since it is note- worthy that I have not yet seen a case of tetanus or gas gangrene in any case treated by this

method, during these eight years. This type of dressing may be used in any part

of the body, for any type of wound. I have

used it in treating dirty gun-shot wounds, or

gun-shot wounds of regions, and of types difficult to excise completely, with constant success.

In children, I mix an equal portion of boracic acid powder with the magnesium sulphate to take the sting out of the first dressing. Since the introduction of sulphonamide and sulpha- pyridine preparations, I have used them with the treatment freely, where indicated, without any bad result. Naturally, wounds of the face or jaw opening the buccal or lingual mucous

membrane cannot be given those drugs. How-

ever, these cases respond particularly well to

magnesium sulphate treatment, and it is rarely necessary to think of giving sulphonamide.

I contend that here is a simple, always avail- able, cheap, most effective and efficient dress-

ing, employing and aiding Nature's forces in the process of eliminating infection and of promot- ing rapid sound healing?a dressing allow-

ing the practice of all first principles, a dressing based on the application of physiological know- ledge rather than on cult, or fashion, or pre-

judice, a type of dressing worthy at least of

the attention and trial of any thinking surgeon.