Carbolic Gangrene of the Hand

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

I stumbled across an old surgery text, A Text-Book of Minor Surgery by Edward Milton Foote, MD, which was published in 1908 at an antique store a few weeks ago. I have enjoyed thumbing through it. There are photos of conditions I have only read of and never seen. Carbolic gangrene of the hand is one of those conditions.

Carbolic acid [car·bol·ic acid   (kär-bŏl'ĭk)]  is now more commonly known as phenol [phe·nol   (fē'nôl', -nōl', -nŏl')].    

1. A caustic, poisonous, white crystalline compound, C₆H₅OH, derived from benzene and used in resins, plastics, and pharmaceuticals and in dilute form as a disinfectant and antiseptic. Also called carbolic acid.

In 1865 Dr. Joseph Lister (1827-1912) began the practice of using an antiseptic in surgery.  He treated wounds with dressings soaked in carbolic acid.  Gangrene cases began to be reported around 1871.  Carbolic acid was commonly found in households during this time.  I’m not sure when that changed.

From Foote’s text (as are both photos):

If carbolic acid is spilled upon the skin accidentally, its caustic action may be prevented by promptly bathing the part with alcohol; but in most of the cases in which gangrene is produced a solution of the acid is employed, and the destruction of the skin, taking place slowly and often painlessly, is not recognized until hours have elapsed.  It is then too late for relief to be obtained by bathing with alcohol.

Gangrene has frequently been produced by the application of a five per cent solution of carbolic acid in water, and in some instances by the use of a watery solution of only one percent. 

Carbolic gangrene is dry and usually painless.  The affected part is at first dark gray or brown, and as the tissues dry and shrivel they grow darker, so that they become almost black.  In a few days a line of demarcation is established between the dead and living parts, and there is some swelling of the latter, due to absorption of septic material along the line of separation.  In a few cases this absorption my lead to a well marked cellulitis with the formation of pus pockets.

The treatment of carbolic gangrene is at first conservative.  The parts should be kept warm and dry, and amputation should be postponed until the line of demarcation through the skin is established.  Not until then is the surgeon able to decide positively how much of the finger can be preserved with benefit.  This delay of ten days or two weeks also increases the vitality in the partially damaged skin, so that it can be used successfully for a flap after two week, when the same flap would certainly not have been viable if amputation had been performed as soon as the gangrene was noticed.

Current day uses of phenol (or carbolic acid) includes deep chemical peels of the face.  Care must be taken with how long it is left on the skin to prevent a deeper burn than intended.  From the second reference article below comes this history of that use:

In September of 1961, Litton courageously presented 50 cases with a 2-year follow-up at the ASPRS meeting in New Orleans, Louisiana. Litton (personal communications, 1996 through 1999) told me he had paid a lay peeler by the name of Coopersmith in Fort Lauderdale, Florida, for the formula in 1958 or 1959. In his follow-up article published in this Journal in 1962, Litton  did not print a specific formula, saying only that a "minute" amount of croton oil was added to a 50% solution of phenol with glycerin and water. He wrote significantly that "croton resin" causes vesiculation and sloughing, but he did not reference those attributes and did not follow up on them. Biopsy photomicrographs at 3 months postoperative and four sets of preoperative and postoperative results were published.

In November of 1961, Baker contributed a specific easily measured and mixed formula in the Journal of the Florida Medical Association. One patient was identified in a photograph as having a 3-month follow-up. No specific number of patients was given. The Baker formula (1961) included the following:

* Phenol USP 88%: 5 cc, 47%

* Distilled water: 4 cc, 49%

* Croton oil: 3 guttas, 1.2% (correct percentage if 1 gutta = 27 drops per cc)

* Septisol: 8 guttas, 2.6%

REFERENCES

A Brief History of Wound Care; Plastic and Reconstr Surg 117(7S):6S-11S, June 2006; Broughton, George II; Janis, Jeffrey E.; Attinger, Christopher E.

An Examination of the Phenol-Croton Oil Peel: Part I. Dissecting the Formula; Plastic and Reconstructive Surgery. 105(1):227-239, January 2000; Hetter, Gregory P.

Is the Phenol-Croton Oil Peel Safe?; Plastic and Reconstructive Surgery. 110(2):715-717, August 2002; Bertolini, Thomas M.