STARCH SPONGE-A NEW HEMOSTATIC AGENT

SAnluEL S. ROSENFELD, M.D., F.A.C.S., NEW YORK, N. Y.

(From the Departments of Obstetrics and Gynecology, The Jewish Memorial and
Lebanon Hosfitals)

H EMORRHAGE is at present acknowledged to be the leading cause of death

in obstetrics. Therefore, any agent which possesses the property of arrest-
ing hemorrhage deserves serious study and consideration by all who either de-
liver or operate on patients.
In 1947 a patent was granted to Dr. Bite and Dr. MaeMasters, and assigned
by them to the U. S. Department of Agriculture for an absorbable starch sponge
which could be utilized both as a food and a surgical dressing. After reading
a. description of this patent, it seemed to me t,hat because of the chemical and
physical composition of the substance that not only would it be useful for the
purposes they had in mind, but that it would also act as a hemostatic agent.
The dry sponge is capable of absorbing sixteen times its weight in water. It
can absorb appreciable amounts of medicaments such as penicillin, streptomycin,
gramicidin, and sulfonamides, etc. The idea of the patentees was to incorporate
medicinal substances into the sponge and introduce them into deep or surface
wounds where they could be left until absorbed. The sponge disintegrates slowly
in body fluids and the dissolved material after enzymatic attack is absorbed by
the t,issues,without harmful results.
Bite and MaeMasters describe the preparation of the sponge as follows:
Make a “slurry” of starch in water. This usually contains 5 to 10 per cent of
starch by weight. In general, the higher the concentration of starch the finer
the texture of the sponge. At equal concentrations, cornstarch makes a firmer
sponge than wheat or potato starch. Additions of chemicals that are to be in-
corporated into the sponge may be made to the “slurry” or to the paste.
Sponge formation is brought about by slowly freezing the paste. Freezing
must be complete throughout the paste before thawing is permitted.
After thawing is completed, the sponge is squeezed or pressed to remove
free water. If it is to be used wet, the material is stored in 70 per cent ethyl
alcohol.
The dry sponge is sterilized by cutting it into the desired size and shape, and
may conveniently be wrapped in heavy paper and tied with a string. These
wrapped pieces may then be placed in a container and autoclaved.
The sponge must immediately be dried, which is accomplished by drying un-
der vacuum in the autoclave, or by subjecting the sponge to a temperature of 90”
C. in a drying oven for at least one hour.
The Engineering and Development Division of the Northern Regional Re-
search Laboratory estimated in 1945 that the actual cost of producing the sponge
exclusive of the cost of the sta.rch, administration, and selling expenseswould be
9.48 cents per pound in a plant wit,h a capacity of one ton of starch a day, and
6.67 cents in one with a daily capacity of five to ten tons. Due to increased prices
of materials and labor, the production costs in 1950 would undoubtedly prove to
be higher.
1179
1180 ItOS%;NFkcI,~~ I.:‘- r 1)I-;r 2 t.;yib
klsc ,“Ci

The starch bar as seen microscopxcall~- is ;i spongelike S~IWE~W WI! 11 I.~T.

tremely tiny cells ant1 t.hreadlike 111’fil)rous lv;l,lls, ilIlt if PCtrilirIi i.llih i~tii’lti
a.fter soaking in water.
Starch powder consists of fiat plates with irregular outlines, oi:~‘~.lis111
small clumps, and when wet appear to increase 10 to 31 times in diamctcr. but
retain t,heir form and become more transparent.
In the majority of cases I found it, most expedient to employ t,he bar 01:
starch sponge. III SOHW cases, such ;~s after cauterization of the ccrvis [jr
after circumcision, the ground starch slmnge or powder is preferable, 111 IJust-
partum and in rectal cases I have fouml the impregnat;ed starch sponge bantl-
age to be more desirable than the bar,
Lee and Lehman2 in searching for a substance tll replace talc which at
times is responsible for the appearancr of granulomatous growths, found a
cornstarch derivative which provnd very sa,tisfactory. This starch product
replaces talc which is ordinarily used in operating rooms for the preparation
of surgeons’ rubber gloves. These authors stated, “Thr: fate of this powder
(starch) does not offer any great l~harnmcological problem. Since it is a cot‘u-
starch powder, it is simply taken up 11,vthe peritoneum and metel)olixetl like
any ingested starch.”
They quoted MacQuiddy (personal cloln~nur~icatiol~~~, who investigated the
sensitizing properties of this substance I)oth in human patient,s and in animals,
and failed to demonstra.te any sensit,iziug or anaphylactogenic properties.
Lee and Lehman, in experiments with the cornstarch product described in
their article, showed complet,e absorption from the peritoneum without any
demonstrable inflammatory reaction. am1 further st,ated that it products 110
adhesions whatsoever.
MacQuiddy and Tollnmn,:’ in an article entitled “An Absorbable l’owdct.
to Replace Talc, ” reported the satisfactory use of a cornst,arch derivative treated
by physical and chemical means to inll)rcbve its lubricating value and to prevent
gelatinization when autoclaved.
Correll, Prentice, and Wise’ report,& that starch implants in the mus;kz
of rats could not be identified by gross inspection after the tenth day.
stained specimens revealed fragments of starch through the fiftieth day. No
significant, tissue reaction to this material was observed, but the forty- and
fifty-day specimens revealed an ext,raordinary cellular infiltration, largely of
mononuclear phagocytes. The type of pha,gocyt,e that, usually engulfs lipoids
seemsto be attract,ctl by this material invading and replacing it.
Although our problem was more concerned with hemostasis than with ad-
hesions, nevertheless WC performed experiments to d&ermine t,he action of
starch in the presence of hemorrhage and its effect on the peritoneum. The
employment of everi a. markedly efficient hemostatic agent that products crip-
pling adhesions woulcl indeed only be justified in the direst emergency. F’or-
tunately this did not prove to be the (aapewhen starch sponge wn.s used.
I found the sponge t,o be an escelleilt hemostatic agent in the rabbit. ‘Es-
perimental animals survived in whom 1 incised either the large veins of the
ear, the femoral vein, or the inferior vcna cava. Tn the case of t,he a-nricular
or femoral veins the fellow of the opposite side was used as a control. Thti
vena cnva experiments were controlled by administering no treatment to corny
of the control animals, and treating others with pressure am.1gauze packing.
All the untreat,ed animals, as espected. died within one to two minutes
a,fter the vena cava was incised.
When plain gauze was pressed against thu opening in the vcna cava and
left in sit.u as a pressure pack, hemostasis resulted. When these animals were
autopsied approximately one month after operation, the adhesions encountered
Volume 61 STARCH SPONGE-NEW HEMOSTATIC AGENT 1181
Number 5

were so dense and the intestines so compromised that at present with the ready
availability of efficient hemostatic agents the practice of employing plain gauze
as a packing in cases of hemorrhage should be abolished, except in those in-
stances where no other suitable hemostatic substance can be obtained. An-
other drawback to the gauze pack is its tendency to disturb the clot and tear
tissues on removal so that bleeding commences again.
In every case where the starch was properly applied to any of the venous
structures mentioned previously, including the vena cava, the animal survived.
We found that the best method of obtaining hemostasis with the starch
sponge was to moisten one end of the dry starch bar with sterile water-or saline
solution, and to cover the opening in the vein with this moistened end, simul-
taneously creating pressure by bearing down on the dry end of the bar. When
all bleeding ceased, usually a matter of one to two minutes, the whole or part
of the bar was left in situ.
Large pieces of starch were left in the peritoneal cavity of some animals
so that the effect of massive pieces of starch sponge could be studied.
Taking into consideration the fact that the vena cava is located in the
retroperitoneal space, the cellular tissue of which is almost embryonal in its
reaction to stimuli such as irritants, foreign bodies, etc., the adhesions we
found at autopsy, usually performed three to four weeks after operation, were
surprisingly moderate.
To study the reaction of the general peritoneal cavity to the sponge rather
than that in the retroperitoneal space, I introduced large pieces of dry and
wet sponge among the intestinal coils without opening any large vessel. At
autopsy, gross inspection in the majority of these animals revealed none or
minimal adhesions. One animal, however, showed a walled-off sac attached to
one of the intestinal coils. Another animal showed a small granulomatous
lesion in the lower angle of the peritoneal incision. It should be taken into
account that much more starch was used in these animals than would ever be
found necessary to employ in a human being weighing many times more than
the experimental animal. All of these animals survived, appeared healthy, and
had gained in weight in the three- to five-week interval between operation and
autopsy. Frantz,5 in discussing Oxycel, stated that cysts are sometimes found
in serous cavities where a relatively large mass of material is surrounded by
serous membranes. Such cysts usually resorb.
T have up to the present employed starch sponge either in the form of
the bar, the powder, or the gauze pack in 155 instances. Table I shows the
types and number of cases so treated:

TABLE I.

Cesarean section 26 Dilatation, curettage and biopsy of

Cesarean hysterectomy 1 cervix 8
Postpartum hemorrhage 3 Interposition operation 16
Salpingectomy 3 Manchester operation 16
For rupture of a hemorrhagic corpus Laceration of vagina 1
luteum cyst of pregnancy 1 Postoperative vaginal hemorrhage 1
Resection of ovarian cysts 3 Resection of Bartholin’s gland
Resection of presacral nerve I Hemorrhoidectomy k
Hysterectomy, abdominal
Hysterectomy, vaginal 13
36 Rectovaginal of fascia
Excision fistula lata :
Myomectomy 5 The Mohalim (Ritual circumcisers)
Amputation of cervix 2 have used starch powder in several
Cauterization of cervix 9 hundred ritual circumcisions.
-~

Two patients presented themselves in such a way that control observations

were possible.
repair of :I cysrorcc~tc~c~cl~,. Sumerous hltwling l,oinfP WHI’I: swn, liut tlw tissurs werr: 90
fri:tlble 111x1 clamps i,~~rlld uot dtay ilt lJ:rc*is, antI sntuw material t r)r’e right through. The
wgin:t was tight,l\- p:wkt~~l with bars ol’ rt:trt.il -~bougt~ 20~1 d:trt~l~ gauzrl :~nll llre lilt+dirig
ceased. ‘l’hc patient. \\-a~ transfused Tvl]ilcL LII+, operatic,u was ill l~rogrrw ( ‘o~~valt’sc*txr~r~r
was unt~rt~ntful. Thi* Iba,tient ‘s ~~hlvui~~ t,cllilis I~1-olJ:ltblyhad :mut(1 +ff’t~ct 0~1 hw Itli~~l cloi
t ing nlwhsnisnl

Seegers ant1 Shari)” stafe that ac!ijcia cahangesthr reactivity c?f purifietf
fibrinogen very markedly. A solution caoutaining 2 pet cent acacia will clot. in
fifteen seconds with hal’t as much thrombin as js required whet1 no acearaiais
p~~esent The favorable eft’ect disappears in solutions stronger than 7 Itt’r cent.
The rrsults I otbainrd with 1 per cent and 2 per cent solutions of starch sponge
rcscmbJet1the findings of Seegers ant1 Sharp. 1 found that in ihese dilutions a
blootl c11)f is ol)tained with one-third lrss thrombin than w0111tl~ttrr~t~ally \W
requiretl.
After observing the action of the spunge ill gynecologic operations, llJt3111-
hers of 1he Genito-Urinary and Otolaryngological Ser*vi& at both Jdeha.non
an{1 Jtwish Memorial Hospitals are JIOW employing sl,arch sponge as a hemo-
stati( agent. The penitourinary staff is loud in the -praise of the starch sponge
pack in prostatectorny easeswhere it JW~only controls bleeding, but posse~sus
il. very great advantage in that its removal is painless. My experience in re-
moving intrauterine and vaginal packs is similar to that of the Genito-Urinary
Service. The reason for the lack of pain on removal is clue to the fact that, t.he
starch sponge lubricates the gauze, thus preventing the adherence of gauze
lo tissur. The ot,olaryngologists in their tonsillect~m~ies insufIlate sponge
powder into the tonsil fossa. The Mohelim dust the powder on the cirsunt-
&ion wound.
When operating in areas where a clamp or suture can injure importa~nt.
structures, such as t,he ureters, bladder, large blood vessels, nerves, etz7 it is
Volume61 STARCH SPONGE-NEW HEMOSTATIC AGENT 1183
Number 5

indeed comforting to have an agent at hand which is capable of controlling

oozing without recourse to clamps or sutures.
The Medical Services have administered solutions of starch sponge powder
orally in cases of hemorrhage from esophageal varices and in bleeding gastric
ulcer. The effects were encouraging, but the series is too small to permit of
valid conclusions.
There was no mortality in this series. There was one morbidity that might
have possibly been due to the intrauterine introduction of starch sponge.
This occurred in a patient who had retained secundines and continued to bleed
after curettage. The uterus was packed with starch sponge. A few hours
after operation her temperature rose to 105” F. One cannot be certain that
the starch sponge was the responsible agent, for she received a blood trans-
fusion, and in addition the possibility of intrauterine infection could not be
excluded. Both of the latter possibilities are competent producing causes for
the reaction that this patient exhibited, and either or both might have been
the cause, The patient left the hospital in good condition on the fourth post-
operative day.
The action of starch sponge seems to be a local one. It absorbs many
times its weight in blood. This causes the sponge to swell and to exert pres-
sure, thus forming a mechanical obstruction to the flow of blood. The adhesive
properties of the sponge may also play a role in imposing the mechanical bar-
rier. Retardation of flow affords the clotting mechanism more time in which to
effect a clot and clotting is further facilitated by reason of the fact that in the
presence of starch sponge, one-third less thrombin is required for clot formation.
Summary and Conclusion
Starch sponge was employed as a hemostatic agent in 155 cases. The
starch was applied either in the form of a bar, a gauze impregnated pack, or
as a powder. Intraperitoneal, intrauterine, vaginal, perineal, rectal, fascial,
and muscle applications were made.
In nearly every instance where oozing of blood resulted from capillary or
venous injury, hemostasis was attained.
The action of the sponge is apparently local and augmented by the fact
that less thrombin is required for the formation of clot.
The 110~ cost of the starch sponge in comparison to other hemostatic agents
such as Gelfoam, Oxycel, etc., is a real contribution in this era of high cost of
medical care.
I wish to thank Dr. M. M. MaeMasters of the United States Department of Agricul-
ture and her staff for their fine cooperation, Dr. B. Lapan for his invaluable assistance,
‘Drs. A. A. Angrist, 5. C. Ehrlich, S. Brodie, and A. Schwarz for examination of tissue and
valuable suggestions, and Miss Beatrice Ferrill, R.N., for ingeniously preparing starch
sponge bandage.
References
1. MaeMasters, M. M., and Blom, R. H.: The Chemurgic Digest 37: December 15, 1945.
2. Lee, C. M., Jr., and Lehman, E. P.: Burg., Gynec. & Obst. 84: 689-695, 1947.
3. MacQuiddy, E. L., and Tollman, J. P.: Surgery 23: 786-793, 1948.
4. Correll, 5. T., Prentice, H. R., and Wise, E. C.: Surg., Gynec. & Obst. 81: 585-589, 1945.
5. Frantz, V. K.: Hemostatic Agents, in Seegers, W. H., and Sharp, E. A.: Springfield,
Ill., 1948,Charles C Thomas, Publisher.
6. Seegers? W. H., and Sharp, E. A.: Hemostatic Agents, Springfield, Ill., 1948, Charles C
Thomas, Publisher.
1882 GRAND CONCOURSE.