War Surgery and Medicine
Types of Infection
The most common organisms found in the septic wounds were the gram-positive streptococci and staphylococci. The gram-negative organisms were less common, though they tended to occur as secondary infections, but they interfered less with wound healing. Anaerobic infection was serious but less common. Diphtheritic infection occurred intermittently.
Streptococcal: The streptococcus was commonly present in gunshot wounds, giving rise to inflammatory changes in the tissues with marked general symptoms of pyrexia and toxaemia, and destroying the growing edge of the skin, thus delaying healing. Fortunately the streptococcus was susceptible to the sulphonamides, and still more so to penicillin. The local application of the sulphonamides had satisfactory results, as was demonstrated by Major Rank, AAMC, in Palestine, in his preparation of large raw burnt areas for skin grafting by saline baths and local sulphonamide. Local rest as obtained by splints was still of great value.
Anaerobic Streptococcal infections were met with and produced extensive inflammation of muscle associated with gas formation, but without gangrene or the profound toxaemia associated with the gram-negative anaerobes. Free incision of the tissues without excision was indicated.
Staphylococcal: The sulphonamides did not have as much effect on the Staphylococcal infections, but did have a beneficial preventive action. In established infection they were not so effective. Penicillin was a more powerful agent, though some resistant strains of staphylococci were recognised early in the experiments with penicillin. The evacuation of pus, the removal of sloughs, and the provision of drainage were called for in established infection.
Anaerobic: This infection was of considerable importance, and many cases of gas gangrene were seen and many deaths occurred from it in all theatres of war. It was mainly in association with damage to the main vessels of the limbs that actual gangrene of a limb occurred, the other cases generally being localised to individual muscles or groups of muscles. The basis of primary wound treatment was the prevention of anaerobic infection by the removal of the devitalised tissue, without which the anaerobes could not establish themselves. If established, the infection was page 22 dealt with by the ruthless removal of dead muscle—either a portion of muscle or a whole muscle or a muscle group, and, when massive gangrene occurred, by amputation. Apart from surgery, which was established as the most important preventive and curative treatment of anaerobic infection, the only treatment which was held to have a marked effect on the infection was the parenteral administration of penicillin. Sulphonamides were given until penicillin was available, but they seemed to have very little definite effect on the course of the infection. Anti-bacterial serum was given, both as a preventative and curative agent, but it did not seem to have any definite effect, though it was still persisted with. Alteration of the composition of the serum by the inclusion of more of the serum of malignant oedema was thought to have brought about better results, but finally reliance was placed first on surgery and then on penicillin given early and in large doses. Fulminating cases did not seem to derive much benefit from treatment.
Blood transfusion, usually of two pints, was given, but in some cases of haemo-concentration serum was given instead. The general effect of the transfusion was held to be of definite value as very anaemic patients were thought to be very prone to develop the infection.
A report on three hundred cases of gas gangrene was submitted to the Rome conference in February 1945. It showed a mortality of 43 per cent. Gas was noted to be present in 93 per cent, and pain in 17 per cent of the cases. The organisms present were B. Welchii 66 per cent, Vibrio Septique 14 per cent, Malignant Oedema 9 per cent. B. Oedematiens was the most toxic organism and the least susceptible to penicillin. The report confirmed the opinion that surgery and penicillin were the only measures that were definitely of great benefit in treatment, but that blood transfusion was also valuable.
An opinion was expressed that the incidence of gas gangrene was similar to that experienced in the First World War, an opinion quite contrary to that held by our officers who had served in both wars. In our experience of the Second World War gas gangrene had been uncommon and very few cases of serious infection had been met with, apart from those associated with damage to the main arteries of the limb. And our deaths had been very few. Our opinion was very definitely that the problem had been a relatively unimportant one, quite different from the ever-present anxiety experienced in the First World War. Contrary opinion could only be held by one without personal experience of large numbers of wounded men in both wars.page 23
Infection by the Pyocyaneus was often seen at a later stage in wound healing, and often following the clearing up of the gram-positive infection. This caused little or no general reaction or symptoms, but interfered with the proper healing of the wound. Five per cent acetic acid solution proved the most satisfactory method of eradication. Coli infections were sometimes seen, often associated with other organisms.
This produced very serious wound infection as well as generalised effects such as severe toxaemia or paralysis in some cases. Locally the wound showed a very unhealthy condition, with indolent, thick, grey sloughs, and there was serious delay in healing. Anti-diphtheritic serum in large doses was indicated and brought relief, but the wounds took a long time to heal. Cases were noted in Egypt at different times, but the most marked epidemic was in Italy at 1 NZ General Hospital in the winter of 1944, when several wounds were seriously affected. The outbreak coincided with an epidemic of faucial diphtheria in the civilian population.
It was realised in the early part of the war in North Africa that the frequent dressing of wounds, especially during the period of evacuation to the Base, led to an increase in wound infection, though the use of the closed plaster treatment for the major wounds, including the fractures, acted as a safeguard, as no dressings were changed in these cases for at least ten days.
At the first Surgical Congress in Cairo in February 1942 the danger of cross infection occurring during wound dressing was recognised, and recommendation was made to leave all wounds alone during transit, except when some definite indications for inspection, such as bleeding or infection, were present.
At the base hospitals the problem was recognised at the pre-Alamein period, and it was found that cross infection was very common in the wards, and that infection was spread both from other wounded cases and by the staff of the hospitals acting as carriers, especially from infective foci in the naso-pharynx. It was also demonstrated that infection could be easily spread by dust from the floors, and also from bedclothes, especially blankets.
This was countered at first by increased ward cleanliness, especially by the control of dust by doing ward dressing at times when there was least movement in the wards, and by insistence on all members of the staff wearing face masks during the page 24 dressing periods. Instruments were sterilised before each dressing, strict aseptic technique instituted, and extra staff employed. Gloves were provided for use when dressing the wounds. Later special dressing rooms were utilised, where as many as possible of the patients were taken from the wards to have their dressings performed; and the rooms were well equipped to ensure asepsis. It was realised that infection was inevitable in every open wound, and that each dressing constituted a serious danger. ' Every open wound sooner or later is an infected wound.' The only safeguard was the closure of the wound.
The type of fresh infection varied as one would expect, but streptococcal infection was common.
Injection at Different Periods
There were marked differences in the incidence of infection in wounds at different periods of the war, and in the different terrains in which the battles were fought.
In the desert campaigns in general infection was not severe and the smaller wounds generally healed without becoming infected, even when no operation of wound cleansing had been undertaken. This was particularly noticeable in the first Libyan campaign, when the facilities for forward surgery had not been developed.
In Greece and Crete infection was marked, especially in Crete, where wound treatment suffered from the disorganisation brought about by the retreat and the capture of most of the seriously wounded. Tetanus was noted for the first time, and a Maori died from it after evacuation to Greece. Gas gangrene was also seen.
During the second Libyan campaign there was more sepsis, though again it was remarked by Major Furkert of the Mobile Surgical Unit that ' the absence of highly pathogenic bacteria minimised the seriousness of delay in admitting the cases for operations, and few fulminating infections were seen '.
Infection, however, was much more marked in cases seen at the Base, due undoubtedly to the delay in primary operation, the lack of water and adequate diet, and the prolonged and rough evacuation.
There was less sepsis noted in the pre-Alamein and Alamein periods. The facilities for forward surgery had improved considerably, the surgeons were more experienced, the lines of evacuation much shortened, and patients could be sent back to the base hospitals by train, road, and air. Sulphonamides were being given regularly following wounding. The Tunisian page 25 campaign was fought under very satisfactory conditions, and little sepsis was seen except in cases where operations had been seriously delayed. At the Base, however, serious sepsis was still seen in fracture cases, and it was realised that sulphonamides at that stage were not of any avail and resort was made to older methods of treatment.
During the Italian campaign the incidence and severity of infection was more marked, and this added interest to the penicillin experiments in wound treatment carried out at Tripoli, which led to the introduction of penicillin as a substitute for the sulphonamides in the prevention of wound infection. The increased infection also led to the more thorough cleansing of the wound.
This increase in infection was, however, successfully countered by the steadily increased use of penicillin, and the introduction of the technique of delayed primary suture of wounds when the cases arrived at the base hospital at about the fourth day led to the marked diminution of infection and the satisfactory healing of the wound in about 90 per cent of the cases. The penicillin had prevented the development of infection by the common gram-positive organisms, especially the streptococcus, and the closure of the wound had prevented subsequent infection of the wound.
The only dressing in the ordinary wound after the primary operation took place in the operating theatre of the base hospital, where the dressings were removed prior to the suture of the wound and under full aseptic techniques.