War Surgery and Medicine
CHAPTER 5 — Gas Gangrene
The anaerobic infection of war wounds presented problems in both World Wars.
First World War
In the 1914–18 War, during the fighting in Europe, anaerobic infection was very common and was responsible for many amputations and deaths. The technique of the primary excision of the wound was developed largely to combat this infection. The radical removal of damaged and avascular muscle was determined because of the ready growth of the anaerobic organisms in this tissue. The priority as regards operation was commonly arranged not by the extent of the wound, but by the presence of anaerobic infection, which was generally rapidly detected by the characteristic smell and often by the discoloration of the skin. General signs of toxaemia with rapid, thready pulse and anaemia were present, and locally the limb was swollen and gas was present in the tissues, giving a feeling of crepitation on examination and showing up in X-ray examination.
The anaerobic infection was accentuated by the wet and dirty condition of the clothing brought about by the nature of trench warfare at that time in Flanders and Northern France. Treatment consisted in the radical excision of all traumatised tissue, especially avascular muscle, and the removal of any retained pieces of clothing or foreign bodies. The wound was freely enlarged and left wide open and treated by antiseptics. The continuous irrigation with the hypochlorites by the Carrel-Dakin method was of great value. Intravenous injection of sodium bicarbonate solution was utilised as well as saline and glucose. Some blood transfusion was also given. X-ray was used as treatment, and some success claimed.
The results of treatment were good as regards prevention and in localised infection. Removal of whole muscle and muscle groups often proved entirely successful in preventing the spread of the infection and amputation of the limb often saved life.
In the fulminating cases associated with generalised infection death normally occurred. Gas infection can be said to have been the main anxiety of the forward surgeon in France in the First World War.
During the 1939–45 War the problem was much less serious and the cases much less numerous, and forward surgeons only rarely came across marked cases. There was no question of sorting out cases for operation because of the presence of signs of anaerobic infection. It has been stated that anaerobic infection was just as common during the last war as it was in 1914–18. No surgeon with experience of the conditions in the forward areas in both wars could possibly hold such an opinion. Our observation showed that anaerobic infection was uncommon during the desert campaigns, and that gangrene seldom developed apart from the destruction of the main blood supply of the limb. In Italy, in spite of the conditions being more suited to the development of the infection, there was no marked increase noted. This was probably due to the satisfactory wound treatment and partly to the action of penicillin in the prevention of infection. The treatment of anaerobic infection during the war was, as in the First World War, largely preventative.
The surgical cleansing of the wound and, as has been pointed out, the removal of devitalised muscle remained the essential part of the treatment. When infection was actually present surgery again was all important, and consisted in the free exposure of the wound and the removal of all infected muscle. When serious infection of a single muscle or muscle group was present, radical removal of the muscle or group was undertaken.
Amputation was only carried out when these measures were insufficient and when the main blood supply of the limb was interfered with. When complete removal of infected tissues was impossible because of the widespread nature of the infection or the condition of the patient, very free incisions were made into the infected tissues. All other forms of treatment were of secondary importance.
Serum was given in large doses throughout the war and was at one time thought to be of benefit, but finally was considered to have no definite effect on the progress of the infection. It was given also as a prophylactic in cases of serious muscle injury and in buttock wounds, and may have been of some benefit in that way. At first it was thought that the serum was ineffective because there was insufficient of the malignant oedema component, and the proportion of this was increased. It was estimated that malignant oedema organisms were present in 9 per cent of the cases, as against Welchii organisms in 66 per cent and Vibrio Septique in 14 per cent. The malignant oedema cases, however, were much more serious and carried a high mortality.page 131
The dose of serum administered as a minimum was 49,500 units (in three ampoules), and this was repeated six-hourly if necessary. When there was no reaction much larger doses were given, especially if B. Oedematiens infection was suspected. There were only 15,000 B. Oedematiens serum in 82,500 units of the composite serum.
The sulphonamides were given regularly during the greater part of the war, both as a preventative and as a curative agent, but were considered finally to be of little use. Penicillin superseded the sulphonamides and proved of definite value in all cases surviving for more than twenty-four hours after infection had been observed.
In the fulminating cases little effect was seen. Large doses were given parenterally in all cases of established infection, and there was general agreement that this was of definite value. Blood transfusion was given both as a means of raising the resistance of the patient to infection and also of combating the anaemia always associated with it. It was also of value in the prevention of secondary infection to which very anaemic patients were specially liable.
In October 1944 it was noted that gas gangrene had been a little more common and that one death had occurred. All the other cases had cleared up rapidly after the excision of the affected muscles, and early secondary suture of the wounds had been successfully carried out. With adequate and prompt surgery, except for the occasional fulminating case, the cases had presented no great difficulty.
At the end of the war anaerobic infection was combated by the preventative measures of surgery, the administration of blood, parenteral penicillin, and serum. Treatment of established infection consisted of the radical surgical removal of muscle, at times of amputation (amputation was unnecessary if the limb was viable), and the administration of large doses of penicillin and moderate quantities of blood.
The signs commonly present in anaerobic infection were:
Swelling and oedema of the limb.
The presence of gas in the tissues.
Discoloration of the skin, a brownish-yellow colour.
The characteristic odour.
Profuse brown watery discharge.
The symptoms shown were those of:
Pain which was noted in about a fifth of the cases.
Rapid thin pulse.
Mental disturbance, generally tending to coma.
The symptoms shown by B. Welchii infection were marked toxaemia, anxiety, brown watery discharge, sometimes jaundice. The muscles were a slate grey colour and there was gas formation.
Infection by B. Oedematiens showed very severe toxaemia, marked swelling, diffuse gelatinous oedema, profuse discharge and a feeling of weight. There was no gas formation. The symptoms developed later than those due to B. Welchii. The majority of the cases recovered or died within twelve hours of the onset of the symptoms.
There were two distinct types of anaerobic infection, gas gangrene proper and claustridial myositis. The latter was associated with the presence of gas in the muscles and also in the subcutaneous tissues, but gangrene did not occur nor was there the profound toxaemia associated with the gangrene cases. Whereas there was a mortality of about 50 per cent in gas gangrene, myositis in itself did not cause death.
Anaerobic streptococcal myositis gave rise to a swollen limb with bright-red muscles which were not gangrenous. The muscle smear showed small chained streptococci. Deep incisions were made into the muscles, and large doses of sulphathiazole, 60 grammes in forty-eight hours, were given till penicillin became available and was administered in full parenteral doses.
In Italy there were 72,000 battle casualties in the Allied armies between September 1943 and October 1944, and among them 236 cases of gas gangrene were reported with a mortality of 46 per cent. Of a total of 312 cases (including accidental injuries), there were 17 New Zealanders. About half the total cases had damage to the main vessels. A few were caused by tight plasters. Some of the deaths were due to other causes, including severe sepsis and anuria. Just over half died in the General Hospitals, and most of the others at the CCSs. The heaviest rate of mortality was seen in wounds of the abdomen, head, and neck (100 per cent), and in buttock and thigh wounds it was about 60 per cent.