Studies in Wound Infections

[Skipman]

Studies in wound infections

BY

S. E. Douglas, M.E.C.S., L.E.C.P. Lond. Captain I.M.S. (retired) ,

Acting Director, Bacteriological Department, Medical Eesearch

Council.

A. Fleming, M.B.jB.S. Lond., F.E.C.S.Eng. Director, Department

of Sytematic Bacteriology, St. Mary's Hospital, London.

L. CoLEBROOK, M.B., B.S. Lond. Assistant, Bacteriological Department,

Medical Research Council.

Case No. 52. Wounded (shrapnel) 25.1.17. Admitted 10.2.17. Transferred

23.6.17.

History. Multiple shrapnel wounds of the left arm, leg, and foot, one also

of the abdominal wall, and one of the right leg. Several pieces of shrapnel were

removed from the left leg at the CCS. , At the Base the left great toe was

amputated and numerous incisions made to combat cellulitis of the leg, forearm,

and upper arm. The left ankle was opened up and pieces of shattered bone

removed.

Condition on admission (15th day). The patient's general condition was fair,

but his temperature was raised, and he showed a great deal of nervous apprehension

and restlessness. There were some twenty-five wounds altogether and practically

all of them suppurating freely. Of these one, about the size of a shilling, was on

the abdomen, five or six were on the left arm, and the remainder on the left lower

limb. The foot was much swollen, with pus tracking downwards ; between the

metatarsal bones from the site of the toe amputation the ankle joint was severely

infected, and the leg muscles much dissected up. There was no infection of the

knee or the elbow joints, nor were there any complete fractures of the long

bones. Skiagram showed very numerous foreign bodies in the left thigh, leg,

and foot.

Treatment. The leg was by far the most troublesome to treat, as it was

extremely difficult to maintain free drainage of the many suppurating pockets

which had resulted from former incisions. A special trough splint was made from

a stout sheet of perforated celluloid which, after having been softened in 5 per

cent, carbolic acid, was moulded to the requisite shape on a Thomas frame, the

foot being kept at a right angle. By this arrangement it was possible to carry

out intermittent irrigation of the many wounds through Carrel tubes, 3 per cent,

salt solution being employed at first and, later, normal saline or dry dressings.

There was for many weeks a most obstinate pustular condition of the skin

of the leg and thigh, due apparently to Staphylococcus. Inoculation of staphylococcus

vaccine failed to control the condition, but applications of a solution

of flavine appeared to have a very beneficial action.

Two operations were performed on the leg and one on the arm to promote

better drainage, and ultimately, after somewhat slow progress, the patient was

transferred with most of the wounds soundly healed, his temperature normal,

and general condition enormously improved.

Bacteriological Notes.

On admission. Pus from the forearm. Films showed many Streptococci.

Cultures gave » pure culture of Streptococcus pyogenes. Heated pus was sterile.

Pus from the abdominal wound. Films showed no bacteria. Pus from the

wounds round the ankle. Films showed very large numbers of bacteria, diphtheroids,

large Gram-positive diplococci, and Streptococci. Cultures gave

Streptococcus pyogenes and Staphylococcus. Heated pus gave a long Grampositive

bacillus with a terminal oval spore which grew aerobically and anaerobically,

and a heat resisting Streptococcus.

February 1 1th-12th. Culture from the wound of the knee gave a pure growth

of Streptococcus pyogenes. Pus from the stump of the great toe. Film showed

many Streptococci and some Staphylococci. Cultures gave colonies of Staphylococcus

and Streptococcus. Pus from the knee wound. Cultures from heated pus were

sterile. February 15th. [ The large Gram-positive spore-bearing aerobe was again

isolated from pvis from the ankle joint. Films showed fewer bacteria than on the

nth, only diphtheroids and Streptococci being seen.

February 18th. Pus from a small sinus which opened about this date near

the right ankle joint showed in iilms large numbers of Streptococci. Cultures

gave Streptococci and Staphylococci.

March 9th. Pus from a fresh opening about the middle of the leg. Films

showed only Streptococci. Cultures gave a practically pure growth of Streptococcus

pyogenes.

March 10th. A small opening on the back of the thigh discharged pus in

films which showed Staphylococcus and Streptococcus.

March 29th. Pus from the ankle. Films showed only Streptococcus. Cultures

gave colonies of Streptococcus and a coliform bacillus.

April 10th. Pus from the right leg. Plates were overgrown with B. proteus.

April 17th. Film from a sinus about the middle of the right leg showed

diphtheroids and Streptococcus. Cultures from the acne-like pustules of the skin

of the leg gave pure Staphylococcus.

April 24th. A small collection of pus which formed in the left upjier arm.

Film showed only a few Streptococci.

Mike