Battle Casualties in Korea: Studies of the Surgical Research Team Volume III
Clostridial Myositis-Gas Gangrene:
Observations of Battle Casualties in Korea*
Captain John M. Howard, MC, USAR
Captain Frank K. lnui, MC, USAR
The period, January 1952 to June 1953, was a time when the front lines on the eastern front in Korea were stable. Only an occasional casualty failed to reach a battalion aid station within a few hours following injury. The flow of casualties was usually light, so that most patients could receive immediate attention at the battalion aid station and throughout the forward chain of evacuation. Each patient was given a booster injection of tetanus toxoid and 300,000 units of penicillin, as well as other resuscitative measures. He was then evacuated to the 46th Surgical Hospital (Mobile Army) which was located approximately 10 miles behind the front lines.
During this phase of the war, the average period of evacuation from the time of wounding to the time of reaching an American hospital in this sector was only 3.5 hours. Furthermore, because of the relatively light flow of casualties, the preoperative time-lag at the hospital was usually negligible. Early, definitive surgery was therefore possible. Primary débridement and secondary closure constituted a standard policy for the management of most wounds. Penicillin was used routinely during the postoperative period. Streptomycin and occasionally Aureomycin were also used following visceral perforations or vascular injuries.
Patients were held at a forward hospital from 1 to 7 days prior to evacuation. Whereas evacuation from a battalion aid station had been by ambulance or helicopter, evacuation from a forward an evacuation hospital was entirely by air. All casualties, except neurosurgical patients, were evacuated from the forward hospital to the 11th Evacuation Hospital located approximately 90 miles behind the front lines. Patients were held at this secondary installation until ready for prolonged trips by train or air to hospitals further to the south or in Japan. Severely injured men were usually held at one of these two hospitals for a minimal period of 7 to 10 days.
*Previously published in Surgery36: 1115, 1954.
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During the 18 months of this study, 4,900 battle casualties were observed on the general surgical service of the 46th Surgical Hospital. Of the 4,900 patients, only four were recognized as having gas gangrene; and none of these four patients died. Including these 4,900 patients, approximately 12,000 casualties were seen by the staff of the 11th Evacuation Hospital. None of the original 4,900 patients were recognized as having gas gangrene at the secondary installation; and only four of the additional 7,100 patients coming through the evacuation hospital were noted to have or to have had gas gangrene. The latter observation is doubtlessly based on incomplete records. Excluding patients with posttraumatic renal insufficiency, because their wound surgery was often compromised because of their critical condition, only eight patients with gas gangrene or severe clostridial myositis were seen by the authors during 18 months in Korea. None of the eight patients died of the clostridial infection. The only fatalities from clostridial infection seen during this period of time were one or more patients with coincident anuria at the Renal Insufficiency Center. Such a casualty was sometimes in too critical a condition to permit primary or adequate secondary débridement of massive, ischemic wounds.
All of the serious clostridial infections were seen in wounds in which débridement had not been achieved. Most of them were secondary to inadequate arterial repairs in which secondary vascular occlusion to the development of an ischemic, gangrenous limb even though the missile tract was débrided. Thus, a major artery was divided in six patients; an arterial tourniquet was left in place on the seventh patient for 48 hours until his condition improved enough to permit operation; and the eighth patient was in such a critical condition that the severe wounds of the extremities were not explored. In the last patient, interruption of the arterial continuity had doubtless occurred but was not proved.
Perhaps the progress since World War I can best be appreciated by noting an excerpt from th report of Pettit of his experiences in evacuation hospitals during the St. Mihiel and Argonne-Meuse operations.
"Of 890 wounds examined bacteriologically,478, or 53 percent, were found to contain anaerobic bacilli. Of these 478 wounds, 321, or 67 percent, at no time showed clinical evidence of gas infection. Of the remainder (33 percent), 3 percent developed gas gangrene after operation-29 percent had gas gangrene clinically evident at the time the bacteriologic examination was made."3
Of the 4,377 patients reported by Pettit, 221 (5.0 percent) developed gas gangrene. The resulting case fatality rate from gas gangrene was 27.6 percent. This may not be an entirely representative figure from
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World War I, for these 4,377 battle casualties were seen between September 10 and November 13, 1918. At this time, a lag period of 48 hours before surgery was not infrequent.
Recording the history of World War I, Coupal wrote: "Of the 224,080 officers and men of our Army who were wounded in battle in France, 13,691 died as a result of their wounds, the total death rate therefore being 6.11 percent. The wounds complicated by gas gangrene may be divided among those who sustained injuries of the soft parts only and those whose wounds were complicated by bone fracture. Injuries to the soft parts as recorded here do not include those due to chemical-warfare gases. There were, with these exceptions, 128,265 wounds of the soft parts with 9,719 deaths; of the wounded in this group, 1,389 developed gas gangrene, which amounts to only a little more than 1 percent (1.08). The death rate among those who received wounds of the soft parts which became complicated with gas gangrene was 48.52 percent, the actual number of deaths being 674.
"Among the 25,272 whose wounds included bone fracture, there were 2,751 deaths. The incidence of gas gangrene among the bone-fracture cases was much higher than among those who sustained wounds of the soft parts only, the total being 1,329 with 593 deaths. The incidence in this group of the wounded was therefore 5.26 percent and the case mortality rate 44.62 percent."4
Writing from an American hospital in India during World War II, North described an incidence of clostridial myositis of 0.7 percent in 4,600 consecutive casualties. The case fatality rate in the 32 patients involved was 31.3 percent.5
The 4,900 casualties at the 46th Surgical Hospital in Korea offer a reasonable comparison (Table 1). Doubtlessly fewer of the less severely injured casualties by-passed the surgical hospital in Korea than by-passed the evacuation hospital in World War I, but the comparison otherwise would appear reasonable. The soil in Korea, without exception, was found to contain Clostridium perfringens,1 and the incidence of wound contamination with clostridia approached that found in the wounds of World War I 3 and World War II 6 The incidence of only 0.08 percent of the clostridial myositis in Korea and the mortality of zero in this series should be attributed to early, adequate débridement, to success in the restoration of arterial continuity following injury, and to the early and consistent use of antibiotics. Antitoxins were not used. Tetanus was not recognized in any casualty.
Studies made in collaboration with the Department of Bacteriology of the 406th Medical General Laboratory of the bacterial flora, of wounds at the time of primary débridement demonstrated at 41 (26.6 percent) of 154 wounds contained clostridia which were pathogenic
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as demonstrated by guinea pig inoculation. Many of the wounds contained Cl. perfringens, yet only one of this entire group developed gas gangrene. Many of the patients had a mild elevation in temperature and pulse, suggestive of a mild systemic reaction to wound infection.1 Such wounds characteristically contained a mixed culture until the time of secondary closure.2 If small areas of necrotic tissue were left, the local infection and systemic reaction were more pronounced. Cl. per fringens, as well as other pathogenic clostridia, were present in many of these wounds, and there is no reason to believe that they did not contribute to the toxity of the wound.
Table1. Clostridial Myositis (Gas Gangrene)
Thus, many of the wound infections were, in part, clostridial infections. The fact that they were usually mild, well tolerated by the patient, and not recognized by the clinician as having a clostridial component should not obscure the underlying process. In this limited sense, clostridial infections were frequent. The term is used here to denote a subclinical clostridial infection and not the wound infection containing gas, which was recognized previously and discussed in the literature. Although clostridial infections were frequent in this limited sense, they were a rarity in the usual sense of life-endangering infections.
Summary
With an average evacuation time of 3.5 hours and a very short time lag before surgery, severe clostridial infections were rare during the latter half of the Korean conflict. Only four among 4,900 consecutive patients seen on a general surgical service at a forward surgical hospital in Korea during the period from January 1952 to August 1952 were recognized as having clostridial myositis. None of the four died.
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The immediate response of an established clostridial infection to adequate surgery and to the continued use of antibiotics led to the conclusion that severe clostridial infections were not a major problem under the existing tactical conditions. All of the prerequisites for life-endangering clostridial infections remained, however, and would doubtlessly become manifest should the time- lag before surgery be again greatly extended.
Case Reports
Patient 1. This 25-year-old American soldier was wounded on September 23, 1952, by artillery- shell fragments. He was admitted to the 46th Surgical Hospital a few hours later. His injuries included an open, comminuted fracture of the lower femur with severance of the popliteal artery. The artery was débrided but re-anastomosed under moderate tension. The distal pulsation subsequently disappeared, although the foot remained warm. On the sixth postoperative day, the patient developed hemoptysis. A diagnosis of pulmonary embolus was made. On the eighth postoperative day, his blood pressure dropped to 70/50; pulse rate increased to 140; and the respiratory rate rose to 54 per minute. He remained afebrile. Although the foot remained warm, gas and edema were evident in the thigh. Exploration of the wound revealed necrotic muscle, obliteration of the arterial continuity, and obvious gas gangrene. A mid-thigh amputation was performed. Four hours following the operation he appeared completely nontoxic.
Penicillin (one million units) and streptomycin (1.0 gut) were used daily throughout his course. Aureomyin (1.0 gin.) was added after the clostridial infection was recognized.
The patient was evacuated on the18th day following injury. His convalescence after amputation was smooth. Wound cultures revealed Clostridium sporogenes, sordelli, aerofoetidum, and tetani.
Patient 2. This 21-year-oldTurkish soldier was admitted to another hospital on October 23, 1952, with a wound of the popliteal artery. The arterial involvement was not recognized and the wound was débrided and closed primarily.
Two days later, he was transferred to the 46th Surgical Hospital. The leg from the knee distally was gangrenous. Gas and edema extended proximally into the thigh. The patient appeared to be quite toxic. Under general anesthesia, he developed a mild shock which responded to multiple transfusions. A low thigh amputation was performed. His subsequent course was smooth on two million units of penicillin and two grams of streptomycin daily.
Wound cultures at the time of amputation demonstrated Cl. perfringens and sporogenes.
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Patient 3. This 21-year-old American soldier was wounded at 1300 hours on November 16, 1952, by the explosion of a land mine. His injuries included incomplete amputation of both lower extremities.
He was brought immediately to the forward hospital. His blood pressure was unobtainable. His peripheral pulse and apical heart sounds were imperceptible. The only sign of life was an occasional gasping respiration. Tourniquets were applied and 9 pints of blood were forced intra-arterially within 35 minutes. His blood pressure was then 120/80, pulse rate 127 per minute.
After 2 hours and the infusion of 16 pints of blood, he was taken to the operating room. Without additional trauma beyond this passive movement, his blood pressure again became unobtainable. Meanwhile, under local anesthesia and with the tourniquets still in place, the dangling legs were trimmed off at the knee and a pressure dressing was applied. One mg. of neosynepherine was given by rapid intravenous drip and the pressure showed a transient rise to 100/70. After receiving the 30th pint of blood, his blood pressure rose to 100/80; pulse was 150 per minute. At 1830 hours, which was 5.5 hours following injury, his blood pressure rose to 110/80. It was maintained at approximately this level by the addition of 5 mg. neosynepherine to each bottle. With the tourniquets still in place, he was returned to the ward to await further stabilization before definitive operation was undertaken. For the next two days his blood pressure ranged around 110/70, pulse rate 130, respiratory rate 30. The tourniquets remained on throughout this period and he developed extensive gas gangrene distal to the tourniquets.
On November 19, 3 days after injury, a bilateral amputation was carried out above the tourniquet. The procedure was performed under light nitrous oxide, oxygen, ether anesthesia. Six pints of blood were given (totaling 42 pints), and the 1.5-hour operation was tolerated without a drop in blood pressure. His subsequent course was smooth. His wound culture revealed Cl. perfrinqens.
Patient 4. This American infantryman was admitted to the 46th Surgical Hospital with bilateral, shattering fractures of the femurs due to artillery-shell fragments. Amputations were delayed in the hope of tissue survival and because of the patient`s severe hypotensive condition.
His shock was reversed by massive transfusion; but he developed a mild posttraumatic renal insufficiency. His course was febrile, and on the third postoperative day a diagnosis of bilateral gas gangrene was made. A bilateral, high thigh amputation was performed. He almost died of the operative shock, complicated by a severe potassium intoxication. The shock responded to further transfusions and the potassium intoxication responded to dialysis on an artificial kidney. His subsequent improvement was dramatic; and he was evacuated 10 days later.
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Wound cultures revealed Cl. perfringens, sporogenes, paraputrificum and bifermentans. Penicillin (one million units) and streptomycin (1.0 gm.) were administered throughout the period of infection.
Patient 5. This American infantryman was admitted to a forward hospital on November 9, 1952. His injuries caused by shell fragments, included a fracture of the femur and a perforation of the popliteal artery. His arterial repair was performed 16 hours after injury.
On the third day following injury, gangrene of the leg was obvious as was crepitation of the thigh. The patient was pale and anorexic. His oral temperature was 980 F. and his pulse rate was 100 to 120 per minute.
With the induction of ether anesthesia, he developed a profound hypotension but recovered as blood was forcibly infused intravenously. Hemorrhagic edema fluid was found extending from the popliteal area upward to the inguinal ligament. The arterial anastomosis was thrombosed.
The facial planes were widely exposed and a mid-thigh amputation was performed. Penicillin and streptomycin therapy had been started on admission and it was continued. His course was exceedingly smooth. Within 10 hours after operation, his blood pressure, pulse, and temperature were almost normal; and he was hungry. Wound cultures included pathogenic Cl. sporogenes and novyi.
Patient 6. This 22-year-oldAmerican soldier was wounded by shell fragments at 1100 hours on February 9, 1953. The popliteal artery and vein were severed; and there was a massive injury to the gastrocnemius. A radical débridement was performed, but tissue of questionable viability was left in the wound. The repair of the popliteal artery was completed at 2300 hours.
Three days later the patient was pale, nauseated, and lethargic. His pulse rate was 120 per minute, and he was afebrile.
The wound was redressed under general anesthesia. The anastomosis was unquestionably patent; but the gastrocnemius and soleus were nonviable. Arterial blood spurted from the cut surface of the dead muscle. A diagnosis of early clostridial infection was made and a supracondylar amputation was performed. His subsequent course was uneventful. Wound cultures demonstrated Cl. perfringens.
Patient 7. This American soldier was admitted to the 46th Surgical Hospital a few hours after shell fragments had caused fractures of both bones of the leg and severance of both anterior and posterior tibial arteries. At the time of primary débridement, the foot appeared markedly ischemic but viable.
Because of the clinical evidence of toxicity, the wound was dressed on the third and fourth days after injury. Dressing on the fourth day showed evidence that the tissues contained gas and wine- colored
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edematous fluid. Immediate amputation was followed by relief of his systemic reaction. Penicillin and streptomycin were administered throughout his hospital course. Wound cultures demonstrated Cl. perfringens.
Patient 8. This American soldier was admitted to a forward hospital with a large penetrating wound of the thigh. Exploration revealed a large hematoma secondary to perforation of the deep femoral artery. The artery was ligated and the wound left open. Four days later he was admitted to the 11th Evacuation Hospital. His vital signs were normal. A routine film of the thigh revealed gas throughout the fascial planes. Exploration demonstrated a massive wine-colored edema. Counter drainage was performed and the wound was opened wide. On a continued course of penicillin and streptomycin, convalescence was uneventful. The patient probably had a clostridial wound infection rather than a true myositis. Wound cultures revealed Cl. perfringens.
References
1. Lindberg, R. B.; Wetzler, T.; Newton, A.; Strawitz, J. G.; and Howard, J. M.: The Early Flora of Battle Wounds in the Korean War. Preliminary Report to the Army Medical Service Graduate School, Washington, D. C., March 1954.
2. Strawitz, J. G.; Vickery, A.L.; Lindberg, R. B.; Wetzler, T.; Marshall, J. D.; Artz, C. P.; and Howard, J. M.: The Healing of Battle Wounds: Bacteriological and Histological Studies. Preliminary Report to the Army Medical Service Graduate School, Washington, D. C., July 1953.
3. Pettit, R. T.: Infections of Wounds of War. J. A. M. A. 73: 494, 1919.
4. Coupal, J. F.: Pathology of Gas Gangrene Following War Wounds. The Medical Department of the United States Army in the World War, Vol. XII, Sec. II. Washington, D. C., 1929.
5. North, J. P.: Clostridial Wound Infections and Gas Gangrene. Surgery 21: 364, 1947.
6. MacLennan, J. D.: Anaerobic Infections of War Wounds in the Middle East. Lancet 245: 63, 94, 123-125, 1943.
