On a new method of war-wound treatment by the introduction to the wound of living cultures of a spore-bearing anaerobe of the proteolytic group embracing a description of the morphological and cultural characters of the organism together with certain experimental investigations directed towards determining its possible modus operandi (illustrated)

Abstract

Three main methods of -wound treatment have characterised surgical procedure during the present war, viz., the antiseptic, the physiological and the surgical i.e. by Excision of the wound in toto. The latter has come into being partly owing to disappointing results obtained by the two first- named methods and partly because, by its adoption, the convalescence of the wounded is hastened.From the physiological method by the use of hypertonic saline solutions, has evolved, as an offshoot, the salt. pack treatment of wounds and extraordinarily good results are claimed for it by its advocates.Hitherto the beneficial results following salt bag treatment have been loosely attributed to the presence of the salt acting more or less on the physiological lines suggested and described by Wright. From a study of the various published articles which discuss this method of treatment, it is evident that Wright's theories are inadequate as an explanation.4. This thesis offers an entirely new explanation of the phenomena observed and will, I venture to hope, supply the key to much that has hitherto been obscure.5. The work which I carried out and which furnished the clue to this explanation, is based, in the first instance, on a clinical observation made by one of my colleagues, viz., that all the wounds which did well under salt-pack treatment were characterised by a peculiar offensive odour which was absent on the other hand from wounds which did not so improve.6. This clinical observation suggested to my mind the possibility that a certain organism might be present in the wounds characterised by this odour but absent from those which were not so distinguished.7. Acting on this assumption I discovered that a certain bacillus was apparently always present in wounds emitting this peculiar odour while it was absent or could not be recovered from wounds which did not smell.S. This bacillus is a spore -bearing anaerobe of a saprophytic nature and belongs to the proteolytic group of organisms - the group which includes bacillus tetani and bacillus oedematis maligns (Koch) .9. Unlike these latter it does not appear to be pathogenic for animals, and what is of much more importance, is non-pathogenic for man when introduced in living culture into open wounds. Further, unlike the pathogenic members of this group it does not appear to set free, in the course of its action on dead tissue, toxic products injurious to the patient.10. I have called the organism temporarily the "Reading bacillus" inasmuch as it may previously have been described and may already possess a name. Owing to the somewhat vague descriptions which are generally given of anaerobes, I have taken no definite steps to identify it with any other known strain. While, for example, it seems to resemble in most respects, the b. oedematis maligni of Koch yet it does not appear to coincide exactly with the latter and moreover such a name possesses a sinister connotation which it is inadvisable to associate with the Reading bacillus.11. I have endeavoured rather to furnish such complete details of its morphological and cultural characters as will enable it to be recognised by other bacteriologists. In addition, I have given particulars of experimental work performed on animals with a view to establishing its Claim to non -pathogenicity and in order to learn something of its probable mode of action. In connection with the latter, certain other experimental work is described in detail.12. Descriptions are also given of a new method of isolating anaerobes from mixed cultures and of an improved form of anaerobic plate which the above investigation has led me to devise.13. The Reading bacillus is probably present along with other organisms in the majority of infected wounds but conditions favourable to its growth and development are not furnished by the various methods of wound treatment in use with the exception of that by means of salt packs.14. I have endeavoured to show, however, that the salt, as such,has no particular virtue in promoting growth of this organism. On the contrary, experiments described in this thesis tend to show that growth is actually retarded by the presence of high concentrations of salt. It is obvious, therefore, that there is no need to call in Wright's theories to furnish an explanation of the success attending the salt bag treatment of wounds. The real reason appears to depend on the fact that by this method, the wound is rendered more or less anaerobic so permitting the development of the Reading bacillus. The salt can be omitted with impunity so long as an effective packing is substituted which will provide the necessary anaerobic conditions.15. I have laid special stress on the necessity of recognising that one of the chief factors which keep a wound septic, is the presence of devitalised tissue in that wound and I have ventured to suggest that the surgical definition of a wound be amended so as to take cognisance of this factor. Failure to estimate sufficiently the importance of this dead tissue probably explains the partial want of success which has characterised the antiseptic and the physiological methods.16. The surgical or excision treatment of wounds, although aimed at the early and rapid removal of pathogenic organisms, actually does remove the bulk of the dead tissue as well, and, in so far as it does this, it differs radically both from the antiseptic and from the physiological methods.; For the same reason also it is superior to them, and the resultsfollowing treatment by excision, are better.17. Such a method, however, is not always anatomically possible, and while successfully removing macro - scopically.dead tissue, it may fail to remove the necrotic material less obvious to the naked eye. Moreover in doing so, it inflicts a fresh trauma and leaves behind a zone of death liable to reinfection.18. Instead of these, I now venture to advocate what I have called the "biological" method, a method which has now been in routine use for some time in Reading. It is not to be confused with the salt bag method of treatment, although the latter depends for its success on the former. The biological or bacteriological method consists in the sowing of the wound with living cultures of the Reading bacillus and the subsequent dressing of the wound in such a way that more or less anaerobic conditions are brought about.19. The employment of the biological method does not mean that no surgical interference is necessary. Here as in every other method it is essential that the wound be thoroughly laid open in the first instance, exposing every pocket and sinus so that the organism and the packing may be brought into direct contact with the wound surfaces.20. The advantages of the method include simplicity of application, the avoidance of daily dressing and daily disturbance of the wound, the rapidity with which a sloughy wound becomes a healthy granulating surf ace, the absence of secondary haemorrhage together with the remarkable and speedy improvement which takes place in the general . condition of-the patient. All this means considerable curtailment of the time generally spent by a wounded man in hospital.-21. A series of 20 clinical cases of gun -shot wounds has been chosen for the purpose of illustrating various points raised in this thesis and in a commentary appended to each, their significance is discussed at some length.22. Treatment with the Reading bacillus appears to be followed by improvement in two directions. All dead material is'rapidly removed from the wound and with it the pabulum for the pathogenic organisms. Prior to this, however, there is a more rapid improvement in the patient's general condition, the reason for which has hitherto not been fully understood.23. The local improvement is shown to depend on the proteolytic activity of the Reading bacillus, while experimental data seem to prove that the constitutional recovery is probably due to interference with the absorption of toxins by the patient.24. The improvement in both cases appears to be due to the enzyme action of the Reading bacillus, whose ability to destroy toxic bodies in general, is suggested by experiments on tetanus and other toxins, whereby many times the minimal lethal dose of these toxins can be tolerated with impunity.25. The application to sloughing wounds of a living organism apparently capable of effecting by means of an organic catalyst, the hydrolysis not only of dead tissue but also of toxic substances produced by pathogenic organisms without itself at thesame - time giving rise to degradation products of a harmful character is probably an entirely new method of treatment and differs in this respect from all other methods of treatment in vogue. It is one. pregnant with possibilities' for the future, suggesting as it does, new lines of research which may throw light on questions still obscure and may lead to further important therapeutic developments.