Mistaken Diagnoses in Common Infectious Fevers
Authors: D. F. Johnstone
Journal: BMJ (1944)

MEDICALi RNAL555surgery in this patient was performed six days after wounding, and at operation the wound was foul-smelling and semi- purulent, and contained a piece of wood two inches long firmly plugging the skull defect and penetrating deeply into the brain.Many bone fragments lay deep in the brain substance; two of them were still visible in post-operative radiographs, indicating that wound excision had been imperfect.The non-occurrence of a cross-infective discharge from these 40 wounds (except in one case of superficial infection) clearly suggests that when such discharge occurs it is more probably due to hospital than to initial infection.It has been shown by Cowan (1938) that organisms occurring in the air and normally regarded as saprophytes may be the cause of serious intracranial infection, and this was later emphasized by Cairns (1939) in reporting a series of 23 deaths from infection following intracranial operations.In Cairns's cases the various organisms isolated had previously been con- sidered non-pathogenic to man and were thought to have gained access to the cerebrospinal fluid spaces from the air during the prolonged exposure of the brain necessitatecl by some neuro- surgical procedures.The effect of introducing Ps. pyocyanea, or any other pathogen, into the brain or cerebrospinal fluid spaces can well be imagined, and would be a matter for serious concern.If, therefore, penicillin is to be given by the method of local instillation the precaution of using an aseptic cap for the tube should certainly be taken.No reflection upon the nursing staff concerned in the treat- ment of the second series of cases is intended: they have shown a capacity for hard work and co-operation which is admirable, and they could not have been expected to adopt and maintain a specialized system of ward asepsis and anti- sepsis which has been gradually developed over a period of four years.Nor could so small a number of nurses, even if trained and experienced in neurosurgical work, hope to attain a high standard (i.e., a low potential rate of hospital infection) when confronted with large numbers of patients with serious head injuries, whose sole ambition appeared to be the immediate removal of their headdress. ConclusionWe feel that attention to three main points is responsible for the very low rate of hospital or cross-infection of wounds in the above series.These points are: (1) The care taken in closing scalp wounds to obtain very early healing.(2) The insistence upon very careful ward and dressing technique as advocated in an earlier paper and the M.R.C. Memoranda on hospital infection.(3) The aseptic cap used to close the penicillin tube.SummaryTwo series of cases are reported, each of 20 battle casualties, in which local penicillin therapy was employed.The incidence of potential cross-infection was three cases in 20 in the unit's original surroundings, and no clinical cross-infection occurred.In the second series, under less perfect conditions, the potential rate rose to seven cases in 20 (35%), and one superficial case of clinical hospital infection resulted (5%).Cross-infection of wounds by way of the penicillin tube is an obvious possibility and, as it has not appeared in the present series (the one case described being only a superficial cutaneous infection), it is suggested that the aseptic screw cap in use is the responsible factor in prevention.The need for proper closure of the scalp wound and very early skin-healing is emphasized in view of the total average potential hospital-(or cross-) infection rate (25%).Our thanks are due to Dr. Lever and Dr. Cross, who carried out the necessary bacteriological investigation of the large number of wound swabs taken during the period under review, and whose admirable co-operation could not have been bettered.