BY THE BUTCHER

Injury and infection go together like fire and gasoline. Even today, with advanced pre-hospital care and a vast technological arsenal that includes safe, complex and aseptic surgery, as well as hundreds of antibiotics and an increasing understanding of how the body’s response to injury screws with our immune system and metabolism, infection is still a huge killer with people who sustain and survive serious injuries.

A History of Festering Injury

In the olden days, before the Industrial Revolution gifted us with such luxuries as anaesthetics and antisseptic agents, infection of traumatic wounds was common enough that bigwigs like Hippocrates, Galen (the father of Roman medicine, who happened to hold an appointment as consultant surgeon to a gladiatorial school and arena) and even the 16th Century CE surgeon extraordinaire Ambroise Paré, all regarded “suppuration”—the discharge of pus, plain and simple—as an absolutely normal, expected and even healthy stage of wound healing. I shit you not; “wound discharging healthy pus” was something you could read on the doc’s notes.

Sure, there were dissonant voices—dating back at least to Theodoric of Cervia, in the 8th Century CE, to the early, pre-anesthesia 19th Century American sawbones Spencer Wells (who obtained extraordinary surgical outcomes by adhering to what was then considered a bugfuck crazy regimen of hygiene, e.g. covering the patient with clean lines instead of the same bloodied, vomited and shat-upon clothes he wore for the last two weeks, or not wiping your scalpel the mud-caked edge of your coat) or famously ill-fated Austro-Hungarian obstetrician Ignaz Semmelweiss (who got fired from his job as lecturer and hospital director for demanding that medical students wash their hands before performing deliveries)—but as I just mentioned, those guys were considered head cases back in the day.

Injury Invites Infection: How Wounds Become Infected

But, I digress. The point of this article is, how to introduce the horrors of deforming, crippling, life-threatening wound infection and sepsis to a roleplaying game?

Right up front, I’d completely disregard non-crippling and non-life-threatening wound infection, which was so common before modern wound care as to be irrelevant, and probably already accounted for in recovery times. We’re going to focus on the ones that are serious enough to kill and/or leave sequelae.

The thing about infection in traumatic wounds is that it's multifactorial. Host factors, such as age, coexisting medical conditions, nutritional status, etc. may be represented, in RPG terms, by an appropriate attribute check or saving throw (Constitution, Stamina, Fortitude, etc.). Note that most adventurers are probably in decent enough health

Bacterial factors such as strain virulence are well beyond the scope of any sane RPG, but innoculum—the sheer amount of bacteria that gets inside the wound – can be represented by as a modifier to the above-mentioned saving throw or attribute check.

The bacterial innoculum can be exogenous, as documented by British surgeons in WWII. Considerable difference was observed between the infection rates of wounds treated in the Boer War and World War I, and largely attributed to the manure-(and bacteria-)rich fields of Europe, versus the arid, "clean" veldt of South Africa.

As a curiosity, note that getting inoculated with bacteria from outside your body is not necessary. This is why people get operated on with sterile instruments, and can still develop infection; the imbalance of host defense mechanics caused by trauma, whether from a surgeon’s scalpel or a gunshot wound, is enough to make us vulnerable to virulent infection from the bacteria that live in our own bodies.

This has everything to do with location of the wound. Even our skin is crawling with potentially disease-causing bacteriae. The human oral cavity and intestinal tract are heavily colonized by bacteria. You are in fact more likely to get a nasty infection from a human bite than from a dog, cat or even rat bite! The large bowel has something in the order of trillions or quadrillions of bacteria ("colony-forming units", CFUs in microbiology speak) per cubic centimeter. I mean, this is literally shit we're talking about. You get a knife or gunshot wound to the colon, and you can imagine what happens as shit-dwelling bacteria get seeded through the wound trajectory into the vulnerable, devitalized tissues of an open wound.

Which leads us to the next factor: tissue damage. Bacteria thrive on dead tissue. Wounds that leave a lot of dead tissue behind are a feast for the little fuckers. Crushing soft tissue injuries, compound fractures, burns…they love this stuff.

Save vs. Gangrene: Systems for Sepsis

Now, how do we stitch this stuff together into something useful and the game table without too much fuss?

If you're using a hit-point system a la D&D: I probably wouldn't check for sepsis except as a "special effect", e.g. some unclean monster has a chance of inflicting grievous infection with its attacks. Subsystems like AD&D 1e’s system shock rolls and ACKS’ mortal wounds table take plenty of complications into account, abstracting them as D&D is wont to do, and infection probably figures in there somewhere.

But if you’re using neither, or use them but find them insufficiently grisly, here’s another idea. You may opt to have anyone who reaches 0 HP (a non-specific marker of severity, i.e. a sure sign that the character has suffered massive trauma—remember the abstract nature of HPs in D&D!) to roll a save vs. poison, or a Fortitude save (depending on edition) for infectious complications that may delay recovery, cripple (dig up your favorite crit table from another game) and/or even threaten the character’s life.

Once infection sets in, you might ask for daily saves (modified by Constitution, availability of ordinary and/or magical health care, source and location of wounds, among others) do determine whether the septic PC emerges unscathed, survives with sequelae or dies of wound complications days later (an all too common outcome in sagas and historical reports, that most RPGs don’t really bother simulating).

If your game features hit locations or critical hit tables, you can modify the risk of sepsis by wound type, roughly as follows.

• Abdominal wounds are the most likely to develop life-threatening infection (as noted above, usually involving perforation of a hollow viscus such as the small or large intestine or stomach). Fecal peritonitis (doctor-speak for "a belly full of shit outside the bowel") in a pre-Industrial Age culture will kill you. Seriously. No save, if you’re a hard-ass old school DM. Most of those "no save" poisons in D&D are far, far more survivable than this.
  
  
• Actually, to be fair, there is a catch. Sometimes the human body manages to wall off the perforation and/or divert it towards the abdominal wall, and you end up with a hole in your belly from which food and/or feces (depending on how far up and/or down the digestive tract is your injury) well up. We call that a fistula. Think of it as a naturally occurring colostomy. It's gross, I know, but like a colostomy, it can be a literal life-saver. The practice of Medicine taught me that people will survive the damnedest things (and that, by the way, is why I personally don’t believe in “death, no save”).
  
  
• Chest wounds come second. Most really serious chest wounds are fatal within seconds to an hour, though sometimes blood collects inside the pleura and bleeding ceases but the collected blood between the lung membranes (pleurae) can infect. Bacteria love caked blood. And an infection there is called a plural empyema, and it's the reason I'm not a thoracic surgeon. It's a pain in the ass to treat, even today. Probably very lethal back in the day.


• Head and neck injuries don't usually develop life-threatening infection, but when they do, it's usually in the form of fulminant meningitis or horrid, disfiguring, and also quickly lethal facial soft tissue infection (cellullitis). Gruesome business.


• Extremity wounds can be sites of life-threatening infection, typically if the injury was bad enough to leave behind a critical mass of dead, devitalized tissue (e.g. crushed or mangled limb, usually associated with compound fractures), in which case most pre-modern surgeons are savvy enough to proceed with battlefield amputations. Failing to amputate or at least to debride (excise the dead tissue) might result in a host of very bad infections of skin and soft tissues that you may know under such names as “gangrene” and “flesh-eating bacteria” —mostly necrotizing fasciitis (courtesy of Streptococcus pyogenes and one or more anaerobic colleagues) and clostridial myonecrosis a.k.a. “gaseous gangrene” (Clostridium perfringens, an infernal little bug that eats muscle and shits carbon dioxide resulting in festering yet mostly dry dead tissue that “creaks” or “crackles” to the touch).
  

Once infection sets in, even today, amputation is commonly necessary, All too often I got to salvage a limb, only to find it crippled, requiring years of rehabilitation, skin grafting and complex wound care. And those were the lucky ones; this, too, is very deadly, at least in our common hospital-going population of diabetics, morbidly obese, alcoholics and other chronically sick people. Strapping young adventurers, like doughty construction workers and young uniformed servicemen, are probably more likely to survive.

Osteomyelitis, chronic infection of the bone marrow, is also a risk (if you have an exposed fracture, with broken bone peering through the skin, it's pretty much a given); and in a pre-antibiotic era will probably lead to permanent disabilty and, given enough time and complications, may lead to death. Hell, it's difficult enough to treat with today's antibiotics. Most surgeons from pre-aseptic technique civilizations will amputate without skipping a beat.

Never Close An Infected Wound, But Closing Remarks Are Okay, I Guess

This should be enough for you to run anything short of a medical drama, and franly, who the fuck runs medical dramas in tabletop RPGs. I mean, it can be done, I’ve thought about it but really, it deserves an article of its own. Maybe some other day. But I feel this is a sufficiently lifelike solution with minimal fuss.
For now, have fun going forth and infecting your game world with flesh-eating bacteriae. If you use this stuff in your game, I  wanna hear the war stories!

About The Author: The Butcher is a poster at the RPGsite, and has been a gamer for 22 years. Away from the keyboard and the dice he’s a medical doctor who practices General Surgery (with quite a few years of emergency and trauma call at inner city hospitals in a fairly dangerous city) and Surgical Oncology.

Butcher, have you checked out this book from Radical Approach?

http://www.radicalapproach.co.uk/trauma/

Do you know if it's any good?

Never heard about it before.

Judging strictly from the preview, it looks accurate, even though I suspect it's a tad more involved than most gamers would like.

In any case, if anyone wants an article on trauma in general, or any other medical subject, this is the place to hit me. My expertise is obviously limited outside my field but more often than not I'll be happy to do a little research and brush up on stuff.

Great article!

Butcher, if you do another article, I'd love to hear your thoughts on the near future history of medicine. AKA, what is medically next for cyberpunk, Tech 10 Traveller, etc.

Quote from: The Butcher;779705Never heard about it before.

Judging strictly from the preview, it looks accurate, even though I suspect it's a tad more involved than most gamers would like.

In any case, if anyone wants an article on trauma in general, or any other medical subject, this is the place to hit me. My expertise is obviously limited outside my field but more often than not I'll be happy to do a little research and brush up on stuff.

So being a medical professional and a gamer do you have any preferred method of handing damage in roleplaying games? Any system of abstraction that you feel like does a better job than others without being too fiddly? Or is this, as I suspect it is, an area where it is better off being highly abstract?

I ask because I have always liked a grittier combat but at the same time it seems like doing more detail on damage means more bookkeeping by default.

Quote from: Spinachcat;780405Great article!

Butcher, if you do another article, I'd love to hear your thoughts on the near future history of medicine. AKA, what is medically next for cyberpunk, Tech 10 Traveller, etc.

Thanks for the kind words!

I'm not 100% sure there's an article there because unsurprisingly, speculative fiction writers are much, much better at speculation than scientists, let alone a meagre technician of the human body like myself.

The closest to "transhuman medicine" I ever did was something I once wrote about cyborgs for the venerable old Quality In Rifts mailing list. I was really glad to see how much of what I wrote all those years ago mapped nicely to the brief "medical" takes on the new Robocop movie. I could dust it off and give it a try.

Quote from: Arkansan;780516So being a medical professional and a gamer do you have any preferred method of handing damage in roleplaying games? Any system of abstraction that you feel like does a better job than others without being too fiddly? Or is this, as I suspect it is, an area where it is better off being highly abstract?

I ask because I have always liked a grittier combat but at the same time it seems like doing more detail on damage means more bookkeeping by default.

Great question. The short answer is that I cling to abstraction because keeping the game moving and interesting is paramount to me, and because the more you know about something, the deeper the rabbit hole goes.

I think it was Alfred Korzybski that best summed up the necessity for abstraction by pointing out that the absolute best map of a territory was the territory itself, and that is precisely what made it useless; the lack of abstraction for ease of reference and understanding.

The real challenge lies in making things feel lifelike without getting bogged down in detail. I think our hobby has developed some interesting ways to tackle the problem, such as hit location charts and critical hit tables. I'm very fond of "something bad happens at 0 HP" tables like Mortal Wounds from ACKS, the injury table from Savage Worlds, and criticals from WFRP. Runequest 6 uses both hit locations and "Special Effects" criticals which should create an interesting synergy when it comes to gritty injury (really looking forward to trying it out). I can't claim first-hand familiarity with Rolemaster's extensive critical tables but I hear good things about them.

With this article, I attempted to inspire GMs to create something similar for their own games, and even went so far as broadly, vaguely suggest some mechanics. My advice is always to work from the system you already know and like; add rather than substitute; and don't let yourself get overwhelmed.