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Use of sulfanilamide powder in gynecologic and obstetric operations
464
AME:RICdN
JOL!IW.K
OF
Therefore, the chief indications in obstetric and gynecologicd opera1
OI3STI!X’KI(‘S
for
1.h~
ions
:I w :
.\SD
GL-SECOI,O(:Y
11s~ ol’ sr11I’iIn ilamidt? powdc~~~
1. Peritonitis, regardless 01' the emsat ivv O~~il.lliSl~~S or t,lrr prwcww of gastric or intestinal contents ; 2. Contamination of t,he perit,oneal cavit,y at operation, either by opening this normally sterile cavity int.o continuity with a normally infected cavity, as for example, the vagina, or by trauma to, or removal of, infected tissues or organs such as pyosalpinges;
BIBB
:
SULFANILAMIDE
POWDER
IN
GYNECOLOGIC
OPERATIONS
465
3. Prevention of formation of adhesions in cases where there is mechanical or chemical irritation or where there are large areas left unperitonealized after the removal of large tumors ; 4. Abscess cavities which are opened and drained, such as a pelvic or Bartholin gland abscess. The dosage depends upon the condition found at operation. The largest amount given is 15 Gm. in the peritoneal cavity plus four or five in the abdominal wall, but this amount is used only in severe cases of peritonitis where drainage is contemplated. Prophylaxis of peritonitis is accomplished by the use of 8 Glm. or less and it is questionable The use of drainwhether any should be put into the abdominal wound. age calls for higher doses in order to allow for the escape of the powder in the drainage fluid. The presence of necrotic material and peritoneal exudates of caseous types also indicates the larger doses. The clean peritoneum absorbs the material more rapidly than the inflamed membrane, and very large doses are contraindicated in preventive applications, because toxic 1eveLs in the blood may be reached quickly. The mode of application is not important, so long as the powder is kept dry and applied thinly and evenly. One good method is application by a sterilized insufflator, especially convenient in inaccessible places. The powder is prepared for use by heating it in tubes at 140° C. in a dry oven for two hours. No serious local effects have resulted from the application of the powder in the doses given. The concentrations obtained in the peritoneum are found to be 75 to 100 times the blood level usually reached, and it is probably not all absorbed from the peritoneum for three days. When a sulfa drug has been used by topical application, it is undesirable and usually unnecessary to supplement it by other methods of administration for three days afterward, and the use of oral medication of this type before operation in which it will be used intraperitoneally These precautions will prevent a number of cases of is inadvisable. chemical hepat,itis, examples of which have been frequently noted, especially before these precautions were recognized as necessary. Cyanosis is frequent but less serious than hepatitis. Fever, which could be assigned to the use of the drug, and optic atrophy have also been reported after intraperitoneal application. Our cases included complete hysterectomies, vaginal plastics, operat,ions on tuboovarian abscesses, and miscellaneous clean cases, such as In addition to these supravaginal hysterectomies and suspensions. there were 23 miscellaneous infected cases with very serious conditions present before operation. In the complete hysterectomies, the powder was divided between the upper end of the vagina and the cul-de-sac of Douglas. In cesarean sections, it was placed under the flap of peritoneum on the surface of
466
A;MEHIC.\S
.JOl:RN;\I,
OF
OIWI’I~:TRI(‘S
.\SI)
(:1-SP:(‘ilI,iN:~
Three of the four imperfect wounds ill the groul) without sul?‘anilamidC were definitely infected, and the avcragv duration of fever was nincx days. In the group with sulfanilanlidc, noue of the imperfect wounds were infected, the defects being clue to l’at nc~l*osis and hematoma. In consist.etl the cases where suH@lamidc was not used, t,htl complications of five urinary trac’t infections, one abscess of t,he vaginal vault, and one bronchopneumonia. Among t,he cues with sulfanilamide~ t.herc was one bronchopneumonia, one s~vcre cyanosis due t,o sulfanllamide (this qxurring in a 67year-old h-pcartcnsivc patient with nephrosclerosis), and one abscess ol’ the ~;lginal vault following a complete hysterectomy done for myoma hut caomplica,ted b?- abscesses in J~th tribes.
BIBB
:
SULFhNII,AMIDE
POWDER
IN
GYNECOLOGIC
OPERATIONS
467
There were three deaths among those without sulfanilamide, one of which was due to carcinomatosis, and two to peritonitis. There was only one deat,h among those treated with snlfanilamide and this was due to pulmonary embolism followed by coronary thrombosis. Thus, among t,he cases where no infection existed before operation, there was no death from peritonitis and no abscess of t,he raginal vault, when sulfanilamide was used. Only the major variet,ics of plastic repairs, such as cpstocele, rectocele, and lacerated pelvic floor, or continence of urine, or fistula, were considered in this series. There were 28 cases of vaginal hysterectomy in which sulfanilamide was not used, and four developed abscesses of t,hc vagina.1 vault. One of these patients diecl from this cause. Six patients who had vaginal hysterectomies and, in whom sulfanilamide was used, all escaped without abscesses.
\Vithout sulfanilamide 1Vith sulfanilamide
Five of the 12 wounds mentioned above were definitely infected, with an average of fourteen days’ fever and evidence of poor healing, ineluding the formation of abscesses, one of which, not included in this five, is the death reported above. Among the cases where sulfanilamide was used, there was only one infected wound and no deaths. The complications were largely urinary, consisting of cystitis and pyelitis, showing Xtaphylococcus alblcs or Bcwillws coli on culture, but there was also one case of bronchopneumonia and one of cndometritis following a curettage and plastic operation. All the complications were urinary among the cases with sulfanilamide. A tot,al of 143 plastics was done without sulfanilamide and 15 with it. As previously noted there was a marked tendency to use sulfanilamidn in the cases considered potent,ially infected. There were 111 cases in which sulfanilamidc was not used and 34 in which it was used.
\Vitllout sulfanilamide With sulfsnilamide
Of really infected wounds, there were two among those without sulfanilamide and one among those with sulfanilamide. The complications were mild respiratory, urinary, breast, and parametrial infections. The patient with the infected wound, in whom sulfanilamide had been used, also developed paralptie ileus, pleurisy, and thrombophlebitis. Her operation was done after she had been in labor for thirty-seven hours. The other complication was a respiratory infection.
468
AMERICAN
,JOURNAL
OJ? OBSTETRICS
AXD
GYNECOLOGY
Without sulfanilamide With sulfanilamide
Ten cases were done without sulfanilamide and 15 with sulfanilamitle. The death occurred in a woman with large bilateral tuboovarian abscesses, myomas, and peritonitis. ,4 (lose of S (h. was put, into the peritoneal cavity, followed by 6 doses of 1 Cm. each every four hours by mouth. On the second postoperative day-, the blood level was 30 mg. The oral medication was stopped, and in forty-eight hours the level fell to 10 mg. ; however, she died on the fifth postoperative clay. There were 27 patients without. evidence of infection and in whom no infected cavit,y was opened into continuity wit-h t,he peritoneum, in which sulfanilamide was used. One of these had thrombophlcbitis and left lower lobe embolism. but rccovcred. Anot,hcr whose hospital course had been normal, die(1 at home ol’ pnlmona~y embolism on the fortict,h da)- after operation. There remain 23 cases of miscellaneous infections in which sulfanilamide was used, bringing the tot,al for all cases in t,he year to 143. The most interesting was that of a white woman of 76 years with no discernible heart or kidney lesions, bn~ emaciated and in only fair general condition, who was admitted because of lower abdominal pain and a mass. A barium enema study showed diverticuli of the colon, but incidentally did not show gallstones. At operaCon, t,he liver felt normal, but the gall bladder was three times normal size and felt tense. So stones were palpable. The uterus contained several large myomas, and the scheduled hystercct,omy was done. The patient went into shock and Sis was given 100 cc. of gum acacia-glucose solution intravenously. She (l(Bgrams of sulfanilamide was put. into the abdominal cavity. veloped increasing jaundirc and fever (107O I’.) and died twent.p-four hours after operation. No addit ional siilfa medication had been given at, any time. A woman with strangulated inguinal hernia and gangrene of the intestine died after an operation in which 8 Cm. was used. Four patients with carcinoma and involvement of the bowel by the tumor oi by radiation effect, all died within a few days of operation from pneu Sulfanilamide was used successfully in three monia and perit,onitis. mastectomies. It was also used in six cases of appendicit,is, but all those whose peritoneal culture showed the presence of bacteria in the perit,oncal fluid at the time of operation, had infected wounds in spite of the sulfanilamide. A middle-aged white woman had peritonitis of unknown origin, which involved the entire cavity equally with a thick, fibrinous exudate. The appendix was removed in the belief that it was the focus of infection, and 8 Gm. were put into the cavit,y and distributed equally. She developed and recovered from a bilateral lobar pneumonia, being given thera,peutic doses of snlfathiazolc by mouth after the second postoperative day. She had only ftve days of fever. One case of pyometra showing gram-positive cocci had an infected wound following puncture of an atrophic uterus by the tenaculum. An-
BIBI
:
SUL~~~hXA3IIDE
POWDER
IN
GYNECOLOGIC
469
OPERATIONS
other patient had a foreign body removed from the abdominal cavity several days after a section. Four grams were placed in the peritoneum at the second operation, with an uneveqtful convalescence. A woman with a carcinoma of t,he fundus and postradiation adhesions had 4 Gm. placed in t,he abdominal cavity. The stay sutures became infected and she had a peritonitis with twenty-nine days of fever, but recovered. A patient admitted with a postoperative vesicovaginal fistula, had one ureter implanted into the bowel, and sulfanilamide was used. She died of pulmonary embolism on the twentieth day. A 240-pound woman with chronic gall bladder disease had a cholecystectomy and appendectomy. followed by evisceration on the fifth day. No snlfanilamide had been used at this operation, but when the wound was resutured, 16 Gm. were used. She died forty-eight hours later. Fourteen grams of powder were placed in the wounds of a combined abdominoperincal resection of the colon for radiation stricture. The patient recovered after forty-eight da.ys o-f fever.
1. A brief review ot’ principles gleaned from the literature is presented. 2. All the cases in which snlfanilamide powder was used at operation at the Woman’s Hospit,al during 1941 are reviewed, and only two complications due to the use of the drug were noted. One was a severe cyanosis, and t,he other was hepatitis, which ended in death of patient, but other factors than the sulfanilamide were operating in this case, and only 6 Gm. were used. 3. Prevention of abscesses at the upper ead of the vagina and prevention of peritonitis are the two clear-cut objectives to be striven for in the use of the powder in complete abdominal and in vaginal hysteree1omies. In our short series, progress was made toward both of these. In cases with infection, prevention of peritonitis is more difficult to evaluat,c, and abscess formation harder to control, due to the variability in degree and virulence of infection and amount of spill. 4. Sulfanilamide did not prevent urinary, respiratory, nor circulatory (aomplications, nor did it rescue moribund patients. Its use cannot obviate the need for good judgment and early treatment.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Bick: J. A. &I. A. 118: 511, 1942. Dees, J. CT.: Mississippi Doctor 18: 215, 19-N. Greene and Hotz: Arch. Int. Med. 63: 779, 1939. Jackson and Coller: J. A. M. A. 18: 194, 1942. Long, Haviland, Edwards, and Bliss: J. A. M. A. 115: 364, 1940. Mueller and Thompson: J. A. M. A. 118: 189, 1942. Rippy, E. L.: .J. A. M. A. 115: 1760, 1940. Rosenburg and Wall: Rurg., Gynec. & Obst. 72: 568, 1941. Thompson, Brabson, and Walker: Surg., Gynec. & Obst. 72: 722, Watson and Spink: Arch. Int. Med. 64: 825, 1940. Lockwood, John 8.: Surg., Gynec. & Obst. 72: 307, 1941.
1941.
AME:RICdN
JOL!IW.K
OF
Therefore, the chief indications in obstetric and gynecologicd opera1
OI3STI!X’KI(‘S
for
1.h~
ions
:I w :
.\SD
GL-SECOI,O(:Y
11s~ ol’ sr11I’iIn ilamidt? powdc~~~
1. Peritonitis, regardless 01' the emsat ivv O~~il.lliSl~~S or t,lrr prwcww of gastric or intestinal contents ; 2. Contamination of t,he perit,oneal cavit,y at operation, either by opening this normally sterile cavity int.o continuity with a normally infected cavity, as for example, the vagina, or by trauma to, or removal of, infected tissues or organs such as pyosalpinges;
BIBB
:
SULFANILAMIDE
POWDER
IN
GYNECOLOGIC
OPERATIONS
465
3. Prevention of formation of adhesions in cases where there is mechanical or chemical irritation or where there are large areas left unperitonealized after the removal of large tumors ; 4. Abscess cavities which are opened and drained, such as a pelvic or Bartholin gland abscess. The dosage depends upon the condition found at operation. The largest amount given is 15 Gm. in the peritoneal cavity plus four or five in the abdominal wall, but this amount is used only in severe cases of peritonitis where drainage is contemplated. Prophylaxis of peritonitis is accomplished by the use of 8 Glm. or less and it is questionable The use of drainwhether any should be put into the abdominal wound. age calls for higher doses in order to allow for the escape of the powder in the drainage fluid. The presence of necrotic material and peritoneal exudates of caseous types also indicates the larger doses. The clean peritoneum absorbs the material more rapidly than the inflamed membrane, and very large doses are contraindicated in preventive applications, because toxic 1eveLs in the blood may be reached quickly. The mode of application is not important, so long as the powder is kept dry and applied thinly and evenly. One good method is application by a sterilized insufflator, especially convenient in inaccessible places. The powder is prepared for use by heating it in tubes at 140° C. in a dry oven for two hours. No serious local effects have resulted from the application of the powder in the doses given. The concentrations obtained in the peritoneum are found to be 75 to 100 times the blood level usually reached, and it is probably not all absorbed from the peritoneum for three days. When a sulfa drug has been used by topical application, it is undesirable and usually unnecessary to supplement it by other methods of administration for three days afterward, and the use of oral medication of this type before operation in which it will be used intraperitoneally These precautions will prevent a number of cases of is inadvisable. chemical hepat,itis, examples of which have been frequently noted, especially before these precautions were recognized as necessary. Cyanosis is frequent but less serious than hepatitis. Fever, which could be assigned to the use of the drug, and optic atrophy have also been reported after intraperitoneal application. Our cases included complete hysterectomies, vaginal plastics, operat,ions on tuboovarian abscesses, and miscellaneous clean cases, such as In addition to these supravaginal hysterectomies and suspensions. there were 23 miscellaneous infected cases with very serious conditions present before operation. In the complete hysterectomies, the powder was divided between the upper end of the vagina and the cul-de-sac of Douglas. In cesarean sections, it was placed under the flap of peritoneum on the surface of
466
A;MEHIC.\S
.JOl:RN;\I,
OF
OIWI’I~:TRI(‘S
.\SI)
(:1-SP:(‘ilI,iN:~
Three of the four imperfect wounds ill the groul) without sul?‘anilamidC were definitely infected, and the avcragv duration of fever was nincx days. In the group with sulfanilanlidc, noue of the imperfect wounds were infected, the defects being clue to l’at nc~l*osis and hematoma. In consist.etl the cases where suH@lamidc was not used, t,htl complications of five urinary trac’t infections, one abscess of t,he vaginal vault, and one bronchopneumonia. Among t,he cues with sulfanilamide~ t.herc was one bronchopneumonia, one s~vcre cyanosis due t,o sulfanllamide (this qxurring in a 67year-old h-pcartcnsivc patient with nephrosclerosis), and one abscess ol’ the ~;lginal vault following a complete hysterectomy done for myoma hut caomplica,ted b?- abscesses in J~th tribes.
BIBB
:
SULFhNII,AMIDE
POWDER
IN
GYNECOLOGIC
OPERATIONS
467
There were three deaths among those without sulfanilamide, one of which was due to carcinomatosis, and two to peritonitis. There was only one deat,h among those treated with snlfanilamide and this was due to pulmonary embolism followed by coronary thrombosis. Thus, among t,he cases where no infection existed before operation, there was no death from peritonitis and no abscess of t,he raginal vault, when sulfanilamide was used. Only the major variet,ics of plastic repairs, such as cpstocele, rectocele, and lacerated pelvic floor, or continence of urine, or fistula, were considered in this series. There were 28 cases of vaginal hysterectomy in which sulfanilamide was not used, and four developed abscesses of t,hc vagina.1 vault. One of these patients diecl from this cause. Six patients who had vaginal hysterectomies and, in whom sulfanilamide was used, all escaped without abscesses.
\Vithout sulfanilamide 1Vith sulfanilamide
Five of the 12 wounds mentioned above were definitely infected, with an average of fourteen days’ fever and evidence of poor healing, ineluding the formation of abscesses, one of which, not included in this five, is the death reported above. Among the cases where sulfanilamide was used, there was only one infected wound and no deaths. The complications were largely urinary, consisting of cystitis and pyelitis, showing Xtaphylococcus alblcs or Bcwillws coli on culture, but there was also one case of bronchopneumonia and one of cndometritis following a curettage and plastic operation. All the complications were urinary among the cases with sulfanilamide. A tot,al of 143 plastics was done without sulfanilamide and 15 with it. As previously noted there was a marked tendency to use sulfanilamidn in the cases considered potent,ially infected. There were 111 cases in which sulfanilamidc was not used and 34 in which it was used.
\Vitllout sulfanilamide With sulfsnilamide
Of really infected wounds, there were two among those without sulfanilamide and one among those with sulfanilamide. The complications were mild respiratory, urinary, breast, and parametrial infections. The patient with the infected wound, in whom sulfanilamide had been used, also developed paralptie ileus, pleurisy, and thrombophlebitis. Her operation was done after she had been in labor for thirty-seven hours. The other complication was a respiratory infection.
468
AMERICAN
,JOURNAL
OJ? OBSTETRICS
AXD
GYNECOLOGY
Without sulfanilamide With sulfanilamide
Ten cases were done without sulfanilamide and 15 with sulfanilamitle. The death occurred in a woman with large bilateral tuboovarian abscesses, myomas, and peritonitis. ,4 (lose of S (h. was put, into the peritoneal cavity, followed by 6 doses of 1 Cm. each every four hours by mouth. On the second postoperative day-, the blood level was 30 mg. The oral medication was stopped, and in forty-eight hours the level fell to 10 mg. ; however, she died on the fifth postoperative clay. There were 27 patients without. evidence of infection and in whom no infected cavit,y was opened into continuity wit-h t,he peritoneum, in which sulfanilamide was used. One of these had thrombophlcbitis and left lower lobe embolism. but rccovcred. Anot,hcr whose hospital course had been normal, die(1 at home ol’ pnlmona~y embolism on the fortict,h da)- after operation. There remain 23 cases of miscellaneous infections in which sulfanilamide was used, bringing the tot,al for all cases in t,he year to 143. The most interesting was that of a white woman of 76 years with no discernible heart or kidney lesions, bn~ emaciated and in only fair general condition, who was admitted because of lower abdominal pain and a mass. A barium enema study showed diverticuli of the colon, but incidentally did not show gallstones. At operaCon, t,he liver felt normal, but the gall bladder was three times normal size and felt tense. So stones were palpable. The uterus contained several large myomas, and the scheduled hystercct,omy was done. The patient went into shock and Sis was given 100 cc. of gum acacia-glucose solution intravenously. She (l(Bgrams of sulfanilamide was put. into the abdominal cavity. veloped increasing jaundirc and fever (107O I’.) and died twent.p-four hours after operation. No addit ional siilfa medication had been given at, any time. A woman with strangulated inguinal hernia and gangrene of the intestine died after an operation in which 8 Cm. was used. Four patients with carcinoma and involvement of the bowel by the tumor oi by radiation effect, all died within a few days of operation from pneu Sulfanilamide was used successfully in three monia and perit,onitis. mastectomies. It was also used in six cases of appendicit,is, but all those whose peritoneal culture showed the presence of bacteria in the perit,oncal fluid at the time of operation, had infected wounds in spite of the sulfanilamide. A middle-aged white woman had peritonitis of unknown origin, which involved the entire cavity equally with a thick, fibrinous exudate. The appendix was removed in the belief that it was the focus of infection, and 8 Gm. were put into the cavit,y and distributed equally. She developed and recovered from a bilateral lobar pneumonia, being given thera,peutic doses of snlfathiazolc by mouth after the second postoperative day. She had only ftve days of fever. One case of pyometra showing gram-positive cocci had an infected wound following puncture of an atrophic uterus by the tenaculum. An-
BIBI
:
SUL~~~hXA3IIDE
POWDER
IN
GYNECOLOGIC
469
OPERATIONS
other patient had a foreign body removed from the abdominal cavity several days after a section. Four grams were placed in the peritoneum at the second operation, with an uneveqtful convalescence. A woman with a carcinoma of t,he fundus and postradiation adhesions had 4 Gm. placed in t,he abdominal cavity. The stay sutures became infected and she had a peritonitis with twenty-nine days of fever, but recovered. A patient admitted with a postoperative vesicovaginal fistula, had one ureter implanted into the bowel, and sulfanilamide was used. She died of pulmonary embolism on the twentieth day. A 240-pound woman with chronic gall bladder disease had a cholecystectomy and appendectomy. followed by evisceration on the fifth day. No snlfanilamide had been used at this operation, but when the wound was resutured, 16 Gm. were used. She died forty-eight hours later. Fourteen grams of powder were placed in the wounds of a combined abdominoperincal resection of the colon for radiation stricture. The patient recovered after forty-eight da.ys o-f fever.
1. A brief review ot’ principles gleaned from the literature is presented. 2. All the cases in which snlfanilamide powder was used at operation at the Woman’s Hospit,al during 1941 are reviewed, and only two complications due to the use of the drug were noted. One was a severe cyanosis, and t,he other was hepatitis, which ended in death of patient, but other factors than the sulfanilamide were operating in this case, and only 6 Gm. were used. 3. Prevention of abscesses at the upper ead of the vagina and prevention of peritonitis are the two clear-cut objectives to be striven for in the use of the powder in complete abdominal and in vaginal hysteree1omies. In our short series, progress was made toward both of these. In cases with infection, prevention of peritonitis is more difficult to evaluat,c, and abscess formation harder to control, due to the variability in degree and virulence of infection and amount of spill. 4. Sulfanilamide did not prevent urinary, respiratory, nor circulatory (aomplications, nor did it rescue moribund patients. Its use cannot obviate the need for good judgment and early treatment.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Bick: J. A. &I. A. 118: 511, 1942. Dees, J. CT.: Mississippi Doctor 18: 215, 19-N. Greene and Hotz: Arch. Int. Med. 63: 779, 1939. Jackson and Coller: J. A. M. A. 18: 194, 1942. Long, Haviland, Edwards, and Bliss: J. A. M. A. 115: 364, 1940. Mueller and Thompson: J. A. M. A. 118: 189, 1942. Rippy, E. L.: .J. A. M. A. 115: 1760, 1940. Rosenburg and Wall: Rurg., Gynec. & Obst. 72: 568, 1941. Thompson, Brabson, and Walker: Surg., Gynec. & Obst. 72: 722, Watson and Spink: Arch. Int. Med. 64: 825, 1940. Lockwood, John 8.: Surg., Gynec. & Obst. 72: 307, 1941.
1941.