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Emphysematous gangrene of the abdominal wall
EMPHYSEMATOUS GANGRENE ABDOMINAL WALL FOLLOWING
ACUTE INTRA,ABDOMINAL REPORT OF 12 CASES
OF THE INFECTIONS
H. A. GAMBLE, M.D., F.A.C.S. GREENVILLE,
T
MISS.
HERE appears to be a genera1 impression that gangrene of the abdomina1 waII foIIowing operations is of comparativeI>- infrequent occurrence. Prior to three years ago it was diffIcuIt to find a reference to it in the current Iiterature, but during the interim there have been reported a number of cases from a11 over the worId. This condition is not to be confounded with the spreading type of gangrene of the skin reported b\- ShipIey, CuIIen, Brewer, Meleney, Bate and Freeman, but it is of an acute fuIminating, toxic character which, unIess recognized earIy, rapidIy proves fata1. In a case reported by HorsIey2 in 1929 an infection of this type was probabIy the causative factor. Beer l2 reported one case foIIowing an appendicia1 abscess in 1925. ButIer6 (I 926) reported 2 cases; one foIIowing an acute appendicitis with rupture, the other cecostomy consequent to an intestina1 obstruction. CIarence A. Traver’ reported one case in 1933. ButIer and Rhodes4 of San Francisco reported 2 cases in 1930, Eckhoff3 of London 7 cases from St. Thomas’s HospitaI in 1930: 2 foIIowing simpIe appendectomies, 2 foIIowing cIean appendectomies with herniotomy combined, one an operation for a ventra1 hernia, one a coIostomy and one an iIeostomy. More recentIy Orrl of Kansas City reported 3 cases compIicating enterostomy foIIowing intestina1 obstruction. Four cases of gas baciIIus infection of the abdomina1 waI1 compIicating Iaparotomy were reported by Nason and Starr.17 The first was a choIecystgastrostomy, the second a suppurative 389
390
H. A. GAMBLE
condition of the peIvis, third an enterostomy with coIostomy, and fourth a choIecystectomy with drainage. AI1 the patients died. Of the 20 cases coIIected, 15 patients died, or a mortaIity rate of 75 per cent. In 1925 I reported 3 casesg; an abstract of the articIe incIuding a description of the method of treatment appeared in the 1926 Year Book of Surgery. Two of these cases were compIicating appendicitis and one associated with acute with one death, foIIowing appendecgaII-bIadder infections, tomy. Again in 1931 I presented a paper before the Southern MedicaI Association upon the treatment of potentiaIIy infected wounds of the abdomina1 waI1, in which were reported 5 to operation for acute additional cases, l8 one subsequent appendicitis, 2 foIIowing choIecystectomy, and 2 after operation for acute intestina1 obstruction. Three of the 5 patients dred.
In view of the increased frequency with which this condition is being reported it is my opinion that it is being recognized more frequentIy than formerIy. Today I wish to add 4 more cases seen since November I, 1931, a11 of them having occurred in the private practice of myseIf and my brother Dr. PauI G. GambIe, making a tota of 12 cases seen since November 2, 1923. AI1 of these werk treated at the white King’s Daughters HospitaI, GreenviIIe, Miss. CASE I. W. H., maIe, aged twenty-eight years, was admitted to the hospita1 November 2, 1923, with a history of having been sick for thirty-six hours with severe pain in the abdomen which began around the umbiIicus and in time was definiteIy IocaIized over the region of the appendix. His white bIood count was 19,000, poIymorphonucIears 87 per cent. An immewas found to be gangrenous diate operation was done. The appendix throughout but unruptured. The abdomen was cIosed in Iayers with a drain at the Iower angIe of the wound. The first five days postoperativeIy were those of a norma convaIescence. On the morning of the sixth day his temperature was 100'F. Inspection of the wound did not show any indication of infection. At 6 P.M. his tempera-
FIG. I. Photograph of wound immediately after being opened widely because of gas gangrene which developed three days after appendectomy and partia1 wound closure. Note edema of subcutaneous tissues I,they are a dirt) green color) and presence of gas bubbIes in exudate at depth of wound. A silver wire sta\- suture on buttons had been left in primary wound.
FIG.
2. Same five days after extending wound because of further extension of gangrene, and after open treatment under a tent. Note necrotic sIoughs clinging to surface.
13921)
FIG. 3. Healthy granuIating wound ready to close.
394
H. A. GAMBLE
ture was IOI’F., p&e I IO, and of good vohrme. Two stitches were removed from the wound which in its depths was black and necrotic. At 6 A.M. the fohowing morning I was caIIed because of profound prostration of the patient. His temperature was IO+$‘F., puIse 160 and bareIy perceptibIe, and the patient was in a state of profound cohapse. AI1 stitches were removed from the wound and it was opened to its depths. The area of infection, which apparentIy had undermined the skin and extended outward, was opened up for a distance of 8 inches, beingguided by the greenish discoIoration of the tissue along the fascia of the externa1 obIique. These ffaps were dissected up as far as the discoIoration extended and the wound kept open with a gauze pack. FeeIing that we were dealing with an anaerobic infection no dressings were appIied, and a tent with a 32 candIe power Iight was pIaced over him. Within twelve hours his temperature was down to IOO’F., puIse IOOand his further convaIescence was uncompIicated except for the added time required for heaIing. The patient has a smaI1 postoperative hernia. CASEII. E. J. W., white, maIe, aged sixty-two, admitted to the hospita1 January 27, 1924, with a history of a miId attack of appendicitis of one week’s duration with subsiding symptoms. On account of the patient having been a diabetic of Iong standing it was decided to make an effort to improve his genera1 condition, before, if necessary, resorting to surgica1 measures. His bIood sugar at this time was 263 mg. per IOO C.C. of bIood. His progress was without any untoward deveIopments until the morning of February jth, eight days after admission to the hospita1, when there was a IocaI flare-up with a bIood count of 15,000 Ieucocytes with 77 per cent poIynucIears. Under spina anesthesia a smaI1 appendicia1 abscess was opened and drained. The appendix was not removed. The patient stood the operation we11but forty-eight hours Iater began suffering with an intractibIe hiccough and in addition to this there was an eIevation of temperature and puIse, a sIight icterus of the skin, and genera1 abdomina1 distention. On the fourth day the stitches were removed from the wound and the deep tissues found to be gangrenous, the process extending upward and inward between the fat and the fascia, which was opened freeIy. However, the gangrene continued to spread in this pIane, unti1 the whoIe of the abdomina1 waI1 was invoIved. The patient died on the fourteenth day foIIowing operation. CASE III. D. K., white, maIe, aged fifty-seven, was admitted to the hospita1 March 7, 1924 with a history of having been sick a week with fever and rigors, and pain IocaIized over the gaII-bIadder region. He had always been heaIthy. A diagnosis of acute ChoIecystitis was made and operation performed upon the morning of his admission. The gall bIadder was found to be acuteIy inflamed and deepIy pIaced, pus and stones were evacuated,
EMPHYSEMATOUS
GANGRENE
the gall bladder drained with a rubber tube, a cigarette drain pIaced in Morison’s pouch, and the wound cIosed in Iayers. The patient stood the operation weI1. However, for the first four days there were toxemic symptoms of a miId character: shght hiccough, drowsiness, flushed cheeks, moist skin, some eIevation of temperature, and an acceIeration of the puIse, al1 of which were attributed to the origina conditionvr On the fourth day, on account of the patient compIaining of pain in the outer side of the wound, two stitches were removed and the wound expIored. Upon their remova the deeper tissues next to the fascia were found to be a greenish bIack and gangrenous with bubbIes of gas present. The wound was opened throughout its whole extent and under a IocaI anesthetic the diseased process folIowed outward and backward for a distance of 9 inches. The Asps were elevated above and beIow as far as the discoIoration extended and the wound packed with gauze. No dressings were appIied, adhesive pIaster was applied across the abdomen to support the wound, and a tent with an eIectric Iight placed over the patient. The gangrenous process spread unti1 it invoIved the whoIe of the origina wound to its fuI1 depths. UItimateIy the patient made a good recovery, except for a Iarge ventra1 hernia which was repaired. CASE IV. E. F., white, maIe, aged forty-two, was admitted to the hospital October 17, 1926 suffering from a recurrent attack of gaIIstone colic. He was operated upon October 18 and the appendix and gaI1 bIadder removed. Three days foIlowing operation the patient had a rise of temperature to 102’F., puIse I IO. Upon inspection the wound was found to be swoIIen and inflamed. The wound was opened and the tissues next to the fascia found to be edematous and a yehowish green in coIor. This discoIoration was foIlowed outward by an incision extending within 4 inches of the midIine posteriorIy. The condition continued to spread however, unti1 it involved practically the whoIe of the abdomina1 waI1 and the patient died on November I I, twenty-three days fohowing operation. CASE v. T. J. S., white, aged fifty-two, maIe, was admitted to the hospita1 September 24, 1927, and operated upon the same day for an acute intestinal obstruction. The obstruction, which was found to be due to a band of adhesions about !i inch in width was reIeased, and an enterostomy tube was pIaced in the proxima1 end of the gut and brought out through a stab wound in the abdomen. The abdomen was cIosed without drainage except for prophylactic strips of rubber tissue between the stitches in the skin. On September 25 he had an eIevation of temperature, and the wound upon being opened discIosed the fact that the deeper tissues were gangrenous with the presence of sanguinous fluid and some gas. The infection had spread subcutaneousIy
H. A. GAMBLE toward the Ieft side of the abdomen which was Iaid open so as to expose it to the air. The patient died on October 5 from suppression of urine, the gangrenous process having never been controIIed. CASE VI. J. N. R., white, maIe, aged twenty-two, was admitted to the hospita1 on JuIy 29, 1930 with a diagnosis of acute gangrenous appendicitis. He was operated upol+immediateIy, one large Penrose drain being pIaced down to the stump of the appendix, the peritoneum being sutured and the interna obIique and transversaIis being approximated with two sutures. The wound was ffushed with ether and packed with gauze saturated with a 2 per cent aqueous soIution of mercurochrome. UntiI August 2, four days after operation, his condition was good with norma temperature and puIse of 80. On August 3, his temperature suddenIy rose to 104’~. The sutures were removed from the interna obIique muscIe and the gangrenous area exposed. His puIse increased in rapidity, and his temperature remained high. An icteroid discoIoration of the conjunctiva deveIoped, the genera1 appearance being that of a severe toxemia. It was then thought, whiIe there were no externa1 evidences of it, that the infection had spread posteriorIy. An incision was made 2 inches from the costovertebra1 angIe and gangrenous tissue encountered beneath the transversaIis muscIe. The incision was extended forward unti1 it united with the origina appendicia1 wound, and the whoIe packed with gauze, which was removed as soon as the oozing was controIIed. The wound was Ieft open without dressings and a tent with a 32 candIe power Iight pIaced over the patient. This patient was given gas gangrene serum therapeuticaIIy. From this time on there was an uninterrupted convaIescence with no postoperative hernia. CASE VII. W. H. S., maIe, white, aged forty-nine, was admitted to the hospita1 November 7, 1930 with an acute appendicitis. The appendix was removed, one Penrose tube inserted down to the stump and the abdominal wall cIosed in Iayers down to the tube. On November 20, symptoms of intestinal obstruction deveIoped, and an enterostomy was done on the Ieft side of the abdomen, the tube being brought out through a stab wound. The opening in the abdomen was cIosed with one Penrose drain. The patient had a rather stormy time with temperature ranging from I o I’ to 102’F., and on November 29 the wound made in doing the enterostomy was opened to its depths and found to be gangrenous. The skin was opened up unti1 a11 gangrenous areas were exposed to the air, then pIaced without dressings under a tent with a light. His further convalescence was without untoward deveIopments. CASEVIII. F. G., white, maIe, aged seventy, was admitted to the hospita1 on June 6, rg3 I with a temperature of IO~“F., and a history of having been sick for three days. A diagnosis of acute suppurative choIecystitis was made,
EMPHYSEMATOUS the
gal1 bIadder
wound
drained
and
was closed except
cholecystostomy temperature
tube.
dropped
GANGRENE
stones
removed
for rubber
The
drains
patient’s
to normal
the
condition
within
quickIy
throughout.
The
with the escape
infection
up of the infected
hospita1 Onset
of iIlness
S.
K.,
white,
12, 1931 with
December
began
aged
sixty-four,
and the cuI-de-sac
admitted been
pain and finally
The appendix
Penrose
drains
and the peritoneum
soIution
considering
became
and gangrenous
were placed
through
of intestina1
The patient
with anaerobic a spreading December
On December developed,
having
with a 2 per cent
Notwithstanding
this precaution
areas. This patient
B. B.,
CASE x.
white,
male,
aged
hospital
December
14, 1931, with
chronic
appendicitis.
The appendix
gall bladder
Forty--eight
hours
of toxemia,
admission
puIse
140, temperature
greenish
sutures
of silver
disruption,
and the \vound opened the patient
six hours his temperature was without
the
black
mattress
his con\,uIesccnce
serum
27.
was admitted
of acute
on
to the
choIecystitis
stones removed
and
from the
The \vc)und was closed in Iayers
after
shohved gas and
ings were removed,
forty-three,
drained.
which
of I 2 inches,
tube.
anesthesia
Within
there developed
on December
was removed,
and the gal1 bladder
up to the drainage
being Ieft
uas given anti-gangrene
a diagnosis
22, was
of infection
the skin and fascia
in Iarge doses. She died as a result of the gangrene
wound
wound
26 \vas opened upward and to the left for a distance
Iaying open a11 infected
symptoms
On December
of the possibiIity
between
we11
an enterostomy
the enterostomy
on account
of this type
pouch
17 a pelvic abscess
to the cervix.
organisms.
infection
throughout
stood the operation
a wound posterior
its whole extent
through
in Morison’s
obstruction
done on the Ieft side of the abdomen, open throughout
IocaIized
cIosed down to the drain. The baI-
her age and genera1 condition.
was evacuated symptoms
of mercurochrome.
to the
sick a week.
which was removed
ante of the wound was washed out with ether and packed aqueous
The wound was were gangrenous
serum, and the patient
of having
incision was found to be ruptured
with a genera1 peritonitis.
and his
twenty-four
upward despite the wide opening
a history
with epigastric
over the region of the appendix. a McBurney
tissues
areas and the use of anti-gangrene
died on the fourth day. CASE IX. Mrs. M.
improved
developed.
of gas. The
spread rapidIy
The
up to the
hue of the skin, his temperature
rose to IO~‘F., puIse 130, and menta1 cloudiness opened
afternoon.
the stitches
a few hours. However,
hours later he began to deveIop an icteroid immediateIy
same
between
01‘ tissues.
wire \\eerc placed placed
had dropped an!-
deveIoped
marked
106~~. Exploration
necrosis
throughout
being
patient
Under
local
so as to prevent
its \vhoIe extent. under
of the
a tent
Al1 dress-
with a light.
to IOO’F., and from then on
developments
of consequence.
The
H. A. GAMBLE patient was given fuI1 doses of anti-gangrene serum immediately upon the deveIopment of symptoms of infection. CASE XI. W. Z. L., white, maIe, aged thirty-six, was admitted to the hospita1 JuIy 7, 1930 with a history of having been operated upon for an acute ChoIecystitis on March 5 of the same year, since which time he had had an intermittent drainage from his gaII-bIadder wound. On JuIy g a choIecystectomy was done, a Penrose tube being pIaced in the wound which was cIosed up to the drain. Within four hours the patient manifested severe toxemic symptoms with a puIse of 120 and temperature of 104’~. By 6 A.M. of the morning of the 10th his temperature was IOS’F., puIse 150. A note at that time is to the effect that the puIse was very rapid and of extremeIy poor volume. The wound was inspected by the remova of a stitch and no infection found. The patient was transferred to the sun parIor because of the possibiIity of pulmonary compIications. The foIIowing morning the wound was again inspected and some crepitation found in the skin above it. It was opened to its depths and found to have become gangrenous since the examination twenty-four hours previousIy. The gangrenous areas were foIIowed up toward the axiIIa, and down within 3 inches of the crest of the iIium, fuI1 doses of anti-gangrene serum being given. This patient died the foIlowing day. CASE XII. Mrs. C. L., white, aged twenty-five, was admitted to the hospita1 on JuIy g, 1934 with a diagnosis of acute ChoIecystitis. Her symptoms subsided and she refused operation. On the night of the I rth there was an acute exacerbation with extreme pain. She was operated upon on the morning of the Izth, with temperature IOI’F., and puIse 120. The gaI1 bIadder was found to be gangrenous and was resected, the mucosa being cauterized with carboIic acid, a pack introduced with surrounding rubber drains, and the peritoneum was cIosed up to the pack, mattress sutures of siIver wire introduced, the wound washed with ether and packed with gauze saturated with a I :IOOO aqueous soIution of merthioIate. SiIkworm gut sutures were tied IooseIy over the merthioIate gauze. Twentyfour hours Iater, the appearance of the wound being heaIthy, the pack was removed and the siIkworm gut sutures tied. At 6 A.M. the foIIowing morning I was caIIed on account of the coIIapse of the patient. Her pulse was 140 and of very poor voIume, the surface of the body coId and clammy, temperature 102.5’F. AI1 stitches were removed and the wound Iaid open. AIthough the appearance did not indicate the presence of a WeIch baciIIus infection, anti-gangrene serum was administered. However, the patient did not improve, her temperature ran high and on the 17th reached a height of 105’~. with pulse 140. Slight crepitation was feIt at the upper margin of the wound and a 4 inch incision upward over the thorax exposed an area or greenish yeIIow discoIoration over the fascia. Anti-gangrene serum was
EMPHYSEMATOUS
GANGRENE
399
continued in fuII doses, and the patient kept under a tent with an electric Iight. Her temperature graduaIIy subsided to normal and ultimately she made a good recovery. (Cases IX, x, XI and XII are reported here for the first time. The illustrations are from a case as yet unpuh1ished.J
An anaIysis of these cases shows that there were 6 following operations upon the biIiary tract, 3 directIy foIIowing appendicitis operations, and 3 foIIowing intestinal obstruction, 2 of which were secondary to drainage appendectomies. EtioIogicaIIy it has aIways occurred as a compIication foIIowing an acute intra-abdomina1 Iesion---either an intestina1 obstruction, a gangrenous appendix, a ruptured appendix, genera1 peritonior a perforation of one of tht tis, an acute ChoIecystitis, hoIIow viscera. It has been shown by Jennings7 that 98 per cent of acute appendices harbor anaerobic organisms, particuIarIy WeIch’s baciIIus. PracticaIIy the same resuIts were reported by Heyd in 191 I from Friedrich’s CIinic in an extensive investigation of the intestina1 flora. Seventeen varieties of anaerobes were isoIated, and he concIuded that anaerobic bacteria were present in IOO out of 102 cases studied, and that they were present in greater profusion than aerobes in a11 stages of appendicitis and peritonitis, and attributed to them the entire causation of gangrene and of toxemia. He found that tht Perfringen’s group-BaciIIus welchii, outstripped a11 others in rapidity of growth. Jennings aIso states that in miIder cases of wound infection foIIowing such Iesions that the WeIch baciIIus can be reguIarI)recovered by proper anaerobic methods. In a number of cases reported today a pure staphyIococcus was found, whiIe in severa the WeIch baciIIus was present in CIinicaIIy the symptoms were those of an pure cuIture. anaerobic infection and toxemia, and I have considered that the reason for anaerobic organism not being found in some was due more to improper methods of cuIturing than to their absence.
400
H. A. GAMBLE
WiIIiams13 in 1926 studied the cause of toxemias of intestina1 obstruction and found that practicaIIy a11 cases of Iower intestina obstruction had a very viruIent and rapid growth of WeIch’s baciIIus. He contended that the norma habitat of this organism was in the Iower iIeum, because the contents of the upper part of the smaI1 bowe1 and coIon were acid and inhibited its growth; but that in obstruction deveIoping beIow the iIeoceca1 vaIve uItimateIy the resuIts were the same as wouId be the case in an obstruction of the smaI1 bowe1. Experiments on Iiver autoIysis in the Iiving by EIIis and Andrews and Hrdina14 furnish a very and Dragstedt,” concIusive expIanation of the reason for the rapid deveIopment and overwheIming toxemia found in those cases associated with acute infections of the gaI1 bIadder, in that it is essentiai that there be present a substance or cuIture medium capabIe of furnishing materia1 for rapid proIiferation of the parasites and the formation of toxins which in their turn are necessary for the further growth of the bacteria. In their experiments Iiver was the medium through which this was accompIished. In contaminated wounds the traumatized muscIes and tissues, and wound exudates, in conjunction with the cIosed wound form an idea1 incubator and cuIture medium for the growth The reIative immunity and weIIof anaerobic organisms. known abiIity of the peritoneum to overcome this type of infection is probabIy due more to the Iack of a suitabIe pabuIum for the deveIopment of toxins than to any other one cause. AIso one cannot but fee1 that their findings in these experiments upon Iiver autoIysis in the Iiving have a cIinica1 appIication when taken in conjunction with the frequent deveIopment of gangrene of the abdomina1 waI1 associated with operations upon the acuteIy inflamed gaI1 bIadder. Six of the cases reported today foIIowed operations upon the biIiary tract; 3 of these patients died, and there were 2 other deaths in our gaII-bIadder operations which I have since been convinced were due to an unrecognized anaerobic infection.
EMPHYSEMATOUS GANGRENE
40 I
Since 1920 we have done 490 operations upon the biliar)tract with a total of 8 deaths. Three of these deaths were due directly to an infection of this character, and two others in the light of subsequent experience wc are convinced were due to unrecognized cases of the same condition. Gordon Heyd’ in I 93 I presented a paper before the Surgical Section of the American Medical Association in which he gave three classilications of liver deaths. The symptoms associated with Type I, the most frequent, closely resembled this type of infection. We have had 6 of these cases following operation upon the biliary tract, 4 of which had extremely early prostration and in which the wound was immediately opened and a gangrenous type of infection found. We cannot but believe, in view of our clinical experience, that a large proportion of deaths ascribed to liver shock and hepatic insufficiency, are really due in large measure to acute infections of the abdominal wall with an anaerobic organism. Particularly is this so if there has been any trauma to the liver bed with the death of liver tissue which acts as a direct stimulant to the growth of Welch’s bacillus. The symptoms are always those of severe toxemia, but the period of onset varies, the most fulminating usually manifesting itself within the lirst few hours following operation by rapid pulse, lowered blood pressure, high fever, high blood count and extreme prostration. Sometimes there is a delay in the onset of symptoms. Whether this is due to the resistance of the patient, the difference in the degree of virulence of the organism or other causes I cannot say; however, when the symptoms do appear they are always those of a severe, not to say overwhelming toxemia. The wound often has a perfectly healthy appearance from the surface and in no way suggests the pathological changes present in the deeper tissues, or very early one may sometimes elicit crepitus beneath the adjacent skin. Upon removing the sutures there is found necrosis of fascia and muscle with the
4.02
H. A. GAMBLE
presence of bubbles of gas. The infection spreads in the fascial pIanes usuaIIy between the skin and the fascia, and in such cases there wiI1 be found a greenish yeIIow discoIoration throughout its course. The treatment that has given us the best resuIts consists in opening the origina wound entireIy down to the peritoneum, combined with a free incision of the skin aIong the subcutaneous spread of the infection unti1 heaIthy tissue is reached, the ffaps being freeIy raised on each side unti1 a11 of the infected area is exposed to the air. The wounds are not dressed but are Ieft open under a tent, with a Iight. Antigangrene serum has been administered in fuI1 doses with, in at Ieast 2 cases, beneficia1 resuIts. In addition bIood transintravenous gIucose fusions are given, and the continuous drip has been administered to a11 patients. Prevention is better than treatment. The cause fundamentaIIy is the cIosure of a wound infected with anaerobic organisms so that an exceIIent incubator is provided with a suitabIe cuIture medium for the deveIopment and growth of these organisms under the most favorabIe conditions. In cIosing these potentiaIIy infected wounds one disregards one of the basic principIes of surgery. No where eIse in the body wouId one consider cIosing or partiaIIy cIosing a wound which had been bathed in pus or contaminated materia1 Ioaded down with viruIent organisms. We now, in a11 cases of peritonitis, ruptured appendix, obstruction, perforations of appendicia1 abscess, intestina1 the hoIIow viscera and acute infections of the gaI1 bIadder, after attending to whatever pathoIogy is present, and inserting drains where indicated, suture the peritoneum down to the drains, as we have aIways found the peritonea1 cavity ampIy abIe to protect itseIf, wash the wound with ether, insert mattress sutures of siIver wire to prevent disruption, then fIush the wound with a I : I ooo aqtieous soIution of merthioIate. The wound is then packed with gauze saturated with a I :IOOO aqueous soIution of merthioIate, and siIkworm gut sutures,
EMPHJ-SEhIATOUS
GANGREKE
403
which have been previousIy introduced, tied ok-er it with a bow knot. We have in some cases Ieft the wound open without packing it, but prefer to fo!Iow this procedure for four reasons: First, it gives stabihty to’ the abdomina1 waI1, so that in case of post-anesthetic strain there is no danger of disruption. Second, we beIieve it promotes a free retrograde ffow of Iymph, third, it promotes the waIIing off of the wound by Nature’s natura1 defensive methods, and fourth, the germicida1 soIution acts to inhibit the growth of bacteria. At the end of twenty-four hours the pack is changed under aseptic precautions, and at the end of forty-eight hours it is removed permanentIy, and the wound Ieft open without dressings under a tent provided with a 32 candle power eIectric Iight. For the first twenty-four hours the patient is pIaced in the position that wiI1 best favor drainage, usuaII-\- upon the abdomen. AI1 seriousIy iI patients are given gIucose, a 3 per cent soIution in buffer saIts subcutaneousIy whiIe upon the operating tabIe, and a IO per cent soIution is given continuousIy I jo-200 C.C. per hour intravenousIy as Iong as ma)- be indicated to overcome dehydration, stimuIate excretion, and furnish nourishment whiIe the digestive processes are heId in abeyance. A prophyIactic dose of combined anti-tetanic and Perfringen’s serum is given routineIy at the compIetion of the operation. Personally I have been empIoying this method except the use of the serum since 1924 and in no case in which it was used has a case of spreading gangrene deveIoped. Often the surface of the wound assumes a dark gray or bIack discoIoration from superficial necrosis which cIears up spon;aneousI;\- with no systemic effects. There have been other advantages accruing from this form of treatment, notabIy the Iessening of postoperative pulmonary comphcations which are very rareIy seen in such cases, whereas former]>- they were one of the most frequent compIications. There are two objections which can be raised; these, however, arc insignificant n-hen compared with the benefits to be
404
H. A. GAMBLE
derived. The first is the Ionger period of hospitahzation, which has varied from twenty-one to thirty-five days, and the second is the possibihty of the deveIopment of postoperative hernias. The Iatter have been comparativeIy few considering the number of cases in which the method was empIoyed. It is our intention, in this communication, to show that gangrenous infections of the abdominal waII pIay an important rBIe in the mortahty rate from operations for acute intraabdomina1 conditions; that they are particuIarIy prone to deveIop in surgery of the biIiary tract, and that the condition is preventabIe. From January, 1920 to January I, 1925 there were treated by us 137 drainage cases of appendicitis with the deveIopment of 3 cases of gangrene of the abdomina1 waII and 2 deaths. I, 193 I there were 292 From January I, 1925 to November drainage cases of appendicitis, 141 being treated openIy as described with no gangrene and no deaths; 151 cases were treated with drainage and partia1 cIosure of the wound with 5 cases deveIoping gangrene and 3 deaths. Among the 292 drainage cases there were 82 cases of generaIized peritonitis; a11 of the patients were treated in this manner, none of whom developed a severe wound infection and none of whom died. Since November I, 193 I my brother and I have operated upon 446 cases of appendicitis in which there were 202 acute appendices without drainage, 33 with IocaI peritonitis or abscess formation requiring drainage and 38 cases of genera1 diffuse peritonitis from a ruptured appendix, a tota of 71 drainage cases. AI1 of these 71 drainage cases were treated as described, there was no deveIopment of gangrene in the abdomina1 waI1, nor were there any deaths in the whoIe series of 446 cases. In regard to its connection with operations upon the biIiary tract: since January I, 1920 we have operated upon the biIiary tract in 490 cases. There have been 9 deaths, 3 of which couId be definiteIy ascribed to infection with anaerobic organisms and spreading gangrene, and as ah-eady
EMPHYSEMATOUS
GANGRENE
405
stated, 2 more we befieve can justfy Ix credited to this as the causative factor. Five out of 9 deaths is a farge percentage for any one cfinicaf entity to be responsibfe for. AI1 of these cases devefoped in cfosed wounds, or wounds partiafly cfosed with drainage. Since we have adopted the method described in this paper there has not been a singfc cast of gangrene in our gaff-bfadder surgery. The fast 3 cases which we have reported here occurred as a resuft of partiaffy closed wounds which shoufd have been feft open. We consider that infection of the abdominaf waff with anaerobic organisms plays a most important part in the mortafity rate of a11 acute intra-abdominaf fesions, and that it is a preventabfe condition when potcntiaffy infected wounds are treated
as outfined. REFERENCES
I. ORR, T. G. Gas bacillus infection 2.
3. 4.
5.
33: 946-947 (Aug. 1) 1933. 6. BUTLER, D. D. Post-operative 7. 8. 9. 10.
I I. 12.
of abdominal
wall. J. A. hf. A., 102: 2081-2082
(June 23) 1934. HORSLEY, J. S. Intussusception due to intestina1 Iipoma in adult, foIlowed by gangrene of the abdomina1 waII. Arch. Surg., 18: 882-891 (Mar.) 1929. ECKHOFF, N. L. Gas gangrene in civi1 surgery. Brit. J. Surg. 18: 3%48 (JuIy) 1930. BUTLER, E., and RHODES, G. Infection of abdomina1 waI1 with B. weIchii folIowing enterostomy for bowel obstruction. Calif. e’p West. Med., 32: No. 4, 248-249 (ApriI) 1930. TRAVER, C. A. Gas baciIIus infection complicating appendicitis. N. York J. ,M. infection
of the abdominal
waI1. Ann.
Surg., 84:
841-844 (Dec.) 1926. JENNINGS, J. E. The relation of the WeIch baciIIus to appendicitis and its compIications. Ann. Surg., 93: 828-836 (April) I 93 I. HEYD, C. G. Liver deaths in surgery of the gaII-bIadder. J. A. M. A., 97: No. 25, 1847-1848 (Dec. 19) 1931. GAMBLE, H. A. Post-operative infections of the abdomina1 waI1. New Orleans M. FTF S. J., 78: 208-213 (Oct.) 1925. ELLIS, J. C., and DRAGSTEDT, L. K. Liver autoIysis in vivo. Arch. Surg., 20: No. I, 8-16 (Jan.) 1930. MCIVER, M. A., WHITE, J. C., and LAWSON, G. M. The roIe of the bacillus Welchii in acute intestinal obstruction. Ann. Surg., 89: No. 5. 647-657 (May) 1929. BEER, E. Appendicitis with gas bacillus infection. Trans. New York Surg. Sot. (Feb. II)
1925.
I 3. WILUAMS, B. W. The importance of toxemia due to anaerobic organisms in intestina obstruction and peritonitis. Brit. J. Surg., 14: No. 54 (Oct.) 1926. I_$. ANDREWS, E., and HRDINA, L. The cause of death in liver autolysis. Surg. Gynec. Obst., pp. 61-66 (Jan.) 1931.
H. A. GAh4BLE
406
15. OCHSNER, A. J. and SCHMIDT, E. R. Gas bacilhrs infection originating in a gangrenous appendix. Surg. Clin. N. America, 5: No. 4, gr 1-913 (Aug.) 1925. 16. BEST, R. R., NEWTON, L. A., and MEIDINGER, R. Absorption in intestinal obstruction. Arch. Surg., 27: No. 6, 1081-1086 (Dec.) 1933. I 7. NASON, L. H., and STARR, A. Gas bacilhrs infection complicating laparotomy. Arch. Surg., 29: No. 4. 546554 (Oct.) 1934. 18. GAMBLE, H. A. The treatment of the potentiaIIy infected abdominal wound, and its relationship to the mortatity rate of acute infection of the abdomen. Soutb. M. .I., 25: No. 5, 515-518 (May) 1932. rg. CONNELL, F. G. Liver deaths (so-caIIed). Ann. Surg., IOO: No. 2, 31g-327 (Aug.) 1934. DISCUSSION
DR. EDWARD H. OCHSNER, Chicago, III:: I wish to caII attention to a method of treatment which we have used in 2 cases, with exceIIent results. We have seen 4 cases, 3 in our own practice and one in a government hospitaI. In the Iast 2 cases in my own practice I empIoyed the foIIowing method: I took off a11 bandages, simpIy covering the invoIved area with some Ioose gauze, kept this gauze saturated with fuI1 strength peroxide of hydrogen day and night and permitted free access of the air by pIacing a cradIe under the bed cIothing. It was surprising to see how quickIy the condition cIeared up. The first patient I saw before I devised the method of treatment died after much suffering. In this case the skin of the entire abdominal waI1 was eaten away by the process and the patient died from cachexia and exhaustion. We made no detailed cu1tur-e studies, oniy making the routine studies, but I am firmIy convinced that these are anaerobic and that hydrogen peroxide is a very reIiabIe method of treatment. AI1 of these cases foIIowed operations for appendicitis. The patients were not very III with appendicitis and yet in each case a smaI1 quantity of pus was evacuated at the time of the operation. Each case was drained and about a week after the operation the skin became undermined, which process continued unti1 we appIied the hydrogen peroxide treatment. DR. RALPH G. CAROTHERS, Cincinnati, 0.: I wish to report a case which occurred when I was house surgeon in rgrg. The patient was a woman, Iarge and fat and quite dirty, suffering with an obstructed but not stranguIated hernia. On the fourth day fohowing the operation, she developed a considerabIe quantity of sugar in the urine and a vioIent case of gas gangrene of the abdomina1 waI1. She died the same day in spite of a11 we could do.
ACUTE INTRA,ABDOMINAL REPORT OF 12 CASES
OF THE INFECTIONS
H. A. GAMBLE, M.D., F.A.C.S. GREENVILLE,
T
MISS.
HERE appears to be a genera1 impression that gangrene of the abdomina1 waII foIIowing operations is of comparativeI>- infrequent occurrence. Prior to three years ago it was diffIcuIt to find a reference to it in the current Iiterature, but during the interim there have been reported a number of cases from a11 over the worId. This condition is not to be confounded with the spreading type of gangrene of the skin reported b\- ShipIey, CuIIen, Brewer, Meleney, Bate and Freeman, but it is of an acute fuIminating, toxic character which, unIess recognized earIy, rapidIy proves fata1. In a case reported by HorsIey2 in 1929 an infection of this type was probabIy the causative factor. Beer l2 reported one case foIIowing an appendicia1 abscess in 1925. ButIer6 (I 926) reported 2 cases; one foIIowing an acute appendicitis with rupture, the other cecostomy consequent to an intestina1 obstruction. CIarence A. Traver’ reported one case in 1933. ButIer and Rhodes4 of San Francisco reported 2 cases in 1930, Eckhoff3 of London 7 cases from St. Thomas’s HospitaI in 1930: 2 foIIowing simpIe appendectomies, 2 foIIowing cIean appendectomies with herniotomy combined, one an operation for a ventra1 hernia, one a coIostomy and one an iIeostomy. More recentIy Orrl of Kansas City reported 3 cases compIicating enterostomy foIIowing intestina1 obstruction. Four cases of gas baciIIus infection of the abdomina1 waI1 compIicating Iaparotomy were reported by Nason and Starr.17 The first was a choIecystgastrostomy, the second a suppurative 389
390
H. A. GAMBLE
condition of the peIvis, third an enterostomy with coIostomy, and fourth a choIecystectomy with drainage. AI1 the patients died. Of the 20 cases coIIected, 15 patients died, or a mortaIity rate of 75 per cent. In 1925 I reported 3 casesg; an abstract of the articIe incIuding a description of the method of treatment appeared in the 1926 Year Book of Surgery. Two of these cases were compIicating appendicitis and one associated with acute with one death, foIIowing appendecgaII-bIadder infections, tomy. Again in 1931 I presented a paper before the Southern MedicaI Association upon the treatment of potentiaIIy infected wounds of the abdomina1 waI1, in which were reported 5 to operation for acute additional cases, l8 one subsequent appendicitis, 2 foIIowing choIecystectomy, and 2 after operation for acute intestina1 obstruction. Three of the 5 patients dred.
In view of the increased frequency with which this condition is being reported it is my opinion that it is being recognized more frequentIy than formerIy. Today I wish to add 4 more cases seen since November I, 1931, a11 of them having occurred in the private practice of myseIf and my brother Dr. PauI G. GambIe, making a tota of 12 cases seen since November 2, 1923. AI1 of these werk treated at the white King’s Daughters HospitaI, GreenviIIe, Miss. CASE I. W. H., maIe, aged twenty-eight years, was admitted to the hospita1 November 2, 1923, with a history of having been sick for thirty-six hours with severe pain in the abdomen which began around the umbiIicus and in time was definiteIy IocaIized over the region of the appendix. His white bIood count was 19,000, poIymorphonucIears 87 per cent. An immewas found to be gangrenous diate operation was done. The appendix throughout but unruptured. The abdomen was cIosed in Iayers with a drain at the Iower angIe of the wound. The first five days postoperativeIy were those of a norma convaIescence. On the morning of the sixth day his temperature was 100'F. Inspection of the wound did not show any indication of infection. At 6 P.M. his tempera-
FIG. I. Photograph of wound immediately after being opened widely because of gas gangrene which developed three days after appendectomy and partia1 wound closure. Note edema of subcutaneous tissues I,they are a dirt) green color) and presence of gas bubbIes in exudate at depth of wound. A silver wire sta\- suture on buttons had been left in primary wound.
FIG.
2. Same five days after extending wound because of further extension of gangrene, and after open treatment under a tent. Note necrotic sIoughs clinging to surface.
13921)
FIG. 3. Healthy granuIating wound ready to close.
394
H. A. GAMBLE
ture was IOI’F., p&e I IO, and of good vohrme. Two stitches were removed from the wound which in its depths was black and necrotic. At 6 A.M. the fohowing morning I was caIIed because of profound prostration of the patient. His temperature was IO+$‘F., puIse 160 and bareIy perceptibIe, and the patient was in a state of profound cohapse. AI1 stitches were removed from the wound and it was opened to its depths. The area of infection, which apparentIy had undermined the skin and extended outward, was opened up for a distance of 8 inches, beingguided by the greenish discoIoration of the tissue along the fascia of the externa1 obIique. These ffaps were dissected up as far as the discoIoration extended and the wound kept open with a gauze pack. FeeIing that we were dealing with an anaerobic infection no dressings were appIied, and a tent with a 32 candIe power Iight was pIaced over him. Within twelve hours his temperature was down to IOO’F., puIse IOOand his further convaIescence was uncompIicated except for the added time required for heaIing. The patient has a smaI1 postoperative hernia. CASEII. E. J. W., white, maIe, aged sixty-two, admitted to the hospita1 January 27, 1924, with a history of a miId attack of appendicitis of one week’s duration with subsiding symptoms. On account of the patient having been a diabetic of Iong standing it was decided to make an effort to improve his genera1 condition, before, if necessary, resorting to surgica1 measures. His bIood sugar at this time was 263 mg. per IOO C.C. of bIood. His progress was without any untoward deveIopments until the morning of February jth, eight days after admission to the hospita1, when there was a IocaI flare-up with a bIood count of 15,000 Ieucocytes with 77 per cent poIynucIears. Under spina anesthesia a smaI1 appendicia1 abscess was opened and drained. The appendix was not removed. The patient stood the operation we11but forty-eight hours Iater began suffering with an intractibIe hiccough and in addition to this there was an eIevation of temperature and puIse, a sIight icterus of the skin, and genera1 abdomina1 distention. On the fourth day the stitches were removed from the wound and the deep tissues found to be gangrenous, the process extending upward and inward between the fat and the fascia, which was opened freeIy. However, the gangrene continued to spread in this pIane, unti1 the whoIe of the abdomina1 waI1 was invoIved. The patient died on the fourteenth day foIIowing operation. CASE III. D. K., white, maIe, aged fifty-seven, was admitted to the hospita1 March 7, 1924 with a history of having been sick a week with fever and rigors, and pain IocaIized over the gaII-bIadder region. He had always been heaIthy. A diagnosis of acute ChoIecystitis was made and operation performed upon the morning of his admission. The gall bIadder was found to be acuteIy inflamed and deepIy pIaced, pus and stones were evacuated,
EMPHYSEMATOUS
GANGRENE
the gall bladder drained with a rubber tube, a cigarette drain pIaced in Morison’s pouch, and the wound cIosed in Iayers. The patient stood the operation weI1. However, for the first four days there were toxemic symptoms of a miId character: shght hiccough, drowsiness, flushed cheeks, moist skin, some eIevation of temperature, and an acceIeration of the puIse, al1 of which were attributed to the origina conditionvr On the fourth day, on account of the patient compIaining of pain in the outer side of the wound, two stitches were removed and the wound expIored. Upon their remova the deeper tissues next to the fascia were found to be a greenish bIack and gangrenous with bubbIes of gas present. The wound was opened throughout its whole extent and under a IocaI anesthetic the diseased process folIowed outward and backward for a distance of 9 inches. The Asps were elevated above and beIow as far as the discoIoration extended and the wound packed with gauze. No dressings were appIied, adhesive pIaster was applied across the abdomen to support the wound, and a tent with an eIectric Iight placed over the patient. The gangrenous process spread unti1 it invoIved the whoIe of the origina wound to its fuI1 depths. UItimateIy the patient made a good recovery, except for a Iarge ventra1 hernia which was repaired. CASE IV. E. F., white, maIe, aged forty-two, was admitted to the hospital October 17, 1926 suffering from a recurrent attack of gaIIstone colic. He was operated upon October 18 and the appendix and gaI1 bIadder removed. Three days foIlowing operation the patient had a rise of temperature to 102’F., puIse I IO. Upon inspection the wound was found to be swoIIen and inflamed. The wound was opened and the tissues next to the fascia found to be edematous and a yehowish green in coIor. This discoIoration was foIlowed outward by an incision extending within 4 inches of the midIine posteriorIy. The condition continued to spread however, unti1 it involved practically the whoIe of the abdomina1 waI1 and the patient died on November I I, twenty-three days fohowing operation. CASE v. T. J. S., white, aged fifty-two, maIe, was admitted to the hospita1 September 24, 1927, and operated upon the same day for an acute intestinal obstruction. The obstruction, which was found to be due to a band of adhesions about !i inch in width was reIeased, and an enterostomy tube was pIaced in the proxima1 end of the gut and brought out through a stab wound in the abdomen. The abdomen was cIosed without drainage except for prophylactic strips of rubber tissue between the stitches in the skin. On September 25 he had an eIevation of temperature, and the wound upon being opened discIosed the fact that the deeper tissues were gangrenous with the presence of sanguinous fluid and some gas. The infection had spread subcutaneousIy
H. A. GAMBLE toward the Ieft side of the abdomen which was Iaid open so as to expose it to the air. The patient died on October 5 from suppression of urine, the gangrenous process having never been controIIed. CASE VI. J. N. R., white, maIe, aged twenty-two, was admitted to the hospita1 on JuIy 29, 1930 with a diagnosis of acute gangrenous appendicitis. He was operated upol+immediateIy, one large Penrose drain being pIaced down to the stump of the appendix, the peritoneum being sutured and the interna obIique and transversaIis being approximated with two sutures. The wound was ffushed with ether and packed with gauze saturated with a 2 per cent aqueous soIution of mercurochrome. UntiI August 2, four days after operation, his condition was good with norma temperature and puIse of 80. On August 3, his temperature suddenIy rose to 104’~. The sutures were removed from the interna obIique muscIe and the gangrenous area exposed. His puIse increased in rapidity, and his temperature remained high. An icteroid discoIoration of the conjunctiva deveIoped, the genera1 appearance being that of a severe toxemia. It was then thought, whiIe there were no externa1 evidences of it, that the infection had spread posteriorIy. An incision was made 2 inches from the costovertebra1 angIe and gangrenous tissue encountered beneath the transversaIis muscIe. The incision was extended forward unti1 it united with the origina appendicia1 wound, and the whoIe packed with gauze, which was removed as soon as the oozing was controIIed. The wound was Ieft open without dressings and a tent with a 32 candIe power Iight pIaced over the patient. This patient was given gas gangrene serum therapeuticaIIy. From this time on there was an uninterrupted convaIescence with no postoperative hernia. CASE VII. W. H. S., maIe, white, aged forty-nine, was admitted to the hospita1 November 7, 1930 with an acute appendicitis. The appendix was removed, one Penrose tube inserted down to the stump and the abdominal wall cIosed in Iayers down to the tube. On November 20, symptoms of intestinal obstruction deveIoped, and an enterostomy was done on the Ieft side of the abdomen, the tube being brought out through a stab wound. The opening in the abdomen was cIosed with one Penrose drain. The patient had a rather stormy time with temperature ranging from I o I’ to 102’F., and on November 29 the wound made in doing the enterostomy was opened to its depths and found to be gangrenous. The skin was opened up unti1 a11 gangrenous areas were exposed to the air, then pIaced without dressings under a tent with a light. His further convalescence was without untoward deveIopments. CASEVIII. F. G., white, maIe, aged seventy, was admitted to the hospita1 on June 6, rg3 I with a temperature of IO~“F., and a history of having been sick for three days. A diagnosis of acute suppurative choIecystitis was made,
EMPHYSEMATOUS the
gal1 bIadder
wound
drained
and
was closed except
cholecystostomy temperature
tube.
dropped
GANGRENE
stones
removed
for rubber
The
drains
patient’s
to normal
the
condition
within
quickIy
throughout.
The
with the escape
infection
up of the infected
hospita1 Onset
of iIlness
S.
K.,
white,
12, 1931 with
December
began
aged
sixty-four,
and the cuI-de-sac
admitted been
pain and finally
The appendix
Penrose
drains
and the peritoneum
soIution
considering
became
and gangrenous
were placed
through
of intestina1
The patient
with anaerobic a spreading December
On December developed,
having
with a 2 per cent
Notwithstanding
this precaution
areas. This patient
B. B.,
CASE x.
white,
male,
aged
hospital
December
14, 1931, with
chronic
appendicitis.
The appendix
gall bladder
Forty--eight
hours
of toxemia,
admission
puIse
140, temperature
greenish
sutures
of silver
disruption,
and the \vound opened the patient
six hours his temperature was without
the
black
mattress
his con\,uIesccnce
serum
27.
was admitted
of acute
on
to the
choIecystitis
stones removed
and
from the
The \vc)und was closed in Iayers
after
shohved gas and
ings were removed,
forty-three,
drained.
which
of I 2 inches,
tube.
anesthesia
Within
there developed
on December
was removed,
and the gal1 bladder
up to the drainage
being Ieft
uas given anti-gangrene
a diagnosis
22, was
of infection
the skin and fascia
in Iarge doses. She died as a result of the gangrene
wound
wound
26 \vas opened upward and to the left for a distance
Iaying open a11 infected
symptoms
On December
of the possibiIity
between
we11
an enterostomy
the enterostomy
on account
of this type
pouch
17 a pelvic abscess
to the cervix.
organisms.
infection
throughout
stood the operation
a wound posterior
its whole extent
through
in Morison’s
obstruction
done on the Ieft side of the abdomen, open throughout
IocaIized
cIosed down to the drain. The baI-
her age and genera1 condition.
was evacuated symptoms
of mercurochrome.
to the
sick a week.
which was removed
ante of the wound was washed out with ether and packed aqueous
The wound was were gangrenous
serum, and the patient
of having
incision was found to be ruptured
with a genera1 peritonitis.
and his
twenty-four
upward despite the wide opening
a history
with epigastric
over the region of the appendix. a McBurney
tissues
areas and the use of anti-gangrene
died on the fourth day. CASE IX. Mrs. M.
improved
developed.
of gas. The
spread rapidIy
The
up to the
hue of the skin, his temperature
rose to IO~‘F., puIse 130, and menta1 cloudiness opened
afternoon.
the stitches
a few hours. However,
hours later he began to deveIop an icteroid immediateIy
same
between
01‘ tissues.
wire \\eerc placed placed
had dropped an!-
deveIoped
marked
106~~. Exploration
necrosis
throughout
being
patient
Under
local
so as to prevent
its \vhoIe extent. under
of the
a tent
Al1 dress-
with a light.
to IOO’F., and from then on
developments
of consequence.
The
H. A. GAMBLE patient was given fuI1 doses of anti-gangrene serum immediately upon the deveIopment of symptoms of infection. CASE XI. W. Z. L., white, maIe, aged thirty-six, was admitted to the hospita1 JuIy 7, 1930 with a history of having been operated upon for an acute ChoIecystitis on March 5 of the same year, since which time he had had an intermittent drainage from his gaII-bIadder wound. On JuIy g a choIecystectomy was done, a Penrose tube being pIaced in the wound which was cIosed up to the drain. Within four hours the patient manifested severe toxemic symptoms with a puIse of 120 and temperature of 104’~. By 6 A.M. of the morning of the 10th his temperature was IOS’F., puIse 150. A note at that time is to the effect that the puIse was very rapid and of extremeIy poor volume. The wound was inspected by the remova of a stitch and no infection found. The patient was transferred to the sun parIor because of the possibiIity of pulmonary compIications. The foIIowing morning the wound was again inspected and some crepitation found in the skin above it. It was opened to its depths and found to have become gangrenous since the examination twenty-four hours previousIy. The gangrenous areas were foIIowed up toward the axiIIa, and down within 3 inches of the crest of the iIium, fuI1 doses of anti-gangrene serum being given. This patient died the foIlowing day. CASE XII. Mrs. C. L., white, aged twenty-five, was admitted to the hospita1 on JuIy g, 1934 with a diagnosis of acute ChoIecystitis. Her symptoms subsided and she refused operation. On the night of the I rth there was an acute exacerbation with extreme pain. She was operated upon on the morning of the Izth, with temperature IOI’F., and puIse 120. The gaI1 bIadder was found to be gangrenous and was resected, the mucosa being cauterized with carboIic acid, a pack introduced with surrounding rubber drains, and the peritoneum was cIosed up to the pack, mattress sutures of siIver wire introduced, the wound washed with ether and packed with gauze saturated with a I :IOOO aqueous soIution of merthioIate. SiIkworm gut sutures were tied IooseIy over the merthioIate gauze. Twentyfour hours Iater, the appearance of the wound being heaIthy, the pack was removed and the siIkworm gut sutures tied. At 6 A.M. the foIIowing morning I was caIIed on account of the coIIapse of the patient. Her pulse was 140 and of very poor voIume, the surface of the body coId and clammy, temperature 102.5’F. AI1 stitches were removed and the wound Iaid open. AIthough the appearance did not indicate the presence of a WeIch baciIIus infection, anti-gangrene serum was administered. However, the patient did not improve, her temperature ran high and on the 17th reached a height of 105’~. with pulse 140. Slight crepitation was feIt at the upper margin of the wound and a 4 inch incision upward over the thorax exposed an area or greenish yeIIow discoIoration over the fascia. Anti-gangrene serum was
EMPHYSEMATOUS
GANGRENE
399
continued in fuII doses, and the patient kept under a tent with an electric Iight. Her temperature graduaIIy subsided to normal and ultimately she made a good recovery. (Cases IX, x, XI and XII are reported here for the first time. The illustrations are from a case as yet unpuh1ished.J
An anaIysis of these cases shows that there were 6 following operations upon the biIiary tract, 3 directIy foIIowing appendicitis operations, and 3 foIIowing intestinal obstruction, 2 of which were secondary to drainage appendectomies. EtioIogicaIIy it has aIways occurred as a compIication foIIowing an acute intra-abdomina1 Iesion---either an intestina1 obstruction, a gangrenous appendix, a ruptured appendix, genera1 peritonior a perforation of one of tht tis, an acute ChoIecystitis, hoIIow viscera. It has been shown by Jennings7 that 98 per cent of acute appendices harbor anaerobic organisms, particuIarIy WeIch’s baciIIus. PracticaIIy the same resuIts were reported by Heyd in 191 I from Friedrich’s CIinic in an extensive investigation of the intestina1 flora. Seventeen varieties of anaerobes were isoIated, and he concIuded that anaerobic bacteria were present in IOO out of 102 cases studied, and that they were present in greater profusion than aerobes in a11 stages of appendicitis and peritonitis, and attributed to them the entire causation of gangrene and of toxemia. He found that tht Perfringen’s group-BaciIIus welchii, outstripped a11 others in rapidity of growth. Jennings aIso states that in miIder cases of wound infection foIIowing such Iesions that the WeIch baciIIus can be reguIarI)recovered by proper anaerobic methods. In a number of cases reported today a pure staphyIococcus was found, whiIe in severa the WeIch baciIIus was present in CIinicaIIy the symptoms were those of an pure cuIture. anaerobic infection and toxemia, and I have considered that the reason for anaerobic organism not being found in some was due more to improper methods of cuIturing than to their absence.
400
H. A. GAMBLE
WiIIiams13 in 1926 studied the cause of toxemias of intestina1 obstruction and found that practicaIIy a11 cases of Iower intestina obstruction had a very viruIent and rapid growth of WeIch’s baciIIus. He contended that the norma habitat of this organism was in the Iower iIeum, because the contents of the upper part of the smaI1 bowe1 and coIon were acid and inhibited its growth; but that in obstruction deveIoping beIow the iIeoceca1 vaIve uItimateIy the resuIts were the same as wouId be the case in an obstruction of the smaI1 bowe1. Experiments on Iiver autoIysis in the Iiving by EIIis and Andrews and Hrdina14 furnish a very and Dragstedt,” concIusive expIanation of the reason for the rapid deveIopment and overwheIming toxemia found in those cases associated with acute infections of the gaI1 bIadder, in that it is essentiai that there be present a substance or cuIture medium capabIe of furnishing materia1 for rapid proIiferation of the parasites and the formation of toxins which in their turn are necessary for the further growth of the bacteria. In their experiments Iiver was the medium through which this was accompIished. In contaminated wounds the traumatized muscIes and tissues, and wound exudates, in conjunction with the cIosed wound form an idea1 incubator and cuIture medium for the growth The reIative immunity and weIIof anaerobic organisms. known abiIity of the peritoneum to overcome this type of infection is probabIy due more to the Iack of a suitabIe pabuIum for the deveIopment of toxins than to any other one cause. AIso one cannot but fee1 that their findings in these experiments upon Iiver autoIysis in the Iiving have a cIinica1 appIication when taken in conjunction with the frequent deveIopment of gangrene of the abdomina1 waI1 associated with operations upon the acuteIy inflamed gaI1 bIadder. Six of the cases reported today foIIowed operations upon the biIiary tract; 3 of these patients died, and there were 2 other deaths in our gaII-bIadder operations which I have since been convinced were due to an unrecognized anaerobic infection.
EMPHYSEMATOUS GANGRENE
40 I
Since 1920 we have done 490 operations upon the biliar)tract with a total of 8 deaths. Three of these deaths were due directly to an infection of this character, and two others in the light of subsequent experience wc are convinced were due to unrecognized cases of the same condition. Gordon Heyd’ in I 93 I presented a paper before the Surgical Section of the American Medical Association in which he gave three classilications of liver deaths. The symptoms associated with Type I, the most frequent, closely resembled this type of infection. We have had 6 of these cases following operation upon the biliary tract, 4 of which had extremely early prostration and in which the wound was immediately opened and a gangrenous type of infection found. We cannot but believe, in view of our clinical experience, that a large proportion of deaths ascribed to liver shock and hepatic insufficiency, are really due in large measure to acute infections of the abdominal wall with an anaerobic organism. Particularly is this so if there has been any trauma to the liver bed with the death of liver tissue which acts as a direct stimulant to the growth of Welch’s bacillus. The symptoms are always those of severe toxemia, but the period of onset varies, the most fulminating usually manifesting itself within the lirst few hours following operation by rapid pulse, lowered blood pressure, high fever, high blood count and extreme prostration. Sometimes there is a delay in the onset of symptoms. Whether this is due to the resistance of the patient, the difference in the degree of virulence of the organism or other causes I cannot say; however, when the symptoms do appear they are always those of a severe, not to say overwhelming toxemia. The wound often has a perfectly healthy appearance from the surface and in no way suggests the pathological changes present in the deeper tissues, or very early one may sometimes elicit crepitus beneath the adjacent skin. Upon removing the sutures there is found necrosis of fascia and muscle with the
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H. A. GAMBLE
presence of bubbles of gas. The infection spreads in the fascial pIanes usuaIIy between the skin and the fascia, and in such cases there wiI1 be found a greenish yeIIow discoIoration throughout its course. The treatment that has given us the best resuIts consists in opening the origina wound entireIy down to the peritoneum, combined with a free incision of the skin aIong the subcutaneous spread of the infection unti1 heaIthy tissue is reached, the ffaps being freeIy raised on each side unti1 a11 of the infected area is exposed to the air. The wounds are not dressed but are Ieft open under a tent, with a Iight. Antigangrene serum has been administered in fuI1 doses with, in at Ieast 2 cases, beneficia1 resuIts. In addition bIood transintravenous gIucose fusions are given, and the continuous drip has been administered to a11 patients. Prevention is better than treatment. The cause fundamentaIIy is the cIosure of a wound infected with anaerobic organisms so that an exceIIent incubator is provided with a suitabIe cuIture medium for the deveIopment and growth of these organisms under the most favorabIe conditions. In cIosing these potentiaIIy infected wounds one disregards one of the basic principIes of surgery. No where eIse in the body wouId one consider cIosing or partiaIIy cIosing a wound which had been bathed in pus or contaminated materia1 Ioaded down with viruIent organisms. We now, in a11 cases of peritonitis, ruptured appendix, obstruction, perforations of appendicia1 abscess, intestina1 the hoIIow viscera and acute infections of the gaI1 bIadder, after attending to whatever pathoIogy is present, and inserting drains where indicated, suture the peritoneum down to the drains, as we have aIways found the peritonea1 cavity ampIy abIe to protect itseIf, wash the wound with ether, insert mattress sutures of siIver wire to prevent disruption, then fIush the wound with a I : I ooo aqtieous soIution of merthioIate. The wound is then packed with gauze saturated with a I :IOOO aqueous soIution of merthioIate, and siIkworm gut sutures,
EMPHJ-SEhIATOUS
GANGREKE
403
which have been previousIy introduced, tied ok-er it with a bow knot. We have in some cases Ieft the wound open without packing it, but prefer to fo!Iow this procedure for four reasons: First, it gives stabihty to’ the abdomina1 waI1, so that in case of post-anesthetic strain there is no danger of disruption. Second, we beIieve it promotes a free retrograde ffow of Iymph, third, it promotes the waIIing off of the wound by Nature’s natura1 defensive methods, and fourth, the germicida1 soIution acts to inhibit the growth of bacteria. At the end of twenty-four hours the pack is changed under aseptic precautions, and at the end of forty-eight hours it is removed permanentIy, and the wound Ieft open without dressings under a tent provided with a 32 candle power eIectric Iight. For the first twenty-four hours the patient is pIaced in the position that wiI1 best favor drainage, usuaII-\- upon the abdomen. AI1 seriousIy iI patients are given gIucose, a 3 per cent soIution in buffer saIts subcutaneousIy whiIe upon the operating tabIe, and a IO per cent soIution is given continuousIy I jo-200 C.C. per hour intravenousIy as Iong as ma)- be indicated to overcome dehydration, stimuIate excretion, and furnish nourishment whiIe the digestive processes are heId in abeyance. A prophyIactic dose of combined anti-tetanic and Perfringen’s serum is given routineIy at the compIetion of the operation. Personally I have been empIoying this method except the use of the serum since 1924 and in no case in which it was used has a case of spreading gangrene deveIoped. Often the surface of the wound assumes a dark gray or bIack discoIoration from superficial necrosis which cIears up spon;aneousI;\- with no systemic effects. There have been other advantages accruing from this form of treatment, notabIy the Iessening of postoperative pulmonary comphcations which are very rareIy seen in such cases, whereas former]>- they were one of the most frequent compIications. There are two objections which can be raised; these, however, arc insignificant n-hen compared with the benefits to be
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derived. The first is the Ionger period of hospitahzation, which has varied from twenty-one to thirty-five days, and the second is the possibihty of the deveIopment of postoperative hernias. The Iatter have been comparativeIy few considering the number of cases in which the method was empIoyed. It is our intention, in this communication, to show that gangrenous infections of the abdominal waII pIay an important rBIe in the mortahty rate from operations for acute intraabdomina1 conditions; that they are particuIarIy prone to deveIop in surgery of the biIiary tract, and that the condition is preventabIe. From January, 1920 to January I, 1925 there were treated by us 137 drainage cases of appendicitis with the deveIopment of 3 cases of gangrene of the abdomina1 waII and 2 deaths. I, 193 I there were 292 From January I, 1925 to November drainage cases of appendicitis, 141 being treated openIy as described with no gangrene and no deaths; 151 cases were treated with drainage and partia1 cIosure of the wound with 5 cases deveIoping gangrene and 3 deaths. Among the 292 drainage cases there were 82 cases of generaIized peritonitis; a11 of the patients were treated in this manner, none of whom developed a severe wound infection and none of whom died. Since November I, 193 I my brother and I have operated upon 446 cases of appendicitis in which there were 202 acute appendices without drainage, 33 with IocaI peritonitis or abscess formation requiring drainage and 38 cases of genera1 diffuse peritonitis from a ruptured appendix, a tota of 71 drainage cases. AI1 of these 71 drainage cases were treated as described, there was no deveIopment of gangrene in the abdomina1 waI1, nor were there any deaths in the whoIe series of 446 cases. In regard to its connection with operations upon the biIiary tract: since January I, 1920 we have operated upon the biIiary tract in 490 cases. There have been 9 deaths, 3 of which couId be definiteIy ascribed to infection with anaerobic organisms and spreading gangrene, and as ah-eady
EMPHYSEMATOUS
GANGRENE
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stated, 2 more we befieve can justfy Ix credited to this as the causative factor. Five out of 9 deaths is a farge percentage for any one cfinicaf entity to be responsibfe for. AI1 of these cases devefoped in cfosed wounds, or wounds partiafly cfosed with drainage. Since we have adopted the method described in this paper there has not been a singfc cast of gangrene in our gaff-bfadder surgery. The fast 3 cases which we have reported here occurred as a resuft of partiaffy closed wounds which shoufd have been feft open. We consider that infection of the abdominaf waff with anaerobic organisms plays a most important part in the mortafity rate of a11 acute intra-abdominaf fesions, and that it is a preventabfe condition when potcntiaffy infected wounds are treated
as outfined. REFERENCES
I. ORR, T. G. Gas bacillus infection 2.
3. 4.
5.
33: 946-947 (Aug. 1) 1933. 6. BUTLER, D. D. Post-operative 7. 8. 9. 10.
I I. 12.
of abdominal
wall. J. A. hf. A., 102: 2081-2082
(June 23) 1934. HORSLEY, J. S. Intussusception due to intestina1 Iipoma in adult, foIlowed by gangrene of the abdomina1 waII. Arch. Surg., 18: 882-891 (Mar.) 1929. ECKHOFF, N. L. Gas gangrene in civi1 surgery. Brit. J. Surg. 18: 3%48 (JuIy) 1930. BUTLER, E., and RHODES, G. Infection of abdomina1 waI1 with B. weIchii folIowing enterostomy for bowel obstruction. Calif. e’p West. Med., 32: No. 4, 248-249 (ApriI) 1930. TRAVER, C. A. Gas baciIIus infection complicating appendicitis. N. York J. ,M. infection
of the abdominal
waI1. Ann.
Surg., 84:
841-844 (Dec.) 1926. JENNINGS, J. E. The relation of the WeIch baciIIus to appendicitis and its compIications. Ann. Surg., 93: 828-836 (April) I 93 I. HEYD, C. G. Liver deaths in surgery of the gaII-bIadder. J. A. M. A., 97: No. 25, 1847-1848 (Dec. 19) 1931. GAMBLE, H. A. Post-operative infections of the abdomina1 waI1. New Orleans M. FTF S. J., 78: 208-213 (Oct.) 1925. ELLIS, J. C., and DRAGSTEDT, L. K. Liver autoIysis in vivo. Arch. Surg., 20: No. I, 8-16 (Jan.) 1930. MCIVER, M. A., WHITE, J. C., and LAWSON, G. M. The roIe of the bacillus Welchii in acute intestinal obstruction. Ann. Surg., 89: No. 5. 647-657 (May) 1929. BEER, E. Appendicitis with gas bacillus infection. Trans. New York Surg. Sot. (Feb. II)
1925.
I 3. WILUAMS, B. W. The importance of toxemia due to anaerobic organisms in intestina obstruction and peritonitis. Brit. J. Surg., 14: No. 54 (Oct.) 1926. I_$. ANDREWS, E., and HRDINA, L. The cause of death in liver autolysis. Surg. Gynec. Obst., pp. 61-66 (Jan.) 1931.
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15. OCHSNER, A. J. and SCHMIDT, E. R. Gas bacilhrs infection originating in a gangrenous appendix. Surg. Clin. N. America, 5: No. 4, gr 1-913 (Aug.) 1925. 16. BEST, R. R., NEWTON, L. A., and MEIDINGER, R. Absorption in intestinal obstruction. Arch. Surg., 27: No. 6, 1081-1086 (Dec.) 1933. I 7. NASON, L. H., and STARR, A. Gas bacilhrs infection complicating laparotomy. Arch. Surg., 29: No. 4. 546554 (Oct.) 1934. 18. GAMBLE, H. A. The treatment of the potentiaIIy infected abdominal wound, and its relationship to the mortatity rate of acute infection of the abdomen. Soutb. M. .I., 25: No. 5, 515-518 (May) 1932. rg. CONNELL, F. G. Liver deaths (so-caIIed). Ann. Surg., IOO: No. 2, 31g-327 (Aug.) 1934. DISCUSSION
DR. EDWARD H. OCHSNER, Chicago, III:: I wish to caII attention to a method of treatment which we have used in 2 cases, with exceIIent results. We have seen 4 cases, 3 in our own practice and one in a government hospitaI. In the Iast 2 cases in my own practice I empIoyed the foIIowing method: I took off a11 bandages, simpIy covering the invoIved area with some Ioose gauze, kept this gauze saturated with fuI1 strength peroxide of hydrogen day and night and permitted free access of the air by pIacing a cradIe under the bed cIothing. It was surprising to see how quickIy the condition cIeared up. The first patient I saw before I devised the method of treatment died after much suffering. In this case the skin of the entire abdominal waI1 was eaten away by the process and the patient died from cachexia and exhaustion. We made no detailed cu1tur-e studies, oniy making the routine studies, but I am firmIy convinced that these are anaerobic and that hydrogen peroxide is a very reIiabIe method of treatment. AI1 of these cases foIIowed operations for appendicitis. The patients were not very III with appendicitis and yet in each case a smaI1 quantity of pus was evacuated at the time of the operation. Each case was drained and about a week after the operation the skin became undermined, which process continued unti1 we appIied the hydrogen peroxide treatment. DR. RALPH G. CAROTHERS, Cincinnati, 0.: I wish to report a case which occurred when I was house surgeon in rgrg. The patient was a woman, Iarge and fat and quite dirty, suffering with an obstructed but not stranguIated hernia. On the fourth day fohowing the operation, she developed a considerabIe quantity of sugar in the urine and a vioIent case of gas gangrene of the abdomina1 waI1. She died the same day in spite of a11 we could do.