Progressive postoperative gangrene of skin

PROGRESSIVE POSTOPERATIVE GANGRENE OF SKIN * REPORT

A.

OF A CASE

MISTER, M.D.

BUDAPEST,

I

N the course of postoperative compIications we have observed a hitherto rare disease-a sIowIy progressive gangrene of the abdominal wall. According to reports in the literature, CuIIen was the first to observe the condition, after the remova of a suppurated appendix, in 1924. Th e same year Christopher reported a simiIar process foIIowing rib resection for empyema thoracis. In 1926, Brewer and MeIeney, Mayeda, Diebold, and Stewart-WaIlace dealt with the question. Kiippers, Doricev, CoacIey and Klein, Branberg, Andersen, Liedberg, Cox, BIaxIand, WiIIard, Wachs and Guszman contributed to the cIearing up of this disease with case reports and, in 1935, according to Stewart-WaIIace, thirty-seven cases had been reported. At this writing, the number of reported cases is about sixty, (1924-1939) which is rather Iow. Probably some of the fata cases have not been pubIished. As new evidence shows that we are deaIing with a clinica entity, it wouId be advisabIe to keep the nomencIature uniform in order that a11 cases may be folIowed up. Brewer and MeIeney were the first to caI1 the entity “progressive postoperative gangrene of the skin,” which seems suitabIe as it expresses the essence of the process. This Iesion usuaIIy occurs in the maIe (about 80 per cent), especiaIIy in the adult. The preceding operations were, in one-haIf of the reported cases, due to suppurated appendices, in 30 per cent to empyema thoracis, in 13 per cent to suppuration of the upper abdominal cavity, gastric perforation and subphrenic abscess and in the remaining 5 per cent to other operations, mainly abdominal. It was * From the Third Surgical Unit of the Royal Hungarian 660

HUNGARY

reported in but aseptic abdomina1

three instances operations.

after

The process usuaIIy begins within a week foIIowing the operation, and occasionaIIy during the second week. One observation was made twenty-one days after operation. Often the fever was gone, the puIse normal and the patient weI1; in the case reported by Patterson, the patient had been discharged from the hospital. CASE

REPORT

A maIe, aged 45 years, was admitted to the clinic on October 28, 1937. Months before, the patient had complained of severe pains in the abdomen and for one month of loss of weight due to polyarthritis. Two days before admission he had severe abdominal pain which soon localized in the lower right side of the abdomen. He suffered from nausea, vomiting, fever and chills, and had lost much weight. There was marked muscular rigidity of the abdomen especially around McBurney’s point and there was an apple-sized, hard, painful resistance at this point. The Rovsing symptom was positive. The white blood cell count was 17,000, the temperature 38”~ the pulse IIO. The tongue was coated and furred. Immediate operation was deemed necessary. A right McBurney incision was made. Behind the cecum a fetid abscess, the size of a fist, was opened and drained with gauze. The abdominal wall was closed with interrupted sutures about the gauze drains. For a week following operation, the patient ill, hiccoughing and vomiting. was very His abdomen was greatly distended, but enemas were ineffectual. The wound showed a profuse drainage of pus. At the end of the week the hiccoughing stopped and gas was passed. Nineteen days after operation the wound showed an area of edema, the edges became separated and were reddened and painful. The redness spread toward the healthy parts of Petrus PbmAny

University

of Budapest,

Hungary.

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the skin and necrosis was observed in the wound edges. Twenty-three days after operation, the subcutaneous connective tissue of the wound

FIG.

was granuIating weI1, but the necrosis of the skin margins already extended 4 mm. from the edges of the wound. On November 26, the wound was very painful and necrosis of the skin had spread to a distance of 6 mm. As this zone became demarcated, part of the necrosis was removed by scissors. The gangrene of the wound continued to spread and on December 7, the wound was treated with I oo Roentgen units. A cuIture taken from the wound on December 14 showed streptococcus and proteus. Blood examination revealed: Red blood cells 3,goo,ooo and white celIs I 1,300, hemoglobin 77 per cent; poIys 76 per cent, Iymphocytes 17 per cent, eosinophiles 2 per cent, basophiIes I per cent and mononucIears 4 per cent; 2 plasma ceIIs per IOO white bIood cells. Operation was performed on December 22. The gangrenous zone spreading from the edges was entirely removed by the Paquelin cautery. Histologic report on the specimen, 12 cm. of necrotic tissue, showed gangrenous fibrous tissues infiItrated with leucocytes, in a state of chronic inflamed infiltration, with purulent ducts and many microbes present. Aerobic cultures showed proteus; anaerobic cultures showed Streptococcus putrides. The purulent discharge continued and wet zephyrolous dressings were therefore used daily. On December 28, six tablets of sulfaniIamide were given. The wound progressed satisfactoriIy unti1 January 3, when new gangrenous foci at three different points on the media1 aspect developed. The electro-

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cautery was used on January 8 and four days later a blood transfusion was given. From January I 3 a protracted hypermanganous bath

I.

foIIowed by a zephyroIous dressing was given daily. Gangrene, however, spread in a11 directions. (Fig. I.) After a consuItation by Professors Ad&m, Zalka, and Guszman, operation was performed. Far into the intact zone to the muscles, the diathermic knife was carried around the whole necrotic area. ZephyroIous dressings were used daily, with the hypermanganous bath every second day. Twenty units of insuIin were given. On February 7 a new focus on the medial aspect was burned out, and five days Iater a new focus on the IateraI side was cauterized into the heaIthy zone. By February 18 extension had stopped, the wound edges cleared, the bottom of the wound was red, fiIIed with clean granulation, and here and there islands of epidermis appeared. (Fig. 2.) Thereafter the patient made a speedy recovery and on March 16, apart from a few smaI1 areas which had to granulate, the wound was epithelized. The patient was then discharged. The wound was compIeteIy heaIed May 5. (Fig. 3.) Pathology. Th e necrosis of the wound edges begins sIowIy, at the beginning invoIving 0nIy smaI1 areas-sometimes in areas of deep sutures. An uIcer invoIves the skin edges which are red, edematous and painfu1. Soon the necrosis spreads over the connective tissue and deeper Iayers. The wound edges become eIevated, thickened,

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and serpiginous in outline, owing to the necrotic process of the subcutaneous tissue, the skin giving a carbuncIe-Iike

FIG.

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MARCH, ~940

back from the neck to the buttocks became uIcerated. HistoIogicaIIy, according to Mayeda, the

2.

FIG. 3.

picture. The extensive infiItration thereupon changes over to dry type of gangrene. After the remova of the gangrenous zone, a reIativeIy heaIthy red granuIating tissue remains in its pIace. WhiIe the uIcerous process continues, serpiginous heaIing is to be seen on other areas, sometimes on the isIes. The extension occurs sIowIy, maliciousIy and usuaIIy spreads. Cox distinguishes four zones of extension: (I) outside, painfu1 infiItration; (2) 0.5 cm. sharp demarcated margin of bIack gangrene toward uIcer; (3) ulcer-ground dirty, grayish-white; (4) we11granuIating heaIthy red tissue. The greatest extension observed was in Poate’s patient, where the whoIe

necrosis destroys first the border between the papiIIary and the reticular stratum of the skin. Part of the epidermis and reticular stratum covers the gangrenous mass to a depth of I .5 cm. and sIowIy necrotises from the wound edge. A part of the reticuIar stratum remains intact and in the subcutaneous fat tissue there is some Ieucocytic infltration. Where gangrene ends and granuIation begins there are a few isIands of epidermis arising from remainders of sweat gIands which provide a partia1 basis for Iater epitheIization. According to Wachs’ seria1 histoIogic examinations, the process is inflammatory and soon Ieads to necrosis. The infiItration consists mostIy of

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Iymphocytes and greatly surpasses the necrotic border. The skin and papiIIae quickIy fuse, and coagulated fibrin and

gangrene of the skin deveIoped on the buttock at the site of injection and spread over the thigh. They beheve that the

Iymphocytic infXtration cover the uIcerated area. Nerves and arteries remain intact; the extensive infiItration around the veins is remarkabIe, even in parts far beyond the inffammatory focus. Many giant ceIIs are present. ThrombophIebitis has been found, not onIy in the uIcerated zone, but aIso in the intact area, invoIving the intima early and Iater the other coats of the vesse1 as we& The border is not sharp. Many staphyIococci, streptococci and Gram-negative baciIIi are to be found in the ulcerated zone. Etiology. In most cases streptococci have been found, and, rareIy, staphyIococci, diphtheroids or Gram-negative baciIli. Heimburger, CoIe and Heideman described cases where the principa1 roIe was attributed to the ameba, but this has not been noted by other authors. Most of the patients were debilitated, but no antecedent specific disease, such as Iues or diabetes is reported. Lynn attached great importance to the icebag on the abdomina1 waII as a causative factor, whiIe BoreIIi attributed the condition to tincture iodine and Tennant to Iiver insufflciency. In the case of Gatewood and BaIdridge, prophyIactic scarIet fever serum was given and scarIatina deveIoped. Great doses of serum were then administered and in consequence

second injection Ied to gangrene in a hypersensitive organism (Arthus phenomenon). BaIlin and Moore supported this view by experiments on animals. However, these various theories have received no confirmation. The most acceptabIe etioIogic theory is that of MeIeney who, after experimentation, expIains the deveIopment of the gangrene by bacteria1 synergism, with the streptococcus chieAy invoIved. MeIeney isoIated the so-caIIed micro-aerophy1 nonstreptococcus (Streptococcus hemoIytic evolutus Prkvot), from the extending zone. In the gangrenous zone the streptococcus was associated with Staphylococcus hemolyticus and diphtheria baciIIus. The diphtheroid baciIIus was not pathogenic for animaIs; nor was the streptococcus or staphyIococcus aIone, but, when injected together, they caused a process simiIar to that in humans. ApparentIy in the extending zone the ground is prepared by the streptococcus, but for the deveIopment of the process, symbiosis with other microbes is necessary. In our case the facuhative anaerobic streptococcus with proteus in symbiosis was found. In the cases of Mayeda, CoIe and Heideman, Stewart-WaIIace and others, necrosis began in deep suture hoIes where

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anaerobic conditions exist. Patterson now omits, for this reason, the use of deep sutures. In our case, however, such sutures were not used. According to Wachs, thrombophIebitis is the basis of the gangrene and spreads into the intact area. No other author has reported this. In the present case (Fig. 4) the veins showed no change beyond perivascuIar infiItration. In one of Wachs’ cases a varicose uIcer had existed for two years; its sudden spread necessitated amputation of the leg. It is quite possibIe that thrombophIebitis appeared in the varicose veins and spread, causing a considerable progress of the ulcer. However, it is less probabIe that this disease had any connection with the skin gangrene. In Wachs’ other case, a severe inflammation began in a smaI1 infection on the hand. Gangrene spread despite the disarticuIation of the fourth and fifth fingers and Ied to the destruction of the back of the hand as we11 as a great part of the hypothenar. This case does not appear to have been caused by thrombophIebitis. It is our beIief that the gangrene is due to the direct Iytic effect of the microbes. Symptoms. Th e cIinica1 symptoms correspond to the previousIy described pathoIogic-anatomic process. The most characteristic symptom of gangrene of the skin is severe pain, most marked on the edges of the wound. The temperature is usuaIIy subnorma1, aIthough, with the spread of the Iesion higher temperatures may appear. Anemia, exhaustion and menta1 depression deveIop with the extension of the gangrene. The process is not contagious. Diagnosis. Diseases which show some simiIarity to postoperative gangrene, according to Stewart-WaJIace, are : I. Wound infection, where the suppurating infiItration may pass over into necrosis if the cause of infection is especiaIIy viruIent and the resistance of the patient is Iow. This might extend to the deeper Iayer of the abdomina1 waI1, and is the so-caIIed “hospita1 gangrene” which was not rare

of Skin before the aseptic period. Skin gangrene differs in that it destroys only the subcutaneous tissue and the skin, not extending to the deeper Iayer. It is not contagious. 2. ErysipeIas in its earIy stages may be simiIar, but does not cause a spreading uIcer. 3. Gas gangrene is foIIowed by more serious genera1 symptoms with subcutaneous crepitation and with characteristic bacterioIogic findings. 4. Hemolytic streptococca1 gangrene of the skin (Meleney) is observed mostIy in China, but recentIy has been seen in New York. This is usuaIIy observed on the thigh, sometimes on several pIaces at the same time, with characteristic bIood cuIture and symptoms of exhaustion. 5. Ecthyma gangrenosum is particuIarIy observed in undernourished chiIdren and is often mu 1tipIex. 6. In specific infarctions, diphtheria, bIastomycosis, tubercuIosis, etc., the demonstration of the cause of the disease simpIifies the differentia1 diagnosis. 7. Amebiasis cutis has been reported onIy by Heimburger, CoIe and Heideman. They beIieve that a good reaction to an injection of emetin hydrochIoride is characteristic, as are the bacteriologic findings. 8. Gangrene may start foIIowing human bites, if the deeper tissues are infected by saIiva. The presence of fusiform baciIIus and spirochetes is characteristic. Treatment. The genera1 opinion is that the only treatment is surgica1. OnIy four cases have been reported as cured without operation. One of these heaIed in consequence of quartz Iight (Gordon); one by treatment with 6 per cent sodium chIoride immunized bIood (CIinton) ; one after transfusion (Probstein and SeIig); and one by the use of maggots (CoakIey and KIein). Experiments were made with the IocaI use of various antiseptic and hypertonic soIutions, with vitamin diets and creams, with the injection of arsenic, caIcium, manganese, antimony, saIvarsan, and of specific and nonspecific serums, heteroprotein vac-

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tine, with bIood transfusions and Roentgen therapy-al1 without results. The onIy sure method is the excision of the gangrenous wound edges far into the intact zone, producing heaIthy wound surfaces. Some authors recommend a knife and some the electrocautery. For styptic action and for cutting off Iymph passages, we consider the eIectrocautery the better. Little may now be expected from nonbut we wish to caI1 surgica1 treatment, attention to the use of suIfaniIamide which we beIieve was beneficia1 in our case. We found aIso that the use of zephyroIous dressings reduced the quantity of secretion greatIy and stimurated the formation of heaIthier granuIating tissue. BIood transfusion may be usefu1 for the recovery of the exhausted patient. In many cases Thiersch grafts have been used to suppIy the missing skin. In our patient this was not necessary as the deficiency was soon supplied, partIy from the edges and partIy from the isIes of epidermis in the affected region. It is most interesting that the surface of the wound becomes much smaIIer and that there is but IittIe contraction of the scar. The cause Iies in the sweat glands which remained intact and which suppIied some we11 adhered pinch grafts capabIe of deveIopment. We consider the 5 per cent mortality of a11 the coIIected cases by Lynn to be too Iow, but the prognosis cannot be caIIed bad if earIy recognition and suitabIe treatment are possibIe. As to prophyIaxis, the sugges-

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tion of MeIeney that deep sutures shouId not be used on suppurated abdomina1 and thoracic incisions, we do not deem necessary in view of the rarity of the compIication. SUMMARY

A case of progressive postoperative gangrene of the abdomina1 waI1 has been presented. Hitherto some sixty cases have been reported. The process is a we11 outIined entity showing itseIf in the progressive necrosis of the skin and subcutaneous connective tissues, deveIoping chiefly after operations on suppurating abdomina1 and thoracic Iesions, and produced by symbiosis of specific streptococcus and nonspecific bacteria. Severe pain is characteristic. The gangrene does not extend to deeper Iayers and it is not contagious. Surgery is the onIy effective treatment. Postoperative treatment consists of sulfanilamide, zephyroIous dressings and bIood transfusion. EarIy diagnosis is important and makes for a better prognosis. REFERENCES BRANDBERG, R. Acta cbir. scandinav., 79: 445, 1937. COAKLEY, W., and KLEIN, D. Am. J. Surg., 33:287, 1936. Cox, H. T. Brit. J. Surg.. 23: 576, 1936. LIEDBERG, N. Acta cbir. scandinav., 77: 354, 1936. NIGHTINGALE, H. J., and BOWDEN, E. C. Brit. J. S&g.,

22: 392. 1934. STEWART-WALLACE, A. M. Brit. J. Surg., 22: 642, 1935. WACHS, E. Beitr. z. klin. Cbir., 165: 564, 1937. WILLARD, H. G. Ann. Surg., 104: 227, 1936.