EMPHYSEMATOUS GANGRENE CAUSED BY THE BACILLUS AtROGENES CAPSULATUS.
DR. GEORGE EMERSON BREWER presented a woman, aged thirty-two years, who was admitted to the Roosevelt Hospital, on the evening of October 26, with the history that one week before she had experienced a throbbing pain in the ischiorectal region, which gradually became more intense, and was treated by the application of a flaxseed poultice. The pain increased in severity, became throbbing in character, and was accompanied by an in duration and an exquisitely tender area on the right half of the ischiorectal space. She did not think that she had fever during this period ; but chilly sensations, loss of appetite, and general illness would indicate that there was some elevation of tempera ture. There was no nausea, vomiting, constipation, nor difficulty in urination.
On admission her temperature was ior.8° F.; pulse, 120: respirations, 28. On examination, the left half of the vulva was enormously swollen, red, and exquisitely tender. The swelling extended downward, and occupied the entire right half of the ischiorectal space, and upward to the region of the external abdominal ring. In the centre of the labium there was an area of superficial gangrene about the size of a silver quarter. On palpation by the House Officer who admitted her, there was a sensation imparted to the hand of an easily reducing hernia. At the same time the tissues were ruptured and a large amount of brownish, foul-smelling fluid was evacuated from the cavity within the labium. Believing that he had to do with a strangulated in guinal hernia, a part of which had been returned to the abdominal cavity by his manipulations, I was at once asked to see the patient with a view to operation.
On further palpation of the abdomen, there was a well marked rigidity of the lower half of the right rectus muscle and an indefinite sense of resistance in the right iliac region, strongly suggesting either an appendicular abscess or an inflamed mass of intestine or omentum which had been reduced or sloughed off from the supposed strangulated inguinal hernia. She was imme diately prepared for operation, and, under chloroform anwsthesia, an incision was made along the outer half of the right rectus muscle. As soon as the skin and subcutaneous fat had been divided, the deeper layer of areolar tissue, the external oblique aponeurosis, and the connective tissue between it and the internal oblique muscle were found to be in a state of emphysematous gangrene. Pressure on the adjacent tissues resulted in the dis charge from the wound of a large amount of gas, foul-smelling fluid, and necrotic tissue.
The incision was extended upward to the free border of the ribs and downward along the inguinal canal, through the tissues of the labium and ischiorectal fossa to the coccyx. The skin and subcutaneous tissue on either side of the incision were dissected up as far as the gangrenous process extended, which was prac tically to the median line of the abdomen in front, and to the border of the sacrolumbalis muscle behind. Other incisions were made posteriorly, extending from the crest of the ilium upward to the level of the breast. A large amount of foul-smelling necrotic tissue was hastily scraped from the wounds, which were afterwards generously scrubbed with peroxide of hydrogen and a 2 per cent. solution of formalin. The wound was packed with wet formalin gauze and the patient placed in bed. Considerable reaction followed the operation, and for several days she presented the appearance of severe illness. The temperature, however, gradually fell to 99° F. For three or four weeks it varied be tween this point and me, the pulse between 112 and 120. The wound was frequently dressed, thoroughly irrigated, and packed with various antiseptic and stimulating agents. For many weeks the discharge was excessively foul, and large areas, including all of the anterior portion of the external oblique muscle, came away. After the wound had sufficiently healed and presented healthy granulations, three or four secondary sutures were taken, which materially hastened her convalescence. At the end of nine weeks only a small granulating area remained.
Cultures taken from the fluid and necrotic tissues removed at the time of operation showed a pure growth of the bacillus aerogenes capsulatus, which was also verified by animal inocula tion made at the Pathological Laboratory of the College of Physi cians and Surgeons.
DR. BERN B. GALLALTDET said the prognosis of cases of em physematous gangrene is usually extremely grave. In two cases which had come under the speaker's observation, the disease was confined to the extremities. One of the cases was that of a woman who came to the hospital with an ordinary suppurative cellulitis of the forearm, which had been incised. The symptoms persisted, and several additional incisions were made as high up as the axilla. Finally, the arm was amputated at the shoulder joint, but the patient succumbed two days later, probably to gen eral sepsis. An examination of the characteristic thin, fetid pus in this case failed to reveal the presence of any bacilli of sapro phytic origin : there were numerous streptococci, staphylococci, and so on, but no saprophytic bacilli. The tissues, however, pre sented the characteristic appearance of gangrenous emphysema.
In the speaker's second case the lower extremity was in volved. The condition originated in the thigh as an ordinary suppurative cellulitis, and subsequently assumed a gangrenous form. Its progress upward could not be checked in spite of numerous incisions, and within forty-eight hours it was decided to amputate. To this, however, the patient would not consent, and the case resulted fatally. The discharge in this case showed a mixed infection ; in addition to staphylococci and streptococci, there was quite a colony of the bacilli of malignant cedema. The origin of the infection in this Dr. Gallaudet said, was rather interesting, and strongly emphasized the importance of cleanli ness in the use of the hypodermic needle. The man had attempted to commit suicide by gas inhalation, and in reviving him a hypo dermic injection was given in the lower thigh, producing infection and fatal consequences.
Dr. Gallaudet said it was interesting to note that in Dr. Brewer's case a pure growth of the bacillus aerogenes capsulatus was found. Not long ago that bacillus was believed to simply produce gas. It is probable that the sharp distinction that has been made between the saprophytic and pathogenic bacilli is not well taken, and that each class may produce effects at one time attributed solely to the other, owing to conditions of which we, as yet, know nothing.
DR. BREWER said that the cultures in his case were taken from the deeper portion of the abdominal wound, and were carefully guarded against contamination from the ischiorectal abscess below.