Gastric Wounds and Septic Gangrene
An esteemed contributor has suggested
in an interesting letter that, if the contused and locally shocked
tissue immediately surrounding the gastric wounds had been cut out
before the sutures were applied, the President might have recovered,
even though gangrene of the tissues back of the stomach subsequently
occurred; because the latter condition might have been relieved
by a later operation and drainage.
The answer by abdominal operators
to this query would be, that in wounds of the stomach and intestines
the edges are never applied to each other, as in the wounds of the
skin, but are turned inwards towards the cavity of the viscus by
some form of suture like that of Lembert. This method causes the
external or serous surfaces to come together, gives rapid adhesions,
and inverts the damaged tissue, at the margin of the wound, into
the stomach or bowel, where it does no damage.
An additional reply, however, may
be found in the official report of the President’s case, published
last Saturday in this journal. This says: “The original injuries
to the stomach-wall had been repaired by suture, and this repair
seems to have been effective. The stitches were in place, and the
openings in the stomach-wall were effectively closed.” The gangrene
surrounding the wounds is seemingly attributed to lowered vitality.
The report also shows that death did not come from these comparatively
small gangrenous spots in the gastric wall, but from the larger
areas of gangrene behind the stomach and about the pancreas and
upper end of the kidney.
In the editorial on “Traumatic Surgery
of the Upper Abdomen,” published two weeks ago, a statement was
made that the President’s death was probably due to septic gangrene,
due to the missile. This was written without any accurate knowledge
of the results of the autopsy. The official report, now given to
the public, says that a conclusion is warranted that bacterial infection
was not a factor in the production of the conditions found
at the autopsy.
This statement deserves great respect,
because of its eminent authorship and its truly scientific wording.
Does it not seem possible, nevertheless, that the gangrene did
occur as a result of bacterial contamination from gastric contents
liberated by the bullet or from the bullet itself? The necrotic
part of the posterior wall of the stomach lay in contact with the
surface of the meso-colon; the portion of meso-colon “coming directly
in contact with the wound in the gastric wall being of a dull gray
color.” This looks like secondary infection by contact. Beyond the
wound in the back of the stomach was a gangrenous track evidently
indicating the course of the bullet. It is stated that here “very
few micro-organisms were found in the fresh state.” This seems to
mean that the tissues and fluids were not entirely sterile. In the
necrotic cavity a short, stumpy bacterium was found which, it is
true, may have been due to a suggested technical imperfection in
making the cultures.
These points would probably lead the
ordinary clinical observer to attribute the death of the patient
to septic gangrene. He would, however, not fail to realize that
the necrosis might have arisen from injury to deep blood vessels,
caused by the undiscovered bullet, and to imperfect blood supply
in the stomach walls, due to the necessary operative detachment
of the omentum. He would also lay proper stress on the fact that
defective tissue resistance in a patient with unsound kidneys and
a fatty heart renders disastrous results more likely from a moderately
virulent micro-organism or a moderate disturbance of circulation.