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.