Gangrene of the oesophago-gastric junction caused by strangulated hiatal hernia: operative challenge or surgical dead end.

BACKGROUND: Gangrene of the oesophago-gastric junction due to incarcerated hiatal hernia is an extremely uncommon emergency situation which was first recognized in the late nineteenth century. Early symptoms are mainly unspecific and so diagnosis is often considerably delayed. Aim of the study is to share experience in dealing with this devastating condition. MATERIAL: We encountered three male patients with gangrene of the oesophago-gastric junction caused by strangulated hiatal hernia within the last years. Clinical symptoms, surgical procedures and outcomes were retrospectively analyzed. Furthermore, we provide a history outline on the evolving surgical management from the preliminary reports of the nineteenth century up to modern times. RESULTS: Early symptoms were massive vomiting accompanied by retrosternal and epigastric pain. Hiatal hernia was already known in all patients. Nevertheless, clinical presentation was initially misdiagnosed as cardiovascular disorders. Upon emergency laparotomy gangrene of the oesophago-gastric junction was obvious while in one case even necrosis of the whole stomach occurred after considerable delayed diagnosis. Transmediastinal esophagectomy with resection of the proximal stomach and gastric pull up with cervical anastomosis was performed in two cases. Oesophago-gastrectomy with delayed reconstruction by retrosternal colonic interposition was mandatory in the case of complete gastric gangrene. Finally all sufferers recuperated well. CONCLUSIONS: Strangulation of hiatal hernia with subsequent gangrene of the oesophago-gastric junction is a life-threatening condition. Straight diagnosis is mandatory to avoid further necrosis of the proximal gastrointestinal tract as well as severe septic disease. Surgical strategies have considerably varied throughout the last 100 years. In our opinion transmediastinal oesophagectomy with interposition of a gastric tube and cervical anastomosis should be the procedure of choice if the distal stomach is still viable. Otherwise oesophago-gastrectomy is unavoidable. Delayed cervical anastomosis or reconstruction is advisable in instable, septic patients.

[The death of Goffredo Mameli in 1849]. / La morte di Goffredo Mameli a Roma nel 1849.

After the introduction of firearms, which became increasingly efficient over time, the number of seriously injured soldiers increased considerably during the nineteenth century. As a consequence, surgeons were called upon to broaden their activity, performing operations which had hitherto been considered too hazardous, since they were deemed to be too extensive, or were contraindicated by the risk of complications during surgery (haemorrhage, heart and circulatory failure). From 1846 onwards, the introduction of anaesthetic techniques carried out with ether had expanded surgical perspectives in anatomical districts like the abdomen, which were previously considered a sort of taboo, such that few surgeons ventured into the realm of this internal surgery. In the mid nineteenth century the possibility of suffering from severe infections, as an immediate complication after a firearm injury or after surgical intervention, was very high, ranging between 23% in London, up to 80% in Munich, according to the available records; in Zurich a 46% mortality is reported, and a similar 43% rate came from Edinburgh. The situation worsened during war time, since injured soldiers were recovered in extremely precarious conditions, ad hoc hospitals were located in dilapidated old buildings, and the physicians and health care providers were unaware of the minimum hygiene conditions required, and performed both operations and medications without taking sterility measures into consideration. The author reports and comments on the most significant parts on the documents written by Agostino Bertani, who described in full detail the clinical evolution of the wound suffered by Goffredo Mameli, the poet and patriot of the Italian Risorgimento who wrote the Italian national anthem. The clinical evolution of Mameli's disease was unfavourable: he underwent amputation of the left lower limb after the firearm injury suffered during the defence of the Roman Republic, since a gangrenous complication had become apparent. The poet died of septicaemia on July 6, 1849, 17 days after the surgical operation.

[Hospital gangrene (Gangraena nosocomialis)]. / La podredumbre de hospital.

Hospital gangrene refers to a historical presentation of septic wounds, which was associated to situation with a multitude of wounded patients. Later, it was proven that hospital overcrowding together with inadequate wound treatment options aggravated the spread of the infection by nurses and surgeons as well as contaminated wound dressings resulting in high morbidity and mortality in the affected hospitals and lazarettos. This article, which reviews the historical situation of this disease in Chile, mainly bases on reports of the physicians Rafael Wormald and Jacinto Ugarte, who reported on this topic in 1852 and 1873, respectively, and on outbreak occurring between 1860 and 1870 at Hospital San Juan de Dios in Santiago.

Karl Gebhardt (1897-1948): a lost man.

Karl Gebhardt (1897-1948) had a distinguished career as professor of sports medicine before the Second World War. He developed sports for the disabled at a specialised orthopaedic clinic at Hohenlychen and was President of the Red Cross in Germany. During the war, Gebhardt also acted as Heinrich Himmler's personal physician and was responsible for medical experimentation on prisoners in the concentration camps at Auschwitz and Ravensbrück. In his capacity as SS consultant surgeon, he treated Reinhard Heydrich (a high ranking Nazi official, also known as 'the Hangman') after an attempt was made on his life. When Heydrich died, Gebhardt was accused of failing to treat him with sulphonamides. To prove his innocence he carried out a series of experiments on Ravensbrück concentration camp prisoners, breaking their legs and infecting them with various organisms in order to prove the worthlessness of the drugs in treating gas gangrene. He also attempted to transplant the limbs from camp victims to German soldiers wounded on the Russian front. He was tried after the war and executed for these crimes in 1948. This paper explores the paradox of a gifted doctor who was also the perpetrator of inhuman crimes.

Gangrene therapy and antisepsis before lister: the civil war contributions of Middleton Goldsmith of Louisville.

It is commonly accepted that Louis Pasteur is the father of microbiology and Joseph Lister is the father of antisepsis. Middleton Goldsmith, a surgeon in the Union Army during the American Civil War, meticulously studied hospital gangrene and developed a revolutionary treatment regimen. The cumulative Civil War hospital gangrene mortality was 45 per cent. Goldsmith's method, which he applied to over 330 cases, yielded a mortality under 3 per cent. His innovative work predated Pasteur and Lister, making his success truly remarkable and worthy of historical and surgical note.

The history of ergot of rye (Claviceps purpurea) I: from antiquity to 1900.

This article outlines the history of ergot of rye up to 1900. Ergot is a fungal disease that affects many grasses but is particularly damaging to rye. It occurs as the result of an infection by the parasitic organism Claviceps purpurea, which produces characteristic black spurs on the grass. When incorporated into grain, the ergot fungus can cause severe outbreaks of poisoning in humans called ergotism. There are two main clinical forms of toxicity, gangrenous and convulsive, where coma and death often supervene: the death rate for ergotism has been reported to be between 10 and 20 per cent in major outbreaks. Historical accounts note that ergot could accelerate labour, stop postpartum haemorrhage and inhibit lactation. At the end of the nineteenth century ergot was still regarded as a 'glorious chemical mess', but help would arrive in the early 1900s and the complex jigsaw would be solved.

Was Maria de' Medici a diabetic patient?

Queen Maria de' Medici (1573-1642) died in a miserable, marasmic state. Infections, gangrene, weight loss, fatigue and respiratory problems suggest a progressive decompensation of a previously existing Type 2 diabetes. The lack of biochemical data, however, permits only circumstantial evidence of this hypothesis. The author proposes that the queen developed subclinical diabetes after the age of 45, when she became obese due to excessive eating and lack of exercise. With a clear familial predisposition, she could have become insulin resistant and chronically hyperglycaemic. The presence of an internal deviation of the left eye, visible on several late portraits, suggests a mononeuropathy of cranial nerve VI. Repeated skin infections and gangrene of the lower limbs during the last month of her life complete the clinical diagnosis. Hyperglycaemic ketosis with Kussmaul respiration without adequate treatment may have caused her death.

The manifestation of "gangrene" in the Hippocratic corpus.

We trace the early historical references concerning "gangrene," specifically in the treatises of the Hippocratic corpus. The term "gangrene" today refers to the necrosis, or death, of tissues resulting from prolonged ischemia, bacterial invasion, and subsequent putrefaction. Apart from the name "gangrene," another term, "sphacelus," exists in the corpus, referring to similar decay. An effort is made to correlate cases of "gangrene" and "sphacelus" described in the Hippocratic texts and related bibliography. In this study we retained only references to "sphacelus" that have the same end points as "gangrene." References to necrosis of the skull, the brain, the teeth, the jaw, the extremities, the ribs, and some resulting from "ulcers" were isolated. Their clinical manifestations, prognosis, and treatment are presented, together with general comments on the disease's etiology.

[Sebald Brugmans and hospital gangrene]. / Sebald Justinus Brugmans' strijd tegen de hospitaalversterving.

Sebald Justinus Brugmans, Professor at Leyden University and from 1795 on Director of the 'Geneeskundig Bureau der Bataafsche Republiek', organized all necessary facilities in the Leyden Military Hospital. His appointment, 1811, as inspector-general of the French Imperial Military Health-Service, seemed to be the next step in a brilliant career of more than 25 years. He became a leading expert in the fight against hospital-gangrene and its prevention, not in the least because of the enthusiastic reception of his treatise on gangrene (1814) in which he meticulously analyzed and explained the causes of this dreadful disease. He completed his entry with a thorough evaluation of all possible and well experienced sanitary regulations. He was convinced of the contagious character of the disease. Quite unusual at the time, he used the terms "miasma" and "contagium" interchangeably. Maybe partly for that reason, his work was instrumental in convincing most later authors that gangrene was a contagious disease. Brugmans' fame was established forever after tha Battle of Waterloo (June 1815).

Hospital gangrene: the scourge of surgeons in the past.

Before the days of antisepsis, the infection rate on surgical wards was very high. Mortality from common operations such as limb amputations could run from 40% to 60%, mostly from infection. Hospital gangrene, a type of necrotizing infection, occurred frequently. It would spread rapidly, and the helpless surgeon could do nothing to stop it. The patient would be in agony for many days before death mercifully intervened.