Mephitic gangrene (the Greek negative prefix an-, azr — air and bios — life; synonym: gas gangrene, gas phlegmon, malignant hypostasis, fulminant gangrene, brown phlegmon) — the terrible wound fever caused by pathogenic anaerobe bacterias, which is characterized by quickly coming and extending necrosis of fabrics, their disintegration, usually with formation of gases, heavy general intoxication and lack of the expressed inflammatory phenomena.
It is possible to consider that the first description of clinical manifestations And. Hippocrates gave the item in the works. In compositions of and Lena is mentioned emergence of «air» in wounded muscles. Ambroise Paré, apparently, described And. and. under the name of «hospital gangrene». In N. I. Pirogov's compositions clinic And. and. wounds it is in detail described under the names «local stupor», «mefitichesky gangrene», «acute malignant hypostasis». At «The beginnings of the general field surgery» N. I. Pirogov says that «the first sign of transition of ostroserozny and purulent infiltrate in gangrenous is the crash (crepitation) felt under skin».
In 1899 Mr. Lidental and Hichman (O. of Lidenthal, F. Hitschman) in 7 years after opening of Cl. perfringens Welsh and Nattoll (W. H. Welch, G. H. F. Nuttall) correctly estimated a role of this microbe in emergence And. and.; they wrote that the disease results from multi-infection, but the leading role belongs to Cl. perfringens. Death is caused by a toxaemia. Toxins are emitted with microbes and formed as a result of decomposition (proteolysis) of protein.
And. and. wounds in peace time arises seldom therefore the base statistical material belongs to wartime. Frequency And. and., arising as a complication of wounds, depends on many factors from which the major are the nature of wound, the term and quality of rendering the surgical help.
Frequency of anaerobic complications, according to statistical data of the Soviet surgeons, is expressed in the following figures: according to M. N. Akhutin, frequency And. and. during fights at the lake Hassan (1938) made 1,5%; during fights in Mongolia (1939) — 1,4%. During the Soviet-Finnish war (1939 — 1940) frequency And. and., according to M. N. Akhutin — 1,25%; according to N. N. Burdenko — 0,8%; according to S. I. Banaytis — 0,8%; according to B. A. Petrov — 2 — 4%; according to M. B. Ryvlin — 2,4%.
According to foreign authors, belonging to years of World War II, frequency And. and. makes: according to W.A. Altemeier — 4,2%, across F. Langley — 1,6%, according to Fischer and Florey (G. H. Fisher, M. E. Florey) — 0,15%. Comparing
the provided figures, it is possible to come to conclusion that And. and. bullet wounds arises approximately at 1 — 2% of wounded. Value of features and localization of wounds can be characterized so: And. and. most often arises at missile wounds of those sites of extremities on which there are powerful muscular arrays concluded in strong bone and fascial cases.
On many statistical materials, 58 — 77% of all cases And. and. arose in wounds of the lower extremities (I. V. Davydovsky). On materials of some authors (I. Sh. Blyumin, I. B. Kolodner, A. N. Berkutov, etc.), the greatest number of cases And. and. (35,8 — 46%) it is the share of wounds of a hip. The second place is taken by wounds of a shin to which share from 27 to 35% of cases of a mephitic gangrene fell. In other body parts it meets much less often. So, on wounds of a shoulder 10 — 12%, forearms — 4%, buttocks — 8,6%, feet — 3,9% fall. Also more rare localizations were described And. and., such as wounds of a brain (N. I. Grashchenkov), wounds of a liver (I. V. Davydovsky). Most often And. and. arises in the wounds given by splinters of shells that was noticed still by N. I. Pirogov writing: «... especially often the outbreaks of mefitichesky gangrene happened after wounds artillery shells». This pattern was confirmed in all wars, including and on experience of the Great Patriotic War. According to statistical data of M. N. Akhutin, 92% of cases And. and. arose at missile wounds.
A lethality at And. and. always was very high. According to the statistical data relating to World War I it, according to N. N. Petrov, fluctuated within 30 — 50%, according to N. N. Burdenko — made 60%, according to A. F. Berdyaev — 54%, according to A. A. Opokin — 40%. Approximately the same figures, according to World War I, were given also by foreign surgeons. So, a lethality, on L. Ombredanne's observations, W. Lohr made 50 — 60%, F. Klose — 43 — 68%, A. Frankel — 75%.
A lethality at And. and. during the Great Patriotic War in all medical institutions also was considerable.
Activators A. and. — pathogenic clostridiums (see. Clostridium ). From them the main is the following.
Cl. perfringens types A, B, C, D, E, F — short polymorphic sticks, without flagellums, form subterminal disputes, seldom central. Cells of different strains differ from each other in the sizes (0,6 — 1 microns × — 8 microns). In material and on the Wednesday with serum form the capsule, grampolozhitelna of a wound. On fluid mediums (meat or casein) grow quickly (3 — 8 hours), giving uniform opacification with rough gas generation, change rn Wednesdays in the acid party. Wilson's circle — Blair blackens and is broken off in 1 — 2 hour after crops, milk violently curdles in 3 — 5 hours with formation of a friable clot. Slowly melt the curtailed serum or boiled pieces of meat, to gelatin liquefy. All strains ferment (with formation of acid and gas) glucose, a galactose, a maltose, lactose, levulose, sucrose and do not ferment a mannitol and dulcite. Some strains decompose glycerin and inulin. Form smooth colonys (S), mucous (M) and rough (R), can form also colonies mixed (0) options.
Cl. perfringens divide into 6 types on their ability to develop 12 lethal and necrotic toxins and enzymes, various on antigenic properties, designated by letters of the Greek alphabet: α, β, γ, δ, ε, η, θ, ι, κ, λ, μ,ν. The type A produces in a large number α-toxin — a lecithinase With, edges has lethal, necrotic and hemolitic properties and plays the main role in a pathogeny of gas gangrene. In much smaller quantity this toxin is produced by all other types of this microbe. Cl. perfringens of type A produces also θ-toxin — hemolysin, κ-toxin — a collagenase, μ-toxin — hyaluronidase and, perhaps, lethal η-toksinony Cl. perfringens of types B, C and F produces β-toxin — lethal, necrotic poison — the main toxic factor of these types, and also in a small amount γ-toksinony Types B and C develop δ-hemolitic, a lethal factor, θ-hemolitic toxin, type C — also a κ-collagenase.......... The type B can develop ε-токспн, to a λ-zhelatinaz. The type D produces in a large number ε-toxin — the strong lethal, necrotic prototoxin activated by proteolytic enzymes. Type E develops lethal ι-toksinony All Cl types. perfringens develop a deoxyribonuclease — the ν-toksinony Main activator wound And. and. Cl is. perfringens of type A, is more rare — other types.
Cl. oedematiens type A, B, C and D — thick large sticks (1 — 2 micron × — 10 microns), are mobile, have 20 — 25 flagellums, there is no capsule, a grampolozhitelna. Disputes are oval, subterminal, strict anaerobe bacterias. Growth on fluid medium is followed by easy opacification and a friable deposit, gas generation moderate. Wilson's circle — Blair blackens in 16 — 24 hours. Proteolytic properties weak, milk turns not earlier than 12 — 24 hours, to gelatin liquefies, the curtailed protein does not change. Cl. oedematiens of types A, B, C, D ferments glycerin, glucose, fructose and a maltose. Some strains of type B do not decompose glycerin. On a blood or hepatic agar forms gray hilly colonies with the raised center, the cut-up edges and with the departing shoots. On a blood agar with benzidine of colony of types A and B during the keeping on air within 30 — 60 min. gradually blacken, there is an active area. In the depth of an agar creates colonies in the form of lumps of cotton wool, snow flakes of a pla of a lens. Cl. oedematiens of types A, B and D produces 8 soluble antigens — toxins and enzymes. Strains of types A and B form thermolabile lethal and necrotic α-toxin which is the strong capillary poison breaking permeability of a wall of vessels. Besides, the type A produces γ-toxin — a lecithinase, δ-toxin — kislorodolabilny hemolysin, ε-toxin — a lipase. The type B produces β-toxin — a lecithinase, and also ζ-toxin — hemolysin and η-toxin — a tropomiozinaza. At the person A. and. causes Cl. oedematiens of types A and B, type C not patogenen.
Cl. septicum. Distinguish 2 types (And yes In). The polymorphic gram-positive stick (0,8 microns × 4 — 5 microns), is mobile (peritry). Disputes are oval, subterminal, there is no capsule. Depending on a strain and Wednesday can turn into the short blown-up forms and long threads which often are found on a serous cover of a liver, spleens or on a diaphragm. Strict anaerobe. On fluid mediums grows, giving uniform opacification and gas generation. Wilson's circle — Blair blackens in 3 — 6 hour. Milk curtails slowly, to gelatin liquefies. On the surface of dense nutrient mediums forms brilliant translucent colonies to dia. 4 mm with uneven fringed edges. On a blood agar forms colonies in the form of dewdrops with an active area. In the depth of a tsgar) brazut colonies to dia. 1 — 2 mm with the condensed center or radially departing threads. Decomposes glucose, lactose, a maltose, salicin, a galactose, fructose; does not decompose glycerin and a mannitol. Separate strains of type A and all strains of type B decompose sucrose. Does not digest koagulirovanny serum and ovalbumin. Cl. septicum produces not less than 4 toxins: the α-toxin having lethal, necrotic and hemolitic properties, β-toxin — a deoxyribonuclease, γ-toxin — hyaluronidase and δ-toxin — kislorodolabilny hemolysin. In filtrates of cultures of Cl. septicum are found fibrinolysin, a collagenase and the general antigen with Cl. histolyticum which is cross neutralized anti-toxic serums against these bacteria. At intramuscular infection of a Guinea pig of Cl. septicum develops typical And. and.
Cl. histolyticum — the small stick, has flagellums, is mobile, the grampolozhitelna, does not form capsules. Disputes are subterminal, in the form of a racket or an eye of a needle. With a growth on fluid mediums gives opacification without gas generation. Forms the proteolytic enzymes causing bystry dissolution of pieces of a liver, mincemeat, ovalbumin in fluid medium. Milk quickly peptonizes without noticeable coagulation, to gelatin quickly liquefies. Does not decompose carbohydrates. Does not form an indole, hydrogen sulfide allocates in a large number. Colonies on an agar a column are compact, shaggy, irregular shape. On a blood agar — small, transparent, as dewdrops, with an active area. Cl. histolyticum produces α-toxin — a lethal and necrotic factor, β-antigen, or a collagenase, edges are destroyed by the native and denatured collagen, an azocall and to gelatin.
Except a collagenase, Cl. histolyticum produces γ-antigen — proteinase, δ-antigen which destroys elastic fibers, an azocall and to gelatin. This enzyme in connection with ability to dissolve elastic fibers is called elastase. Introduction of 0,5 ml of fresh culture to muscles of a Guinea pig causes bystry fusion of fabrics and death of an animal in several hours or days.
Cl. sordellii forms chains on 3 — 4 joints, there is no capsule, is mobile, sometimes grows in a type of long threads. Easily forms oval disputes, on fluid mediums causes sharp opacification and gas generation. Has proteolytic properties. Milk completely peptonizes during 2 — 3 days, liquefies to gelatin; ferments glucose, levulose and a maltose with formation of acid and gas, it is weak — sucrose. On an agar with blood forms round or irregular shape of colony an active area. Virulent strains of Cl. sordellii allocate highly active lethal toksinony the Microbe emits also hyaluronidase, kislorodolabilny hemolysin like θ-toxin, and also fibrinolysin and other proteolytic enzymes.
At experimental infection the animal perishes from And. and. within 1 — 2 days.
In addition to listed, also other clostridiums can have etiological value: Cl. fallax, Cl. sporogenes, Cl. putrificus, Cl. bifermentans. Besides, wound botulism should be considered as And. and. At last, sometimes at a classical picture A. and. the anaerobic streptococcus can appear the activator that is established only by a bacteriological research.
The bacteriological analysis of the materials taken from a wound at And. the item, always finds microbic associations of various structure at which along with anaerobe bacterias there is also other microflora. Almost like the rule, there are pyogenic microbes — staphylococcus, streptococci, often find a protea, a pyocyanic stick and other microbes. It is undoubted that these associations exert a certain impact on the course of a disease.
See also Anaerobe bacterias .
Native habitat of anaerobe bacterias, including activators A. and. — intestines of animals, in particular herbivorous, and also omnivorous (pigs). As a rule, find Cl in their intestines. perfringens, and is frequent also other activators A. and.; here they breed as saprophytes, without causing a disease of an animal. From intestines of the healthy person a number of authors also allocated along with other anaerobe bacterias and Cl. perfringens. Economic activity of the person — fertilizer of fields excrements, a pasture of the cattle etc. — promotes a wide spread occurance of activators A. and. in external environment, first of all in the soil. In some soils in the presence of nutrients, sufficient humidity and temperature pathogenic anaerobe bacterias can even breed. But also under unfavorable conditions of external environment anaerobic bacteria are capable to remain very long time the being able dispute; together with sterns they get into intestines of animals again.
Pathogenic anaerobe bacterias can be quite often found on clothes and on skin of the person, and intensity of planting depends from household, a dignity. - a gigabyte. conditions can also be very considerable. Very much popular belief that in epidemiology And. and. fighting wounds the leading value has an edaphic factor, therefore, those geographical, climatic and seasonal conditions which determine as a condition of the soil, so and probability of direct hit of the earth in a wound, and degree of impurity by soil anaerobe bacterias of clothes of soldiers and their skin. Meanwhile, comparing numerous observations which were made in various latitudes at various temperature and on various soils, it is possible to conclude that factors climatic, soil, meteorological and others do not exert decisive impact on increase or reduction of frequency of complications And. and. So, frequency And. and. during war with Finland when fighting was conducted at very low temperature, did not differ from the frequency registered by Mack-Lennan (J. D. Mas-Lennan) in Africa, Langley — in Tunisia and M. N. Akhutin — during fights at the river Halkhin-Gol in hot weather.
There are observations showing that percent of the wounds complicated And. and., fluctuated in the hospitals of the same group which were at one place, at the same time years. So, this percent decreased during the periods when the small number of wounded arrived, and increased at mass receipt, especially if it proceeded a long time. As the nature of wounds, geographical and seasonal conditions remained invariable, the only reason of increase in number of complications during the periods of mass arrival of wounded should be considered lengthening of the terms separating the moment of wound from rendering the surgical help. Recognition of this factor as the main reason can significantly reduce frequency And. and. Recognition of the leading role of a condition of the soil, weather or season will demobilize the surgeon since these reasons do not give in to elimination.
In peace time And. and. the hl meets sporadic. obr. as a complication of a severe open injury, transport or received during the performance of page - x. works. In rare instances And. and. can arise as a postoperative complication, usually at the expense of autoinfection. Cl. perfringcns at the person found not only in intestines, but also in an oral cavity (in the presence of carious teeth), at women — in a vagina. Cl. perfringens. being in a vagina, occasionally can be a source And. and. in a puerperal period, and a thicket after extra hospital abortions.
Cases of emergence are described And. and. after hypodermic, intramuscular and even intravenous injections. In opinion And. N. Chistovich, emergence And. and. in these cases it is caused by introduction of a high dose of the infected material since the mechanical injury in itself is insignificant.
It is accepted to distinguish two classical forms A. and.: emphysematous (gas gangrene, gas phlegmon) and edematous (malignant hypostasis), to-ruyu hl connect. obr. with infection of Cl. oedematiens. Division it, however, very conditionally since and at an edematous form gas generation also takes place though is not always defined clinically. For that and other form A. and. the progressing necrosis of fabrics with their disintegration and bystry distribution of pathogenic microflora out of limits of a wound is characteristic.
There is no consensus concerning the anatomic substrate first of all struck And. and. One authors consider such substrate muscular tissue and are inclined to define And. and. as a klostridialny miositis, others, without denying special weight and demonstrativeness of changes in muscles, recognize these changes secondary, connected with primary defeat of blood vessels at distribution of the activator on intermuscular cracks and cellulose of neurovascular bunches. Distribution of process on living tissues happens under the influence of toxins and enzymes, such as a collagenase, hyaluronidase, protease which, having cytolytic properties, lay a way to microbes. Bacterial toxins, being soaked up from the center of an infection, have also the all-toxic effect which is shown in the form of toksikorezorbtivny fever. The progressing hypostasis is expressed by accumulation of free liquid in fabric spaces, swelling and dissolution of a considerable part of fibrillar structures. If living tissues have sufficient resilience, the limited center, sometimes in the form of gas abscess can be formed.
Necrotic changes at And. and. come in various terms. Muscles, cellulose, vessels, nerves Nekrotizirutsya. Such changes are especially expressed in muscular tissue, edges becomes dim and gray (color of boiled meat). Sometimes muscles lose elasticity inherent in them, are easily pounded by fingers, and on a consistence represent jellylike weight (a symptom of «a crimson lysis of fabrics» according to A. V. Melnikov). At emphysematous forms the muscle becomes porous since all intersticial fabric is stuffed with vials of gas (tsvetn. rice). At edematous forms treatment of fabrics liquid prevails, and gas generation is insignificant or is absent. It is one of the most characteristic symptoms of an edematous form A. and. In most cases gas generation is connected with infection of Cl. perfringens, though presence of the most various microbes, except Cl. perfringens, at disintegration of fabrics can lead to development of the processes which are followed by gas evolution. Gases, infiltriruyushchy fabrics at And. and., are various on the structure — in them there can be a methane, hydrogen, carbonic acid. During the progressing of disintegration, especially under the influence of the joined putrefactive microflora, in gases impurity of hydrogen sulfide, ammonia and others badly the smelling chemical connections are found. Occasionally cases met And. and. the foot caused by Cl. histolyticum. At the same time there occurred full fluidifying of all soft tissues, except skin and the copular device so the skeleton of foot was put in the skin bag filled with liquid. At And. and. sometimes there are metastatic centers which are most often formed in places of pressure, pricks, bruises though sometimes and in the unimpaired cellulose. At And. and. there are various changes and in internals. These changes are expressed in hemolysis, formation of inflammatory and degenerative and necrotic changes in internals. Sometimes arise also original a septicaemia — anaerobic sepsis (see). Despite considerable changes of internals at And. and., it is considered that in most cases defeat of c is the main reason for lethal outcomes. N of page products of fabric disintegration and microbic toxins. Nevertheless, apparently, it is impossible to consider that a cause of death from And. and. defeat only is c. N of page. Death from And. and., probably, result of the impact of toxins on all organism in general leading to emergence of functional and some morphological changes in many bodies and systems. The reasons of lethal outcomes established during the openings most often are distributed as follows: 1) distribution of specific process and intoxication — 85%; 2) pneumonia — 1,5%; 3) the changes characteristic of sepsis — 4,5%; 4) acute anemia — 2,1%; 5) specific process in combination with weight of wound — 1,3%; 6) the metastatic centers of a mephitic gangrene — 0,5%; 7) the reason is not established — 0,5%.
Foreign surgeons speak the reasons of lethal outcomes very vaguely and consider that the nature of a toxaemia is still insufficiently studied as well as «the vital centers» which toxins affect though at the same time most of authors considers that in a pathogeny the role of klostridialny toxins is not subject to doubt [Hampton (O. Hampton), Paterford and Evans (R. Putherford, I. R. Evans), S. Tarbiat, etc.].
Fact of frequent emergence And. and. at missile wounds it is connected with features of a pathogeny of this wound complication. Missile wounds differ in the fact that in them there is always a large amount of necrotic fabrics and fabrics with sharply lowered viability; besides, at missile wounds the so-called force of side blow, i.e. distribution of energy of a hurting shell aside from a wound is more expressed, as a result of it considerable sites of fabrics are in addition damaged. In the damaged fabrics traumatic hypostasis quickly develops, and they are squeezed in a strong aponeurotic case, also small vessels of muscles are squeezed, microcirculation and, therefore, supply of fabrics with oxygen is broken. The site of ischemic fabrics in which anaerobe bacterias find favorable conditions for reproduction is as a result formed.
Action of force of side blow causes a long spasm and larger arteries that breaks blood supply even more. Especially considerable sites of ischemic fabrics are formed after pulling of an extremity by a styptic plait. Action of energy of a hurting shell extends and on nervous trunks, temporarily breaking their function owing to what also neurotrophic processes in a zone of wound change. Fragmental wounds always have complex structure, and some sites of a wound are often insufficiently aerated, than favorable conditions for development of anaerobic microbes are also created. It is necessary to consider at the same time and that scales of microbic pollution of missile wounds are always quite considerable as splinters often carry away scraps of clothes, footwear, a particle of the earth in a wound. Therefore, in the mechanism of development And. and. a number of factors participates, and leaders should be considered features of the center of damage, in Krom along with necrotic fabrics the sites of fabrics with the broken microcirculation which are in conditions of ischemia and oxygen insufficiency are formed. Microbic pollution of a wound can be considered the factor operating only depending on the certain conditions which are created in the center of damage. It is known that pollution of a wound pathogenic anaerobe bacterias (including Cl. perfringens) takes place considerably more often than And. and. wounds. More rare, sporadic emergence And. and. at not gunshot wounds it is possible to explain with the fact that at such damages the conditions favorable for development of anaerobic microbes are seldom created.
Fire changes are much more subject And. and., than wounds of soft tissues. This pattern is expressed to those more clearly, than less muscle bulks of the damaged segment. So, on observations And. N. Berkutova, 49% of cases And. and. hips was registered at wound of soft tissues and 51% — at a fire change, on a shin of 30% of cases And. and. was at wounds of soft tissues and 70% — at fire changes, on a forearm — respectively 10 and 90%. Value of a change as the factor promoting development And. and., it was established also at pilot studies. So, in G. P. Kovtunovich's experiences even after introduction of 100 million washed microbic bodies to muscles of a hip to Guinea pigs And. and. did not develop; in the same cases when after introduction of microbes the fracture of a bone was made, And. and. developed almost in all cases. Value of injury of a bone to development And. and., especially at a gunshot wound, it is possible to explain, first, with the fact that the architecture of a muscular and bone wound differs in bigger complexity in comparison with a structure of a wound of soft tissues; secondly, at a fire change the zone of the damaged fabrics increases the scattering free bone splinters and, at last, at a fire change more considerable, than at wounds of soft tissues, a part of energy of a hurting shell is transferred to fabrics.
Classification of forms of a mephitic gangrene
Exists very large number of classifications of forms A. and. In Europe and America after World War I big distribution Veynberg's classification — Segena (M. of Weinberg, P. Seguin), on a cut received all cases And. and. it is offered to divide into two groups: 1) virulent gas gangrene and 2) avirulent. Group virulent And. and. it is divided napyat forms: 1) emphysematous, or classical; 2) edematous, or toxic-3) the mixed forms; 4) putrefactive forms; 5) phlegmonous form. According to authors, their classification to a nek-swarm of degree indicates also the microbic associations causing these or those clinical forms.
Veynberg's classification — Segena, rather full being very static since in its definitions it is not given any features characterizing the course of infectious process. In the USSR (official «Instructions on field surgery») classification is accepted And. and., offered by A. N. Berkutov in 1951, considering speed of distribution of process, kliniko-morphological indicators and anatomic features of process (tab).
Using this classification, it is always possible to formulate the dynamic diagnosis which to some extent serves also as the guide to action. E.g., the diagnosis «quickly extending deep form of a mephitic gangrene» obviously indicates the need uses bystry and sometimes very radical ways of treatment.
Classification is widespread in the USA, according to a cut clinical manifestations And. and. are systematized as follows.
I. Traumatic wound fevers. 1. Simple pollution. 2. Anaerobic cellulitis. 3. Anaerobic mionekroz: a) klostridialny mionekroz; b) streptococcal mionekroz. II. Not traumatic infections. 1. Idiopathic. 2. The infected vascular gangrene.
The term «simple pollution» is understood only as finding of klostridialny flora in slowly healing wound without the expressed general reaction.
Carry cases of massive klostridialny pollution of a wound when infectious process is developed in impractical fabrics to anaerobic cellulitises, without going beyond their limits, and healthy muscles are not surprised. Anaerobic cellulitis was described under the name «gas abscess» or «the localized form of gas gangrene» earlier.
The name «klostridialny necrosis» or «klostridialny miositis» is understood as classical clinical manifestations And. and. with the progressing necrosis and disintegration of muscular tissue, with the expressed intoxication of an organism. Streptococcal mionekroz clinically does not differ from klostridialny and it is diagnosed only on the basis of bacteriological researches. At anaerobic cellulitis in wound separated find many leukocytes and gram-positive sticks and other flora; at a klostridialny mionekroz there are not enough leukocytes, there are gram-positive sticks and other flora; at a streptococcal mionekroz in separated many leukocytes, are absent gram-positive and other flora, except streptococci which are found in a large number.
Clinical picture, diagnosis and forecast
Current And. and. can be fulminant, quickly progressing and torpid. At a fulminant current already several hours later after wound the terrible phenomena leading to death in 1 — 2 days develop; treatment in most cases is inefficient. At quickly progressing current signs of a complication appear not earlier than 24 hours after wound (usually in 2 — 3 days); death can follow in 4 — 6 days; this look meets most often. The torpid current is characterized late (not earlier than 5 — the 6th day) by development And. and., its distribution goes slowly and can lead to a lethal outcome in 2 — 3 weeks and later. At quickly progressing, and furthermore at a torpid current And. and. life of the wounded can be saved by timely and radical medical actions. Optimum form A. and. — late formation of gas abscess, usually around a foreign body or a splinter of a bone.
Diagnosis And. and. shall be very early since at quickly extending forms the toxaemia in short terms gains irreversible character. For early diagnosis And. and., especially at mass arrival of wounded, it is necessary even before removal of a bandage and before survey of a wound to look for suspicious symptoms of this complication. At the same time special attention is paid to those wounded who have wounds of extremities, especially missile wounds of a hip, shin (if there is a fire change) and a rump. In the most initial stage And. and. excitement of the wounded, garrulity and concern is noted a nek-swarm, complaints to pains in a wound which sometimes characterize as «arching», or on feeling of completeness in an extremity, on a prelum by allegedly hardly applied bandage are frequent. Drugs often do not eliminate pain, and the wounded spends nights without dream (a symptom of sleepless night). Very patognomonichno sharp increase of pulse — 110 — 120 ud. in 1 min., body temperature usually fluctuates within 38 — 38,5 °. In later stages there is an easy ikterichnost of scleras that can be a consequence of hemolysis. Still later, at the come heavy intoxication, there is euphoria, changes of the fades hippocratica person. At survey of area of wound, especially after removal of a bandage, it is possible to define degree of edematization, and at emphysematous forms by means of percussion and a palpation to find gas crepitation and a high-pitched tympanic sound. At survey of a wound the sizes of hypostasis and the field of distribution of gas are defined. At the same time, in addition to percussion and a palpation, it is necessary to use auscultation a phonendoscope: pressing a membrane on skin in the field of a wound, it is possible to hear a crunch of vials of gas in the most initial stages of gas generation. Smaller value has a so-called symptom of the razor — a special ringing crunch of the hairs which are shaved off from a circle of a wound. Important precursory symptom A.i. — morbidity at a palpation on the course of a vascular bundle, proksimalny areas of wound. Characteristic sign And. and. spread of hypostasis on far distance from a wound or hypostasis of all damaged segment serves. For overseeing by increase of hypostasis N. N. Burdenko, A. V. Melnikov suggested () to tie an extremity with silk thread and on extent of its incision to judge increase in hypostasis. This sign is doubtful since it is found also at uncomplicated (e.g., closed) changes with the accruing traumatic hypostasis. Besides, its identification leads to loss of time. In a circle of a wound sometimes it is possible to find landkartoobrazny spots of hemorrhages of unusual coloring (tsvetn. fig.) and subepidermal bubbles. Color of spots caused such names A. and., as «brown phlegmon», «a bronze ugly face», «a white ugly face», «blue phlegmon». Color of spots is changeable (in process of decomposition of extravasate it can change) and has no communication with character of microflora. Outward of a wound depends first of all on its sizes: at a small wound opening it is possible to note only scarcity separated, a cut has serous and bloody character. It can sometimes be foamy (an important diagnostic character). At a wound of the considerable sizes or at emergence And. and. in already dissect wound it is possible to see changes of muscles which become wax-like, and in later terms — gray («boiled meat»). At a major defect of skin and a fascia or in a dissect wound sometimes it is possible to see that edematous muscles are given (stick out? from a wound (A. F. Berdyaev's symptom). The smell separated (a smell of cheese, sourcrout, a mouse smell etc.) is not an essential symptom since depends on extent of decomposition of muscular tissue. The heavy fetid smell of separated is not characteristic for And. and. also points to the putrefactive process which for the second time developed in devitalized fabrics.
Radiodiagnosis. Very convincing diagnostic data can be obtained by means of a X-ray analysis. She allows to find such minute quantity of gas, a cut it is not possible to define by percussion and a palpation. Use of a X-ray analysis proved, division of forms A is how conditional. and. on emphysematous and edematous. According to the roentgenogram it is possible to establish also in what fabrics gas is located, so — to judge depth and prevalence of process. When muscular tissue of an impregnirovan gas, on the roentgenogram it is presented by the drawing reminding a fir-tree (fig. 1).
At distribution of gas only on hypodermic cellulose the image reminds the drawing of bee honeycombs (fig. 2), limited accumulation of gas demonstrates existence of gas abscess (anaerobic cellulitis — on the American terminology).
Microbiological diagnosis. For a bacteriological research at primary operation take exudate, pieces (2 — 3 g) of the changed fabric from a wound on border with healthy fabric, and also blood from a vein (5 — 10 ml).
Cadaveric material (a discharge of a wound, pieces of the changed muscles, blood from heart, pieces of a spleen and liver) should be taken not later, than in several hours after death in order to avoid a posthumous invasion of pathogenic anaerobe bacterias from went. - kish. path.
The taken material is placed in sterile airtight glass or plastic ware and urgently sent to bacteriological laboratory. Immediately after intake of material in laboratory of test mikroskopirut. For this purpose prepare smears prints and paint them across Gram. Existence in test of large gram-positive sticks is an approximate sign And. and. Dense material is crushed sterilely scissors and pounded in a mortar with sterile sand or pounded glass in the equal volume of normal saline solution. Blood or exudate centrifuge at 3000 rpm within 30 min. and sow a deposit on Wednesdays (a blood agar, Willis's circle — Hobbs, Wilson's agar — Blair and the benzidine agar).
Crops incubate in anaerobic z conditions at t ° 37 ° (in micro and macroanaerobic jar with pyrogallol), crops on Wilson's circle — Blair is looked through in 3 — 6 hours, and by crops on other environments — next day and then every day to 7 days. The grown colonies causing hemolysis on a blood agar, opalescence or emergence of a nacreous aura on Willis's circle — Hobbs, blackening on Wilson's circle — Blair, blackening on the benzidine agar, check for purity and existence of gram-positive sticks and then oversow in test tubes with fluid meat or casein and mushroom medium under a layer of a liquid paraffin with pieces of meat or cotton wool. Crops incubate in the thermostat of 24 — 48 hours, check purity of cultures by means of microscopy and for identification of species of the activator and its toxin put a neutralization test with anti-toxic diagnostic serums to all activators A. and. Reaction is put in six test tubes: bring 0,9 ml of a tsentrifugat of the studied culture in each test tube; to the five first test tubes are added on 0,6 ml of the monovalent serums containing antitoxins against each of activators A. and. in number of 50 — 100 ME, add 0,6 ml of normal saline solution to a control test tube. Mixes of toxin with antitoxin maintain 40 min. at t ° 20 ° in the dark place and then enter intravenously 0,5 ml to white mice or vnutrikozhno on 0,2 ml to Guinea pigs. Results register in 5 — 6 hours and on the 3rd days. Specific accessory of the studied culture is established on neutralization of toxin by serum.
In case of death of all animals the neutralization test is put repeatedly with standard specific diagnostic Cl serums. perfringens of types A, B, D and E.
Cultures of Cl. perfringens of the D and E type are capable to produce prototoxins to which detection apply a method of activation by means of proteolytic enzymes — of trypsin or Pancreatinum.
Investigated 5 — 6-hour culture of Cl. perfringens received on fluid meat or casein medium is exposed to centrifuging or filtering. The initial 1% solution of trypsin in number of 1 ml is added to 10 ml of the studied cultural liquid. If instead of trypsin apply 4% solution of Pancreatinum, then mix cultural liquid with an equal volume of solution of Pancreatinum and rn mixes lead up through 10% of NaOH to 8,0 — 8,4.
The received liquids place in the thermostat at t ° 37 ° for 1 hour. After the specified term the neutralization test with Cl serums is put. perfringens of type D and E.
In the laboratories having to a possibility of work with cultures of fabrics, the neutralization test can be put on initially m tripsinizirovanny fabrics 10 — 11-day chicken embryos.
Microbiological diagnosis can be carried out by the accelerated methods.
1. If it is possible to receive a large number rather pure separated from a wound, put a neutralization test with tsentrifugaty this liquid.
For definition of a letsitnnaza it is also possible to put reaction with the studied in vitro liquid, using letsitovitellin or erythrocytes of a sheep, mouse, rabbit for reaction of hemolysis. Suppressing reaction by serums against Cl. perfringens, Cl. oedematiens, etc. establish specificity found lecithinases, hemolysin.
2. For the purpose of identification of pure toxicogenic growths of Cl. perfringens of type A, Cl. oedematiens, Cl. septicum, etc. to transparent nutrient agar on the basis of Hottinger or Marten's broth add one of homologous antitoxins to concentration 8 ME on 1 ml. It is necessary to have four cups with four different antitoxins on which sow the studied cultures. In 48 — 72 hours around the grown colonies with homologous serum the ring of precipitation is formed.
3. One of the accelerated diagnostic methods of in vitro is based on change of morphology and the nature of growth of anaerobe bacterias at cultivation in the semi-fluid environment in the presence of specific anti-toxic serums (O. A. Komkov).
For this purpose use the Wednesday consisting of Poup's broth from 0,1% of an agar, 0,4% gelatin and 0,5% of glucose. Wednesday is spilled in test tubes on 10 ml and sterilized fluid steam 2 times 20 min. with a daily break.
The studied material is placed on some pieces in ten test tubes with the semi-fluid environment; five test tubes warm up at t ° 80 ° within 20 min. — heated-up and not heated-up — add various monovalent diagnostic antigangrenous serums to each couple of test tubes so that contained in 1 ml of the environment anti-toxic Cl serum. perfringens of type A not less than 200 ME, Cl. oedematiens of type A — not less than 300 ME, Cl. septicum and Cl. histolyticum — not less than 50 ME. To the last two test tubes serum is not added.
Contents of each test tube are carefully mixed and all test tubes place in the thermostat at t ° 37 — 38 °. In 10 — 18 hours read result. The Streptobatsillyarny form and growth by the isolated colonies in test tubes with any anti-toxic serum and lack of these phenomena in other test tubes indicate existence in the studied material of the activator A. the item, corresponding to this type of serum.
Detection of streptobatsillyarny forms in test tubes with different serums demonstrates presence of activators A. and. several types.
4. The second accelerated method offered O. A. Komkova represents an advanced neutralization test of toxin antitoxin by means of intradermal introduction to Guinea pigs. One analysis requires 3 — 5 Guinea pigs at whom depilprut a side surface of a stomach in advance. To one mumps enter vnut-rpkozhno 0,1 ml of ispytuyemy liquid from 0,1 ml of normal saline solution, and the rest on 0,1 ml of the studied liquid into mixes from 0,1 ml of monovalent diagnostic antigangrenous serum against each type of the activator. Overseeing by pigs is conducted by 24 hours. Diagnosis is based on quickly coming discoloration of skin of Guinea pigs (coloring in violet, pink, blue tone) owing to a local circulatory disturbance. The method allows to find toxicogenic strains of activators A sometimes. and. during the period of 30 min. to the 4th hour.
For definition of a lecithinase prepare double consecutive cultivations of the examinee of a filtrate of culture in the borate or acetate buffer (rn = 6,0) with calcium acetate (0,005 M). It is convenient to apply a chlorvinyl plate with 72 holes to this purpose. In holes spill 0,5 ml of the buffer. In the first two holes the buffer is not poured, filling them on 0,5 ml of ispytuyemy cultural liquid. Add to the first hole then 0,1 ml of the specific anti-toxic diagnostic serum supporting not less than 50 ME in 1 ml. In the third hole add 0,5 ml of ispytuyemy liquid and, having mixed it with the buffer, prepare consistently double cultivations. A plate leave then for 30 min. at t ° 20 ° in the darkened place. Specific serum during this time manages to neutralize action of a homologous lecithinase. Then add 0,1 ml of a letsitovitellin to each hole, mix liquids circular rockings and place a plate in the thermostat at t ° 37 ° for 2 hours. Reaction is considered in a transmitted light, noting opacification of liquid in holes by means of three-plus system. Specificity of reaction is confirmed by lack of opacification in the first hole containing homological anti-toxic serum.
It is necessary to emphasize that the bacteriological research cannot help urgent diagnosis And. the item since the answer can be received only in several days and even during the use of the accelerated methods — in 2 — 3 hours. Besides, detection of pathogenic anaerobe bacterias is valuable only in the presence of clinical symptoms And. and., since even Cl. perfringens very often find in the wounds which do not have any signs And. and. and not exposed to it in the subsequent.
Data of bacteriological researches can be used, however, at further treatment, especially at a serotherapy.
Histologic diagnosis, to-ruyu K. P. Ulezko-Stroganova and P. V. Makarov offered, was not widely adopted though at collaboration of surgeons, bacteriologists and pathologists diagnosis And. and., undoubtedly, can become more reliable. The simplified method based on studying of prints of a wound and the cytologic characteristic of wound separated can serve rather as an indicator of reactive and reparative processes, but not etiologies of an infectious complication though authors of a method (M. P. Pokrovsk and M. S. Makarov) consider that at And. and. it is possible to receive a specific tsitogramma — absence and sharp weakening of the phenomena of phagocytosis, lack of monocytes, presence of leukocytes with the phenomena of disintegration, and also existence of a large number of gram-positive sticks.
Other diagnostic methods And. item: serological, immunological, tests on specificity of toxins, precipitation tests and others — are based on pilot studies and did not gain distribution in clinical practice.
Hematologic researches at And. and. have no diagnostic value. Summing up numerous researches, it is possible to consider that a gemogramma at And. and. reflects the changes inherent in general to very heavy wound fever: quickly coming hypochromia anemia with a peytrofilny leukocytosis, an eosinopenia, a lymphopenia, acceleration of ROE and morphological changes of erythrocytes. Bacteriological detection in blood of anaerobic microbes is predictively very adverse symptom since is a sign of sharp oppression of protective mechanisms of an organism.
Treatment And. and. it is carried out in a complex. The wounds complicated And. and., shall be immediately subjected to surgical treatment on a way of a section — excisions: the wound shall be widely cut, its edges are moved apart by hooks then it is necessary to make full, sometimes very extensive excision all struck (gray, not bleeding) muscles on all course of the wound channel. Criterion of viability of muscles are reductions of muscle bundles during the crossing and bleeding from the crossed small vessels of muscles. After the termination of surgical treatment it is necessary big longitudinal (lampasny) or cuts to open with Z-obraznymp all bone and fascial cases on the damaged segment and to exempt muscles from a prelum. Cuts of fastion on the unimpaired proximal segment need to be made if on this segment there are symptoms of hypostasis and furthermore gas generations.
In the presence of a change imposing of a circular plaster bandage and intra bone fixing are contraindicated. For an immobilization use skeletal traction or immobilize an extremity by means of plaster splints. The wound is surely left widely open and rykhlo is tamponed by dry or wet gauze tampons. For wetting of tampons the set of various antiseptic solutions is offered though any of them has no clear advantages. In general these solutions shall be a little gipertonichny intercellular lymphs and have nek-ry antiseptic properties. Well work hypertensive (10 — 20%) the solutions of sodium chloride, solutions emitting oxygen (hydrogen peroxide), oily-balsamic emulsions etc. Krom of tampons enter a thin rubber tubule into depth of a wound, on a cut continuously or periodically enter mix of solutions of antibiotics with solution of Sulfamilonum or other germicides. Further apply intravenous drop continuous administration of polyvalent antigangrenous serum, edges by 3 — 5 times gets divorced normal saline solution. It is necessary to enter not less than one medical dose a day. According to the official instruction approved by the Ministry of Health of the USSR, the medical dose of antigangrenous serum makes 150000 ME (50000 ME serums antiperfringens, antiseptikum, antiedematiyens). After establishment of the bacteriological diagnosis it is necessary to enter only serum, of the same name with the allocated activator. Before administration of serum for detection of hypersensitivity to horse protein carry out an intracutaneous test with the divorced 1:100 serum taken from a test ampoule, edges is available in a box with a set of serums. 0,1 ml of serum from a test ampoule enter vnutrikozhno. Test is considered negative if diameter of a papule is no more than 0,9 cm, positive — with a diameter of papule of 1,0 cm and more and if the papule is surrounded with a big zone of redness. At a negative intracutaneous test enter subcutaneously 0,1 ml of serum and in the absence of reaction in 30 min. enter intramusculary all appointed dose or begin drop introduction. At positive test serum is entered only according to absolute indications. It is recommended to enter before it under skin bucketed divorced serum 20 min. in doses 0,5; 2,0; 5,0 ml. In the absence of reaction to these doses enter 0,1 ml of not divorced serum, at repeated lack of reaction enter intramusculary all appointed dose or start intravenous administration. When it is impossible to apply drop administration of serum (e.g., at evacuation), not divorced serum is entered intramusculary. In the course of treatment enter intramusculary or intravenously high doses of various antibiotics.
There is a positive experience of use of penicillin which is entered intravenously and intramusculary on 2 — 10 million. Piece a day. To avoid emergence of penitsil-lnnoustoychivy races of microbes, it is reasonable to alternate use of various antibiotics: Sigmamycinum, tetracycline, Kanamycinum, etc. Make hemotransfusions. The dose of a hemotransfusion is defined by the sizes of blood loss and degree of anemia. Massive hemotransfusions at And. and. patients transfer badly therefore apply frequent transfusions in a dose of 250 ml a day. The best effect is observed at direct transfusions directly from the donor to the recipient. The intravenous administration of polyionic solutions on 1 — 3 l a day promoting cultivation and removal of toxins, reduction of viscosity of blood and normalization of a hemodynamics is shown. In treatment And. and. sometimes use gaseous oxygen which theoretically shall promote death of anaerobic microbes. In 1917 B. S. Ioffe infiltrirovat the struck fabrics hydrogen peroxide. V. D. Sokolov in 1927 made inflation of oxygen in a circle of a wound directly from a cylinder. In 1941 J. D. Almeida applied oxygen under the pressure of 3 atm. All authors applying oxygen could not note clearly the expressed medical effect. At treatment And. and. oxygen and in the form of a so-called oxybarotherapy is applied (see. Oxygen therapy ). The oxybarotherapy shall be applied only after performance of surgical ways of treatment And. and.
Also partial perfusion of an extremity was tested (see. Perfusion ). By means of this method tried to create high concentration of antibiotics in tissues of an extremity, to wash blood clots and to eliminate a vascular spasm (I. L. Krupko et al., B. S. Grekov). In experiments satisfactory results were received. A. N. Syzganov for treatment And. and. suggests to impose a plait which shall squeeze only veins on a root of an extremity; inflow of an arterial blood is not broken. Then vnutrikostno the solution containing antibiotics is entered, fabrics become impregnated with this solution, surplus to-rogo continuously flows through a wound.
And. and. often is the cause of amputation of an extremity, and treatment sometimes is even begun with amputation when the damage rate of an extremity does not allow to expect its functional full value after recovery. Secondary indications to amputation are put in the presence of clinical symptoms quickly extending And. and. with it is clear the expressed heavy general reaction and especially at the extensive and deeply located center of an infection. Cutting off of an extremity is made above the center of an infection; at the same time visible borders of distribution of gas and hypostasis cannot serve as a reference point, and determine the level of amputation only by a condition of muscular tissue after a section of skin and a fascia. At detection in this section of the gray, not reduced and not bleeding muscle the level of amputation is increased to that site where are live, by brightly painted, bleeding and reduced muscles. The way of amputation of special value has no though it is more preferable to use scrappy cuts (see. Amputation ). After cutting off of an extremity delay skin of a stump in the proximal direction and make a section of all bone and fascial cases. Stitches are not put, the stump is covered with gauze tampons.
the Most effective remedy of the prevention And. and. is full primary surgical treatment of wounds (see), executed in early terms after wound. However always there passes some time before struck or the victim is brought to institution where primary surgical treatment therefore the majority of preventive measures aims to suppress temporarily microbic flora of a wound and by that to prevent or slow down development of infectious process can be executed. Vaccinal prevention And. and. carry out administration of the associated vaccinal drugs — polyanatoxins. Cl anatoxins. perfringens and Cl. oedematiens are a part of complex drug — a sorbed typroid vaccine with sekstaanatoksiny. 1 ml of a vaccine (a dose on each inoculation) contains 30 EU of Cl anatoxin. perfringens and 10 EU Cl. oedematiens, At immunization of the population are vaccinated aged people from 17 to 60 years by hypodermic introduction of a vaccine at an interval of 25 — 30 days twice. Vaccinated revaktsinirut 6 — 9 months later and then every 5 years or according to any special indications. At the correct dosage vaccination does not create the immunological competition between the antigens entering drug. Practical value of active immunization by anatoxins of activators A. and. it is not estimated quite authentically yet.
Seroimmunity And. and. during the Great Patriotic War it was carried out by administration of mix of antigangrenous anti-toxic serums.
In the beginning recommended to enter intramusculary 5000 ME (antiperfringens 1500, antiedematiyens 2500, antiseptikum 500 and antigistolitikum 500). Lack of effect was the cause of increase in a dose of the entered serum up to 14 000 ME (The instruction on field surgery, 1944). Preventive administration of serum was recommended at the wound of top and bottom extremities and buttocks which is followed by extensive destruction of muscles and at the wounds contaminated by the earth, scraps of clothes and also in cases when the plait was imposed. In post-war years preventive introduction 30000 ME is recommended (on 10000 ME antiperfringens, antiedematiyens and antiseptikum). Antigangrenous serums receive from horses, immunizirovanny anatoxin or toxin of the corresponding microbes. Serums are produced in a liquid or dry look, after cleaning and concentration with method of enzymic hydrolysis (diaferm-3) in the form of a set of ampoules, each of which contains monovalent serum (antiperfringens, antiedematiyens, antiseptikum), or in the form of mix of all three anti-toxic serums in one ampoule.
However, despite increase in a dose, the effect of a seroimmunity is so insignificant that there are no convincing proofs of its expediency, and preventive administration of anti-toxic serum by the wounded in wartime is considered optional. And germicides were much more effective bacteriostatic. The convincing experimental and clinical materials testimonial of the fact that under the influence of these drugs cultural, toxigenic and morphological properties of anaerobe bacterias change are given in the numerous works devoted to studying of sensitivity of anaerobic microbes to penicillin and other antibiotics. Changes especially clearly come to light if in a wound high concentration of antibacteritic drugs that manages to be reached at simultaneous introduction them — the general and local, i.e. directly in a wound or in fabric on its circle are created. When under the terms of a fighting or medical situation the wound cannot be subjected to surgical treatment in early terms, introduction of antibiotics allows to delay primary surgical treatment a little. With the same purpose enter into a wound solution of sulfanamide drug — Sulfamilonum, sometimes in a look penicillin-sulfamilonovoy of mix.
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A. H. Berkutov; T. I. Bulatova (epid), K. I. Matveev (mikr.).