Case Report

‘‘Flatus Profuse Present in the Muscles’’:Subcutaneous Emphysema of the Lower Abdominal Wall

and Thighs, Described in 1593 by Fabricius Hildanus

Erwin J.O. Kompanje and Ben van der Hoven

Abstract

Background: Between 1598 and 1641, 600 medical and surgical observations made by the famous Germansurgeon Guilhelmius Fabricius Hildanus (1560–1634) were published in his Observationum et curationum chir-urgicarum centuriae I–VI.Methods: Review of the extant document for evidence of infection-related cases.Results: One of the case reports, published as Observatio LXX in the fifth Centuria, bears the title (in translation)Of flatus, profuse present in the muscles. This case report probably is the earliest accurate description of subcu-taneous emphysema of the lower abdomen and thighs secondary to a retroperitoneal abscess.Conclusion: The presence of gas in the superficial tissues of the abdominal wall or thighs is a rare feature and canbe a late sign of an otherwise-obscure intra-abdominal abscess with gas-producing bacteria. Fabricius Hildanusalmost certainly was the first to document this rare feature in 1593, and judged it important enough to describein his Centuriae.

The presence of gas in the superficial tissues of the ab-dominal wall or thighs is a rare feature. Intra-abdominal

disease can cause subcutaneous emphysema, and it usually isassociated with perforation of the gastrointestinal tract, mostoften the rectum [1–11]. It also can point to a local gas-producing clostridial or non-clostridial infection [12]. Severalauthors have described retroperitoneal infections as a sourceof subcutaneous gas in the lower abdomen and thighs, whichalso can be a sign of an unsuspected intra-abdominal, retro-peritoneal, or scrotal abscess [10,13–24].

Between 1598 and 1641, 600 medical and surgical ob-servations made by the famous German surgeon Guilhel-mius Fabricius Hildanus (1560–1634) (Fig. 1) were publishedin his Observationum et curationum chirurgicarum centuriae I–VI [31]. Each of the observations is illustrated by one ormore case histories and some by woodcuts. The natural his-tory of the condition and the invented treatment are dis-cussed.

One of the case reports, published as Observatio LXX in thefifth Centuria, bears the title (in translation) Of flatus, profusepresent in the muscles. This case report probably is the earliestaccurate observation of subcutaneous emphysema of thelower abdomen and thighs attributable to a retroperitonealabscess.

Case Report

Here is an English translation of the most essential part ofthis case report:

In the year 1593, in Keulen, I was sent for a boy of about tenyears old, who has suffered heavily from smallpox, of whichhe was almost cured, but now his belly, down from the um-bilicus, and his hips and thighs were peculiarly extended withflatus, which was present between the skin and the muscles,and partly in the muscles, and when these parts were touchedwith our hands, they rustled, just as fresh calf’s meat, thatthe butcher has inflated with air. He felt no pain, his inter-nal parts were comfortable, and with almost no effects ofthe previous illness. We used several means, internally, tostrengthen the noble internal organs, and externally, to makethe flatus disappear, which ultimately resulted in a favour-able outcome. If this excess in flatus penetrated the musclesfrom the stomach or intestines, or developed locally, I willleave that judgment to the experts.

Discussion

Hildanus gives an accurate description of abdominal wallcrepitus attributable to subcutaneous gas in a ten-year-old

Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, The Netherlands.

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boy recovering from a severe case of smallpox. In the 16thCentury, only variola major, the serious form of smallpox,occurred.

One can only speculate what caused this subcutaneousemphysema. Variola major was a serious infectious disease inthe 17th Century, in many cases affecting several organs, in-cluding the intestines [25–27]. The virus can destroy the liningof the intestines, making the membranes disintegrate. Thepalpation of crepitus caused by gas in the subcutaneous tissue

of the lower abdominal wall and thighs can be a late sign of anotherwise-obscure intra-abdominal abscess caused by gas-producing bacteria [7]. This seems to be the cause of thesubcutaneous emphysema in this boy. Bacterial infectionsresulting in abscesses were common in the 16th Century,especially as complications after viral infections and in chil-dren with lower resistance [25–27]. Possibly the boy had aperforation of the gastrointestinal tract affected by smallpoxor a secondary infection, resulting in a retroperitoneal abscess

FIG. 1. Guilhelmius Fabricius Hildanus (1560–1634).

350 KOMPANJE AND VAN DER HOVEN

with gas-forming non-clostridial bacteria. The gas gains ac-cess to the lower extremity under the inguinal ligament or viathe sciatic foramen [13]. The boy did not complain about ab-dominal pain, but signs of peritoneal irritation are uncommon[13]. Another consideration is that the boy was suffering fromdiabetes mellitus type I with a gram-negative infection lead-ing to crepitant cellulitis [13,15,28].

Several authors mentioned that Abeille [28] described thefirst case of subcutaneous emphysema arising from the gas-trointestinal tract in 1853 [8,23,30]. Regardless of the etiologicmechanism, Fabricius Hildanus almost certainly recognizedin 1593 the first documented case of this rare feature, andjudged it important enough to describe in his Centuriae.

Author Disclosure Statement

No conflicting financial interests exist.

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Address correspondence to:Dr. Erwin J.O. Kompanje

Department of Intensive CareErasmus MC University Medical Center Rotterdam

P.O. Box 20403000 CA Rotterdam, The Netherlands

E-mail: e.j.o.kompanje@erasmusmc.nl

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