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and the small sediment consisted of mucus and bladder epithelium. The blood count showed 4,500,000 red and 12,000 white corpuscles. The hæmaglobin was not estimated. There were no malarial parasites. The digestion was feeble, and he was given only liquid food, but milk curds appeared in the stools frequently, in spite of dilution with an equal amount of water.
On August 10th, after the usual preparations, ether was administered, and the abdomen was opened by an incision two inches long, beginning half an inch above the pubic bone and one and onehalf inch to the left of the median line, extending upward parallel with the linea alba and over the most prominent part of the tumor. The adhesions were burrowed through with the finger in a direction vertical to the incision, but no pus was found. The muscles and skin were then retracted an inch toward the median line, and the peritoneum opened at this point. Using the finger again to break through the adhesions, a pus cavity, containing about two and onehalf ounces of pus, was opened and emptied by mopping. After exploring the walls of the cavity, it was packed with iodoform gauze.
The cavity was situated over the bladder and a little to the left of its center. Its walls were smooth, and it was tightly adherent to the anterior abdominal walls. A sinus, not large enough to admit the finger, extended downward behind the bladder.
The temperature rose to 100° F. and the pulse to 160 within a few hours after the operation, but fell the following day, the temperature to normal and the pulse to 115. The bowels acted on the third day, and convalescence was rapid. The gauze packing was removed on the fourth day and renewed every third day thereafter. He was discharged on the first of September, just one month from the date of his admission, with this observation: The abscess cavity has closed completely and only a small superficial wound remains unhealed.
I understand there was some delay in the final closing of this small wound, and that a physician in San Antonio removed what he thought was a ligature, but which must have been a thread of gauze, for there was no ligature placed in the wound.
The chief point of interest in this case, was, to me, the determination of the original source of infection of the peritoneum. To say that the case was one of peritonitis, with local suppuration, was easy, but to name the exact cause of the peritonitis and abscess formation, was a more difficult matter. Certain diseases of the alimentary canal naturally suggested themselves as the most likely cause, and a perforated typhoid, gastric or duodenal ulcer, ulceration of the sigmoid and appendicitis, were considered. The history of perfect health up to the time of the onset and the location of the chief amount of trouble in the lower half of the abdomen seemed sufficient to eliminate gastric and duodenal ulceration, while the age, history and absence of any symptoms referable to the lower bowel made it comparatively certain that the sigmoid was not diseased.
When we come to typhoid fever, one might be inclined to exclude it because of the sudden onset, without previous symptoms. Reflection reminds us, however, of an occasional case of typhoid that goes on to perforation without marked symptoms and without the patient being aware of the fact of his having any disease.
I saw a young man, about a year ago, who plowed in the field every day, until he was attacked suddenly with severe pain in the abdomen, collapse and death within thirty-six hours. An autopsy was not done, but inquiry elicited the fact that he had been a little unwell for two weeks or more; that he had complained of feeling feverish at night, and that he did not look as well and did not seem as energetic as usual. I thought I was fully justified in concluding that he had had typhoid fever for at least two or three weeks, and that a perforation had put an end to his life.
In the present case, however, there was absolutely no symptom of the slightest illness before the attack, and there was no collapse, as is usually the case in a perforation of typhoid. These facts enabled me to conclude with confidence that we were not dealing with typhoid fever.
Of all the diseases of the alimentary canal, then, we have left only appendicitis as a possible cause of the trouble before us. Studying carefully the symptoms of the beginning of the attack, which I consider of very great importance in the diagnosis of appendicitis, we have the sudden onset with previous good health, pain and tenderness in the right iliac fossa, nausea and vomiting, without relief of pain, and these followed by rise of temperature and increase of pulse rate. Add to this, rigidity of the right rectus muscle, which was not noted but which probably existed, and we have all the cardinal symptoms of an acute appendicitis. On the following day, however, this distinct picture becomes blurred. Pain is felt as severely in the left iliac fossa as in the right, and there is also pain in the right hypochondrium. Later on, a tumor appears in the right hypochondrium, disappears and another forms in the left iliac region; certainly sufficiently irregular to justify one in reconsidering the diagnosis. Infection from a diseased gall bladder, a suppurating cyst of the liver, or a suppurating lymph gland, tubercular peritonitis and tuberculosis of the bones of the abdominal walls, were all thought of and dismissed, as not conforming reasonably to the symptoms.
Suppuration, occurring in the space of Retzius, was strongly suggested by the location of the abscess, as it appeared in the latter part of the patient's illness, but in no other respect could it be made to answer to the conditions present. The operation showed, too, that the abscess was intra-peritoneal.
So, after all, the diagnosis of appendicitis would be most likely to be correct. Accepting it as the correct diagnosis, what explanation of the irregular features of the case can be made ?
How are we to explain the existence of pain in both the right and left iliac regions, and the formation of an abscess on the left side? The case began as a fairly typical case of right-sided appendicitis, and ended as a left-sided one. The simplest explanation, and the only one I have to offer, is that the appendix situated normally on the right side was long enough to reach across the median line into the left iliac fossa where it infected the peritoneum sufficiently to produce pain and result in the formation of an abscess. The patient being a boy and probably not fully developed (although he was unusually large for his age), it might seem likely that th eæcum had not assumed its normal position in the right iliac fossa; but if we accept that view, how will we account for the pain in the right side, in the beginning of the attack?
I hope to have a free expression of opinion on this point, and to gain a clearer understanding of it from the discussion.
DR. H. W. CROUSE, Victoria: I believe that the case that the doctor has just so beautifully described for us to be one of appendicular abscess. It is a well-known fact that we have at times a true wandering abscess existing in appendicular cases; further that the location of the appendix is decidedly varying, at times beneath the liver, at others in the right iliac fossa, and again to the left of the median line. I have seen one or two cases, which, when observed at first, were located in the normal position of McBurney's point which, with all the signs of rupture, wandered, as it did in one case that I recall, into the cul-de-sac of Douglas in a female patient. Taking all the points the doctor has laid before us, I am quite sure that his case was one which we could denominate properly as wandering appendicular abscess.
THE GLYCERITE OF BOROGLYCERIN AS A SURGICAL
R. W. KNOX, M. D.,
The United States Pharmacopoeia states that boroglycerin is a combination of 62 parts of boric acid and 92 parts of glycerine reduced by heat to 100 parts. Kennedy states that boroglycerin is a definite chemical compound and not a mechanical mixture. The official preparation and the one used as a surgical dressing, and ordinarily called boroglyceride, is correctly named glycerite of boroglycerin and is prepared by combining, under heat, equal parts of boroglycerin and glycerine. It is commercially known as 40 per cent boroglyceride. I have found that the druggists in this climate prepare a very inferior product, due probably to the excessive moisture in the atmosphere and the hydroscopic properties of the glycerine. On this account, I have made it a rule to order this preparation ready-made from certain well known pharmaceutical houses. The 50 per cent solution may be still further reduced with glycerine or distilled extract of witch hazel, or with water when a solution is desired, or it may be made into an ointment salve, by combining it with the ointment of rose water or other simple cerate.
I have found this preparation useful in burns, scalds, phlegmons, and other inflammations; also for packing abscess cavities, ulcerations and infected wounds. For burns or scalds the distilled extract may be used as a diluent. In hospital practice especially, I find it meets a long-felt want, and much superior to the various and sundry powders that are ordinarily employed. My preference for the use of boroglyceride is based on the following: 1. It is antiseptic. 2. It is easy to apply, very clean, and has no odor. 3. It hastens the healing process by not crusting the wound and retaining pus. 4. Prevents exuberant granulation and the formation of pus.