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On examination, I found patient's condition as follows: Temperature 99, considerably emaciated, tongue slightly furred, heart, liver, lungs and kidneys as nearly normal as one would expect to find them after such a prolonged illness. His pulse was 68 and unusually full and strong; facial expression, good. Patient had been taking quite a good deal of nourishment, and was in excellent spirits. The mass on right side was now about the size of a large orange, with half its diameter above the normal level of the abdominal wall, soft and fluctuating. As there was no necessity for immediate operation, the patient by reason of having made a trip of twenty miles by rail during the day, it was decided best to allow him to rest until the following day before operating. There was now very little tenderness on palpating the mass, and by being careful, it was not necessary to anesthetize the patient while shaving and scrubbing the abdomen, preparatory to operating. The condition apparently demanded nothing more than a local anæsthetic, but as one can not often be positive in regard to what will be found in such cases, it was decided to administer chloroform. Accordingly, assisted by Drs. Pope and Swonger, the operation was done December 30, 1902. Observing the usual aseptic and antiseptic precautions, an incision one and one-half inches long Iwas made over the mass. To reach the abscess cavity, it was only necessary to cut through the skin and an unusually thin layer of muscular tissue. About a pint of yellowish pus, of a not very fetid. odor, was quickly evacuated, and as the cavity was perfectly walled off from the general abdominal cavity, the sack was flushed out with a warm saline solution, until the water came away clear. Only a few minutes was required for the operation, the greater part of the time being consumed in the preparation. As there was a considerable cavity, a strip of gauze was inserted for drainage, the usual dressing applied, the patient put to bed in good condition. On recovering from the anesthetic, the patient expressed himself as feeling all right, except some slight nausea. On visiting him in the afternoon, his condition was good, except considerable nausea

and frequent vomiting. On evening of same day, his nausea had become less intense and he had retained a little fluid, the pulse, however, being 102. As a few doses of aromatic spirits of ammonia had partly relieved the vomiting, I ordered a hypodermic of 1-30 grain of strychnine, with instructions to repeat the ammonia if nausea recurred, and left the patient for the night, in care of a brother and a nurse.

I was called early in the morning, and to my chagrin, surprise and keen disappointment, found my patient in the act of dying, he living only a few minutes after my arrival. The nurse stated that the patient rested fairly well until midnight, when there was a recurrence of the nausea and vomiting. No alarming symptoms were noticed until a few moments before I was called. There was absolutely no distension of the abdomen. Temperature, one hour before death, 99; pulse, 120.

On account of the apparent splendid condition of the patient, and comparative insignificance of the operation to be done, I regret to say, a blood examination, which would probably have cleared up matters some, was not made.

CASE 2. J. R., age 38 years, merchant by profession, complexion fair, weight 190 pounds. This patient was suddenly seized one night with severe pains in lower part of abdomen, but not localized or more severe on one side than the other. He called a physician, and he gave his -grain hypodermic morphia, and also prescribed a mercurial purge. On the following morning his condition had not improved, and he now complained of pain being more severe on right side. As stated by his physician, patient's temperature on day following attack was 102; the bowels not having moved, citrate of magnesia was administered, followed later during the same day by soap and water enema, after which bowels moved freely, and patient stated that he felt better. On the second night there was a recurrence of the pains experienced on the first and also considerable distension and rigidity of abdomen. The pain had now become much more severe in the region of the appendix and there was also extreme tenderness in the same region. Temperature 102.5. I

saw the patient on the third day after the beginning of illness, having been called in consultation with the patient's physician, Dr. T. B. Haynes, of Beaumont. Patient's temperature on this day was 103. Thick brownish fur on his tongue, pulse 110, tenderness over whole lower part of abdomen, being much more marked in the region of McBurney's point. There was also a marked rigidity of abdominal wall, together with retraction of right lower limb. If there was any mass in region of appendix, it could not be made out by reason of extreme thickness of patient's abdominal wall. Other symptoms of appendicitis were also present, and his condition was unmistakably becoming progressively worse. Hence, we did not hesitate to advise an immediate operation, as holding out for him the best chance of ultimate recovery. The mere suggestion of operation was enough to strike terror to this man and his family, and they at first positively refused to consider such a procedure; however, after further explanation, the patient finally consented to undergo operation on the following day; provided, there should be no sign of improvement. To this I was obliged to reluctantly consent; not neglecting, however, to impress on the patient that, in my opinion, such a delay was very injudicious and dangerous. On the following day his condition was much improved, and his recovery was rapid and uneventful. His health has remained good up to the present time.

CASE 3. L. P., oil well driller, age 26, an unusually strong and robust individual, being six feet tall and weighing 180 pounds. Previous health good. I was called in consultation with my friend, T. W. Beckman, of Beaumont, to see the above described patient on November 10, 1902. On Sunday, four days previous, patient stated that he felt somewhat indisposed, and did not attempt to work; he suffered some slight pains in abdomen, also considerable nausea. On Monday following his suffering had become more intense, and a physician was called, who stated to me that he found the patient with a temperature of 101, pulse 95, thickly furred tongue, nausea and some vomiting, with pain and tenderness over whole of abdomen. A mercurial purge was prescribed,

followed by quinine and a saline, if necessary. On Tuesday, the third day from the beginning of illness, the doctor was again called, and found the patient with a temperature of 102, pulse 98, with other symptoms as described above, only considerably exaggerated. The doctor stated that the tenderness over the abdomen had increased very much in intensity, especially on right side, in region of appendix, where it was apparently becoming localized. The physician deciding that an operation would probably be necessary, had the patient transferred to the Sisters Hospital in Beaumont, Texas, where I saw him on Wednesday, the fourth day after beginning of illness. His condition at this time was as follows: Considerable distension and rigidity of abdominal wall, marked pain and tenderness in region of appendix, where a mass, the size of a small fist, could easily be felt. Patient's temperature was 102, pulse 110. Nausea, but no vomiting for twelve hours. Pain in region of appendix had become very intense, requiring morphine at four to six hour intervals. As the patient's condition had been constantly and rapidly growing worse from the first, it was decided to advise an immediate operation. This was done, and the patient consented to have it done as soon as possible. Dr. T. W. Beckman assisting, and Dr. R R. Sullivan administering the anesthetic, the operation was done on Wednesday evening following the beginning of illness, on the previous Sunday. The usual incision was made over McBurney's point, which was also directly over the mass. On reaching the peritoneum, it was soon evident that the adhesions, if any, were not very firm, as coils of intestines could be distinctly felt passing beneath the finger and pressing upward into the wound. On opening the peritoneum, more than a pint of sero-purulent discharge escaped, which possessed a distinctly fecal odor. In fact, the last of the discharge to come away was mixed with fecal matter. The adhesions only partially protected the general cavity. The cæcum was bound down and omentum adherent at several points. On careful exploration with the finger, it was found that the appendix had already sloughed off, leaving a small opening in the cæcum, from which its contents were slowly oozing. During this

exploration every precaution had been taken, by careful gauze packing, to prevent, as far as possible, the soiling of the general peritoneal cavity. On further exploration with the finger, a mass, the size of a medium sized orange, was found lying somewhat behind the cæcum. It was freely movable to a limited extent in all directions, except upward through the wound. This mass proved to be the missing appendix, which was more than half enveloped by the omentum, and held in position by part of its own mesentery. As the omentum was so firmly attached that it could not be separated from the mass, ligatures were thrown around it in sections, and after tying the mesentery of the appendix, the mass was cut away with the scissors. On examination, what was once a normal appendix was now the size of a hen's egg, soft in consistency, and almost black in color, with three perforations, from which pus was oozing. An attempt was now made to close the cæcal opening, but without success, as its walls were so friable that the least tension would cause the sutures to cut through, leaving the condition worse than before. Failing in this, we decided to pack, as carefully as possible, around the perforation, and thus to a certain extent at least, protect the adjacent parts from the discharge. The gauze was introduced in such a way as to leave a tubular passage down to the cæcal opening, thus making a free exit for the fecal discharge. Silk worm gut sutures were used in closing the wound. An opening, two inches in length, was left in the central part of the wound for drainage purposes. While great care had been exercised in protecting the abdominal cavity, and its contents not already involved by the disease, it had not been altogether successful. During the progress of the operation, distended coils of the small intestines presented in the wound more than once, and that they became soiled, goes without saying. Although great care was exercised in cleansing them, they could not possibly be scrubbed to that extent one would wish one's hands to receive before introducing them into the abdominal cavity. The usual outside dressing being applied, patient was sent to bed in good condition. Considering the extremely rapid progress of the disease in this case, together with

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