Arrosion Hmmorrhages in Perityphlitis. The already protean picture of appendi citis is further enriched by this communication of the erosion in two instances of the larger vessels in proximity to the inflam matory process. The first case occurred in a male aged twenty one years. The symptoms of perforative appendicitis were asso ciated with a large exudate occupying the iliac fossa and reaching to the psoas. In the course of four weeks, regressive changes set in, so that barely any resistance could be made out. Suddenly an aggravation of the condition set in characterized by a very rapid reappearance of a large mass in the iliocostal region, rapid pulse, and a rise of temperature in twenty-four hours. This afforded an indication for operative interference.
Operation. Incision with the idea of effecting drainage through a retroperitoneal incision. In the act of peeling off the thickened peritoneum, one ounce of pus escaped, followed by a stream of fluid blood coagula and masses of fibrin. Digital ex ploration outlined a cavity extending to the spine up to the pan creas and out as far as the kidney. The cavity was extraperito neal. A counteropening was made at the outer margin of the sacrolumbalis. This case recovered.
The second a girl of fourteen, was laid low with appen dicitis for two weeks. An exudate extended into the pelvis and to the left iliac region. Rectal incision followed by free flow of blood. The presence of coagula partly organized and masses of fibrin show that the vessel was not injured at operation. An iodoform tampon controlled the hxmorrhage. Delay to operate in the first case was based on the collapsed condition with eventual signs of improvement. From a diagnostic stand-point the sud den accession of a larger area of dulness might suggest a Immor rhage, and will in the future be taken into consideration ; yet Sonnenberg narrates serofibrinous exudates attaining a larger size in a few hours. The site of the hxmorrhage was in all likeli hood one of the larger iliac vessels ; in support of which a number of instances from American literature are quoted where secondary hmmorrhages were all located in iliac vessels. Beitrage zur klinischen Chirurgie, Band xxix, Heft 1.
The Rectal Incision of Perityphlitic Abscesses. The author champions the rectal drainage of perityphlitic exudates that present themselves in the pelvis and are palpable per rectum.
Based on successful efforts of nature to thus effect a spon taneous cure the technique is thus outlined. Under narcosis the sphincter is dilated, and with the aid of a speculum the exploring needle is thrust into the exudate. On the appearance of pus, the needle is left as a guide upon which but a small incision is made, then to be dilated with forceps. This opening, while sufficient to effect thorough drainage, must not be too large for the drainage tube which is enveloped in iodoform gauze. To prevent the tube slipping, it is sutured to the edge of the wound. Daily irrigations through the drainage tube are performed. Opiates are given during the first days after operation. If the tube slips, it might be replaced, but five to six days are sufficient time for its remain ing. The erect posture is to be assumed as soon as possible, to still farther favor drainage supplemented by sitz-bath. When the rectal wound is healed, the abdominal route can be chosen with the safety peculiar to the interval operation, and with the additional security, of the avoidance of a hernia.
The fears of secondary infection from the rectum are purely theoretical, and not borne out by practice. Abscesses on either side of the pelvis may thus be drained. Any haemorrhage occur ring may be controlled by tamponade. Analogous to this tech nique is drainage by vagina in females or the perineal or para sacral route in males. Beitrage cur klinischen Chirurgie, Band xxix, Heft i.