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Acute Appendicitis Abscess of the Lung Gangrenous Cholecystitis Dr Brewer



DR. BREWER presented a man, aged fifty years, who was ad mitted to Roosevelt Hospital in October last. Family and previ ous personal history negative. Three weeks before he had ex perienced an attack of diarrhcea, which continued for several days. This was accompanied by abdominal pain of moderate intensity at first, afterwards it became localized in the right inguinal region and was more severe. There was no vomiting. The pain finally became paroxysmal in character, and at times so severe as to pre clude the possibility of his performing his ordinary work. When admitted to the hospital his symptoms were apparently subsiding ; temperature, 99.8° F. ; pulse, 72. There was slight muscular rigidity over the right half of the abdomen, with tenderness more marked midway between the region of the appendix and the gall bladder. He was kept under observation for several days with a view to performing later an interval operation. At the end of three days his temperature was mo° and pulse 80. On the even ing of the third day there was a slight rise in the temperature, increased pain, slight tenderness, and an indefinite sense of resist ance about the middle of the right half of the abdomen ; he looked septic, and it was decided to perform at once an exploratory operation.

Under ether anwsthesia the abdomen was opened over the appendix region by an intermuscular incision. As the cxcum could not be found in its normal position, but could be felt partly surrounded by an indurated mass well upward near the free bor der of the liver, the original incision was closed and a second one made over the region of the indurated mass. After the peritoneal cavity was opened, the adhesions were broken down, and an in flamed appendix discovered lying in a small abscess cavity behind the caecum. This was removed and found to be the seat of a gangrenous perforation. The abscess cavity was treated with peroxide of hydrogen, and drained posteriorly through an inci sion in the flank ; the abdominal cavity was closed.

The following day his temperature rose to me F.; pulse 124: there was evidence of a well-marked local peritonitis. The wound was freely irrigated, and the lower anterior wound opened and through-and-through drainage employed. His condition gradually improved, but his temperature never fell below me.

Thirteen days after the operation there was a sharp rise in temperature to 105° F., and well-marked evidences of a pneu monia of the lower right lobe detected. As the abdominal wounds seemed to be in satisfactory condition, he was transferred to the medical side of the hospital. For three weeks he remained in much the same condition, the pneumonia apparently limited to the lower and middle lobes of the right lung, although his temperature and pulse and general symptoms indicated a graver degree of sepsis than the presence only of an unresolved pneumonia would warrant.

At the end of three weeks from the first appearance of the pneumonia his condition was so grave that a diagnosis of em pyema was made, and he was readmitted to the surgical service. His temperature at this time was 105° F.; pulse, 144; respira tions, 40. He had profuse sweats, chills, and other evidences of grave sepsis. An aspirating-needle was introduced in several locations from behind without reaching pus ; it was then intro duced from the anterior region of the chest and a pocket of pus reached, apparently situated about the centre of the middle lobe of the lung. As his condition was now extremely critical, he was taken to the operating room and given a few whiffs of chloroform, and about three inches of the sixth rib quickly resected. As the parietal and visceral layers of the pleura were firmly adherent, an incision was made directly into the lung tissue. At the depth of about two inches a large pocket of pus was found and evacuated. The wound was washed with peroxide of hydrogen, and, although considerable ha2morrhage was present, a double drainage tube was introduced and the rest of the cavity packed with gauze.

Following this operation there was a gradual improvement in his condition, and in twelve days his temperature had fallen to normal, and only a small sinus, leading to the cavity in the lung, remained. As the abdominal wounds were now healed, it was thought that convalescence was thoroughly established. For two weeks he continued to do well ; temperature, pulse, and respira tions were practically normal, appetite keen, gaining rapidly in flesh and strength. After being up and about the ward for several days, on the day of his expected discharge from the hospital his temperature suddenly rose to 105° F.; pulse, 130. With this there was acute abdominal pain, with muscular rigidity, and a rapidly increasing distention. The tenderness was general at first, but gradually became localized in the epigastric region. The follow ing day there was slight improvement, and, as there had been no vomiting, a delay of a few hours was thought advisable until his symptoms suggested a more definite lesion. The original abdomi nal wounds were reopened, but nothing found to account for his symptoms.

The following day, as there was no improvement, and as there was a marked tenderness over the gall-bladder and right half of the abdomen, an incision was made over the outer border of the right rectus muscle, extending from the ribs to a point opposite the umbilicus. When the peritoneal cavity was opened a large amount of free, turbid fluid escaped ; there was an enor mous mass of adhesions, consisting of liver, omentum, hepatic flexure of the colon, and duodenum. This was carefully explored, and at a depth of two inches the gall-bladder was found greatly distended and gangrenous. This was opened and about half a pint of foul-smelling pus evacuated. A second incision was made in the flank and a large collection of pus found lying to the outer side of the ascending colon. The cavities were irrigated with peroxide of hydrogen and salt solution. A large drainage tube was introduced into the gall-bladder, an enormous drain of gauze into the upper part of the abdominal cavity, which led outward through both incisions. He was extremely ill for several days ; after free catharsis, there was a gradual improvement. At the end of a week the muscular rigidity and abdominal distention had subsided, and at the end of two weeks his temperature had fallen to normal, and both wounds were granulating nicely.

It may be added that at the first dressing gentle traction upon the drainage tube resulted in its removal, together with the entire sloughing gall-bladder. The biliary fistula remained open for about three weeks ; one week later all wounds were closed, and he was discharged from the hospital.

_ DR. F. LANGE said that in cases of appendicitis where the exudate can be felt above a line corresponding to the anterior spine of the ilium he has adopted the plan of making a posterior incision, no matter whether the exudate is in the vicinity of the anterior wall of the stomach or not. In a large percentage of such cases one will find that the exudate comes from an appendix which is located on the outer aspect of the ascending colon. Such an incision may obviate the necessity of opening the free cavity.

temperature, cavity, abdominal, days, pulse, incision and weeks