The next morning the patient was unable to pass his water, and had to be catheterized. Aside from this no ill effects were seen, and his temperature and pulse remained practically at the same place. At the end of 48 hours the drains and dressings were changed and the patient was doing well and the wound draining profusely. At no time was the bed elevated and at no time was a stimulant administered, with the exception of a hot normal salt enema on the day following the operation. Several times during his stay a dose of castor oil was given, but no other medication was necessary. As the dressings were reapplied and drains introduced daily the wounds were found to be granulating up, and gradually these closed, first the one in the lumbar region and then the one in the abdomen. By the tenth day a normal temperature was present, and he sat up on the twelfth.
The child went on to an uneventful recovery, and went home on January 21st fully cured.
This was undoubtedly one of those cases of gangrenous appendicitis where, owing either to the intensity of the infection or to a thrombosis of the vessels supplying the appendix, the vitality of the tissues is lost and gangrene results. Now, "even in this, the gravest form of appendicitis, the general peritoneal cavity is often protected against infection by walling off the pus, and the appendix, detached in the form of a slough, is often found on opening the localized abscess." But "in other cases there is from the beginning the symptoms of peritoneal sepsis and peritonitis."
Now, it seems to me that a great deal depends on the kind of infection--or, rather, the kind of organism infecting--and often the difference between a localized abscess and a general peritonitis is really the difference between a colon and a streptococcus infection. Again, should a general peritonitis develop, I have noticed from a number of cases in the wards that the prognosis practically depends on the organism, although we all know that a general peritonitis is a mighty grave condition, no matter what it is due to.
Another point in favor of the child was the fact that the gangrenous process seemed to start in the tip of the appendix, and it seems that when it starts there, there is greater likelihood of localization, and when it starts in the base a greater likelihood of general peritonitis.
I said that there was often doubt as to the condition in the abdomen in these cases. Now, there can be no doubt that the two main points in the diagnosis of a localized abscess are tumor and an aggravation of the symptoms present. But this case exemplified the fact that there may be cases where there is no aggravation of symptoms, and in a great many cases it may be impossible to feel the tumor until it has become very large, owing to its situation, viz., post caecal. Even in this case, from which a great quantity of pus was evacuated, there was no absolute certainty of finding pus on opening the abdomen, although it was suspected strongly.
I have seen a patient walk into the hospital on Sunday with a temperature of 100 and a pulse of 99, and when the abdomen was opened on Monday morning a most virulent form of general streptococcus peritonitis was found, from which the patient died the next day. It is said that it is much better to depend on the pulse and its variations than on the temperature.
I would like to call attention to several points in the treatment of this case also.
First, the place of incision was, as I said, well up towards the iliac crest, and not in the time-honored McBurney point. The wisdom of this is self-evident.
Second, the care used in not breaking up the wall of the abscess formed by the peritoneum.