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The following case is of clinical interest from the fact that the disease developed during the time that the obstetrician is on the lookout for a puerperal infection and, also that the symptoms were at no time as marked as one would expect from the conditions found at operation.
Mrs. P. Aet. 21. Primipara. Had been constipated for years. Several times previous to pregnancy and twice during pregnancy she had had attacks of abdominal pain of several hours' duration, but never of sufficient severity to confine her to her bed. These attacks of pain had not been accompanied by vomiting and as near as I could learn from her, had never been localized. For some time previous topregnancy and also during pregnancy, there had existed a very marked polyuria, the amount of urine averaging about four quarts during the time she was under my observation, which was from the sixth month. I had never seen her during one of these attacks of pain, but she stated that the amount of urine was always increased during their continuance. Gestation was otherwise normal, there being no symptoms of toxemia or renal disease.
During the twenty-four hours preceding labor, she complained of paroxysmal abdominal and lumbar pains which were probably due to the onset of labor. She stated afterwards that they were not at all similar to her previous attacks of pain. Labor was very slow and almost powerless, it being necessary to use manual dilatation of the cervix and delivery was made with forceps. At this time, 4 A. M., her temperature was normal. The temperature for the next three days ranged from normal in the morning, to 100° F. at night. Her general condition was good, the lochia normal and nothing was thought of this slight rise of temperature. On the evening of the second day after labor, she complained of pain in the right side, which was entirely relieved by an enema. This pain returned on the third and fourth days and was relieved in the same way, each enema bringing away a large fecal stool. Up to this time I had thought the pain was nothing unusual and was due partly to the traumatism of labor and partly to gas on account of the constipation.
On the morning of the fifth day, the temperature was 101° F., and suspecting an infection, I made a careful examination. I had not thought of the possibility of an appendicitis and was surprised to find an indurated mass in the right iliac fossa with slight tenderness over McBurney's point and some rigidity of the abdominal muscles on the right side. I diagnosed appendicitis and operated during the after
noon of the same day. I confess that the conditions did not seem to demand haste in operating, and I hesitated about doing so, but I followed my belief that operation should be made as soon as the diagnosis is made.
• The operation revealed a pus case, the abscess walled off, but its walls so thin that rupture took place while outlining its extent. The appendix had completely sloughed off at its base, leaving a large opening in the cæcum. Fully a pint of pus was evacuated. The abscess cavity was flushed with salt solution, the patient being turned on the right side. Nothing was done further than to enlarge the opening in the abscess wall sufficient to place a large Mikulicz drain, which filled the abscess cavity.
The following morning a septic general peritonitis had developed with temperature, 103° F., hiccough, vomiting, tympanites, etc. The gauze strips were removed from the drain and continuous irrigation of the abdominal cavity with normal salt solution was made for three hours, from 8 A. M. to 11 A. M. The symptoms of peritonitis disappeared by evening of that day, the evening temperature being 99° F. The Mikulicz drain was continued for one week and gauze strips thereafter until the fecal fistula had closed. The patient made an uninterrupted recovery and was discharged three weeks after the operation.
An interesting and unexplained feature of the case was that the polyuria ceased before she left the hospital.
Comments.-It is difficult to fix the time when the attack of appendicitis began. The pains felt during the day preceding labor might have originated partly from an inflammation in the appendix, but the first real symptoms which were referred to the region of the appendix were not present until the evening of the second day after labor. Even then, the symptom of pain was the only one of which the patient complained.
The fact that this case of appendicitis was allowed to go on to abscess formation without diagnosis was a serious error on my part, and it should emphasize the importance of an early and careful examination of a parturient woman to determine the cause of slight elevations of temperature and presence of pain during the puerperium. It has always been my practice heretofore to ignore a temperature below 100° F. after labor. Had I examined the patient, instead of deciding off-hand that all she needed was an enema, I might have made an earlier diagnosis.
The history of the case after operation shows the value of early irrigation of the abdominal cavity with salt solution in cases of septic post operative peritonitis. I am sure that this case would have been one of the fulminating post-operative type had the irrigation been delayed for 12 hours. It was the first successful experience I had had with this treatment and I am convinced that previous failures were due entirely to the fact that the treatment was too long delayed.Bishop in American Physician.
TONSILITIS A CAUSE OF ACUTE NEPHRITIS. Morse (Annals of Pediatrics) believes it to be reasonable that tonsilitis, being due to bacterial infection and being often complicated by cervical adenitis, peritonsillar abscess, or acute inflammation of the middle ear, should lead to inflammation of the kidney, as do other acute infectious diseases. He describes four cases of tonsilitis that were followed by acute nephritis.
It is evident from these cases that tonsilitis, whether of a severe or of a mild type, may be the cause of acute inflammation of the kidneys. It is probable that tonsilitis is more often followed by nephritis than is commonly supposed, and it is very likely that in many cases which are considered primary the infection enters through the tonsils, the local manifestations not being severe and having been forgotten. This being so, tonsilitis should not be looked upon, as it usually is, as a simple disease and of but little importance. A disease which can cause acute endocarditis and acute nephritis is certainly one worthy of consideration. The heart and urine in tonsilitis should, therefore, be examined as carefully as in rheumatism or scarlet fever, and the examination kept up for a time during the convalescence.
INJURY AS A CAUSE OF NERVOUS DISEASES. The writer discusses the severe nervous disorders which are sometimes attributed to trauma, such as multiple sclerosis, though there is very little evidence of this condition being primarily caused by trauma. Similarly with locomotor ataxia. Trauma may be the exciting cause in a syphilitic subject, but as to its being the primary cause, he questions it. He doubts also whether it can be secondary to injury of the peripheral nerves, causing an ascending neuritis, as has been held by some authors. Paralysis agitans is another disorder which is frequently ascribed to trauma. The writer has no doubt that certain injuries are perfectly competent to cause that disease. Neurasthenia and hysteria are also disorders that can be due to trauma, and are serious enough to be entitled to recognition by the surgeon as actual morbid entities.-C. P. Gildersleeve (Brooklyn Medical Journal, March, 1904).
Books of the Month
STRABISMUS, OR SQUINT, Latent and Fixed. A Supplement to the
Errors of Refraction. By Francis Valk, M. D., Professor of Diseases of the Eye, New York Post-Graduate School and Hospital;
G. P. Putnam's Sons. New York and London. The Knickerbocker Press. 1904.
This is not the only book Prof. Valk has written. He has paid particular attention to the correction of errors of refraction and his first work bears that title. He has certainly made a complete study of the motility of the eye and the present volume will do much towards creating an understanding of the muscles and their action-what the author calls “a fusion of the power of the eyes and the physiological processes that govern their movements.” He takes up the study of squint in all its phases, beginning with a chapter on The Eye in General, following this with chapters on Movements of the Eyes, Classification of Squint, Description of its Different Varieties, Illustrative Cases, Indications for Operation, Operation, and After-Treatment.
Of course it is a book which is intended mostly for the specialist, though there is no question but that the general practitioner could gain much knowledge and benefit from a careful reading of the same. It is concisely illustrated, and gives the impression of careful handling in its mechanical make-up.
HAND-BOOK OF SURGICAL ANATOMY. By G. A. Wright, M. A., M. D.
(Oxon) F. R. C. S., Professor of Systematic Surgery in the Owens College; Surgeon to the Manchester Royal Infirmary, etc.; and C. H. Preston, M. D., B. S. (Lond.), F. R. C. S., L. D. S. (Eng.), Lecturer on Dental Anatomy in the Owens College; Assistant Dental Surgeon to the Victoria Dental Hospital of Manchester. $1.50 net. Philadelphia. P. Blakiston's Son & Co., 1012 Walnut St.
A rather unique book is this which comes from two of the surgeons in the far-famed Owens College, of Manchester, England. It is arranged so as to bring directly in connection with a description of the anatomical structure suggestions arising from a surgical view of the same part. Of primary importance to the student in surgical anat, omy, it is a book upon which the operating surgeon could well spend
a few minutes before he enters the operating room, because it will give him many points which will help in his operative work, and the information is put in such a concise and terse way that it requires only a short time to cover any ordinary operation.
A striking feature of the book is the side-headings in black type indicating the subject matter in the paragraphs opposite. These are printed along the edge of each page and are very helpful in the study. The book is well indexed, well printed and bound, and is one that we can heartily recommend.
A TEXT-BOOK OF DISEASES OF WOMEN. By Charles B. Penrose, M, D.,
Ph. D., formerly Professor of Gynecology in the University of Pennsylvania. Fifth Edition, Thoroughly Revised. Octavo volume of 539 pages, with 221 fine original illustrations. Philadelphia, New York, London: W. B. Saunders & Company, 1904. Cloth, $3.75 net.
After three years Prof. Penrose gives us another edition of his very excellent work on gynecology. It has become a classic and needs no commendation from the reviewer. It is well-known to both students and operators and has long been used as an authoritative reference book. This new edition has been carefully revised, much new matter has been added, and a number of new original illustrations have been introduced. That it can be recommended to the student, general practitioner and operator goes without saying.
A TEXT-BOOK OF PATHOLOGY. By Joseph McFarland, M. D., Professor
of Pathology and Bacteriology in the Medico-Chirurgical College of Philadelphia ; Pathologist to the Medico-Chirurgical Hospital, Philadelphia. Handsome octavo volume of 818 pages, with 350 illustrations, a number in colors. Philadelphia, New York, London: W. B. Saunders & Co., 1904. Cloth, $5.00 net; Sheep or Half Morocco, $6.00 net.
McFarland's Pathology is destined to become a standard. The author has had a wide experience in two great institutions of Philadelphia, namely, the Philadelphia Hospital and the Medico-Chirurgical College, with its hospital. This places him before the medical world as an authority. The book is written particularly for use as a text-book and contains a clear and careful exposition of what is known upon the subject of pathology without entering into a discussion of theoretical problems. One characteristic feature of the book which is commendable, is the use of two sizes of type, with the larger size the most important facts being outlined, while with the smaller the explanatory notes are made. Many illustrations, of which a number are in color, are scattered throughout the work and assist in making the text clearer and better understood.
We see no reason why it should not be adopted as a text-book in our Colleges, feeling that this is due the author because of the vast amount of work he has done in preparing the book and because of his being most competent to instruct.