Chapter 2

Saturday evening, Feb. 7th, condition worse, pulse 112, temp. 103, tongue furred ash-colored, countenance typhoid in expression, loss of appetite, no abdominal symptoms, mind clear. Sunday, Feb 8th. pulse 120, temp. 105.4, tongue same as yesterday, had a chill last night. The skin over the sinus is inflamed somewhat more than it was yesterday. With the advice and assistance of doctors Brown, Thorne, Benj. Cory and Kelly, sixty-eight ounces of blood was removed from the sinus, by aspiration. One hour after this operation, the pulse was 140 and the temp. 104. The specific gravity of the blood removed was 1030, and after standing for two or three hours, a grey or ash-colored sediment settled, the proportion of this being about 20 per cent. of the whole amount of the blood. This sediment consisted of corpuscles that seemed to be undergoing decomposition; they were a little larger than the red corpuscles; contained granules or spots, from three to four and seven and eight in each corpuscle. Some of them seemed to be simply swollen red blood corpuscles, ready to burst, or as it were, suppurate. If there be such a thing as inflammation of the blood,--and I believe there is,--then this change must effect the red corpuscles themselves, as to size, temperature and perhaps pain, thus supplying three of the well known characteristics of inflammation, expressed so tersely by the old latin formula, _rubor, tumor, calor cum dolore_. Owing to the color of the blood, the rubor, or redness, is not produced by inflammation here as it already exists.

But to return to the patient. After the blood was withdrawn, compresses were carefully applied, and the body bandaged from the lower ribs as low down as the bandage could be applied with the legs flexed at right angles to the body. The patient stood on all fours, as it is called, while the bandage was applied.

Monday, Feb. 9th, 9:30 A. M., pulse 100, temp. 103.8. There appeared to be about one-half a pint of fluid in the sack. Monday, Feb. 9th, 6:30 P. M., pulse 100, temp. 102. Tuesday, Feb. 10th, 9:30 A. M.,--the fluid in the sack has increased--perhaps a pint now in it, pulse 110, temp. 104. Wednesday, Feb 11th, 9:30 A. M.,--pulse 90, temp. not taken. Condition good. Ordered a laxative.

Friday, Feb 13th,--considerable inflammation over the left iliac crest, in the centre of which, a spot as large as the thumb nail, looks gangrenous. The inflammation extends over a surface as large as the two hands. Some bullae or blebs have formed in the vicinity of the gangrenous spot. Ordered a large flaxseed poultice applied, expecting an abscess would form at this place. The cathartic moved the bowels two or three times. I will here state that the patient, after the withdrawal of the blood on Sunday, was ordered iron, quinine and whisky; twenty minims of Tr. Ferri Muriat., three grs quinia, in a tablespoonful of glycerine and a little whisky. I afterward had the quinia made into pill and left off the iron, as the latter seemed to disagree with the stomach.

Saturday, Feb. 14th, 5 P. M.,--pulse 112, temp. 102.4. The inflammation over the left ilium is much better; but there is now as much inflammation over the right ilium as there was over the left. The fluid in the sinus has increased gradually since the evacuation of it with the aspirator. The inflammation that has now existed for two or three days over these parts of the sinus, led me to conclude that the blood which was left and that which had accumulated, had undergone decomposition and was now pus. I used an exploring needle and found this to be the case. I then introduced a trocar and canula, and drew off fifty ounces of pus, slightly tinged with blood. I re-adjusted the compresses and bandage over the sinus, hoping that a part of it at least would become obliterated before it became necessary to open it more freely.

Feb. 15th, 5 P. M.,--pulse 112, temp. 102.5. The inflammation over that part of the sinus to the right of the spine is still about the same as yesterday; also that over the left ilium. The fluid has increased during the last twenty-four hours so that there is now nearly as much as was drawn off through the canula yesterday. I concluded that further delay to a free opening was useless; consequently with the patient lying on his right side, and near the edge of the bed, I made an opening one inch long in the lower portion of the abscess,--for I now considered it one,--near the spot where the needle of the aspirator and the trocar had been previously introduced.

After the discharge of about a pint of bloody pus, the stream was checked by a clot of blood coming into the opening. I enlarged the opening, making it about two inches long, when a clot the size of a hen's egg came through, followed by about a pint more of bloody pus. After syringing the cavity with a five per cent. solution of carbolic acid in distilled water, and introducing a tent about four inches long, I applied compresses and bandages. Ordered the quinia continued, and whisky and beef tea.

Feb. 16th, 9 A. M.,--pulse 100, but feeble; temp. 97.8. Removed dressings which were saturated with pus and blood. The latter had excited the anxiety of the Superintendent during the night, and he applied an additional bandage. There was perhaps five or six ounces of thick, flaky, yellow pus discharged. No hemorrhage; syringed the cavity with a five per cent. solution as before, and introduced a clean tent.

On examining the inflamed spot over the left ilium, I detected fluctuation over the anterior part of the crest of the ilium, near the gangrenous spot, and extending down over the abdomen. However, it seemed to be superficial, at least, not deeper than the connective tissue between the external and internal oblique muscles, and not more than one inch by two in size. This I opened, and squeezed out about half a ounce of pus. Introduced a tent and applied oakum over both tents, for the purpose of absorbing the pus, and applied a compress over the main sinus or pouch, and a bandage over the whole lower part of the body.

Feb. 17th, 9 A. M.,--pulse 96, temp. 99. Ordered a laxative of carbonate of magnesia. Both openings discharging very freely. The gangrenous spot over the left ilium is separating from the surrounding tissues. Removed considerable dead flesh from this spot, leaving an opening or pouch one inch in diameter, leading down to the pubis, just beneath the oblique muscles.

Feb. 19th, 9 A. M.,--pulse 106, temp. 99.5. Both sinuses discharging very freely. Made an opening in the lower part of the pouch to the left of the pubis for better drainage, as the patient usually lies on the right side. Laxative has operated. After washing out both sinuses with a five per cent. solution of carbolic acid, I inject the smaller sinus with liquid vasaline.

Feb. 20th, 9 A. M.,--pulse 112, temp. 103.5. There is a great amount of pus being discharged from the large sinus on the back, not so much from the small one. Patient had a chill last night. After the usual washing out of the sinuses with the carbolic solution, I inject both of them in with liquid vasaline. This I do, a well as the washing out, by means of a No. 10 catheter, attached to the end of a Davidson's syringe. The sinus on the back extends from the coccyx to the ribs, and from one ilium to the other. The skin and fascia of the external wall being so thin that the catheter can be seen over the entire extent, as I push it from one part to another for the purpose of washing out all parts of the sack. Patient has been complaining of pain and want of sleep; had a chill last night. He still takes beef tea twice a day, and eggs and other food twice a day, making four meals a day; also, continues the quinine and whisky.

Feb. 21st, 9:30 A. M.,--pulse 98, temp. 101. Feels more comfortable. Discharge of pus much less than yesterday. Wash out the sinuses and inject liquid vasaline.

Feb. 23d, 9:30 A. M.,--pulse 98, temp. 101. Complains of being "very sick." Speaks English but poorly. Considerable discharge of laudable pus, but not so much as before the use of the liquid vasaline. There is one point near the left hand side of the large sinus on the back, where the walls are adherent. I wash them out with a five per cent. solution of carbolic acid in water, and again inject the liquid vasaline. By gentle pressure made over the upper part of the pouch, I force everything out of it at the opening below, bringing the walls of the sack together over the greater part of the surface. Hoping that the adhesion between the walls, which has commenced, will continue, and soon obliterate, at least, all the upper part of the pouch. Put on the usual compresses; this time using oakum instead of folded cloths.

Feb. 24th, 9:30 A. M.,--pulse 108, temp. 101. Did not wash out the upper or left hand part of the pouch on the back, for fear of disturbing adhesions that are taking place. Washed out the lower part and injected vasaline. A small spot, as large as a ten cent piece, has sloughed, making a hole into the pouch over the lower lumbar vertebra. Another spot immediately above this, and about the same size, looks as if it would slough.

Feb. 25th, 9:30 A. M.,--pulse 100, temp. 100.

Feb. 27th, 9:30 A. M.,--pulse 115, temp. 99.2. Adhesion is taking place between the walls of the sinus, on the left of the vertebræ.

Feb. 29th, 9:30, A. M.,--pulse 104, temp. 100. The sacks, or sinuses, have been washed out regularly every day, and dressed with vasaline.

This case presents several features of interest. The first is the very large amount of secondary hemorrhage, and its location, there being sixty-eight ounces removed at one time and fifty at another, and perhaps thirty or forty at another, from just beneath the skin and superficial fascia of the lower part of the back. The second point of interest would be to know from what vessel this hemorrhage took place. The third interesting feature of the case is its progress and treatment.

At the time of the aspiration the patient was in a critical condition; temp. 105.4, pulse 120; the tongue and chill denoting danger of pyemia. This danger was avoided by drawing off the decomposing blood, and giving the patient a new lease of life. This was but temporary, for six days afterward the same danger presented itself again. This was also avoided by opening the sinus freely, by an incision two inches long, which could not have been done sooner for fear of adding to the hemorrhage.

At the end of six days from this last critical period, the temperature again went up to 103.5, and the pulse and condition of the patient indicated great danger of death from exhaustion--the result of the formation of so much pus. This was avoided by preventing the excessive formation of pus by washing out the sinus with liquid vasaline. The patient is still under treatment in the hospital now under the care of my esteemed friend, Dr. Benj. Cory.

The patient will probably recover. It will be simply a question of endurance with him. That is, if the supply of nourishment can be kept up, and the waste prevented, which must result from the formation of such a large quantity of pus, there is no reason why he should not recover.[A]

[A] On March 25th, date of publication of this report, the patient is considered convalescent.

At the time of putting him under the care of Dr. Cory, he was taking nine grains of quinia daily, about six ounces of whisky, beef tea twice a day, and eggs twice, with such other food as he might relish; taking four meals a day.

Thus you see I was carrying out the theory mentioned in the first part of this paper:--that of supplying the system with all the flesh producing food the stomach would digest, and using whisky and quinia to prevent disassimilation or waste; also vasaline locally for a similar reason.

With this case I conclude my report; only adding that perhaps the thought of a poet, who evidently knows much of human nature, is applicable to this hastily written paper. This poet says:

"A fool will pass for such through one mistake, While a philosopher will pass for such, Through said mistakes being ventured in the gross And heaped up to a system."

Thus I, as one or the other of the personages here mentioned, offer this, my mite, to the literature of surgery, leaving you to decide which of the titles I deserve.