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A CASE OF ABDOMINAL ACTINOMYCOSIS.
By K. F. D. Waters, B.A., B.M., B.Ch., F.R.C.S. (Edin.), Deputy Medical
Superintendent, St. Stephen's Hospital.
The patient was a general labourer, aged 22, and was transferred to St. Stephen's
hospital from St. Luke's for operation as a case of acute appendicitis. The history
was typical of this condition, with the exception that the temperature was abnormally
high, being 102.8° on admission. It is rare for the temperature to be above
101° in acute appendicitis in an adult; in fact, a pyrexia higher than this would
cast doubt on the diagnosis, and necessitate a close scrutiny of the signs and
symptoms before it could be regarded as settled.
Condition on admission, 21.9.34. The man was of medium habit and looked pale and ill.
T. 102.8°. P. 98. R18. His tongue was very dry and slightly furred, and some carious teeth
were present. He complained of continuous abdominal pain most marked in the right lower
quadrant. His heart, lungs and urine were normal. The abdomen was resistant all over, and
rigid and tender on palpation in the lower half, especially in right iliac fossa. Rectal examination
was negative. The diagnosis of acute appendicitis with peritonitis was made, and immediate
operation performed under percaine anæsthesia. The appendix was acutely inflamed, and there
was turbid free fluid in its neighbourhood. The fluid was mopped up, the appendix removed,
and the wound closed except that a drainage tube was inserted down to the cæcum.
Case report.
23.9.34. The drainage tube was removed. The patient felt much better; he was free
from pain, the abdomen was soft, and an enema gave a good result. T. 103°. P. 106.
26.9.34. Not much change except that the general condition was better. The abdomen
was soft and moved freely, and the bowels were opened naturally. There was a small amount
of purulent discharge from the site of the drainage tube. T. 102.° P. 100.
30.9.34. Better. Appetite good. No pain. Abdominal condition quite satisfactory.
Bowels open. Some purulent discharge from the part of the wound through which the drainage
tube had been inserted. T. 101°. P. 96.
3.10.34. Still pyrexia to 100°. P. 90. The patient still said that he felt quite well.
Appetite good. No pain or tenderness. A rigor occurre1 the previous evening when T. rose
to 101°. Urine clear and sterile. Abdominal and rectal examination negative. Heart and
lungs normal. Wound clean. The cause of the pyrexia was very obscure, as there appeared
to be nothing in the chest and abdomen to account for it. W.B.C. 20,000. Actinomycosis
was now suspected, and a smear taken from the wound, but only B. coli and non-hæmolytic
streptococci were found.
5.10.34. T. rose to 102° the previous night, but still no symptoms. No swelling or tenderness
detected anywhere in the abdomen. The patient was seen by the consulting surgeon, but
he was unable to account for the pyrexia.
10.10.34. Still the same degree of pyrexia, but the patient complained of headache and
vomited once: he was inclined to be constipated and had some flatulent distension, which
was relieved by a turpentine enema. The Widal reaction was negative to the enteric group
and brucella abortus. Skiagrams showed no evidence of subphrenic abscess, or of pneumonia,
empyæma or tuberculosis. The operation wound was healed.
12.10.34. The patient was seen by the consulting physician, who considered that at least
the cause of the pyrexia was not above the diaphragm.
14.10.34. In the evening there was another rigor lasting ten minutes, during which T. rose
to 104°. No other symptoms or abnormal signs were present, except that general condition
was not so good. The T. was now definitely swinging between 103° at night and 100° in the
morning.
17.10.34. Still the same swinging pyrexia. Blood culture negative W.B.C. 21,000, of
which 89.5 per cent. were polymorphs.
18.10.34. Slight dullness low down over the right chest. An exploring needle was inserted
through this area, but no fluid either clear or purulent was obtained.
19.10.34. Height of pyrexia increasing. Now definite but slight tenderness over the liver
just to the right of the gall bladder. The stools were examined tor dysentery, but no amoebae
were found.
22.10.34. The percussion note over the right lower chest was rather more impaired. Still
the same pyrexia T. 104°. P. 130.
24.10.34. Skiagrams of the chest showed haziness of the right lower lobe, but the diaphragm
moved freely. T. 101°. P. 108.
26.10.34. Right chest was again explored, but no pus was found. T. 102°. P. 120.
The tenderness over the liver was more marked. The patient was seen in consultation with the
consulting surgeon and physician, who agreed that it was advisable to explore the liver. Under
gas and oxygen anaesthesia, transpleural laparotomy was performed. The pleura was normal
and no free fluid was present in the pleural cavity. As the two layers of the pleura were not
adherent, the parietal was sewn to the diaphragmatic over a circular area, in the centre of which
the diaphragm was incised, the peritoneal cavity opened and the liver exposed.
(109) h