ABSCESSES

OEIGINATING IN THE

RIGHT ILIAC FOSSA

BY

GURDON BECK, M. D.,VISITING SUBGEON TO NEW TOBK AND PEESBTTEEIAN HOSPITALS ; CONSULTING SUBGEON

TO EOOSEVELT AND ST. LUKE’S HOSPITALS.

[FROM THE TRANSACTIONS OF THE NEWYORK ACADEMY OFMEDICINE FOR SEPTEMBER , 1874.]

UNA BIDES, ALTABB COMMUNE.

NEWYORK:D. APPLETON & COMPANY,

649 & 551 BROADWAY.1874.

ABSCESSES

ORIGINATING IN THE

RIGHT ILIAC FOSSA

BY

GURDON BUCK, M. D.,VISITING SURGEON TO NEW YORK AND PRESBYTERIAN HOSPITALS ; CONSULTING SURGEON

TO ROOSEVELT AND ST. LUKE’S HOSPITALS.

[FROM THE TRANSACTIONS OF THE NEWYORK ACADEMY OFMEDICINE FOR iSEPTEMBER ,

1874.]

UNA NIDUS, ALTARE COMMUNE.- —IT ,-a

NEWYORK:D. APPLETON & COMPANY,

549 & 551 BROADWAY.1874,

ABSCESSES ORIGINATING IN THE RIGHT ILIACFOSSA, WITH STATISTICS.

GORDON BUCK, M.D.,

VISITING SURGEON TO NEW YORK AND PRESBYTERIAN HOSPITALS ; CONSULTING SURGEON

TO ROOSEVELT AND ST. LUKE’S HOSPITALS.

Eead September 17, 1874.

Ik preparing this paper on abscesses in the right iliac fossa,my object has been not so much to prepare a complete treatiseon the subject as to present the most practical points involvedin the diagnosis and treatment of this formidable disease, asillustrated by cases that have occurred in my own practice orthat of my colleagues.

Abscesses in the lower portion of the abdominal cavity andits parietes may be divided into three classes:

The first class comprises abscesses produced by perityphlitis,or, as the term implies, inflammation around the caecum, duemost frequently to perforation ofthe vermiform appendix. Thecollection of pus formed in this abscess occupies the peritonealcavity itself, and is walled in by adhesions.

The second class comprises abscesses originating in the iliacfossa of either side, and situated underneath and inclosed bythe iliac fascia.

The third class comprises abscesses developed in the con-

4

nective tissue external to the peritonaeum, and between it andthe parietes of the abdominal cavity. Besides these distinctclashes of abscesses, collections of pus may form in the samelocalities as the abscesses of the second and third classes; but,in these cases, the pus will be found to have migrated from itsoriginal place of origin at a distance, the lumbar region beingthe most frequent seat of origin of such collections.

It is my object, however, only to treat of the first class ofabscesses; those resulting from perityphlitis, and occupyingthe right iliac fossa.

The following case occurred recently in my own practice:Case I.—G. hi., a lad, aged twelve years, residing in this

city, while in the enjoyment of ordinary good health, and aftera day of accustomed activity, was, on Thursday, June 11th, at-tacked, on going to bed, with violent colic-pains and vomiting.Hot poultices and anodynes were resorted to, and on the fol-lowing day free evacuations from the bowels were obtained bya dose of live grains each of calomel and Dover’s powder. OnSaturday evening, June 13th, forty-eight hours after the at-tack, I saw him in consultation with Dr. J. Linsly, the attend-ing physician, and found his condition as follows: Yomitinghad almost ceased, his pulse was moderately accelerated, andthe temperature of the surface was normal. The abdomenwas tumid, but not tense; and tenderness on pressure, whichat first had been diffused over the whole abdomen, was nowconfined to the right iliac region, where a deep-seated tumorcould he defined, though rather indistinctly. It occupied aspace above the outer half of Poupart’s ligament, and close toit. There wT as no elevation of the surface over the tumor, andthe pain produced by the most cautious attempts at deep press-ure, deterred from as thorough an exploration as might havebeen desirable. Ho dullness on percussion was appreciable,and flexion and extension of the thigh caused no pain. Thetongue was clean, and there was no aversion to taking nourish-ment. Dr. Linsly had already prescribed pills of s. morph,gr. , which were to be continued every two hours. The con-clusion we arrived at respecting our patient wr as that an abscess

5

was forming in connection with, perforation of the vermiformappendix. Six leeches were applied over the tumor the sameevening, and followed by poultices. Under the influence ofthe morphia pills a quiet condition was maintained ; the pulseranged from 80 to 100; the temperature of the surface wasuniformly natural. On Wednesday (seventh day) the morphiawas suspended, and a movement of the bowels obtained bymeans of 01. ricin. § ss, and an enema of catnep-tea, but withonly partial effect, owing to bis instinctively avoiding anystraining effort. After the suspension of the morphia he be-came nervous, and complained more of pain in the tumor, es-pecially after an examination of it, however carefully made.No chill or feverishness was at any time observable, nor anyextension of abdominal tenderness beyond the limits of thetumor itself. Nothing abnormal could be felt by digital ex-ploration jper rectum. On Thursday, 18th (eighth day), Prof.W. Parker joined our consultation, and arrived unhesitatinglyat the conclusion that an abscess had formed, and required tobe opened from the surface. The absence of dullness on per-cussion over the tumor was the only condition that did notconcur in establishing the diagnosis arrived at. All the otherconditions and antecedents corroborated it; and the existenceof resonance was afterward explained by the presence, withinthe cavity of the abscess, of an abundant collection of gas.The morphia and poultices were resumed, preparatory to anoperation on the following day. On Friday (ninth day), attwelve o’clock, the operation was performed, after the inhala-tion of ether. Some elevation of the surface over the tumorwas now manifest, but no redness, or oedematous infiltration,or adhesion of the skin to the underlying parts, existed; norwas any fluctuation perceptible. By a bolder palpation, nowadmissible under anaesthesia, the deeper outlines of the tumorcould be better defined, and its longest diameter was ascer-tained to be parallel with Poupart’s ligament. The operationwas performed as follows: A point two fingers’ breadth distantfrom and to the inside of the anterior superior spinous processof the ilium, and a little below its level, where the tumor ap-

6

preached nearest to the surface, was chosen for an opening,which was made with a small cannlated trocar (equivalent insize to No. 1 bougie scale). A puncture was iirst made atthe point chosen with a tenotomy-knife, through the skin, tofacilitate the onward passage of the trocar. This was then in-serted, and advanced till it encountered the tendon of the ext.oblique muscle, which presented great resistance to its furtherpassage. To overcome the resistance safely, the trocar waswithdrawn within its sheath, and the canula held in firm con-tact with the surface of the tendon, while the point of thetrocar was pushed on. By successive repetitions of this ma-noeuvre, the trocar at length encountered no further resistance;and, on being withdrawn entirely while the canula was ad-vanced, matter escaped from its outer orifice, and the successof the procedure was demonstrated. The canula, being stillheld in situ, served as a guide, along the outer surface of whicha sharp-pointed knife was conducted into the cavity of the ab-scess, and used to enlarge the track of the canula. On with-drawing the knife, the wound was enlarged to the extent ofmore than an inch at the surface of the skin. The little-fingerwas then thrust into the cavity of the abscess, and the openingdilated sufficiently to allow a free escape of the matter, whichwas fetid and of a dirty-grayish aspect, but without any biliarydiscoloration. With the matter there was also an abundantescape of fetid gas, to the presence of which may be attributedthe resonance on percussion over the tumor. A plug of cot-ton-wick well greased was inserted in the opening, and thepoultices resumed. For the first three or four days an injec-tion of salt-and-water (3 j to § viij) was thrown into the ab-scess at the daily dressing. His subsequent progress was favor-able. On the fifth day after the operation, when the dischargewas no longer fetid, and had regained a healthy character,two tufts of sloughy connective tissue came away, followed bya more copious discharge of pus, which had accumulated inthe cavity of the abscess from obstruction of the outlet. OnJune 25th, the sixth day after the operation, a dark-colored,gritty substance, of the size of a small pea, was discharged. A

7

chemical analysis ascertained it to be a phosphatic concretion.On the day following, another substance, of the shape and sizeof half an inch of small clay pipe-stem, was found on the dress-ing ; it had all the characters of compact fecal matter. Afterthis, the suppuration progressively diminished. On June 29tha third smaller tuft of sloughy tissue was discharged. Hissubsequent progress requires no special notice. Under excel-lent care at home, with generous diet and a moderate allow-ance of stimulants and tonics, he steadily improved both local-ly and generally. On July 18th he accompanied his familyto their summer residence in the country, where he continuedto gain rapidly. On August 14th his father reported that thewound had healed, and he was quite himself again.

In the Medical Record of March 15, 1867, Prof. WillardParker reported a case of this disease in which he first em-ployed successfully a method of treatment which may be saidto have disarmed this disease of its terrors, and changed itsissue from an almost invariably fatal result to the reverse.This method consists in making an early incision into theabscess without waiting for fluctuation to demonstrate thepresence of pus. In the Medical Record of 15th of June fol-lowing, Dr. J. H. Hobart Burge, of Brooklyn, reported a sec-ond successful operation performed by Dr. Parker on a patientof Dr. Burge’s. Since the publication of these two cases, twoothers equally successful have been reported in the New YorkMedical Journal, one by Dr. Leonard Weber, in the Augustnumber of 1871, the other by Prof. H. B. Sands, in the Au-gust number of 1874. Other cases, not yet made public, havebeen ascertained to have occurred in the practice of other sur-geons, to whose courtesy the author is indebted for such par-ticulars as will enable him to develop more fully this interest-ing subject. These cases, together with one reported by Mr.Hancock, ofLondon, in 1848, which will be more particularlynoticed hereafter, and the one in my own practice just nar-rated, form an aggregate of ten cases, from which the fol-lowing deductions may be drawn :

8

Tableop

TenCasesof

Ileo-C-ecalAbscess

followingPerforation

opVermiformAppendix.

No.Nameof

Operator,where

recorded.Date ofOpera- tion.

M©oc6 tnInvasionand

Localizationof

Disease.DayofOpera- tion.

Modeof

Operation.Nature ofDischarge

Foreign substances dischargedon whatday.

Result.Remarks.

1

Hancock,LondonMed.

Gazette,New

Series,vol.

viii.,p.547.

1848F

•B<Abrupt,withsymptomsof

acuteperitonitisearly

localizedinileo-csecal

region.

9

Incisionovertumor

4»long.

Fetid, withgas.

Twofecal lumps,incrusted with

concre-tion15day.

Recovery.Attackedtheday

after

confinementwithfifth

child.Nofluctuation

felt.

2

Prof.W.

Parker,M.D.,N.

Y.Med.

Record,March

15th.

1867M40Do.do.do.do.

9

Incision6"long,downto

fasciatranversalis,then

exploring-needleinserted.

Fetid.None.

Recovery.Nofluctuationfelt.

3

W.Parker,M.D.

Reported

byDr.J.H.H.

Burge,N.

Y.Med.

Rec.,June15th.

1867F

15Do.do.do.do.

14Incision3'

long.

Fetid.None,

Recovery.Nofluctuationfelt.

4

L.Weber,M.D.,N.Y.Med.

Journal,August.

1871M22Do.do.do.do.

7

Incision9"long,downto

fascia,thenleftto

open

spontaneously.Fetid.

Concretion on16thday.

Recovery.Nofluctuationfelt.

— Spontaneousopening,

anddischarge

took

placetwoandahalf

daysafter

operation.

5

E.Krackowizer,

M.D.Com-

municated.

1872M-2Do.do.do.do.11

Incisiondowntofascia

transv.,thendividedon

director.

Fetid, nostain

ofbile.

Noneseen.

Recovery,Nofluctuationfelt.

6

Sam.B.Ward,M.D.Com-

municated.

1872M17

Do.do.do.do.early.

Incisionasforligatureof

ext.iliacart.downtofasc.

trans.Leftto

openspon-

taneously.

Fetid, nostain

ofbile.

Noneseen.

Recovery.Nofluctuationfelt.

— Spontaneousopening

onsecondday

after

operation.

7

Prof.IT.B.Sands,M.D..N.

Y.Med.

Journal,August.

1874M41Do.do.do.do.13

Incisiondownto

fascia,

thentrocar.

Fetid.8

or9 concretions.

Recovery.Nofluctuationfelt.

8

C.

Kelsey,M.D.Commu-

nicated.

1874F16

Do.do.do.do.

8

Incisiondowntofasc.,as-

pirated,thenenlarged.

Fetid.None

seen.Recovery.Nofluctuationfelt.

9

J.P.P.White,M.D.Com-

municated.

1874M32Do.do.do.do.

Withintwoyears

previous,

hadtwoacuteattacks,re-

lievedwithoutdischarge,

butleavinga

deep-seatedtumorinileo-caecalre-

gion.

*|l11J

P-15

Incision5'long.

Fetid, nostain

ofbile.

Concretionlikea date-pit.

Recovery.Fluctuation

distinct.— Firstaspiration

on

ninthday.

Drewoff

26ouncespus.

Sec-

ondaspiration

on11th

day.Drewoffsixteen

ounces.Freeopening

madeon15th

day.

10Gurdon

Bnck,M.D.Nar-

ratedherein.

1874M12

Do.do.do.do.

9

Puncturedfirstwithfine

trocar,thenenlargedby

incisionwith

knife.

Fetid, nostain

ofbile.

1

concret’n,1

lump faeces,3

tuftsofslough.

Recovery.Nofluctuationfelt.

9

Seven were males and three females. Their ages were asfollows: two males were twelve ; one female fifteen ; one six-teen ; one male seventeen ; four males were respectively twen-ty-two, thirty-two, forty, and forty-one; one female was themother of five children. In every case the invasion of thedisease was abrupt, and attended with symptoms of acuteperitonitis, which early became localized in the ilio-csecal re-gion, and in all a deep-seated tumor was more or less distinctlyfelt at an early period in the same locality. In nine of theten cases no fluctuation could be detected at the time of theoperation, which wT as performed on the ninth day after theattack in four cases, in one case early, so stated, and in onecase each on the seventh, eighth, eleventh, thirteenth, andfourteenth days respectively. A discharge of fetid mattertook place after the opening of the tumor in all cases, and insome it was accompanied with gas-bubbles. In four cases itwas stated that the matter was not stained with bile, fromwhich it might be inferred that there existed no open com-munication between the intestine and the cavity of the ab-scess ; the same was probably true of the other six cases inwhich the fact of biliary discoloration was not stated. In fiveof the cases one or more foreign substances were discharged atvarying intervals after the operation, and in the other fivecases none were found. Where none was found it may bepresumed that, if retained in the cavity of the abscess, it be-came embedded in exudation material, and thus was renderedinnocuous. These substances were concretions, and fecalmasses incrusted with concretion. In one case three tufts ofsloughy connective tissue were discharged besides the foreignsubstances. In one case (No. 9), communicated by Dr. White,the collection of pus was excessive in quantity, and was there-fore readily detected by existing fluctuation. The patient be-came collapsed on the ninth day, and was in imminent dangerof his life. Instead of a free opening being made for the exitof matter, the aspirator was used, and twenty-six ounces ofpus drawn off; two days after, sixteen ounces were drawn offby a second aspiration, and four days after the second aspira-tion a free opening was established.

10

The method of operating inaugurated by Dr. Parker, andadopted by his imitators, was the following : An incision threeto six inches in length was carried across the tumor a littleabove and nearly parallel with Poupart’s ligament, and di-vided the skin and subjacent tendinous and muscular layerstill the fascia transversalis was exposed. An exploring-needle,or fine trocar, was then inserted in search of matter, and thepuncture afterward enlarged to a free opening with a knife.In one case (JSTo. 8), after the exposure of the fascia, the aspi-rator was first used, and then a free opening made. In twoother cases (bTos. 4 and 6), after the exposure of the fasciatransversalis, fluctuation not being perceptible, the wound wasdressed open, and a spontaneous opening formed on the sec-ond and third days after.

This cautious procedure was adopted, no doubt, as a surermeans of avoiding a wound of the intestines. In my owncase, however, I deviated from this plan by first penetratingthe abscess without any preliminary incision of the abdominalparietes, and then enlarging the punctured track sufficiently toafford a free outlet for the contents of the abscess. The rea-sons for this modification of the operation were these: Re-garding the most prominent point of the tumor as an indica-tion of the approach to the surface of pus, and not of intestine,this point was chosen for the insertion of a fine, canulatedtrocar, or, what is preferable, a sharp-pointed canula, such asis used in the operation of aspiration. The insertion of sucha small-sized canula into the intestine itself would be harm-less, inasmuch as on its withdrawal there would be no escapeof fecal fluid, and consequently no danger of the formationof a fistula. Matter having been reached by this first step ofthe procedure, the canula is held in situ

,and used as a guide,

along the outer surface of which a sharp-pointed knife is con-ducted into the cavity of the abscess, and the track of thecanula enlarged to the requisite dimensions. In case of a fail-ure to reach the collection of pus by a first attempt, a secondintroduction of the canula may be safely tried at anotherselected point. By this method, also, an extensive incision

11

of the abdominal parietes is avoided, and the subsequent lia-bility to a hernial protrusion prevented. After completingthe opening with the knife, a finger should be introduced tostretch it, and a full-sized tent, well greased, should be keptin for the first three or four days after the operation.

Remarks. Diagnosis. —The abruptness of the onset of thedisease, with symptoms of acute peritonitis, early becominglocalized in the ileo-csecal region, or restricted mostly to thisregion from the first of the attack, will distinguish it from theother forms of abscess that originate in this region, and fromfecal accumulations in the caecum, which are gradual in theirdevelopment. Its precise locality in the hollow of the iliacfossa should also distinguish it from strangulated hernia, theattendant symptoms of which are not unlike those of perity-phlitis. A close observation of the daily progress of the dis-ease will also very much aid our judgment in arriving at a cor-rect conclusion in regard to its nature.

Prognosis. —Authors who have treated of this disease haveregarded it as almost invariably fatal in its termination. Itis true, however, that sometimes recovery has taken placeafter the spontaneous formation of an opening into the intes-tine, probably the caecum, and the discharge of the contentsof the abscess jper anum. A like favorable result has followedafter an opening into the bladder, and the expulsion of pusperurethram. In much rarer, instances the abscess has emptieditself by a spontaneous opening through the abdominal pari-etes. A favorable termination by resolution is perhaps of therarest occurrence, and yet it has taken place. Happily, thisdisastrous tendency need now no longer exist, but may beaverted by a seasonable operation.

Treatment.—In the onset and early progress of the dis-ease, Mr. John Burne (in vol. xx. of “ Medico-ChirurgicalTransactions ”) very judiciously cautions against the energeticdepleting treatment that might be applicable to acute idiopathic peritonitis. It is well to apply leeches early over thetumor to the extent of six to twelve in number, and to repeatthem if necessary. Poultices are also indicated, but they

12

must be adjusted so as not to be burdensome by their weight.Five to ten grains of calomel, followed by 01. ricini, with theaddition of tinct. opii, or sol. s. morph., should be given.After this a state of moderate narcotism should be maintainedby the administration of pil. opii gr. jor sulph. morphia to£ gr., repeated at first every hour till their effect is produced,and afterward at intervals of two to four hours. The objectof our treatment should be to moderate the production ofpus, and thereby diminish the strain upon the adhesionswhich wall in the abscess, and shut it off* from the generalperitoneal cavity, till the favorable moment arrives for givingexit to the matter through an external opening upon the sur-face of the abdomen. To determine the time of operating isa point of chief importance. It should be borne in mind thatwe are not to wait to detect fluctuation, which is regarded asthe unequivocal sign of the existence of matter. Before thatpoint is reached, the patient is exposed to a disastrous issuefrom different sources, such as the giving way of the adhe-sions that wall in the abscess, and the supervention of fatalgeneral peritonitis; from gangrene; and exhaustion from thehectic of purulent cachexia. If we interrogate experience onthis point, we find that, in the ten cases cited in this paper,the operation was performed at the earliest moment on theseventh day after the onset of the disease, and at the latest onthe fourteenth day. We may therefore, perhaps, safely lay itdown as a rule that after the lapse of one week from the onsetof the disease there should be no delay in resorting to theoperation, unless there should be clear indications of resolu-tion going on, which is an extremely rare issue of this disease.This treatment, so remarkably successful in the cases desig-nated, is quite inapplicable to those other cases that proverapidly fatal from general peritonitis. It should also be statedin this connection that Mr. Hancock, of London, performedthis same operation with success in 1848, but, for some rea-son or other, his report of the case failed to receive the at-tention it deserved. In his report {see London Medical Gazette,

Hew Series, vol. vii., p. 547) before the London Medical So-

13

ciety, of which he was then president, Mr. Hancock remarkedas follows: <£ Abscesses of the abdomen connected with the cm-cum or large intestines, and attended with fluctuation, hadfrom time to time been opened, but he was not acquaintedwith any instance in whicli an operation had been attemptedunder the circumstances about to be detailed in his own case,and where the result had been so entirely satisfactory. In thecases recorded, the presence of fluctuation has proved the ex-istence of matter, but the details of his case would show thatwe should not always wait for this unequivocal sign,” His casewr as that of an adult female, in whom the attack began on theday following her giving birth to her fifth child, six or sevenweeks before the full time, with a severe pain in the rightgroin and a sensation of something having snapped asunderas she turned herself over in bed. After nine days of appro-priate treatment, Mr. Hancock operated by an incision fourinches long carried across the tumor from the spine of theilium inward above and close to Poupart’s ligament. A quan-tity of fetid matter with gas-bubbles was discharged. Onthe fifteenth day after the operation, two masses of faeces,incrusted with calcareous deposit, and moulded upon eachother, were discharged. From their size, Mr. Hancock judgedthat they had been impacted in, and had escaped by ulcera-tion from the vermiform appendix. At a meeting of the sameSociety held March 27,1871 (British Medical Journal, 1871,vol. i., p. 450), the subject of perityphlitis was brought for-ward, and, in the discussion that followed, no allusion wasmade to Mr* Hancock’s method of treatment. Although Mr.Hancock’s report was also republished in full in the Ameri-can Journal of Medical Sciences of 1849, the only notice ofit in this country was by Dr. George Lewis, then Physicianto the Eastern Dispensary, in an article on “ Abscesses in theAppendix Yermiformis,” that appeared in the New YorkJournal of Medicine , 1856, Third Series, vol. i. Under thehead of “ Treatment ” he remarks upon the question of thepropriety of making a free incision downward upon the tu-mor, and states that he is inclined to favor the operation.

“ The favorable issue of a single case, and this, so far as ourinformation extends, the only one on record in which thispractice was adopted, taken in conjunction with other con-siderations ” (already stated by the writer), “if they do notconclusively settle the utility of this mode of procedure, atleast justify a more extended trial of it.” lie then reproducesthe report of Mr. Hancock’s case in full. This importantsubject attracted no further notice, nor is any allusion to theoperation to be found in the most recent text-books on medi-cine and surgery, such as Aitken, Reynolds, and Flint, orHolmes, Gross, or Hamilton, Happily for suffering human-ity, this same method of treatment was reproduced by one ofour own number, in 1867, as before stated, and has alreadyhad so many successful imitators that its vitality may now beconsidered as assured.

Besides abscesses following perforation of the vermiformappendix, there are lesions of the caecum giving rise to ab-scess. Mr. John Burne (“ Medico-Chirurgical Transactions ”

1839, vol. xxii,, p. 41) remarks :“ Of perforative ulceration of

the caecum from within, no case verified by dissection has oc-curred under my own observation. One is described by Fer-rall, in the Edinburgh Medical and Surgical Journal, vol.xxxvi,, p. 12, Case Ho. 4, of tubercular ulceration, in which atumor formed in the right groin, burst in a few days, anddischarged faeces and caraway-seeds. On dissection, severalulcers were found in the caecum, one of which had perforatedits posterior wall and communicated directly with an abscessin the iliac fossa, the abscess also communicating with theexternal opening in the groin.” Perforative ulceration of thecaecum from without, however, does occur in those cases inwhich abscesses following perforation of the appendix burstinto the intestine, and are discharged per anum. A veryremarkable case in which the caecum was involved came toray knowledge in a recent visit to St. John, Hew Brunswick.It was communicated to me by Dr. William Bayard, an emi-nent practitioner of that city, to whose courtesy I am indebtedfor the following history of the case, drawn up by Dr. ThomasWalker, the medical attendant upon the patient;

15

Case 11. Worms discharged from the Caecum throughan Opening in the Abdominal Parietes.—Was called sud-denly on the morning of April 29, 1814, at six o’clock,to see Mrs. L., aged sixty-five. She had been in tolerablygood health until four days ago, when she was seized withvomiting, rejecting every thing swallowed. She had sufferedduring the preceding twelve months with occasional attacksof pain across the bowels, which she had attributed to flatu-lence, and which had generally been promptly relieved bythe use of some warm carminative. During the present at-tack she did not appear to have suffered much pain. Shewas pale, partially insensible, with a small, feeble pulse, 96 ;

tongue coated; bowels constipated. There had been no ster-coraceous vomiting. On examining the abdomen, an ovalswelling was found above Poupart’s ligament, about fourinches in length, extending from just above the crest of theilium toward the symphysis pubis. It was hard, reddish, andhad all the appearance of a pointing abscess. It had no im-pulse on coughing. She had not complained of pain there toany marked degree, though it was quite tender to the touch.Five grains of calomel were given, and a sedative and anti-spasmodic mixture ordered to be taken every three hours.She was allowed ice to suck, a sinapism was directed to beapplied over the stomach, and a poultice to the swelling; also,beef-tea and brandy were ordered, in small quantities. Ateleven o’clock in the forenoon the bowels had been freelymoved; she had vomited only once since six o’clock, and hadbegun to retain every thing she took ; pulse much stronger; sheis quite sensible. Her condition remained much the same untilMay Ist, when the abscess having clearly pointed, and fluctua-tion being very distinct, it was opened about its middle, and awineglassful of very fetid, dirty-brown pus escaped. Poulticeto be continued, with the addition of a carbolic-acid lotion.

3d.—Abscess has discharged freely since it was opened.The discharge continues offensive; the edges of the openinghave sloughed slightly, and another opening has formed, byulceration, below the first. Bowels have been opened fre-

16

quently within twenty-four hours, the stools being thin andyellowish, but devoid of blood or pus.

4th.—On dressing the wound to-day I extracted from it aperfect worm (Ascarus luinbricoides ), about six inches inlength. Two similar worms, I was informed, had been foundthat morning on the poultice, with the discharge. Diarrhoeastill continues.

s th.—Two more worms have been discharged from theopening, making five in all. Bowels still loose ; the edges ofthe opening have sloughed still more.

Ith.—She was seen by Dr. William Bayard ; her conditionhas undergone no material change since the last report.

12th.—Diarrhoea has ceased; the edges of the openinghave healed considerably, and now look healthy; the dis-charge has very much diminished in quantity, and lost itsotfensive character.

13^4.—Faeces have begun to come through the opening,and from this date forward they continued to pass, and thecase presented all the characters of a case of artificial anusuntil she died, in August. The worms were all dead whendischarged, and one of them came away in two pieces.

Note.—Since the foregoing article was read at a stated meeting of theNew York Academy of Medicine, held September 17, 1874, the author hasreceived a communication from Prof, James R. "Wood, M. D,, of which thefollowing extract relates to this subject:

“ I have operated on three cases by Dr. Parker’s method; the patientswere all males and adults. In all of them the onset of the disease was ab-rupt, with acute symptoms of peritonitis that became localized in the rightiliac region. In two of the cases the offending substance was discharged;in the third case none was seen. Two cases recovered rapidly; one diedon the second day after the operation. Although I saw these cases earlyafter the attack, I did not operate earlier than the seventh day. I think itis as important not to operate too soon as it is to defer the operation toolong.”