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on the anterior surface of left lung was a recent adhesion; some lymph, and a little pus, no serum. In the lower lobes of both lungs were large solid masses, evidently the result of pulmonary apoplexies; such a mass was also found in the lower portion of upper lobe of left lung; these portions were solid, like liver; and on section black blood oozed from the cut surfaces.

Heart. The heart was greatly enlarged; (there were no scales for weighing it). No pericardial adhesions; no valvular lesions. There was a slight excess of bile-stained serum. The apex bulged greatly; it was darker than the rest of the organ; the vessels on the surface of apex. were enlarged and intensely congested; to the touch it was hard and resisting. On section, a mass of fibrin, size of a hen's egg, was found in the apex, (left ventricle) clinging tightly to the heart-walls; it was not a recent clot; but was light colored, resisting, and somewhat laminated. Some portions of the left ventricular walls were three-quarters of an inch in thickness; but in the thinnest portions over the clot not more than one-eighth of an inch. The case was pronounced to be one of aneurism of the heart.

Liver. The liver appeared to be fatty; was small for so large a man. There was hardly any left lobe; the upper portion of the right lobe bulged directly upwards, forming a tuberosity as large as a small fist; section revealed nothing peculiar. No anatomical cause observed to account for the jaundice.

For constant assistance in the treatment of the case I am indebted to Dr. E. C. Kinney of Norwich.

TYPHLITIS, AND PERI-TYPHLITIS OR DISEASE OF THE CÆCUM, AND VERMIFORM APPENDIX, RESULTING IN INFLAMMATION AND ABSCESS IN THE RIGHT ILIAC FOSSA.

E. C. KENNEY, M.D., NORWICH.

This disease has been described by various writers as typhlitis, tuphloenteritis, peri-typhlitis, cæcitis, lumbar abscess, fecal abscess of iliac fossa, etc.

The literature of the disease as given in the medical text-books is quite limited, but scattered through the periodicals of the past thirty years, especially those of the last fifteen, are many very interesting records of cases, with treatment. Among those of particular notice, I would refer to the celebrated article of Dr. Willard Parker, published in the New York Medical Record, March, 1867; that of Dr. Gurdon Buck, in the same, January, 1876; that of Dr. Leonard Weber, in the same, vol. 13, p. 39, with remarks by Dr. Sands; also Dr. Weber's article in the New York Medical Journal, August, 1871; the very valuable paper of Dr. Bartholow of Cincinnati, in Hays' American Journal, 1866, p. 351; the ac

count of the disease in Copeland's Dictionary of Practical Medicine; the able article in Ziemssen's. Cyclopædia, by Bauer, in which reference is made to some eighty-seven different papers, ten of which are by American authors, about half-a-dozen by English, and the rest principally by German and French. The peculiar anatomy of the cæcum and appendix, which probably strongly predisposes to the retention of fecal matter and foreign substances, is worthy of notice.

Gray says of the cæcum, "It is the large, blind pouch in which the large intestine commences. It is the most dilated part of the tube, measuring about two and a-half inches both in its vertical and transverse diameter. It is situated in the right iliac fossa, immediately behind the anterior abdominal walls, being retained in its place by the peritoneum, which passes over its anterior surface and sides,-its posterior surface being connected by loose areola tissue with the iliac fascia.

Occasionally it is almost completely surrounded by peritoneum, which forms a distinct fold,-the meto-cæcum connecting its back part with the iliac fossa. When this fold exists, the cæcum obtains considerable freedom of movement. Attached to its lower and back part is the appendix vermiformis, a long, narrow, worm-shaped tube, the rudiment of the lengthened cæcum, found in all the mammalia, except the highest forms, as the ourang-outang and wombat. The appendix varies from three to six inches in length, its average diameter being about equal to that of a goose-quill. It is usually directed upwards and inwards behind the cæcum, coiled upon itself, and terminating in a blind point, being retained in its position by a fold of peritoneum, which at times forms a mesentery for it. Its canal is small, and communicates with the cæcum by an orifice, which is sometimes guarded by an incomplete valve. Its coats are thick, and its mucous lining furnished with a large number of solitary glands. The appendix not unfrequently occupies abnormal positions. In the cæcum the longitudinal fibers are arranged in three bundles, much shorter than the mucous membrane lining the same. This arrangement permits a great increase in size when distended by fæcal accumulation. When not so distended, the mucous membrane lies in folds and sacs which form a most convenient place for the lodgment of foreign substances. From its attachment the motions of the cæcum are quite limited; consequently foreign bodies lodged in its folds are less easily detached than in other parts of the intestines.

The pathological conditions we are considering may commence either in the appendix (by far its most frequent site), in the cæcum, or more rarely in the sub-cæcal connective tissue. In the cæcum and appendix some irritating substance, most often hardened fæcal matter, or some foreign article, as seeds of fruits, particles of bone, shot, pins, etc., become lodged. These from their pressure cause inflammation of the mucous membrane. The inflammation extends to the other coats, and ultimately to ulceration and perforation. As a rule, before perforation is accomplished circumscribed peritonitis takes place, adhesive lymph

is poured out and attachments are formed with the neighboring parts, thus, for a time at least, inclosing the pus and perforating article in a sac, and shutting them off from the abdominal cavity. In this way an abscess may form and grow to the size of a man's fist, and even larger. Having formed, its contents may be absorbed, leading to a firm union of its walls, in which the offending substance is imbedded, or ulceration may destroy the wall of the abscess, leading to perforation, either into the abdominal cavity, into the intestines, or externally. Cases have been recorded in which the pus took very strange routes, having discharged itself into the bladder, vagina, uterus, vena cava, lighting up secondary abscesses in the kidney, liver, lungs, or even opening into the thoracic cavity. Again, it has filtered between the layers of the abdominal walls, leading to immense abscesses and sloughing of the parts. As a primary disease, inflammation commencing in the sub-cæcal connective tissue must be rare. It is probably owing in most cases to some traumatic cause, or perhaps to pressure of a much-distended cæcum. As a secondary affection-perityphlitis-its pressure is very constant. These inflammations show a marked predisposition to attack the male sex in preference to the female, in the proportion of about five to one. Volez says, thirty-seven females to nine males. Bamberger, as twenty to four; and others in about the same proportion. Also they appear to be diseases of the earlier half of life, the very great majority of recorded cases occurring under forty years of age.

The causes of these conditions are often very obscure; those agencies that interfere with the normal physiological action of the intestine probably in many instances afford a starting-point for the trouble. Thus in constipation with great distention of the cæcum, its muscular coat may be partially paralyzed, a portion of the fæcal contents becomes entangled in its folds, the fluid parts are absorbed, the solid portion (the phosphates and carbonates) remains, and an intestinal calculus results. This result is much favored by the peculiar movements of the contents of the cæcum, which all physiological anatomists tell us are propelled against gravity, backwards and upwards.

These calculi may remain in the cæcum, or be pressed into the appendix, or they may be formed in the latter situation. Again, external injuries, catching cold, foreign substances swallowed, lesions remaining from preceding disease, as imperfectly healed ulcers of typhoid fever, dysentery, etc., tubercular and scrofulous ulceration. These diseases may occur in a very insidious manner or be ushered in with great severity. The course they run may be acute or chronic, and show every variety of symptoms. Perhaps a careful study of the forms and terminations that these inflammations present may enable us to arrive at a more correct appreciation of their pathology and indications as to treatment. No doubt there are many cases that do not advance beyond inflammation of the mucous membrane lining the appendix or cæcum. Dr. Austin Flint in his lecture says that Dr. James Jackson of Boston,

in his "Letters to a Young Physician," describes an affection under the name of "Painful tumor near the cæcum," which under appropriate treatment disappears, and confesses his inability to form an opinion as to its precise site and character. Dr. Flint says, "I will venture the conjecture that it is an inflammation of the mucous membrane lining the vermiform appendix, with dilatation." In illustration of this form permit me briefly to describe a case I had under observation a few months since. William S., a strong, healthy boy fourteen years old, had been sick in the house several days before I saw him. He had some cathartic medicine administered by his mother, which operated freely, but growing worse instead of better I was sent for. Found him in bed; temperature 100°; pulse 100; respiration 20; tongue furred; no appetite; some nausea; complained of severe pain in the abdomen. Upon examination discovered in the right iliac fossa a well-marked tumor, perfectly distinct in its outlines, dull and resistant upon percussion, and intolerant of the least pressure. Under treatment his symptoms improved, and in about a week he was up and around the house.

In the next form the inflammation extends to the other coats, circumscribed peritonitis is induced, adhesive lymph is poured out, and the neighboring parts are glued together; pus forms, and if perforation occurs, the offending substance with the pus is confined in the protecting cyst. In time the more fluid parts of the pus are absorbed, the walls of the sac become firm and contracted, and recovery slowly ensues. An example of the above form I think the following case exhibits :

E. A. C., twenty-eight years old, a moderately healthy man, on the morning of May 11, 1875, was seized with very severe pain in the abdomen, accompanied with incessant nausea and vomiting; temperature 1034; pulse 120; respiration 30 and thoracic; skin dry; tongue much furred; countenance expressive of great suffering. On examination the abdomen was moderately tympanitic, and the right iliac fossa occupied by a tumor, its outlines perfectly definable, exquisitely tender to the touch, giving upon percussion a dull sound and marked sense of resistOn the 17th of May Prof. Fordyce Barker was called in consultation, and did me the great honor to confirm the diagnosis, and to approve the treatment. After the tenth day the more acute symptoms began to subside, and the patient was convalescent in about six weeks. As long as he was under observation an irregular induration could be felt deep in the iliac fossa. At about the eleventh day there were some evidences of septic poisoning.

ance.

Instead, however, of the fortunate issue above described, the walls of the cyst may break down, the contents are discharged into the abdominal cavity, and general peritonitis occurs, quickly ending in death. A very painful case that resulted fatally in a young man of great promise was, I conceive, typical of this form.

February 3, 1876, was called to see C. H. D., a robust, healthy boy, aged nineteen years. The history was, that he had been sick for two days with pains in his bowels, and vomiting. His mother, thinking it an ordinary “bilious attack," had given him two blue pills of five grains each, and followed them with a saline, which had acted freely. The pain and fever increasing, I was sent for. I found him in bed, lying upon his

back, and complaining of great pain; temperature 104°; pulse 125; respiration frequent and shallow; tongue furred; skin hot and dry; nausea almost constant; urine scanty and high-colored. An examination revealed the abdomen tympanitic, with marked dullness in the right iliac fossa, which was occupied by a firm, resisting tumor of excessive tenderness, and affording much pain in any attempt to assume a sitting posture. During the progress of the disease I had the advantage of a number of consultations with Drs. Carleton and Perkins. The propriety of an operation was earnestly debated, but owing to the reluctance of the parents and an apparent amelioration of the symptoms, it was unfortunately deferred. On the twentieth day he became much worse, signs of general peritonitis supervened, and he died on the 22d of February. A post mortem was permitted, and made the next day by Dr. Perkins, Dr. Carleton, and myself present. Weather intensely cold. Upon section of the abdomen most extreme peritonitis was disclosed, and the entire contents of the right iliac fossa in such a gangrenous condition that it was impossible to make any dissection of them. In fact the fossa was filled with a mass of broken-down and decomposed matter.

In the last two forms I presume the ulceration and perforation (if it proceeds as far) occurs in the posterior part of the cæcum, which, as a rule, is uncovered by the peritoneum, and the abscess is formed in the sub-cæcal connective tissue. If the ulceration is in the appendix, and it occupies its usual site behind the cæcum, the abscess would be in the same locality. Another variety of this disease not unfrequently met with, is that in which the inflammation is so intense and rigid that ulceration and perforation take place, causing death by general peritonitis, before nature has time to form the protecting cyst. Death generally occurs about the end of the first week. In illustration: I remember one afternoon, in the fall of 1859, going into Bellevue Hospital, and being told a post-mortem was about to be made by Dr. Charles Phelps on the body of one of the resident physicians, who had died that morning of perityphlitic abscess after an illness of about a week. He had been attended by Dr. Alonzo Clark, which is equivalent to saying, that every resource that the science and art of medicine affords had been exhausted in his behalf. Section of the abdomen revealed general peritonitis of a high grade. The appendix was distended to twice its normal size by a number of fæcal calculi, ulceration had resulted, and several had escaped into the abdominal cavity, causing the mischief. Nature had succeeded in constructing the protecting cyst around about one-half the distance necessary to enclose the cæcum and appendix. In this instance the appendix, instead of occupying its more usual position behind the cæcum, extended downwards towards the pelvic cavity.

In the chronic course these plegmonous inflammations sometimes pursue, each individual one presents a history peculiar to itself..

To briefly recapitulate, we may have this disease first as inflammation of the mucous membrane lining the parts. Next the inflammation extending to the other coats, setting up circumscribed peritonitis, and adhesive attachments enclosing the products of the inflammation, and

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