ON 
ABSCESSES 
IN THE 
LQWER ABDOMINAL CAVITY 
AND 
ITS PARIETES. 
BY 
GURDON BUCK, M.D., 
New York. 
NEWYORK: 
JOHN F. TROW & SON, PRINTERS. 
187G, ON 
ABSCESSES 
( IN THE 
LOWER ABDOMINAL CAVITY 
AND 
ITS PARIETES. 
BY 
GUKDON BUCK, M.D., 
New York. 
JOHN F. TROW & SON, PRINTERS. 
NEWYORK: 
1876. This pamphlet contains three separate articles, all of which have 
been published before in different medical journals : that on “ Peri- 
typhlitic Abscess in the Ilio-Coecal Region,” in the Transactions 
of the New York Academy of Medicine for September, 1874, and 
in the New York Medical Record of January 15, 1876 ; that on 
cc Migration of Purulent Matter,” in the Richmond and Louisville 
Medical Journal for March, 1876 ; and, finally, that on “ Post-Fas- 
cial Abscesses originating in the Iliac Fossa,” in the New York 
Journal of Medicine for March, 1857. These different subjects are 
so intimately related to each other, and have such important bear- 
ings on surgical therapeutics, that the author has thought it advis- 
able to republish them under the title of “ Abscesses in the Lower 
Abdominal Cavity and its Parietes.” THE MIGRATION 
OF 
PURULENT MATTER 
AND THE 
ANATOMICAL AND OTHER CONDITIONS 
UPON WHICH IT depends; 
ILLUSTRATED BY CASES. 
BY 
OrTJttiDOJsr ibtjcik:, uvc. id.. 
Visiting Surgeon to New York Hospital, etc., etc. 
[Read at a Stated Meeting of New York Academy of Medicine, July 1875. | 
FROM MARCH NO. RICHMOND AND LOUISVILLE MEDICAL JOURNAL. 1876. 
LOUISVILLE, KY.: 
RICHMOND AND LOUISVILLE MEDICAL JOURNAL BOOK AND JOB STEAM PRINT, 
KM Green Street, 2d door west of Post-office. 
187 G. MIGRATION OF PURULENT MATTER. 
By migration of pus is understood its accumulation in a 
locality more or less remote from the seat of suppuration. It 
may take place in certain regions of the body, and is favored 
by the anatomical relations of the parts involved, especially the 
aponeuroses and membranous structures, and also by gravitation. 
The following cases are examples in which the parietes of the 
lower abdominal and pelvic cavities were concerned: 
Case I.—On Sunday afternoon, July 29,1868, a poor woman 
from Hudson City, New Jersey, brought her infant, a robust 
and full-sized boy, eleven months old, to the office for advice, 
accompanied by her physician. The child was exceedingly 
restless, crying out in interrupted, short exclamations, and 
seizing, incessantly, the mother’s breast for comfort. His 
countenance was expressive of severe suffering. The left but- 
tock and thigh were very much swollen and tense, especially 
along the crest of the ilium ; the left inguinal region was also 
swollen. The temperature of the surface was elevated, and the 
subcutaneous tissue oedematous. The thigh was semi-flexed, 
somewhat everted, and motionless; when cautiously handled, 
however, it was found free at the hip-joint. Attention was ar- 
rested by a tumor in the left groin of the size of the last phal- 
anx of the little finger, occupying the site of the internal ab- 
dominal ring, with its longest diameter parallel to Poupart’s 
ligament. It was found to emerge from the abdominal parietes, 
but without adhering to the superjacent skin, it had the feeling 
of an enlarged lymphatic gland. The superficial veins upon 
the lower half of the left side of the abdomen and the upper 
part of the left thigh were remarkably enlarged and conspicu- 
ous. The swelling and tension existing along the crest of the 
left ilium entirely prevented the anterior superior spinous pro- 4 
MIGRATION OF PURULENT MATTER. 
cess of the ilium from being grasped between the thumb and 
fingers; while, on the right side, it could be done with great 
facility. 
The mother gave the following account of the antecedents of 
this condition; On the 4th of July (this being the 29th), the 
child fell from her arms upon the pavement, but upon what 
part of the body he struck, she was unable to say. The hurt 
was evidently severe, judging from its immediate effects. About 
one week after the fall, she first noticed a swelling on the left 
nates, and since then the child had made no attempt to stand upon 
the limb as he had been accustomed to do previously. The 
swelling in the left groin first attracted her attention on the 
25th of July. He had had a passage from the bowels regularly, 
and they had also been acted on by medicine prescribed by a 
physician. There had been no vomiting at any time. The tu- 
mor in the left groin suggested the suspicion of an inguinal 
hernia, but the absence of all symptoms of intestinal obstruc- 
tion, and the recent appearance of the tumor, taken in connec- 
tion with other considerations, put at rest the question of her- 
nia. The swelling involving the left buttock was most promi- 
nent behind the trochanter, where an obscure, doubtful feeling 
of fluctuation was recognized. For several days past, the child’s 
sufferings had been very severe. The mother was advised to 
take her child the next day to St. Luke’s Hospital, and in the 
meantime to poultice the hip, to employ a Sitz bath with hot 
bran water, and give small doses of Hover’s powder every three 
hours. 
On Monday, the 30th, the child was seen at the hospital. 
The swelling in the left groin appeared to have increased, and 
fluctuation behind the trochanter to have become more distinct. 
The same treatment was directed to be continued another twen- 
ty-four hours. 
31s£.—Hrs. Geo. A. Peters, W. H. Draper, F. J. Bumstead, 
and T. B. Pveynolds, were present at the hospital and examined 
the patient. The child’s restless and suffering condition con- 
tinued unabated. The swelling in the left groin had still fur- 
ther increased, and the fluctuation behind the trochanter was 
no longer doubtful. In view of all the facts of the case, the MIGRATION OF PURULENT MATTER. 
5 
following explanation of the patient’s condition appeared to me 
to be the most reasonable : The markedly acute phlegmonous 
character of the swelling, supervening, as it did, upon a 
severe injury, clearly pointed to the existence of a deep-seated 
abscess, following inflammation, as the most probable cause of 
the obstruction of the superficial venous circulation, which was 
so conspicuous. The distended condition of the superficial 
veins upon the lower part of the left side of the abdomen and 
upper part of the thigh, all of which convey their blood to the 
common iliac trunk, appeared to indicate that the seat of obstruc- 
tion existed at that point in the course of the iliac vein where it 
skirts the upper margin of the pelvic cavity and rests upon the 
iliac fascia, with the peritoneum covering it. The absence of any 
symptoms of peritonitis precluded the supposition that the abscess 
had formed in the cavity of the peritoneum itself. If, on the other 
hand, the abscess had formed in the iliac fossa underneath the 
iliac fascia, an accumulation of matter in that locality, shut in 
as it would be by the resisting fascia, could only have the effect 
of elevating the fascia, and with it the vein, but not to such a 
degree as to obstruct the flow of blood through it. If, how- 
ever, suppuration had taken place in the connective tissue out- 
side of the peritoneum and between it and the iliac fascia, 
where the abscess would be in immediate contact with the vein 
itself, it might readily encroach upon it and diminish its calibre 
to such a degree as to obstruct the flow of blood through it. Such 
a conclusion in regard to the precise seat of the abscess in the 
pelvic cavity would also explain, on anatomical grounds, how 
the collection of matter, which was approaching the surface 
upon the buttock behind the trochanter, might communicate 
through the ischiatic notch with the abscess in the pelvis. 
Guided by these considerations, I proceeded to make an open- 
ing in the abscess at a point behind the trochanter, where the 
matter appeared to have approached nearest to the surface. A 
sharp-pointed, narrow bistoury, after penetrating three-fourths 
of an inch, arrived in the cavity of the abscess. The opening 
being enlarged, five or six ounces of thick, healthy pus escaped, 
and was followed by the immediate subsidence of the swelling 
in the left groin, and the disappearance of the distended super- 6 
MIGRATION OF PURULENT MATTER. 
ficial veins. The tension and fullness over the crest of the left 
ilium also became relaxed, so that the anterior superior spinous 
process could now be readily grasped between the thumb and 
fingers. From the immediate subsidence of the tumor in the 
left groin, there appeared good reason to infer that the suppu- 
ration had also approached the surface and was seeking an out- 
let in that direction. A greased tent was inserted in the open- 
ing, and the poultices were resumed. A copious discharge 
continued for a few days, and gradually subsided. A female 
catheter was, on one occasion, inserted through the opening 
and passed nearly its whole length in the direction of the ischi- 
atic notch. The patient steadily improved thereafter, and in a 
few days was removed from the hospital to his home. 
In the month of October following, the mother brought him 
to my office to show that the opening had been closed for some 
time, and all traces of swelling had disappeared. The hip had 
regained its natural contour, and the use of the limb was being 
steadily recovered. 
Case lI.—J. Dreenan, aged twenty-four; Ireland; a foundry 
workman ; admitted into New York Hospital September 15, 
1866, with a prominent tumor in the hypogastric region, occu- 
pying the entire space in the median line between the umbili- 
cus and the symphysis pubis. It was of a symmetrical, ovoid 
form, elastic, fluctuating, and painless. The skin covering it 
was supple, unchanged in color, and unadherent to the under- 
lying parts. It presented the aspect of an overdistended blad- 
der, but no encroachment upon the rectum could be felt by the 
finger inserted per anum, and no difficulty was experienced in 
urinating. A catheter entered the bladder without encounter- 
ing obstruction, and gave exit to only a few ounces of healthy 
urine, but without any effect upon the size of the tumor. 
The patient gave the following account of his antecedent con- 
dition : About six or seven weeks previously, he experienced, 
while handling a heavy piece of iron-casting, a sudden sensa- 
tion of something giving way in the left flank that caused severe 
pain, obliged him to give up work, and keep in the house. 
Subsequently, he had chills, followed by fever, and at a later 
period the tumor was gradually developed in its present local- MIGRATION OF PURULENT MATTER. 
7 
ity, accompanied by pain in the left hip, and lameness when he 
attempted to walk. His general condition when I first saw him 
was as follows: He was emaciated and weak; his pulse was 
accelerated, and his countenance expressive of suffering. An 
incision had been made over the tumor by the House Surgeon 
after his admission, but matter not having been reached, the 
wound was closed by sutures. 
Diagnosis.—The presence of a collection of fluid within the 
tumor was evident from the elasticity and fluctuation that were 
perceptible; the nature of the fluid, however, seemed to be in- 
dicated by the following considerations. No direct violence 
having been inflicted upon the part itself occupied by the 
tumor, and its development having taken place tardily, at a point 
distant from the site of original injury, precluded the inference 
that the contents of the tumor consisted of extravasated blood. 
That suppuration had taken place might however reasonably 
be inferred from the fact, that an injury had been sustained in 
the first instance, and that, subsequently, chills, followed by 
fever, had occurred, and were accompanied by wasting and 
other symptoms of constitutional disturbance. But, admitting 
the existence of suppuration, the question still remained, where 
could the collection of matter constituting the tumor be located 
anatomically, so as to explain its presence at a point so remote 
from the seat of the original injury which the patient, from 
his sensations, experienced at the time, referred to the left ilio- 
lumbar region ? 
To answer this, we should inquire, Ist. Was it situated in 
the subcutaneous connective tissue? The suppleness of the 
skin covering the tumor, the absence of adhesions between the 
skin and underlying surface, as well as the absence of inflam- 
matory, oedematous infiltration, were conditions quite incom- 
patible with such a conclusion. 2d. Was the collection of 
matter confined within the sheath of the recti abdominis mus- 
cles which occupy this region ? The extent of surface covered 
by the tumor, its oval and salient form, exceeding the narrow 
and sharply defined limits within which »the matter would have 
necessarily been confined had it occupied the cavity of the 
sheath, were considerations unfavorable to such a view. 3d. 8 
MIGRATION OF PURULENT MATTER. 
Could the abscess be located in the peritoneal cavity itself, and 
there, be circumscribed by adhesions of the intestines to each 
other, and to the parietes ? Such a condition could only be the 
result of peritoneal inflammation, of which there had been in 
this case no antecedent symptoms. 4th. And finally, did the 
collection of matter occupy the loose, connective tissue outside 
of the peritoneum and between it and the abdominal parietes? 
This was the only remaining locality it could occupy, and here, 
it was concluded that it was actually lodged, having migrated 
to this point from the left ilio-lumbar region, where, at the 
site of the original injury, suppuration must have commenced. 
It was on this anatomical plane alone that migration of pus 
could take place between these two points. It was decided 
accordingly to establish an outlet for the matter at the most de- 
pending point, by making an opening in the linea alba between 
the pyramidal muscles, immediately above the symphysis pubis. 
As the medical students attending the hospital were to make 
their visit on the following Monday (it being Saturday) the 
operation was postponed, and the patient directed to keep in 
bed in the meantime. 
17th.—During the previous night, patient had had several 
thin, fsecal evacuations, in quick succession, the last of which, 
on being inspected by the nurse, was found to consist chiefly of 
pus. The abscess had evidently opened into the descending 
colon, and the pus had thus found an exit per anum. The hy- 
pogastric tumor, though relaxed, was still quite prominent. 
Notwithstanding what had happened, it was thought best to 
establish, as was originally intended, a direct outlet at the 
most depending point. By this means, it was believed that the 
matter would be diverted from passing into the bowel, and the 
final closure of the communication between the abscess and in- 
testine, be more surely brought about. An incision, two inches 
long, was accordingly made in the linea alba immediately above 
the symphysis pubis and continued into the cavity of the ab- 
scess. An abundant discharge of pus followed, and was suc- 
ceeded by the subsidence of the tumor. A greased tent was 
inserted to maintain the opening free. 22d. Some pus contin- 
ued to be discharged with the fsecal evacuations. Pressure MIGRATION OF PURULENT MATTER. 
9 
over the left ilio-lumbar region increased the discharge of 
matter from the abdominal opening, showing conclusively the 
source from which the suppuration proceeded. September 28th, 
discharge less copious; pulse 120. October 27th, the discharge 
much abated; patient’s general health much improved. Novem- 
ber 16th, the discharge had nearly ceased from the abdominal 
opening, and pus had disappeared from the fsecal evacuations. 
28th, the left hip-joint was becoming limber. December 21st, 
the sore, having nearly closed, patient was discharged cured. 
Remarks.—If we carefully consider the distribution of the 
peritoneum where it lines the parietes of the lower abdominal 
and pelvic cavities, we find it in the lumbar region covering 
the anterior surface of the psoas magnus muscle, and thence 
spreading out interiorly and laterally over the iliac fossa, and 
further down over the walls of the pelvic cavity. In all these 
regions, as well as in the contiguous hypogastric and inguinal 
regions, this membrane adheres loosely to the surfaces which 
it covers, by means of a delicate connective tissue interspersed 
scantily with a fine adipose tissue, and can readily be detached 
by pressure with the ends of the fingers alone without the aid 
of a scalpel. The slight resistance to its spreading which sup- 
puration would encounter on this anatomical plane favors the 
migration of pus to a distant point, especially if aided by gravi- 
tation. This anatomical peculiarity also serves as a protection 
to the peritoneal cavity itself against ulcerative perforation of 
the membrane, the consequences of which would be so disas- 
trous. On this same plane, migrating pus would gain access to 
the track by which the great sciatic nerve and vessels pass out 
through the ischiatic notch into the gluteal region, as happened 
in Case No. I. of the infant before narrated. A further illus- 
tration of this subject is furnished in the case of what is known 
as psoas abscess, where suppuration takes place in the lumbar 
or dorsal region of the spine, and depends on caries of the ver- 
tebrae. Aided by gravitation the pus follows the psoas muscle, 
and in its descent may take either one of two directions. Ist. 
By passing behind the iliac fascia it may accumulate in the iliac 
fossa and make its way behind the outer half of Poupart’s liga- 
ment, distending and elevating it in some degree, and then may 10 
MIGRATION OF PURULENT MATTER. 
arrive upon the upper part of the thigh, below the outer half of 
Poupart’s ligament, where it presents a more or less extensive, 
elastic and fluctuating swelling. Continuing along the course 
of the iliacus and psoas muscles, the matter may burrow its way 
on even to the region of the hip-joint. 
2d. Purulent matter in its descent from the lumbar region, 
instead of passing behind the iliac fascia, may keep in front of 
and between it and the peritoneum, and accompany the femoral 
vessels in their passage from the pelvis, behind the inner half of 
Poupart’s ligament. In this case a superficial subfascial swelling 
may form on the anterior aspect of the thigh, below the inner 
half of Poupart’s ligament. Another point at which matter may 
make its escape from the pelvic cavity, is in company with the 
obturator vessels as they traverse the obturator foramen at its 
upper margin, where the obturator membrane is wanting. In 
this case the accumulated matter makes room for itself among 
the abductor muscles and forms a bulging elastic tumor on the 
inner aspect of the thigh close to the perineum. An example of 
this last mode of migration is afforded by the following case: 
Case lll.—John Rahelly; thirty-two years; Ireland; laborer; 
admitted into New York Hospital August 7, 1838, under the 
care of Dr. J. C. Cheesman. Patient had suffered from chills 
and fever the two preceding summers, but had previously en- 
joyed robust health. In the month of December preceding, he 
first noticed a swelling that appeared without local injury on 
the anterior aspect of the left thigh high up. It increased 
rapidly at first, but more gradually afterward, and was unac- 
companied by pain. He had continued at hard work without 
interruption. His condition when admitted to the hospital was 
as follows: The swelling of a bulging form extended from the 
perineum to a point below the middle of the thigh, and occupied 
its inner and anterior surface. The skin covering it was supple 
and unchanged in color. The tumor itself was elastic, distinctly 
fluctuating, painless, without pulsation, and conveyed no impulse 
to the hand during the act of coughing. The passage of the gra- 
cilis muscle over it in a vertical direction, was marked by a shal- 
low sulcus on the surface. The extension of the tumor beneath the 
adductor muscles became obvious when the. thigh was flexed on MIGRATION OF PURULENT MATTER. 
11 
the trunk and adducted. A puncture was made in the tumor on 
its inner aspect about one hand’s breadth below the perineum, and 
more than one quart of pus evacuated. Constitutional reaction 
supervened in a few days and was developed into hectic, accom- 
panied by profuse suppuration, under which patient succumbed 
on the 14th of September, about five weeks after entering the 
hospital. From his fellow workman who visited him, it was 
ascertained that for some time past, patient avoided stooping to 
lift anything from the ground, and accomplished it by assuming 
a squatting position. His laborious occupation often obliged 
him to lift heavy weights. Although no post-mortem exam- 
ination was obtained to establish the diagnosis, the history of 
the case clearly pointed to the lumbar vertebrae as the seat of 
disease and source of suppuration. The location of the accu- 
mulated pus among the adductor muscles at the highest point of 
the thigh, and on its inner aspect also pointed to the obturator 
foramen as the passage by which it might emerge from the 
pelvic cavity and reach its destination rather than by either of 
the other points indicated above. PERI-TYPHLITIC ABSCESS IN THE 
ILIO-CCECAL REGION. 
The form of abscess here under consideration occurs exclu- 
sively on the right side, and is produced by peri-typhlitis, or, 
as the term implies, inflammation around the coecum. It is 
due most frequently to perforation of the appendix vermifor- 
mis; and the collection of matter resulting therefrom occupies 
the peritoneal cavity itself, and is walled in by adhesions. 
The present communication is offered especially with the 
view of illustrating the successful treatment of this abscess 
by the early establishment of an external opening in the ab- 
dominal walls for the discharge of the pus. 
The following cases that occurred in the Author’s own 
practice are offered in illustration. 
Case I.—G. IST., a lad, aet. 12, residing in the city, while in 
the enjoyment of ordinary good health, and after a day of ac- 
customed activity, was, on Thursday, June 11, 1871, attacked, 
on going to bed, with violent colic-pains and vomiting. Hot 
poultices and anodynes were resorted to, and on tire following 
day free evacuations from the bowels were obtained by a dose 
of five grains each of calomel and Dover’s powder. On Satur- 
day evening, June 13th, forty-eight hours after the attack, I 
saw him, in consultation with Dr. J. Linsly, the attending 
physician, and found his condition as follows: Vomiting had 
almost ceased, his pulse was moderately accelerated, and the 
temperature of the surface was normal. The abdomen was 
tumid, but not tense; and tenderness on pressure, which at 
first had been diffused over the abdomen, was now confined to 
the right iliac region, where a deep-seated tumor could be 
defined, though rather indistinctly. It occupied a space above 
the outer half of Poupart’s ligament, and close to it. There 
was no elevation of the surface over the tumor, and the pain 2 
PEEI-TYPHLITIC ABSCESS IN 
produced by the most cautious attempts at deep pressure deter- 
red us from making as thorough an exploration as seemed 
desirable. Iso dulness on percussion was appreciable, and 
flexion and extension of the thigh caused no pain. The tongue 
was clean, and there was no aversion to taking nourishment. 
Dr. Linsly had already prescribed pills of morph, snlph. gr. 
of which one was to be taken every two hours. The conclusion 
we arrived at respecting our patient was, that an abscess was 
forming in connection with perforation of the vermiform 
appendix. Six leeches were applied over the tumor the same 
evening, and followed by poultices. Under the influence of the 
morphia pills a quiet condition was maintained; the pulse 
ranged from 80 to 100 ; the temperature of the surface was 
uniformly natural. On Wednesday (seventh day) the morphia 
was suspended, and a movement of the bowels obtained by 
means of 01. ricin. | ss., and an enema of catnip-tea, but with 
only partial effect, owing to his instinctively avoiding any 
straining 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, 
bio chill or feverishness was at any time observable, nor any 
extension of abdominal tenderness beyond the limits of the 
tumor itself. Nothing abnormal could be felt by digital explor- 
rectum. On Thursday, June 18th (eighth day), Prof. 
W. Parker joined onr consultation, and arrived unhesitatingly 
at the conclusion that an abscess had formed, and required to 
be opened from the surface. The absence of dulness on per- 
cussion over the tumor was the only condition that seemed to 
militate against the diagnosis arrived at. All the other con- 
ditions and antecedents corroborated it; and the existence of 
resonance was afterward explained by the presence, within the 
cavity of the abscess, of an abundant collection of gas. The 
morphia and poultices were resumed, preparatory to an opera- 
tion on the following day. On Friday (ninth day), at twelve 
o’clock, the operation was performed, after the inhalation of 
ether. Some elevation of the surface over the tumor was now 
manifest, but no redness, or oedematous infiltration, or adhesion 
of the skin to the underlying parts, existed; nor was any fluc- 
tuation perceptible. By a bolder palpation, now admissible THE ILIOCCECAL EEGIOX. 
3 
under anaesthesia, the deeper outlines of the tumor could he 
better defined, and its longest diameter was ascertained to be 
parallel with Poupart’s ligament. The operation was per- 
formed as follows: A point two fingers’ breadth distant from 
and to the inside of the anterior superior spinous process of 
the ilium, and a little below its level, where the tumor ap- 
proached nearest to the surface, was chosen for an opening, 
which was made with a small canulated trocar (equivalent in 
size to ISTo. lof the bougie scale.) A puncture was first made, 
at the point chosen, with a tenotomy-knife, through the skin, to 
facilitate the onward passage of the trocar. This was then inserted, 
and advanced till it encountered the tendon of the obliquus exter- 
mis muscle, which presented great resistance to its further pas- 
sage. To overcome the resistance safely, the trocar was with- 
drawn within its sheath, and the canula held in firm contact 
with the surface of the tendon, while the point of the trocar 
was pushed on. By successive repetitions of this manoeuvre, 
the trocar at length encountered no further resistance; and, 
on withdrawing it entirely while the canula was advanced, 
matter escaped from the outer orifice of the tube, and the suc- 
cess of the procedure was demonstrated. The canula, being 
still held in situ, served as a guide, along the outer surface 
of which a sharp-pointed knife was conducted into the 
cavity of the abscess, and used to enlarge the track of the 
canula. On withdrawing the knife, the wound was further 
enlarged to the extent of more than an inch at the sur- 
face of the skin. The little-finger was then thrust into the 
cavity of the abscess, and the opening dilated sufficiently 
to allow a free escape of the matter, which was fetid 
and of a dirty-grayish aspect, but without any biliary dis- 
coloration. With the matter there was also an abundant escape 
of fetid gas, to the presence of which was attributed the re- 
sonance on percussion over the tumor observed previous to the 
operation. A plug of cotton-wick well greased was inserted 
in the opening, and the poultices were resumed. Bor the first 
three or four days a solution of salt and water (3 jto 3 . viij) 
was injected into the abscess at the daily dressing. The 
patient’s subsequent progress was favorable. On the fifth day 
after the operation, when the discharge was no longer fetid, 4 
PEEI-TYPHLITIC ABSCESS IN 
and liad regained a healthy character, two tufts of sloughy 
connective tissue came away, followed by a more copious dis- 
charge of pus, ■which had accumulated in the cavity of the 
abscess from obstruction of the outlet. On June 25th, the 
sixth day after the operation, a dark-colored, gritty substance, 
of the size of a small pea, was discharged. A chemical 
analysis ascertained it to be a phosphatic concretion. On the 
day following another substance, of the shape and size of half 
an inch of small clay pipe-stem, was found on the dressing; it 
had all the characters of compact fecal matter. After this the 
suppuration progressively diminished. On June 29th a third 
smaller tuft of sloughy tissue was-discharged. The subsequent 
progress of the case requires no special notice. Under ex- 
cellent care at home, with generous diet and a moderate 
allowance of stimulants and tonics, he steadily improved both 
locally and generally. On July 18th he accompanied his 
family to their summer residence in the country, where he 
continued to gain rapidly. On August 14th his father 
reported that the wound had healed, and that the boy was 
quite himself again. 
Case ll.—Mr. J. M., set. 26, of Liverpool, of good constitu- 
tion and regular habits, being in good health and free from 
any premonitions of the attack that was impending, returned 
on Monday, Nov. 8, 1875, to the city, from Philadelphia, by 
an early morning train, took his ordinary dinner at half-past 
six in the evening, and retired to rest at about eleven o’clock. 
After a good night’s sleep he was awakened in the morning of 
Tuesday, 9th, by pains in the right iliac region, which he de- 
scribed as a peculiar sensation rather than pain, and which he 
feared might be the precursor of an attack of colic such as he 
had experienced on two previous occasions, but at remote 
periods. He had two small loose evacuations, following each 
other after a short interval. Hoping to obtain relief by pro- 
voking vomiting, he drank freely of hot water, which he re- 
jected, unmixed with other substances. The pain increasing in 
severity, he resorted to hot fomentations. At 9 o’clock lie was 
visited by Hr. Gr. H. Wynkoop, who prescribed six grains of 
calomel and administered a hypodermic injection of Magen- 
die’s solution of morphia, and repeated it a second time later THE ILIO-OCECAL REGION. 
5 
in the day. The same evening, about twelve hours after the 
attack, I made my first visit, and found him suffering from 
very severe pain in the right iliac region, which had persisted 
all day. He had vomited two or three times some bilious mat- 
ter subsequent to the vomiting produced by taking hot water 
in the morning:. There was no febrile heat nor acceleration of 
«_) 
the pulse, nor had there been any rigor. The abdomen was 
supple, but extreme tenderness on the slightest pressure existed 
over a spot that could be covered with the thumb at a point 
three fingers’-breadths distant from and to the inside of the an- 
terior superior spinous process of the right ilium, and on the 
same level with it. The tenderness diminished in a marked 
degree as the pressure receded from this circumscribed spot. 
Suspicion of the existence of a lesion of the vermiform ap- 
pendix was excited. Without delay one dozen leeches were 
applied, and followed by hot fomentations. 
Second day, at 9.30 a.m.—Yisited Mr. M. with Dr. Wynkoop, 
and found him still suffering severe pain by paroxysms, and 
with the same extreme tenderness on pressure over the spot 
already indicated in the right iliac region. He had had a 
shiver, lasting ten minutes, since daylight. Pulse had risen to 
106 and temperature to 101°. A second application of six 
leeches was made and poultices were continued. A narcotic 
treatment was now instituted. Magendie’s solution of morphia 
was directed to be taken, 15 minims every hour, till narcotism 
should be produced, and thereafter to be continued every two 
hours. At 7.30 p.m. patient wTas more comfortable and suffering 
less pain; there wras less tenderness on pressure; he had not 
vomited for 24 hours. Pulse was reduced to 86. Temp. 
100.6°. A moderate degree of narcotism has been main- 
tained by 75 minims of Magendie taken since morning. 
Third day, at 9.30 a.m.—Has passed a comfortable night 
without severe pain; tenderness on pressure is less marked; 
its locality, however, is unchanged ; has vomited bile. During 
our visit he had an attack of severe colic pain, diffused over the 
abdomen. The abdominal muscles were tense and retracted ; 
pulse 98. Temp, between 99° and 100°. Has taken 60 minims 
of Magendie through the night, up to eight o’clock this morning. 
Ordered enema of infusion of catnip, and the use of the catheter 6 
PEEI-TYPIILITIC ABSCESS IN 
to relieve fruitless efforts at urination. Ordered to take cal- 
omel, gr. x. 
At 7.30 p.m., patient somewhat relieved after the operation 
of the enema ; has succeeded in urinating. The abdomen has 
now become tumid. Local tenderness not increased ; the sur- 
face of the body is moist. Dysuria persistent. Pulse 98. 
Temp. 99°. Morphia has been taken in increased quantity 
through the day; but the original dose of 15 minims is to be 
resumed again. 
Fourth day, at 9.30 a.m.— Has passed the night without 
severe pain. Pulse 94. Temp 99°. Abdomen still tumid. 
Is much disturbed by nausea, evidently aggravated by the 
morphia. It was therefore stopped. Ordered calomel gr. ij., 
sub-nitrate of bismuth gr. v., to be repeated three times at inter- 
vals of three hours. At 7.30 p.m., has taken no morphia since 
6 a.m., without increase of pain. Nausea persists. Pulse 84. 
Temp. 98°. Ordered sinapism to epigastrium, 01. ricini 3 ss., 
and enema of infusion of catnip. 
Fifth day.—Pulse 84. Temp. 98° morning and evening. 
Flatulence and nausea persist. Abdomen tumid. Cap. cal- 
omel gr, ij,, sodse bicarb, gr. v., every four hours. 
Sixth day, at 9.30 a.m.—Continued flatulence and nausea, 
with eructations accompanied by severe colic pains. Pulse 
102. Temp. 101°. Stopped calomel powders, of which he had 
taken six. At 7.30 p.m., no decided relief. Ordered 01. ricini 
% ss., and an enema of catnip, to be administered through an 
O’Birne rectum tube, inserted high up. 
Seventh day, at 9.30 a.m.—The severe colic pains continue. 
Pulse and temperature abated. At 8,30 p.m., Prof. Alonzo 
Clark joined us in consultation, and after a careful examination 
of the patient, confirmed the diagnosis already arrived at. 
By careful percussion he outlined a dull space upon the sur- 
face identical with the seat of local tenderness, but unaccom- 
panied by any elevation of the surface corresponding to it. 
He also defined by palpation the outlines of a deop-seated 
tumor of somewhat firm consistence, the centre of which also 
corresponded to the tender spot on the surface. Patient’s suf- 
ferings were further aggravated by the development of an 
inflamed swollen hemorrhoid, occupying the right half of the THE ILIO-COECAL REGION. 
7 
verge of the anus. It was split into two halves by transfixing 
it lengthwise at its base with a sharp-pointed bistoury, and 
cutting outward through the surface. An enema of 20 drops 
of Magendie’s solution was then administered. 
Eighth day, at 9.30 a.m.—Patient has passed a distressing 
night, chiefly caused by the hemorrhoid, but obtained some 
sleep toward morning after a hypodermic injection of morphia. 
Has had several free liquid evacuations, and has vomited two 
or three times; the abdomen has now become more supple. 
Pulse 98. Temp. 99° to 100°. At 7.30 p. m,, Prof. T. M. Markoe 
joined our consultation, and also confirmed the diagnosis. 
Ninth day, at 9.30 a.m.—Patient passed a better night, more 
free from pain. No vomiting, no eructations. Takes more 
liquid nourishment. Pulse 72, Temp. 98.2°. At 7.30 p.m,, 
pulse 68. Temp. 98.° 
Tenth day.—A good night. Pulse, morning and evening, 
61. Abdomen less tumid and more supple. Local tenderness 
on pressure is again becoming more marked; its centre of 
greatest intensity remains at the same point. 
November 19th, eleventh day.—At 1,30 p.m., Prof. Clark 
met us again in consultation, with special reference to an oper- 
ation. Patient’s condition was as follows : The tumidity of 
the abdomen had subsided to such a degree, that the surface 
between the umbilicus and crest of the right ilium, from being 
elevated, had become sunken. The deep outlines of the tumor 
could be more easily distinguished by palpation, though there 
was still no circumscribed elevation upon the surface at the 
point where the greatest sensibility to pressure existed. No 
fluctuation was perceptible, nor was there any redness of the 
surface nor adhesion of the skin to the underlying parts. In- 
stead of dulness, there was now resonance on percussion over 
the seat of greatest sensibility. This condition of resonance, 
conflicting as it did apparently with the supposed presence of 
purulent matter, was believed to depend, as afterward proved 
to be the case, on the co-existence of gas with pus in the cavity 
of the abscess. This apparently conflicting condition did not, 
however, deter from the proposed explorative operation, which 
was performed as follows : 
Operation.—Before the inhalation of ether was commenced, 8 
PERI-TYPHLITIO ABSCESS IN 
the precise seat of greatest sensitiveness under digital pressure 
was once more determined and located, as it had uniformly been 
by daily repeated previous examinations, midway on a line be- 
tween the umbilicus and the anterior superior spinous process 
of the right ilium. After complete anaesthesia and relaxation 
were produced, the deep-seated outlines of the tumor were 
again confirmed by a more thorough palpation than had been 
admissible at previous examinations. At the point chosen upon 
the surface a puncture was made through the skin with a ten- 
otomy knife, to facilitate the onward progress of a sharp- 
pointed canula (of the size of No. 1 of the bougie scale), which 
was advanced cautiously through the aponeurotic and muscular 
parietes of the abdomen to a depth of more than one inch, ‘when 
23us escaped by the side of the canula, and immediately after 
through the canula itself. The canula, which was held in situ, 
served as a guide, upon the outer surface of which a sharp- 
pointed bistoury was conducted into the cavity of the abscess, 
and the opening enlarged. At the same time the external 
wound was also enlarged by dividing the skin and underlying 
parts to the extent of nearly two inches. A dressing force23S 
was then introduced with closed blades, and withdrawn with 
the blades 023ened, so as to enlarge the entrance of the abscess. 
A free discharge of grayish fetid pus, without stain of bile, 
to the amount of more than an ounce, followed, together with 
an abundant escape of gas. A finger was next inserted into 
the wound, to enlarge still further the opening and explore the 
cavity of the abscess, which was found to extend in every direc- 
tion laterally beyond the reach of the finger; its opposite wall, 
however, was reached by the end of the finger, but nothing 
definite was ascertained by it. A plug of cotton wick well 
greased was inserted, and left in the opening to maintain it free, 
and 2>oultices were directed to be continued. In the evening 
patient was found comfortable, and his pulse at 84. 
Second day after operation.—Has passed a good night, and 
taken food with some appetite. Removed the plug, and gave 
exit to a copious discharge of brownish matter, followed by 
thick laudable pus. Pulse, 82; temperature, 99J°. Replaced 
the plug, which was thereafter to be kept in only during the 
day. On the third day poultices were discontinued, and a THE ILIO-CCECAL KEGIOX. 
9 
dressing of simple cerate substituted. The abscess was injected 
with salt and water, and the injection was to be repeated on 
the two following days. On the fourth day a particle of green- 
ish fecal matter of the size of a split pea was expelled with 
the injection. On the fifth, sixth, seventh, and eighth days 
small tufts of sloughy tissue, ascertained to be connective tissue 
by microscopic examination, were discharged, the suppuration 
continuing healthy and abundant. On the twelfth day sup- 
puration no longer proceeded from the cavity of the abscess, 
but from the external wound alone, which was steadily filling 
up and contracting. Patient’s general condition has steadily 
improved, since the abscess was opened, under the use of gener- 
ous diet and the citrate of iron and quinine, gr. v., ter in die. 
On December 4th, the fifteenth day, he was able to be removed 
to the house of a friend in the vicinity of the Central Park. 
Decemljer 11th.—The wound has healed, and patient has re- 
sumed his out-of-door life. General health excellent. 
The conditions upon which a diagnosis was based in this case 
were the following: Ist. The abrupt onset of the attack, with 
out any premonition of its approach. 2d. The early develop- 
ment of acute local sensibility referred to the ilio-coecal region, 
and restricted within a small circumscribed space, where the 
slightest degree of digital pressure could not be tolerated. 3d. 
The uninterrupted persistence of the acute local sensitiveness 
within the same restricted limits, as was verified on each suc- 
ceeding day, by carefully repeated exploration, up to the day of 
the operation. 4th. The recognition of a deep-seated circum- 
scribed tumor of rather firm consistence, indistinctly definable 
in the earlier stages of the disease, owing to the general tumi- 
dity of the abdomen, but becoming more clearly outlined as the 
tumidity subsided and the abdominal parietes became more 
supple. The centre of the deep-seated tumor also corres- 
ponded to the focus of greatest sensibility on the surface. It 
was not, however, until the eleventh day after the attack that 
the deep outlines of the tumor could be defined with such a 
degree of distinctness as to render it clearly advisable to resort 
to an operation for establishing an external opening in the abdom- 
inal walls, and the operation was then undertaken, notwithstand- 
ing the absence both of fluctuation and elevation of the surface 
O 10 
PEEI-TYPHLITIC ABSCESS IN 
over the tumor, and also notwithstanding the presence of re- 
sonance on percussion over the tumor, where previously there 
had been dulness (the resonance being attributable, as has 
already been stated, to the co-existence of gas with pus in the 
cavity of the abscess). It wTas a matter of regret in this case 
that a digital exploration per anum was rendered inadmissible 
by the presence of an inflamed and very sensitive hemorrhoid. 
Symptoms.—ln a retrospect of the progress of the symptoms 
in this case, it is interesting to observe that constitutional reac- 
tion was first noticed twenty-four hours after the attack, when 
the pulse had risen to 106 and the temperature to 101°. 
Twelve hours later, and after a second application of leeches 
had been made, and the narcotic treatment put in operation, the 
pulse had fallen to 86, and the temperature to 100|-0. On the 
third day the pulse was 98, temp. 99°, On the 4th and sth days 
the pulse was 84, temp. 98°. On the 6th day the pulse rose to 
102, and the temperature to 101°. On this day the distressing 
colic pains, with eructations and nausea, reached their maxi- 
mum of intensity, and the tumidity of the abdomen its greatest 
degree of development. On the Bth, 9th, and 10th days the 
pulse subsided to 78, 72, and 64, and the temperature to 99°, 
98.4-s°. On the day of the operation (the 11th of the disease), 
the pulse was 82, and the temperature 99.1-s°. 
The uniformly moderate rate of the pulse and temperature, 
notwithstanding the severity of the abdominal pains, indicat- 
ing as it did the absence of inflammatory action affecting the 
peritoneum, afforded a sure ground for hope of a favorable 
termination. 5 
Remarks.—ln the New York Medical Record of March 15, 
1867, Prof. Willard Parker reported a case in which he first 
employed successfully a method of treatment which may be 
said to have disarmed this disease of its terrors, and changed 
• ' o 
its issue from one almost invariably fatal to the reverse. This 
method consists in making an early incision into the abscess, 
without waiting for fluctuation to demonstrate the presence of 
pus. In the same journal of the 15th of June following, Dr. J. 
H. Hobart Purge, of Brooklyn, reported a second successful 
operation performed by Dr, Parker on a patient of Dr. 
Burge’s. Since the publication of these two cases, two others THE ILIO-CCECAL EEGION. 
11 
equally successful have been reported in the New York Med- 
ical Journal, one by Dr. Leonard Weber, in the August num- 
ber of 1811, the other by Prof. 11. B. Sands, in the August 
number of 1874. Other cases, not yet made public, have been 
ascertained to have occurred in the practice of other surgeons, 
to whose courtesy the author is indebted for such particulars as 
will enable him to develop more fully this interesting subject. 
These cases, together with one reported by Mr. Henry Hancock 
of London, in 1848, which will be more particularly noticed 
hereafter, and the two in my own practice above narrated, form 
an aggregate of thirteen cases, which make up the following 
table and from which some instructive deductions may be drawn. 
Ten of the cases were males, three females. The ages of the 
females were 15, 16, and about 35 years ; of the males, 2, 12,17, 
22, 25, 30, 32,40, 41. In every case the invasion of the disease 
was abrupt, and attended with symptoms of acute peritonitis, 
which early became localized in the ilio-coscal region ; and in all 
a deep-seated tumor was more or less distinctly felt at an early 
period in the same locality. 
The times at which the operation was performed are as fol- 
lows: In one case, early, as stated ; on the seventh day in 
two cases ; on the eighth day in one.; on the tenth in five; on 
the eleventh in two ; on the thirteenth in one, and on the four- 
teenth in one. In only two of the thirteen cases could fluctua- 
tion be detected at the time of the operation. A discharge of 
fetid matter took place after the opening of the abscess in all 
the cases, and in some it wras accompanied with gas-bubbles. 
In five cases it was stated that the matter was not stained with 
bile, from which it might be inferred that there existed no open 
communication between the intestine and the cavity of the abscess; 
the same was probably true of the other eight cases in which the 
fact of biliary discoloration was not stated. In seven of the 
cases one or more foreign substances were discharged at varying 
intervals of from four to sixteen days after the operation, and in 
the other six cases none were found. Where none were found it 
may be presumed that they might either have been overlooked, 
or, if retained in the cavity of the abscess, they became imbed- 
ded in exudation material, and thus were rendered innocuous. 
These substances were concretions, and fecal masses incrusted 12 
PEKI-TYPHLITIO ABSCESS IN 
with chalky material. In four cases tufts of sloughy connective 
tissue were discharged besides the foreign substances. In one 
case (No. 9), communicated by Dr. White, the collection of pus 
being excessive in quantity, its presence was readily detected by 
fluctuation. The patient became collapsed on the ninth day, 
and was in imminent danger of his life. Instead of a free 
opening being made for the exit of matter, the aspirator was 
judiciously used, and twenty-six ounces of pus were drawn off; 
two days after sixteen ounces more were drawn off by a second 
aspiration, and four days after the second aspiration a free 
opening was established. 
The method of operating inaugurated by Dr. Parker, and 
adopted by his imitators, was the following: An incision from 
three to six inches in length was carried across the tumor a little 
above and nearly parallel with Poupart’s ligament, and divided 
the skin and subjacent tendinous and muscular layers till the 
fascia transversalis was exposed. An exploring-needle, or fiiyj 
trocar, was then inserted in search of matter, and the puncture 
afterward enlarged to a free opening with a knife. In one 
case (No. 8), after the exposure of the fascia, the aspirator was 
first used, and then a free opening made. In two other cases 
(Nos. 4 and 6), after the exposure of the fascia transversalis, 
fluctuation not being perceptible, the wound was dressed open, 
and a spontaneous opening formed on the second and third 
days after the operation. 
This cautious procedure was adopted, no doubt, as a surer 
means of avoiding a wound of the intestines. In ray own cases, 
however, I deviated from this plan by first penetrating the ab- 
scess, without any preliminary incision of the abdominal parie- 
tes, and then enlarging the track of the puncture sufficiently 
to afford a free outlet for the contents of the abscess. The 
reasons for this modification of the operation were these : Re- 
garding as I did the most prominent point of the tumor as indi- 
cating the approach to the surface of pus, and not of intestine, 
this point was chosen for the insertion of a line canulated tro- 
car, or, what is preferable, a sharp-pointed canula, such as is 
used in the operation of aspiration. The insertion of such a 
small-sized canula into the intestine itself would be harmless, 
inasmuch as on its withdrawal there would be no escape of THE ILIO-CCECAL REGION. 
13 
fecal fluid, and consequently no danger of the formation of a 
fistula. Matter having been reached by this first step of the 
procedure, the cannla is held in situ, and used as a guide, along 
the outer surface of which a sharp-pointed knife is conducted 
into the cavity of the abscess, and the track of the canula en- 
larged to the requisite dimensions. In case of a failure to 
reach the collection of pus by a first attempt, a second intro- 
duction of the canula may be safely tried at another selected 
point. By this method, also, an extensive incision of the ab- 
dominal parietes is avoided, and the subsequent liability to a 
hernial protrusion prevented. In cases 11 and 12 of the table, 
the patients were obliged, on their recovery, to wear a truss, in 
consequence of the thinning of the cicatrix at its centre and 
the tendency to protrusion. After completing the opening with 
the knife, a finger should be introduced to stretch it, and a 
full-sized plug of cotton wick, well greased, should be kept in 
for the first three or four days after the operation. 
Diagnosis.—The abruptness of the invasion of the disease, 
with symptoms of acute peritonitis, and the fact that the pain 
early becomes localized in the ilio-coecal region,or restricted most- 
ly to this region, from the first of the attack, will distinguish it 
from the other forms of abscess that originate in this region, and 
from fecal accumulations in the coecum, which are gradual in 
their development. Its precise locality in the hollow of the 
iliac fossa should also distingush it from concealed strangulated 
hernia, the attendant symptoms of which are not unlike those 
of peri-typhlitis. A close observation of the daily progress of 
the disease will also very much aid our judgment in arriving 
at a correct conclusion in regard to its nature, especially if we 
are able to recognize the existence of a circumscribed spot of 
tenderness on pressure occupying uniformly the same locality 
on the surface in the ilio-coecal region, and surmounting a deep- 
seated induration. By percussion the deep-seated induration 
may also be outlined. It should he borne in mind, however, 
that the central point of the induration, from being dull may 
in the process of the disease become resonant on percussion, as 
occurred in the author’s two cases above narrated ; the explana- 
tion .of which is the co-existence of gas with pus in the cavity 
of the abscess. 14 
PEEI-TYPHLITIO ABSCESS IN 
Prognosis.—Authors who have treated of this disease have 
regarded it as having almost invariably a fatal termination. It 
is true, however, that sometimes recovery has taken place after 
the spontaneous formation of an opening into the intestine, 
probably the coecum, and the discharge of the contents of 
the abscess per anum. A like favorable result has followed 
after an opening into the bladder, and the expulsion of pusher 
urethram. In much rarer instances the abscess has emptied 
itself by a spontaneous opening through the abdominal pari- 
etes. A favorable termination by resolution is perhaps of the 
rarest occurrence, and yet it has taken place. The disastrous 
tendency of this disease may now happily be averted by a sea- 
sonable operation. 
Treatment.—ln the onset and early progress of the disease, 
Mr. John Borne (in vol. xx. of Medico- Chirurgical Transac- 
tions) very judiciously cautions against the energetic deplet- 
ing treatment that might be applicable to acute idiopathic 
peritonitis. It is well to apply leeches early over the tumor to 
the extent of from six to twelve in number, and to repeat them if 
necessary. Poultices are also indicated, but they must be ad- 
justed so as not to be burdensome by their weight. From five to 
ten grains of calomel, followed by 01. ricini, with the addition of 
tinot. opii, or sol. s. morph., should be given. After this, a state 
of moderate narcotism should be maintained by the adminis- 
tration of pil. opii gr. j or sulph. morphise, from (| to \ gr., 
repeated at first every hour till the desired effect is produced, 
and afterwrard at intervals of from two to four hours. 
The object of our treatment should be to moderate the 
production of pus, and thereby diminish the strain upon 
the adhesions which wall'’ in the abscess, and so shut it off 
from the general peritoneal cavity, till the favorable mo- 
ment arrives for giving exit to the matter through an ex- 
ternal opening upon the surface of the abdomen. To deter- 
mine the time for operating is a point of chief importance. 
It should be borne in mind that we are not to wait to detect 
fluctuation, "which is regarded as the unequivocal sign of the 
existence of matter. Before that stage is reached, the patient 
is exposed to a disastrous issue from different sources, such as 
the giving way of the adhesions that wall in the abscess, and THE ILIO-CCECAL REGION. 
15 
the supervention of fatal general peritonitis, gangrene, and 
exhaustion from the hectic of purulent cachexia. If we in- 
terrogate experience on this point, we find that, in the thir- 
teen cases cited in this paper, the operation was performed at 
the earliest moment on the seventh day after the onset of the 
disease, and at the latest on the fourteenth day. We may 
therefore, perhaps, safely lay it down as a rule that after the 
lapse of one week from the onset of the disease there should 
he no delay in resorting to the operation, unless there should 
be clear indications of resolution going on, which is an ex- 
tremely rare issue of this disease. This treatment, so remarka- 
bly successful in the cases above reported, is quite inapplicable 
to those other cases in which adhesions fail to wall in the sup- 
puration, and general peritonitis hastens on a fatal termination. 
It is due to Mr. Henry Hancock, of London, to state that he 
performed this same operation with success in ISIS, but, for 
some reason or other, his report of the case failed to receive th'e 
attention it deserved. In his report (see London Medical 
Gazette, New Series, vol. vii., p. 547) before the London Medi- 
cal Society, of which he was then the president, Mr. Hancock 
remarked as follows : “ Abscesses of the abdomen connected 
with the coecum or large intestines, and attended with fluctua- 
tion, had from time to time been opened, but he was not ac- 
quainted with any instance in which any operation had been 
attempted under the circumstances about to be detailed in his 
own case, and where the result had been so entirely satisfactory. 
In the cases recorded, the presence of fluctuation has proved 
the existence of matter, but the details of his case would show 
that we should not always wait for this unequivocal sign.” His 
case was that of an adult female, ifi whom the attack began 
on the day following her giving birth to her fifth child, six or 
seven weeks before the full time, with a severe pain in the right 
groin and a sensation of something having snapped asunder as 
she turned herself over in bed. After nine days of appropri- 
ate treatment, Mr. Hancock operated by an incision four inches 
long carried across the tumor from the spine of the ilium in- 
ward, above and close to Poupart’s ligament. A quantity of 
fetid matter with gas-bubbles was discharged. On the fifteenth 
day after the operation, two masses of fseces, incmsted with cal- 16 
PEEI-TYPHLITIC ABSCESS IN 
careens deposit, and moulded upon eaclx other, were discharged. 
From their size, Mr. Hancock judged that they had been im- 
pacted in, and had escaped by ulceration from, the vermiform 
appendix. At a meeting of the same Society, held March 27, 
1871 {British Medical Journal, 1871, vol. i., p. 150), the sub- 
ject of peri-typhlitis was brought forward, and, in the discussion 
that followed, no allusion was made to Mr. Hancock’s case, or 
to his method of treatment. Although Mr. Hancock’s report was 
also republished in full in the American Journal of Medical 
Sciences of 1819, the only notice of it in this country was by 
Hr. George Lewis, then Physician to the Eastern Dispensary, 
in an article on “ Abscesses in the Appendix Yermiformis,” 
that appeared in the Mew York Journal of Medicine, 1856, 
Third Series, vol. 1. Under the head of “ Treatment ”he re- 
marks upon the question of the propriety of making a free in- 
cision downward upon the tumor, and states that he is inclined 
to favor the operation. “The favorable issue of a single case, 
and this, so far as our information extends, the only one on re- 
cord in which this practice was adopted, taken in conjunction 
with other considerations,” (already stated by the writer), “if 
they do not conclusively settle the utility of this mode of pro- 
cedure, at least justify a more extended trial of it.” He then 
reproduces the report of Mr. Hancock’s case in full. This im- 
portant subject attracted no further notice, nor is any allusion 
to the operation to be found in the most recent text-books on 
medicine and surgery, such as those of Aitken, Reynolds, and 
Flint, or those of Holmes, Gross, or Hamilton. Happily for 
suffering humanity, this same method of treatment was repro- 
duced by one of our own number, in 1867, as before stated, and 
has already had so many successful imitators that its vitality 
may now be considered as assured. 
Note.—Since the completion of the foregoing article, the author has received 
a communication from Prof. Jas. R. Wood, M.D., of which the following ex- 
tract relates to this subject; “ I have operated on three cases by Dr. Parker’s 
method; the patients were all males and adults. In all of them the onset of 
the disease was abrupt, with acute symptoms of peritonitis that became local- 
ized in the right iliac region. In two of the cases the offending substance was 
discharged ;in the third case none was seen. Two cases recovered rapidly ; 
one died on the second day after the operation. Although I saw these cases 
early after the attack, I did not operate earlier than the seventh day. I 
think it is as important not to operate too soon, as it is to defer the operation 
too long." THE ILIO-COECAL EEGION. 
17 
TABLE OF THIRTEEN CASES OF ABSCESS IN THE ILIO-C(ECAL REGION, FOLLOWING PERFORA- 
TION OF THE VERMIFORM APPENDIX. 
Name of Operator. 
Where Recorded. 
No. 
Sex. 
Age 
Invasion and Local! 
zation of Disease. 
I 
Day of Operation 
after Invasion. 
Mode of Operation 
Contents of 
Abscess. 
Foreign Substances 
Discharged; on 
what Day after 
Operation. 
Result. 
Year of Operation. 
Remarks, 
Henry Hancock 
London Medical 
Gazette, New 
Series, Yol. 
VIII.,p. 547. 
I. 
F. 
3 
Ti 
Abrupt invasion, 
with symptoms 
of acute perito- 
nitis, early lo- 
calized in ilio- 
coecal region. 
9th. 
Incision over tu- 
mor 4 inches 
long. 
Foetid pus 
and gas. 
Two lumps oi 
foeces incrust- 
ed with calca- 
reous matter, 
15th day. 
Recovery. 
1848. 
Attacked day after con- 
finement with fifth child. 
No fluctuation felt. 
Prof. W. Park- 
er, M.D. 
N. Y. Medical 
Record, 15th 
March, 1867. 
II. 
M. 
40 
do. do. do. 
9 th. 
Incision 6 inches 
down to fascia 
transv. ; then 
exploring nee- 
dle inserted. 
Foetid pus. 
None seen. 
do. 
1867. 
No fluctuation. 
Prof. W. Park- 
er, M.D. 
Reported by Dr. 
J. H.H.Burge, 
N. Y. Medical 
Record, 15th 
June, 1867. 
HI. 
F. 
15 
do. do. do. 
14th. 
Incision 5 inches. 
Foetid pus. 
None. 
do. 
1867. 
No fluctuation. 
L. Weber, M.D. 
N. Y. Medical 
Journal, Aug., 
1871. 
IV. 
M. 
22 
do. do. do. 
7th. 
incision 6 inches 
down to fascia 
transv., and left 
to open sponta- 
neously 2j- days 
later. 
Foetid pus. 
Concretion on 
16th day. 
do. 
1871. 
No fluctuation. 18 
PEKI-TTPHLITIC ABSCESS IN 
Name of Operaror. 
Where Recorded. 
No. 
Sex. 
Age 
Invasion and Locali- 
zation of Disease. 
| Day of Operation 
after Invasion. 
Mode of Operation. 
Contents of 
Abscess. 
Foreign Substances 
Discharged; on 
what Day after 
Operation. 
Result. 
Year of Operation. 
Remarks. 
E. Krackowizer, 
M.D. 
Communicated, 
V. 
M. 
2 
Abrupt invasion, 
with symptoms 
of acute perito- 
nitis, early lo- 
calized in ilio- 
ccecal region. 
nth. 
Incision down to 
fascia, then di- 
vided on direc- 
tor. 
Foetid pus; 
no stain of 
bile. 
None. 
Recovery. 
1872. 
No fluctuation. 
Sam’l B. Ward, 
M.D. 
Communicated. 
VI. 
M. 
17 
do. do. do. 
Early. 
Incision down to 
fascia transv., 
and left to open 
spontaneously 2 
days after. 
Foetid pus; 
no stain of 
bile. 
None. 
do. 
1872. 
No fluctuation. 
Prof. H. B. 
Sands, M.D. 
N. Y. Medical 
Journal, Aug., 
1874. 
YU. 
M. 
41 
do. do. do. 
13th. 
Incision down to 
fascia. 
Foetid pus. 
Eight or nine 
concretions. 
do. 
1874. 
No fluctuation. 
C. Kelsey, M.D. 
Communicated. 
VIII. 
P. 
16 
do. do. do. 
8th. 
Incision down to 
fascia; aspirator 
used ; opening 
then enlarged. 
Foetid pus. 
None seen. 
do- 
1874. 
No fluctuation. 
J. P. P. White, 
M.D. 
Communicated. 
IX. 
M. 
32 
do. do. do. 
9th. 
Aspirated on 9th 
and 11th days ; 
incision on 15th 
day 5 in. long. 
Foetid pus; 
no stain 
of bile. 
Concretion like 
date pit. 
do. 
1874. 
Fluctuation very dis- 
tinct. Within two years 
preceding the present at- 
tack, patient had two 
acute ones ; recovered 
TABLE CONTINUED, THE ILIOCCECAL EEGION. 
19 
from without discharge, 
but a deep-seated tumor 
remained in ilio-coecal re- 
gion. 20 oz.pus evacuated 
by first aspiration, on 9th 
day; 16 oz.by second aspi- 
ration, on 11th day; a free 
opening made on iSthday. 
Gurdon Buck, 
M.D. 
Reported above 
X. 
M. 
12 
do. do. 
do. 
9th. 
First punctured 
with fine trocar, 
then enlarged 
by incision. 
Foetid pus 
and gas ; 
no stain of 
bile. 
One concretion, 
one lump of 
faeces, three 
tufts of slough 
do. 
1874. 
No fluctuation. Sound 
cicatrix 18 months after 
operation. 
L. Weber, M.D. 
Communicated. 
XI. 
M. 
30 
do, do. 
do. 
9th. 
Free incision. 
On 5 th, 6th 
and 10th 
days foetid 
pus & gas. 
Sloughy con- 
nective tissue 
& foecal lump, 
12th day. 
do. 
1875. 
June. 
No fluctuation. On 14th 
day after operation, ery- 
sipelas attacked wound, 
and lasted five days. A 
tendency to hernia in cen- 
tre of cicatrix, for which 
a truss was worn. 
L. Weber, M.D. 
Communicated. 
XII. 
M. 
32 
do. do. 
do. 
7th. 
Free incision. 
Foetid pus 
and gas. 
Dead tissue; no 
foreign body. 
do. 
1875. 
March. 
Fluctuation felt. In 3d 
week after operation, an 
attack of peritonitis, with 
discharge of pus per rec- 
tum. In 6th week another 
attack, and discharge of 
pus per urethram. Con- 
tinued free suppuration 
from abdominal opening. 
Centre of cicatrix thinned; 
required support of a truss 
Gurdon Buck, 
M.D. 
Reported above 
XIII. 
M. 
26 
do. do. 
do. 
11th. 
First punctured 
with sharp-p’td 
canula, then en- 
larged by incis- 
ion. 
Foetid pus 
and gas ; 
no stain of 
bile. 
Foecal mass of 
size of split pea 
on 4th day; on 
7th & 8 th day 
sloughy connec 
do, 
5tl 
s tl 
five 
1875. 
Nov. 
i, 6th, 
ifts of 
tissue 
No fluctuation. Sound 
cicatrix. POST-FASCIAL ABSCESS 
ORIGINATING IN THE ILIAC FOSSA. 
The aim of the author in the following article is to establish 
the diagnosis of a class of abscesses originating in the parietes 
of the abdominal and pelvic cavities, and invite attention to a 
method of treatment by which they may be conducted to a 
successful issue. A correct diagnosis of the class in question 
is the more important, inasmuch as another class of abscesses 
involving the same parts, and known as psoas abscesses, tending 
as they do to a disastrous termination, might be accelerated in 
their progress by the employment of the same treatment. By 
a careful study of the anatomy of the parts, especially of the 
relations of the aponeurotic structures involved, the conditions 
have been ascertained by which the suppuration is confined 
within the same uniform anatomical limits, and the most favor- 
able point has been determined at which an outlet can be early 
and safely established for the discharge of the deeply seated 
pus, even without waiting for its presence to be ascertained by 
the existence of fluctuation. This abscess may occur in the 
iliac fossa of either side. The following cases, derived from 
the author’s own practice, will be first communicated, and from 
these will be drawn such deductions as will serve more fully to 
elucidate the subject. 2 
POST-FASCIAL ABSCESS 
Case I.—John Roach, a seaman, native of Pennsylvania, set. 
32, was admitted into ward Ho. 12, Marine Department of 
the Hew York Hospital, on the 3rd of July, 1843, with a deep- 
seated phlegmonous swelling in the left iliac and inguinal 
regions, of fourweeks’ standing. At the time of its appearance 
he had been already suffering for a fortnight from inflammation 
of the lymphatic vessels of the lower limb of the same side, 
that had been followed by several small subcutaneous 
abscesses, the remains of which were still to be seen: five or six 
between the groin and knee, and three between the inner con- 
dyle and malleolus. 
The swelling in the groin has, from its commencement, been 
attended with pain on moving the limb, and has gradually 
increased in size. It fills up the iliac fossa, so that the fingers 
cannot be buried in it along the inner margin of the crest of 
the ilium, as on the sound side. It also involves the outer 
half of Poupart’s ligament, and extends to a distance of four 
fingers’-breadths below it, a superficial furrow crosses the swell- 
ing on a line with this ligament. Its inner limits can be traced 
from the middle of Poupart’s ligament, where the femoral 
artery bounds it, upwards and outwards in a curved line, 
approaching within three fingers’-breadths of the umbilicus. A 
general fulness of the parts on the surface, rather than a well- 
defined tumor, indicates its existence. The skin covering the 
swelling continues movable, supple, and unchanged in color. Ho 
increased heat is perceptible to the touch, though the patient 
himself is, at times, sensible of an increase in the temperature. 
An obscure, deep-seated fluctuation can be felt. There is con- 
stant pain extending to the hip, and down the thigh nearly to 
the knee. The thigh is kept semi-flexed on the trunk, and can- 
not be straightened out. Patient feels very weak, and has 
been deprived of sleep for a fortnight by nocturnal exacer- 
bations of pain. His countenance is haggard and anxious; 
pulse 100, and weak ; respiration somewhat laborious. Any 
movement of the limb or coughing aggravates the pain in the 
groin; his easiest position is on his left dde. His belly is 
somewhat tympanitic, but supple. He has never had pain in 
the lumbar region, nor is there any tenderness on pressure 
there. His tongue is furred, dry in the middle, moist at the OEIGINATING IN THE ILIAC FOSSA. 
3 
edges, and pale ; appetite tolerable; bowels move spontaneously 
every second day. Ordered—poultices to abdomen, Magendie’s 
sol. sulph. morph., gutt. xx., at bedtime. 
July s.—Opened the abscess in the following manner ;—An 
incision, one inch in length, was made at a finger’s breadth 
below the middle of the outer half of Poupart’s ligament, 
through the skin, sub-cutaneous tissue, and fascia lata ; a probe 
was then passed deeply upwards and backwards behind Pou- 
part’s ligament and in front of the psoas and iliacus muscles ; 
and, on being withdrawn, was followed by an escape of pus ; 
whereupon the track of the probe was enlarged, and a free 
outlet afforded for the contents of the abscess, with evident 
relief to tlic patient. 
July 6.—Still more decided relief has been afforded by the 
continued free discharge of matter, and the limb can be moved 
with greater ease. 
For about five weeks the suppuration from the abscess con- 
tinued very abundant, with considerable febrile action, and, at 
times, free perspiration; his pulse averaged 120 per minute, 
and his strength became much reduced. Two or three attacks 
of cholera morbus, within the same period, contributed very 
much to aggravate his other symptoms. After this the suppu- 
ration gradually diminished, and his general condition steadily 
improved. Early in September the discharge had entirely 
ceased, and the opening had closed. 
On the 18th of September the patient was able to walk 
about. Some degree of fulness still remained in the left 
groin; the deep swelling in the iliac fossa, and behind and 
below Poupart’s ligament, had very much diminished ; and the 
suppleness of the superjacent tissues was, in a great measure, 
restored. The thigh, which had very much emaciated, was 
regaining its plumpness, and motion at the hip joint was every 
day increasing. A steady, progressive improvement was also 
taking place in his general health. On the 27th of September 
he was discharged from the hospital, cured. 
Case ll.—William Davis, Bet. 37 years, a seaman, native of 
the Sandwich.lslands, of robust appearance, was admitted into 4 
POST-FASCIAL ABSCESS 
the New York Hospital, November 27, 1845, with a prominent 
tumor occupying the left iliac and inguinal regions, and ex- 
tending laterally from the anterior superior spinous process to 
within four fingers’-breadths of fhe root of the penis. In this 
direction it presented its longest diameter; its upper and inner 
margin approaches within four fingers’-breadths of the umbili- 
cus. Interiorly, it somewhat overhangs Poupart’s ligament, 
and is limited at its outer circumference by the crest of the 
ilium. The circumference of the tumor, towards the median 
line, is gradually lost in the surrounding surface, while its 
summit stands out in relief about two inches. The integument 
covering it is supple, without adhesions, without increased heat 
or discoloration. 
The tumor itself is elastic, fluctuating, closely bound down 
at its circumference, and not admitting the fingers to be 
insinuated under its base at any point. By grasping the tumor 
and crowding it backwards and downwards, its contents are 
made to transmit an impulse behind and below the outer half of 
Poupart’s ligament. This impulse is felt at a distance of nearly 
two inches below the ligament; on the surface, however, no 
external swelling is perceptible in this situation. A slight 
impulse is communicated to the swelling by coughing. In the 
erect position, it becomes somewhat more tense than in the 
recumbent; no translucency exists; no gurgling; no func- 
tional disturbance of the bowels; no pain is occasioned by 
handling it nor by the motions of the thigh upon the trunk. 
The neighboring lymphatic glands are slightly enlarged, but 
not tender. The patient is under no restraint in moving his 
body in any direction, and feels able to perform any sort of 
work. There is no tenderness on pressure over the lumbar 
region or along the spine. The spermatic cord is felt at the 
inner margin of the tumor, supple, and in a normal condition. 
The previous history of this case, so far as the patient’s 
imperfect knowledge of the language permitted it to be 
ascertained, was as follows: The tumor first appeared about 
four months ago, while he was at hard work on board a vessel. 
A feeling of soreness drew his attention to the part, when the 
swelling was discovered, of the size of a hen’s egg. For one 
week he gave up work and kept below, and then, of his own ORIGINATING IN THE ILIAC FOSSA. 
5 
accord, resumed his duties. The swelling attained its present 
size in about a month, since which time it has remained 
stationary. His general health is apparently good, and his 
strength unimpaired. Pulse somewhat accelerated, and tongue 
coated with a yellowish fur. 
The extension of the tumor downwards behind and below the 
outer half of Poupart’s ligament, as evinced by the transmis- 
sion of fluctuation to the superior and outer part of the thigh 
when pressure was made above, warranted the conclusion that 
the collection of fluid was situated behind the iliac fascia. 
From the anatomical conformation of this region, it wras 
impossible for any collection of matter developed more super- 
ficially to make its way behind the outer half of Poupart’s 
ligament. Though the great prominence of the tumor, and 
the entire absence of all signs of inflammatory action, together 
with the freedom of motion of the thigh, were features which 
cast doubt on its nature, still the fluidity of its contents was 
apparent, and the necessity of their evacuation clearly indi- 
cated. At a consultation of the visiting surgeons held upon 
the case, one opinion was expressed that it might be a tumor 
of a consistence that might afford a sensation of pseudo-fluctu- 
ation. The surgeon in charge proceeded with reference to 
this possible condition, and made an incision five or six inches 
in length across the surface of the tumor and parallel with 
Poupart’s ligament; after carefully dividing the skin and 
sub-cutaneous tissues, layer by layer, the knife suddenly 
penetrated the cavity of the tumor and gave exit to about a 
pint of thin, ill-conditioned, scrofulous matter of a brownish 
color, with particles of a curdy substance floating in it. After 
enlarging the opening, two fingers introduced into the cavity 
of the cold abscess passed downward behind the outer half of 
Poupart’s ligament, and below it to the extent to which the 
sensation of fluctuation had been felt before the operation. 
The conclusion previously formed respecting the anatomical 
location of the confined matter was thus demonstrated. Ko 
denuded bone was detected in the iliac fossa. 
December 27.—Up to this date the patient’s general health 
continued good; the discharge was small in quantity, and of 
good appearance. A small abscess pointed below Poupart’s 6 
POST-FASCIAL ABSCESS 
ligament and opened. In the further progress of the case, 
however, symptoms of phthisis supervened, with cough, hectic 
and gradual emaciation. The abscess continued open. 
April 3, 1846, he was discharged at his own request. 
Case lll.—Benjamin C. Smith, set. 54 years, a native of the 
State of New York, seaman, with fair complexion and sandy 
hair, entered the hospital on January 13, 1847, with unhealthy 
sloughy ulcers on the nape of the neck, that had been preceded 
by undermining abscesses. Soon after admission, erysipelas 
supervened, involving the face and scalp, and followed by ab- 
scesses in the eyelids, and extensive undermining suppuration 
of the scalp. While gradually convalescing from the low 
cachectic condition thus induced, he began, early in the month 
of March, to complain of pain in his left groin, and inability to 
straighten out the thigh. At the same time his appetite fell 
off; he became feverish, and his general condition deteriorated. 
March 15.—0n careful examination of his groin, a deep 
swelling, tender, and painful on pressure, 'was felt behind the 
outer half of Poupart’s ligament, and extending upwards and 
occupying the iliac fossa. Its surface could be traced along 
the inner margin of the crest of the ilium, and in such close 
contact with it as not to allow the fingers to be buried at all in 
the fossa. The swelling also extended below Poupart’s ligament 
a distance of two or three fingers’-breadths; along the inner 
margin of the swelling, the course of the femoral artery was 
traced. Fluctuation was perceptible below the outer half of 
Poupart’s ligament, when deep pressure was made over the 
iliac fossa above. The skin and subjacent tissues covering the 
swelling were still supple and unadherent, and the surface free 
from heat or redness. On comparison with the sound side, an 
increased degree of fulness was observable. The thigh was 
kept flexed at an angle of about 145° with the trunk, and could 
not be extended to the straight position without causing pain. 
Stinging pains occasionally extended down the thigh, more 
particularly when the swelling was handled. 
An incision was made, as in Case No. 1, down through the 
fascia lata, and a grooved exploring needle passed upward 
and backward to the depth of about two inches, when a few ORIGINATING IN THE ILIAC FOSSA. 
7 
drops of pus escaped along the groove. The opening was then 
enlarged, and a quantity of matter evacuated. Two ligatures 
were‘applied to a small artery that was divided by the incision 
March 17.—Great relief has followed the opening of the ab- 
scess. The outlet having become blocked up, a female catheter 
was introduced, and a large discharge followed. The catheter 
could be passed in nearly its whole length, and came in contact 
with denuded bone. The thigh can be extended almost to its 
full degree. General condition favorable—no fever. 
March 25.—The discharge of pus continues, but has dimin- 
ished in quantity. Generous diet and tonics are allowed. 
April s.—The abscess has ceased to discharge, and the pa- 
tient is rapidly gaining in health and strength. 
April 26.—lie was discharged cured, with the abscess closed. 
Case IY.—Robert Brown, set. 40 years, native of Ireland, 
shoemaker, was admitted into the Hew York Hospital, January 
11, ISSI, with compound comminuted fracture of the right leg, 
involving the ankle joint, that had happened just before admis- 
sion, while in a state of intoxication. On the 29th of the same 
month amputation below the knee was performed. On the 9th 
of April, when the stump had nearly healed, and patient’s gen- 
eral condition had become tolerably good, my attention was first 
called to a soreness in the right groin and iliac region. He 
had previously complained of this part; and from superficial 
examination it was supposed to depend upon infiamed lym- 
phatic glands, caused by the sore of the stump, and for which 
blisters had been applied. A careful examination being now 
instituted, it was ascertained that the iliac fossa was filled up 
by a deep-seated hard swelling, extending down behind Pou- 
part’s ligament, and confined to its outer half. The femoral 
artery could be distinctly felt skirting the inner margin of the 
swelling. The fingers could not be buried in the fossa, nor 
could they embrace the crest of the ilium, or the anterior superior 
spinous process, as could readily be done on the opposite side. 
Ho fluctuation could be distinguished, nor was there any red- 
ness of the surface, nor oedema of the subcutaneous tissue, nor 
increased heat. Pressure gave pain at every point where the 
swelling could be reached. The outer half of Poupart’s liga- 8 
POST-FASCIAL ABSCESS 
ment was tense and unyielding, while the inner half retained 
its natural suppleness. The swelling could not be distinguished 
much below the ligament. Flexion of the thigh caused no 
pain, but extension did when carried to an extreme degree. 
There was no pain in the lumbar region, nor had there been at 
any time. The patient, who was of a weak constitution, and 
had had symptoms of phthisis, dated back the origin of this 
ailment three months prior to the accident to his leg. He could 
assign no other cause for it than that he had strained the part 
while engaged in piling wood, being obliged at the time to 
stand on tiptoe and place the wood as high as he could possibly 
reach. 
Operation.—An incision being made as already described, 
the fascia lata was found tense and unyielding. A trochar 
exploring needle in a canula was passed upwards and back- 
wards, and soon arrived in a free cavity, from which pus 
escaped through the canula. After enlarging the track, a tent 
was introduced and a poultice applied. Generous diet, cod- 
liver oil and quinine were given. 
May 4.—The discharge from the abscess is decreasing. 
Strength is good, and patient is able to sit up. 
May 28.—The discharge, having become thin and scanty, 
ceased three days ago. A firm, circumscribed tumor, about the 
size of a hen’s egg, is still felt in the iliac fossa. 
May 29.—The patient was discharged cured. 
Several months subsequent to leaving the hospital, he re- 
ported himself in good condition. 
Case Y.—Mrs. 8., set. 25 years, a lady of delicate constitu- 
tion, residing at Ho.— Pike street, a patient of Dr. I. W,, has 
a deep swelling in the left groin, filling up the iliac fossa and 
extending down behind Poupart’s ligament, but confined to its 
outer half. A fulness, rather than a defined swelling, is all 
that is observable on the surface. The femoral .artery skirts 
its inner margin. The presence of the swelling prevents the 
ends of the fingers from being buried in the fossa, along the 
crest of the ilium, or at the anterior superior spinous process, 
though this can readily be done on the opposite side. The in- ORIGINATING IN THE ILIAC FOSSA. 
9 
tegument covering the swelling is free from redness or heat, 
and retains its natural suppleness. The subcutaneous cellular 
tissue is also free from oedema and induration. Ao fluctuation 
can be perceived. Deep pressure causes pain wherever the 
swelling is within reach; the outer half of Poupart’s ligament 
is tense and unyielding. About a hand’s breadth lower down 
on the thigh and toward its inner margin, the skin is oedema- 
tous, indurated, and somewhat swollen over a space of about 
five inches in circumference; this has appeared within a few 
days, and is disconnected from the swelling above. The thigh 
is kept flexed at an angle of about 135° with the body, and 
attempts to extend it cause pain in the swelling. Two months 
prior to my first visit (on March 30, 1852) Mrs. B. had been 
confined with her second child, after an ordinary labor. On 
the second day following her confinement she was seized with 
a severe rigor and pains in the lower part of the abdomen, ac- 
companied with tympanites and a rapid pulse, which led Dr. 
W. to apprehend an attack of puerperal fever. Purging, etc., 
without the aid of blood-letting, subdued these symptoms. In 
a short time, however, she began to be seized with chills, which 
recurred at irregular periods, sometimes twice within twenty- 
four hours, and were followed by fever of short duration and 
profuse perspiration. At the expiration of between three and 
four weeks after confinement, her left thigh began to be drawn 
up, so that, in attempting to walk across the room, she was 
obliged to lean her body forward, and was unable to stand 
erect with her foot fiat on the floor. She experienced, how- 
ever, no pain in the groin, nor has she, to the present time. 
Her countenance is pale and languid, and her pulse feeble. She 
has at no time had pain in the lumbar region, nor is there any 
tenderness on pressure over this part. The absence of fluctua- 
tion was the only feature which made me hesitate in regard to 
the existence of matter behind the iliac fascia; all the other 
symptoms, general as well as local, were unequivocal. On 
careful inquiry, no connection could be established with the 
lumbar region or colon, as the point of departure of this phleg- 
monous swelling. Flax-seed poultices were advised, and kept 
constantly applied until 
April 3, when it was decided to make an explorative punc- 10 
POST-FASCIAL ABSCESS 
tnre. An incision was made, as in the preceding cases, below 
the outer half of Ponpart’s ligament, through the integument 
and subjacent tissues, down to the fascia, which was found 
tense and unyielding. A small-sized trochar exploring needle, 
sheathed in a canula, was passed upwards and backwards 
behind Poupart’s ligament, and soon arrived in a free cavity. 
The needle being withdrawn, matter escaped through the 
canula. Before withdrawing the canula, a narrow-bladed 
knife was passed up by the side of it, and the track enlarged 
to afford a free outlet. A tent was then inserted, and poul- 
tices directed to be continued. The tonic and supporting 
treatment, already in nse, was also continued. 
April 7.—The use of the tent, which had been changed 
daily, was laid aside. The discharge was moderate in quan- 
tity, and the patient’s condition was gradually improving. 
The subsequent progress was favorable. At the expiration of 
about six weeks the opening had closed, and the patient was 
able to ride and walk out. 
Case Yl.—Mary Ann T., set. 12 years, a girl of pale com- 
plexion and very delicate appearance, whose father had been 
of a very scrofulous constitution, suffered in the month of 
May, 1853, from a large abscess that formed spontaneously 
in the axilla, and which, having been opened, discharged very 
copiously for some time. After a gradual recovery, she 
enjoyed a comfortable state of health until the month of 
August following, when she began to complain of pain in 
the right hip and groin. Two or three weeks after this she 
was observed to walk lame, with the thigh retracted, and to 
have hectic fever at irregular periods. On the 22nd of 
November following, she was first examined at her residence, 
No. 193 West 25th street, and the following particulars ascer- 
tained : The right thigh -was kept flexed upon the trunk, 
and adducted towards its fellow. The body was inclined to the 
opposite side, and caused a notable projection of the lame 
hip, suggesting at once the suspicion of hip disease; the 
motion of the joint, however, was found free, and unattended 
with pain or swelling about the trochanter; attempts to 
extend and bring down the thigh, however, caused pain in ORIGINATING IN THE ILIAC FOSSA. 
11 
the region of the psoas and iliacns muscles. There had been 
at no time pain in the lumbar region, nor was there any 
tenderness on pressure in this part. She was still able to walk, 
by stepping on her toes, and inclining her body forward, taking 
care to maintain it always at the same angle with the thigh. 
In the recumbent position, a swelling was recognized in the 
right iliac fossa, closely hugging the crest of the ilium and the 
outer half of Poupart’s ligament, so that it was impossible to 
bury the ends of the fingers in the fossa, or to grasp the anterior 
superior spinous process between the thumb and fingers, or to 
depress the outer half of Poupart’s ligament. The inner mar- 
gin of the tumor could be traced from the middle of Poupart’s 
ligament upwards and backwards in a line corresponding to the 
superior strait of the pelvic cavity. There was no redness of 
the surface, nor adhesion of the skin to the subjacent tissues, 
nor oedema, nor elevation of temperature. A moderate degree 
of fulness was observable at and above Poupart’s ligament. 
Deep pressure caused pain. The perception of fluctuation was 
obscure and doubtful. Her pulse was habitually frequent, and 
her countenance wore an anxious expression. She still retained 
a good degree of strength. Directed poultices to the swelling. 
Pepeated examinations having corroborated the condition 
above described, and confirmed my opinion of the existence of 
a collection of matter behind the iliac fascia, an opening was 
made on the 28th of November, in the presence of Drs. Yan 
Buren and Halsted, and my pupil Mr. IT, D. Noyes. This 
was performed, as in the preceding cases, and a grooved ex- 
ploring needle passed upwards and backwards nearly two inches, 
when matter escaped. After incising the opening, and giving 
vent to a large quantity of thick pus, a tent was introduced; a 
copious suppuration followed. Poultices were kept applied 
and cod-liver oil and syr iodide of iron were administered for 
several weeks; also super-sulphate of quinine,,with generous 
diet and malt liquors. 
On the 4th of March, 1854, I found my patient had already 
been walking about several weeks; the discharge had become 
reduced to a small quantity of thin matter. She had almost 
regained the power of holding the body erect, with the foot ap- 
plied flat upon the floor; hardness continues in the seat of the 12 
POST FASCIAL ABSCESS 
tumor. She survived till the 23rd of November following. 
The discharge continued from the groin, sometimes abundant 
and at other times scanty and thin. An attempt was made to 
use injections of a weak solution of the bichloride of mercury, 
by means of a gum elastic catheter introduced into the remotest 
part of the abscess ; but this was rendered impossible by her 
extreme timidity and uncontrollable intractability. Gradual 
emaciation took place, and progressed to an extreme degree. 
She kept up till within a few days of her death, and was at 
exhausted by a profuse diarrhoea. No examination of the 
body could be obtained. 
Case Yll.—John Burr, set. 27 years, a native of New York, 
boatman, entered the New York Hospital on the 15th of 
March, 1855, with an inflammatory swelling in the right iliac 
region, of which he gave the following history: About six 
months ago, without injury or other obvious cause, he began to 
notice a swelling on the inner side of the middle of the crest of 
the ilium, accompanied with pain and inability to straighten the 
thigh to its full extent on the trunk. These symptoms passed 
off and again recurred, according to the patient’s recollection, 
once in about two or three weeks. He was not obliged, however, 
to give up his occupation, or to keep in the house until wuthin 
eight or ten days of his admission. At this time the following 
condition was observed: The lower and right portion of the 
abdomen was swollen and prominent; the swelling was limited 
below and to the outside by the crest of the ilium and the 
outer two-thirds of Poupart’s ligament, with which parts it was 
so closely connected that it was impossible to insinuate the ends 
of the fingers between them and the swelling, although this 
could easily be done on the opposite side. Toward the umbil- 
icus, the swelling was gradually lost, and its limits could only 
be defined by percussion, wdiieh was dull for about two-thirds 
of the distance from the ilium to the umbilicus. The line of 
dulness receded farther from the umbilicus as it was traced 
upwards and outwards. The abdominal muscles on the right 
side kept in such a state of tension as to prevent the limits 
of the swelling from being felt by deep pressure. The integu- 
ment covering the swelling had undergone no change in color, ORIGINATING IN THE ILIAC FOSSA. 
13 
but had lost suppleness, and was movable only to a limited 
extent on the subjacent tissues. Deep pressure with the ends 
of the fingers disclosed the existence of oedema and tenderness 
over every part of the swelling, especially in the neighborhood 
of the anterior superior spinous process. Poupart’s ligament 
was evidently pushed downwards, as well as forwards ; its inner 
half retained its natural suppleness, while its outer half was 
tense and unyielding. No fluctuation was perceptible. The 
thigh was kept flexed upon the trunk and somewhat abducted, 
and could not be extended without causing pain in the swelling. 
When the patient stood up, he inclined his body forward, so as 
to keep his groin relaxed. On careful inquiry, it was ascer- 
tained that there had not been any pain or lameness in the 
lumbar region. The patient had generally enjoyed good 
health, was free from fever, though his pulse was somewhat 
accelerated. Six leeches were directed to the swelling, to be 
followed by poultices. 
March 19.—Patient had a smart rigor, followed by a fever. 
The swelling appears to have somewhat increased, and become 
much more painful; the pain spreading upwards, towards the 
false ribs, and around the body. Made an explorative puncture 
below the outer half of Poupart’s ligament, in the same man- 
ner as already described, and reached a cavity in the iliac fossa, 
containing pus. Five or six ounces were evacuated, of a gray- 
ish color and fetid odor. Poultices directed to be continued. 
March 21.—Patient has experienced great relief since the 
evacuation of the matter. The swelling has somewhat subsided 
so as to render the prominences of the crest and the spinous 
process of the ilium more visible. The dulness has disap- 
peared to within a finger’s breadth of the crest of the ilium 
and Poupart’s ligament. The discharge continues free, and 
the thigh is still flexed. 
March 27.—A large slough came away from the abscess, and 
a slight blush of redness'extends about a hand’s breadth around 
the opening; the discharge is free; he has had no chill; is 
allowed tonics and good diet. 
This patient remained in the hospital under treatment for sev- 
eral months. The abscess continued to discharge more or less 
without interruption. About the middle of April he had an 14 
POST-FASCIAL AJ3SCESS 
attack of acute pnenmomia of the right lung, from which he 
gradually recovered. 
May 26.—Began injecting the abscess with Lugol’s solution 
of iodine, and repeated it every third day until the 27th of 
June without benefit. 
July 7.—A small slough appeared at the orifice of the abscess; 
and, after its removal, a hard substance was encountered, about 
one inch deep, which, on being withdrawn, proved to be a pin 
of ordinary size, encrusted with biliary concretions, except at 
its head and point. The body was of the size and form of a 
small olive, with a rough, uneven surface. He had no recol- 
lection of ever having swallowed a pin. 
July 14.—Air escaped from the abscess. The discharge 
fluctuates in quantity, and sometimes has a fsecal odor. The 
thigh is still retracted. 
August 9.—He was discharged from the hospital, and went 
into the country. In October, after his return from the coun- 
try, the abscess still continued to discharge. Several months 
afterward the author encountered the patient in the street; he 
represented himself as quite restored to health, and again en- 
gaged in his former laborious occupation of coal-heaver. The 
abscess had ceased to discharge and the opening had healed. 
Remarks.—Of the seven cases reported above, five were 
males and two females. Their ages ranged from twelve to 
fifty-four years.. In four of their number the disease occupied 
the left side; and in three, the right. In one of the two female 
patients the disease occurred during the puerperal state, and 
might be regarded as a case of pelvic cellulitis. 
Anatomy.—The importance of an accurate knowledge of the 
relative anatomy of the parts involved in this form of abscess 
will be admitted, if it is remembered that both the diagnosis 
and treatment are based upon it. 
The crural arch, which is spanned by Poupart’s ligament, is 
divided into two halves by a strong process of aponeurosis, sent 
off posteriorly from the middle of this ligament, and inserted 
into the ileo-pectineal eminence. The inner half serves for the 
passage of the great blood-vessels, lymphatics, etc.; the outer ORIGINATING- IN THE ILIAC FOSSA. 
15 
for the psoas magnus, and iliacns interims muscles, and crural 
nerves. The fascia iliaca, of which the above process is also a 
continuation, is a strong aponeurosis, which is continuous up- 
ward with the outer half of Ponpart’s ligament, and, spreading 
out over the anterior face of the iliacns and psoas magnns mus- 
cles, is inserted outwardly into the inner margin of the crest of 
the ilium, and inwardly into the linea ileo-pectinea. It is also 
prolonged upwards upon the psoas, as high as its origin from 
the lumbar vertebrae. Below Poupart’s ligament, and continu- 
ous with it, the fascia lata covers the psoas and iliacns, in com- 
mon with the other muscles of the thigh, and, at the inner 
margin of these two, gives off posteriorly a septum, which is 
continuous above with the process of aponeurosis, already de- 
scribed as inserted into the ileo-pectineal eminence. Now, if 
an incision be made parallel with Poupart’s ligament, and be- 
low its outer half, down through the fascia lata, the psoas and 
iliacns muscles will be exposed, and the fingers can be passed 
upwards behind Poupart’s ligament so as to arrive in the fossa, 
behind the iliac fascia. The same track can be followed from 
above downwards, by incising the iliac fascia transversely, and 
passing the fingers downwards behind it and the outer half of 
Poupart’s ligament, till they arrive on the anterior face of the 
thigh. Here, then, we have a well-defined track, bounded pos- 
teriorly by a bony surface, anteriorly by a strong fascia, and 
shut in on either side by the insertions of the fascia into the 
bone. Suppuration taking place in this track could only reach 
the surface through the fascia, by the slow and gradual process 
of ulceration and absorption. 
Pathology.—The able author of an article in the British and 
Foreign Medical Review (page 456, April No. for 1840) re- 
marks : “An abscess in the cellular tissue of the right iliac 
c! 5 
fossa, when it does not result from a blow or external wound, 
from perforation of the appendix or coecnm, or from child-birth 
is, we believe, in almost every instance, the consequence of dis- 
ease of the bones, either of the back or pelvis. There may be 
cases in which an abscess forms in the iliac fossa from idiopa- 
thic inflammation of the cellular tissue, but we have never seen 
one.” Several of the cases narrated above prove, as we believe 16 
POST-FASCIAL AJ3SCESS 
beyond a doubt, that suppuration may take place in the iliac- 
fossa behind its fascia, unconnected with caries of the lumbar 
vertebrae or pelvis, or morbid lesions of the coecura or colon. 
There is no reason why the cachectic condition, upon which the 
formation of abscesses depends, may not manifest itself in this 
particular region as well as in any other of the body. The 
functions of the psoas and iliacus muscles render them liable to 
the injurious effects of over-straining efforts, and such efforts 
may be the exciting cause of suppurative inflammation in the 
cellular tissue surrounding these muscles, especially where a 
general cachectic condition co-exists to favor it. Such seems 
to have been the fact in Case ISTo. IV. 
Causes.—ln Case No. 1, the irritation was propagated in the 
course of the absorbent vessels, which had recently been the 
seat of inflammation, resulting in numerous small subcuta- 
neous abscesses along their track from the inner ankle to the 
groin. 
In No. 11., which was a remarkable example of cold abscess, 
the patient, though apparently in good health when the abscess 
was opened, exhibited subsequently all the signs of tubercular 
cachexia. 
In No. 111. a low cachectic condition, induced by copious 
suppuration following erysipelas of the face and scalp, coin- 
cided with the development of suppurative inflammation in the 
iliac fossa, without any obvious exciting cause. 
In No. IV., after violent efforts, by which the psoas and 
iliacus muscles were overstrained, pain and lameness first seated 
themselves in the iliac region; and at length, while the system 
wTas suffering under depressing influences, suppuration devel- 
oped itself. 
In No. Y., the only case of an adult female, the disease origi- 
nated in the puerperal state. 
In No. VI. the patient’s whole aspect was expressive of a 
hereditary scrofulous diathesis, which had manifested itself, 
previous to the suppuration in the iliac region, by the develop- 
ment of a large abscess in the axilla. 
In No. VII. the escape of a foreign body from the intestine 
(probably the ccecum) first excited suppurative inflammation, and ORIGINATING IN THE ILIAC FOSSA. 
17 
its protracted sojourn in the abscess perpetuated its continuance 
for a long period. 
Diagnosis.—Other forms of abscess, besides the one in ques- 
tion, are found located in the iliac region, forms which it is 
important to distinguish. 
1. In this, as in other regions of the abdomen, suppuration 
may take place in the muscular parietes, or in the cellular tissue 
between the muscles and peritoneum. Such an abscess would 
not, however, be confined within the same defined limits; nor 
in case it was seated in the cellular tissue of the fossa anterior 
to its fascia could it extend behind or below Poupart’s ligament, 
detraction of the thigh would not be produced by it, and ad- 
hesion of the skin and subjacent tissues, as well as redness and 
inflammatory oedema, would take place early in its progress. 
2. Abscesses form in consequence of perforation of the ver- 
miform process and coecuin. The suppuration in this case is 
commonly confined by adhesions between the peritoneal sur- 
faces of the intestines and parietes, and the tumor produced is 
not confined within the same anatomical limits as the abscess in 
question. The same deviation from the anatomical characters 
already so often insisted on is observable in abscesses produced 
by fcecal obstruction, as well as in those that are developed in 
the appendages of the uterus during the puerperal state. 
3. Ordinary psoas abscess, which is understood to depend on 
disease of vertebrae, may and does, in its descent along the 
psoas muscle, sometimes keep behind the iliac fascia, and oc- 
cupy the same track as the idiopathic abscess; but its connec- 
tion with the vertebrae can be readily ascertained by careful 
inquiry. 
4. The question may arise, whether caries of the os ilii itself 
may not cause suppuration in the fossa, and present a swelling 
confined within the same anatomical limits. Doubtless it may, 
and so also may a fracture of the ilium. The author believes he 
has seen such an example after fracture, where, besides other 
abscesses around the pelvis, one formed and occupied exactly the 
limits of the fossa, and was evacuated by an opening made 
below the outer half of Poupart’s ligament. 
The true post-fascial abscess originating in the iliac fossa 18 
POST-FASCIAL ABSCESS 
from idiopathic inflammation of the cellular tissue, may be de- 
scribed as follows: It presents itself in a chronic (though much 
more rarely) as well as in an acute form, and locates itself in 
either the right or the left iliac region. Though it may occur in 
early youth, it is most frequently met with in adult age, and affects 
alike both sexes. The tumor which it forms rises up from the 
hollow of the ilium, pushing before it the fascia and outer half of 
Poupart’s ligament, so that the crest of the ilium and the anterior 
superior spinous process can no longer be grasped between the 
thumb and fingers. The outer half of Poupart’s ligament is 
rendered tense and unyielding, and a deep-seated induration 
may extend two or three fingers’-breadths below it. The pre- 
cise limits of the swelling can only be appreciated by the touch 
and by percussion over its abdominal portion ; upon the surface 
the eye only perceives a fulness or a diffuse swelling of these 
parts. Ho increased heat or redness of the skin existed in 
either of the cases above narrated. In four of them (Nos. 1., IY., 
Y., and YII.) no fluctuation could be detected; in two (Nos. 
111. and YI.) it was obscure and doubtful; while in one only 
(No. 11., the cold abscess), it ■was unequivocal. In all (except 
No. II.) the thigh wTas retracted, and attempts to straighten it 
caused pain. In all the cases (except No. II.) constitutional 
disturbance and fever accompanied the local disease. In all the 
acute cases, the absence of heat, redness, adhesions, oedema, 
and also of fluctuation in three of them, is to be attributed 
to the remoteness of the abscess from the surface, and its con- 
finement beneath the fascia. 
Treatment.—The treatment of abscesses in the iliac region, 
laid down by surgical authorities, does not differ materially 
from that of abscesses situated elsewhere. Means suited to 
produce resolution of the inflammation and prevent suppu- 
ration are advised in the early stage. When these have 
failed, such means as will hasten the approach of matter to 
the surface, and thus afford an opportunity to evacuate it by 
an opening, are then to be resorted to. In this form of 
abscess, the first object would be very rarely attained, owing 
to the remoteness of the seat of inflammation from the surface 
and its confinement beneath a strong and tense fascia. For 
the same reason, the approach of suppuration to the surface ORIGINATING IN THE ILIAC FOSSA. 
19 
would be very tardy, and hence great danger might be appre- 
hended from the injurious effects of long pent-up matter, such 
as caries of the os ilii, as was threatened in Case Ho. 111., where 
denuded bone was encountered at the bottom of the abscess; 
also, deep burrowing along the walls of the pelvic cavity and 
openings into the peritoneum, intestines, vagina, and bladder. 
With the view of averting these disastrous consequences, a 
point was sought where an opening might be early established 
for the escape of the pus. The point selected possesses 
the advantage of safety in respect Uq its anatomical rela- 
tions, it being remote from the peritoneum and important 
blood vessels; it affords, also, the most dependent outlet. The 
mode of performing the ojieration has been sufficiently 
described in the preceding narrative. Iso time should be lost 
in resorting to it; the absence of fluctuation need not deter 
from it. The phlegmonous character of the swelling; its 
anatomical relations to the iliac fossa and Poupart’s ligament; 
the absence of disease of the lumbar vertebrae, and the co-exist- 
ing retraction of the thigh; these points being clearly made 
out, are sufficient to warrant the conclusion that suppuration 
has taken place in the fossa behind the fascia. 
It is hardly necessary to add that the approved auxiliary 
means of abating inflammation, such as leeches, poultices, etc., 
together with appropriate constitutional remedies, are not to be 
omitted.