A Large Faecal Abscess point- ing in the Popliteal Space and resulting in a Spontaneous Closure of the Perforated Intestine. bt EDWIN R. CHADBOURNE, M. D. REPRINTED FROM Neto ¥orlt jjttetitcal journal for January 30, 1886. Reprinted from the New York Medical Journal for January 30, 1886. A LARGE F2ECAL ABSCESS, POINTING IN THE POPLITEAL SPACE AND RESULTING IN A SPONTANEOUS CLOSURE OF THE PERFORATED INTESTINE. EDWIN R. CHADBOURNE, M. D. June 6, 1885, I was called to see Mrs. , aged fifty- eight years, a native of New York, a widow for seven years, had never borne a child, and was given the following history of her illness: She had left the city two weeks previously apparently in good health. One week later she was attacked with a severe pain in the right lumbar region, which also extended through the right hip joint. She consulted a physician, and was told by him that it was of rheumatic origin, and was given salicylate of sodium and opiates. She continued to become rapidly worse, and was brought back to her home in town. When I saw her, at 8 p. m., her condition was as follows: The facial expression was anxious; the skin congested, with large beads of perspiration over the forehead; she vomited everything taken into the stomach; she complained of a severe throbbing headache; the tongue was heavily furred; the tem- perature was 105'8° F., the pulse was 140, and the respiration was 70 a minute and very shallow. The abdomen was very tympanitic, and there was a marked induration over the caecum and ascending colon, which was very tender upon slight press- ure, and the thigh was flexed upon the abdomen. The bowels 2 A LARGE FAECAL ABSCESS. had not acted since the day preceding the beginning of the pain. The feet were cold. The body was well nourished, and her weight was about 150 pounds. A small femoral hernia was dis- covered (which the patient was unaware of), but it was easily reduced and was not tender to the touch. I applied fomentations to the abdomen and gave morphine to relieve the pain. She was given whisky and aromatic spirits of ammonia, with powdered ice, in small quantities and at short intervals. After the first doses, it was retained. The face and hands were sponged often with alcohol. A jug of hot water was placed at the feet, and ten grains of quinine were ordered every six hours. At 12 p. m. she was restless, but suffering no pain. The same treatment was continued. June 7th, 8 a. m.-She had been free from pain during the night. The vomiting had ceased entirely. The temperature was 102,8°, the pulse 124, and the respiration 40. The same treatment was continued, with one ounce of milk, to which lime- water was added, every hour. At 3 p. m. the temperature was 100'6°, the pulse 136, and the respiration 36, but very shallow. The abdomen being greatly distended and causing much discomfort, I ordered injec- tions to be given, with a fountain syringe and rectal tube, con- sisting of strong soap-suds. At 10 p. m. : After several enemata had been given, the gas was expelled with corresponding relief to the patient. The temperature was 100°, the pulse had fallen to 120, and the res- piration to 24 and much deeper in character. The quinine was reduced to five grains every six hours. 8th.-The temperature, pulse, and respiration were the same at 8 a. m. as recorded at ten o'clock last evening. She rested quietly during the night, and required morphine but once after midnight. The abdomen being again very tympanitic, the ene- ma was ordered to be repeated. At 3.30 p. m. : The enemata caused the expulsion of much gas but no faeces. The temperature was 100°, the pulse 120, and the respiration 22. At 10.30 p. m. the condition of the patient was much im- A LARGE F2ECAL ABSCESS. 3 proved. The temperature had fallen to 99°, the pulse to 106, and the respiration to 17. This change could be largely attri- buted to a copious action of the bowels, aftei- an enema, early in the evening. She was taking milk and whisky freely. 9th.-At 9 a. m. the temperature was 99°, the pulse 100, and the respiration 17. She had rested quietly all night, without opiates. There was no tympanites. The tongue was clean, ex- cept in the center at the back, but the edges were very red. At 9.30 p. m. : The bowels acted a second time during the afternoon voluntarily. The faeces were dark and very offensive, but there was no pus present. She had no pain, although she had taken but one opiate during the last forty-eight hours. The temperature was 98'9°, the pulse 94, and the respiration 17. 10th.-After a restful night, at 8.30 a. m. the temperature was 98'6°, the pulse was 88, and the respiration 17. There was no flatulence. Upon firm pressure over the caecum and iliac fossa, the patient complained of tenderness. There was a perceptible fullness, but neither a distinct tumor nor any fluctu- ation could be detected. The femoral hernia could be easily reduced by the patient herself. She took nourishment in sufficient quantity and moved about the bed without incon- venience. 11th.-The temperature was 98'6°, the pulse 84, and the res- piration 16. During the two weeks following the patient complained of no special symptoms, nor did she make any perceptible im- provement in her strength, although her appetite was usually good and all food taken was retained and properly digested. Her nourishment consisted principally of very nutritious fluid food with a liberal quantity of milk. The bowels acted once at least each day, and occasionally twice a day. She took five grains of quinine with twenty minims of tincture of iron three times daily. The pulse, temperature, and respiration were nearly normal each time when noted. The urine was examined at intervals and nothing abnormal discovered. She was able to move about from the bed to the easy-chair and to the sofa several times daily; but in bed she involuntarily flexed the thigh upon the abdomen, although if her attention was 4 A LARGE FAECAL ABSCESS. called to it she would fully extend the thigh and state that it caused her no pain. Other than this, there were no indications of disease, except that there was a flush upon the cheeks during the afternoon on several days. 25th.-At 9 p. m. I was called, to see the patient suffering great pain. It was referred to the entire lower part of the ab- domen. The bowels had not acted during the day, and there was much tympanites. The hernia was easily reduced. I ad- ministered morphine and had fomentations applied. The tem- perature was 100°, the pulse 100, and the respiration 19. 26th.-The patient rested quietly during the night. At 8 a. m. the temperature was 100°, the pulse 90, and the respira- tion 16. An enema was given, but without effect. At 12 m. I was called to see her in a severe chill, which nearly resulted in collapse. The description given of the attack was: "The pain came on suddenly, like a stab in the thigh; then the chill followed." The temperature was below 98°, the pulse 110, and the respiration 26. The thigh was much swollen and painful, and had a mottled appearance. She complained of great heat in the parts, but they were cold to the touch. The leg was elevated. Hot fo- mentations were applied to the thigh and hot jugs to the feet. Whisky and morphine were administered. At 10 p. m. the pain was the most severe in the groin. The foot and leg were very oedematous, and were supported by a roller bandage. The cheeks were red. She vomited every- thing but the pounded ice and whisky. The temperature was 103°, the pulse 124, and the respiration 20. 27th.-At 11 a. m. the greatest pain was referred to the knee. The thigh was doughy. She said it felt as heavy as her body. She rested well, and the vomiting had ceased. The temperature was 102'2°, the pulse 108, and the respiration 17. At 9 p.m.: The bowels acted voluntarily during the after- noon. She took milk and whisky freely. The temperature was 100'5° and the pulse 104. There was a painful swelling in the popliteal space, but no pain in the thigh above. 28th.-At 9 a. m. the temperature was 100'4°, the pulse 98, and the respiration 15. Sho slept all night by the use of mor- A LARGE FzECAL ABSCESS. 5 phine. She was unable to move the foot or leg at all. The swelling under the knee was increasing. At 9 p. m. the condition was the same as at 9 a. m. %9th.-1The temperature, pulse, and respiration were the same at 8 a. m. as they were the preceding morning. There was a decided hectic flush upon the cheeks. The swelling in the popliteal space was larger and more painful than the night be- fore. There was much oedema over Poupart's ligament. The foot and leg were much swollen, but kept tightly bandaged, which relieved the pain entirely. The bowels acted during the night voluntarily. At 5 p. m. she was seen by Dr. H. B. Sands in consultation. He advised free incision of the parts upon the following morn- ing. 30th.-At noon Dr. Sands again met me in consultation. He found the entire thigh tympanitic, it being tensely distended with flatus. Assisted by Dr. R. J. Hall and myself, he made three incisions: one being to open the abscess in the popliteal space; another just below Poupart's ligament, where fluctuation was detected, it being directly over the anterior crural nerve; and the third on the outer part of the thigh, at the junction of the middle and lower thirds, where the tissues had a sloughy appearance. After the gas and pus had escaped, a large quan- tity of faeces and dead tissue was removed through these open- ings. The whole thigh was then thoroughly irrigated with a solution of boric acid and salicin, after which a perforated drainage-tube, of the size of the index-finger, was passed from the opening in the groin to the one under the knee. The wounds were then dressed with absorbent dressings. Just before the operation the temperature was 101'8°, the pulse 110, and the respiration 20. At 11 p. m. she was resting comfortably without opiates, and expressed herself as feeling complete relief since the abscess was opened. The temperature had fallen to 100°, the pulse to 96, and the respiration to 17. The milk, quinine, and whisky, were continued. July 1st.-The patient passed a good night, and at 8.30 a. m. the temperature was 98'6° and the pulse 90, The wounds were 6 A LARGE FJECAL ABSCESS. very offensive. There was a steady flow of fluid faeces and fre- quent escape of gas from the wound in the groin. The parts were again thoroughly washed out with the boric acid and salicin solution. She complained of neither pain nor soreness in the parts. At 12 m. Dr. Sands saw her with me and found her in the same condition as recorded this morning, and advised the same treatment to be continued. 2d.-The condition remained the same as the day before. The wounds had a dirty, sloughy look, and were very offensive. The discharge of pus and faeces was very abundant, for the ab- sorption of which bags of peat were used. 3d.-The pulse, temperature, and respiration were normal. Much sloughing tissue was removed, and the parts were washed thoroughly three times during the day. 4th.-At 9 a. m. the patient complained of thirst. The tem- perature was 102'4°, the pulse 110. The odor from the wounds was putrid. After the parts were thoroughly washed, the wounds were filled with boric acid. At 9 p. m. the temperature had fallen to 99'8° and the pulse to 90. The odor from the wounds was that of fgeces only. The urine was voided morning and night. It was examined and found to be normal, except the specific gravity, which was 1'030. 5th.-At 8 a. m. the temperature had again risen to 102° and the pulse to 116. All of the wounds had a very gangrenous look, and the odors were almost unbearable to the patient. After washing the parts thoroughly I cut away all of the sloughing tissue possible and dried the parts with absorbent cotton. I then applied eighty grains of iodoform with a powder- blower. The thigh was then firmly bandaged to prevent the froces passing below the opening in the groin. At 3 p. m. the temperature had fallen to 99° and the pulse to 90. The parts were discharging pus freely. She had no pain, but was restless. There was no odor except of iodoform. At 7 p. m. I was sent for to quiet the patient. I found her unable to call her friends by their correct names. She would converse with imaginary persons and would make answers to A LARGE FAECAL ABSCESS. 7 questions that were not asked her. She also insisted upon get- ting out of her bed. She constantly rolled her head from side to side, and pressed her temples with her hands, but said her head did not ache when asked about it. At short intervals she took a long sighing breath, then she would pucker the lips as if to whistle, or blow the fire. If asked a direct question, she would answer correctly, but, if allowed to continue, she would say many things not relating to it. Her articulation was indis- tinct. If she was told of things she had said or done, she would exclaim, "What is the matter with me?" Suspecting poison- ing by iodoform, I filled the wounds with glycerin to dissolve what had not been absorbed, then washed it off with warm water. I then ordered codeine and tincture of hyoscyamus, to be given at short intervals until it took effect. At 11 p. m. she was sleeping quietly, having taken two grains of codeine and three drachms of tincture of hyoscyamus. 6th.-The patient slept all night, only waking for a few minutes every two hours. At 8.30 a. m. the temperature was 98-5°, and the pulse 86 but weak. She had taken no opiate after midnight. The tongue was clean, but very red. The wounds had a more healthy look, and there was no odor from them. There was a free flow of fluid feces from the wound below Poupart's ligament. The urine that was passed at 6 a. m. was of a dark-brown color, and the specific gravity was 1'030. She had become very much jaundiced during the night, both the eyes and skin being much stained. At 9 p. m. : There was no indication of delirium during the day. She took her nourishment with relish. The fecal dis- charge was free from any scybala, it having previously con- tained lumps from the size of a pea to that of a hickory-nut. 7th.-Her condition remained the same as on the preced- ing day. 8th.-There was nothing worthy of note except the scanty nature of the faecal discharge. 9th.-There had, at 8.30 a. m., been no discharge of feces during the preceding twelve hours. The patient suffered se- verely from the intensely hot weather. The wounds looked healthy and the pus was thick, with no offensive odor to it. 8 A LARGE FJECAL ABSCESS. The temperature was normal. At 9.30 p. m. no fasces had passed the wound during the day. On firm pressure over the iliac fossa there was a free flow of thick pus from beneath Pou- part's ligament. After passing the finger into this pus cavity as far as it would reach I inserted a drainage-tube, of about the size of the finger, to a depth of six inches. Its course was in the direction of the caecum, and it neither met with any resistance nor caused any pain. 10th.-iShe seemed exhausted by the oppressive heat during the night. There had been no faeces in the discharge for twenty- four hours. I washed some sloughing spots with a strong solu- tion of permanganate of potassium. 11th.-At 9 a. m. there was a bad odor from the sloughing tissues about the popliteal space. The parts were again washed with a strong solution of permanganate of potassium and the wound was packed with marine lint. The strength of the pa- tient was much improved. At 8.30 p. m. the wounds were again dressed the same as at 9 a. m. The pus from the groin was healthy and contained no faeces. 12th.-Iler condition was the same as the day before. 13th.-When I saw the patient at 8 a. m. she complained of the very offensive character of the wounds. The temperature was 98,5° and the pulse 84. There was no faecal matter with the pus from the iliac fossa. The bad odors came from a slough under the knee, consisting of the connective tissue in the pop- liteal space, including some tendinous fibers from the insertion of several muscles which were slow to separate. After remov- ing all of the dead tissue that was possible with the scissors I applied twenty grains of iodoform to what remained. I then packed the wound with marine lint. At 4p.m. I was called to see her, all the symptoms that she had upon the 5th inst. being repeated : the delirium with a rambling incoherence in speech, the inability to call friends by name, seeing floating objects and insects before the eyes, the sighing respiration, etc., were all present. I washed the iodoform from the wound with glycerin and water, and gave a hypodermic of morphine. A LARGE FAECAL ABSCESS. 9 At 10.30 p. m. she was quiet but not sleeping. The hypo- dermic was repeated and the wound again washed with glycerin and water. 14th.-At 9 a. m. the pulse and temperature were normal. She slept from midnight until 7 a. m. without waking. The drainage-tube would enter the iliac fossa but three inches, and the pus from it was thick and clear, but much less in quantity. At 8 p. m. : The only unnatural thing said or done by the pa- tient during the day was to speak of persons as having visited her the day before who bad not done so. She seemed much stronger. The last slough had separated during the afternoon, and the wound was odorless. 15th.-Since 5 a. m. she had felt an approaching action of the bowels. I directed an enema to be carefully given with the fountain syringe, consisting of starch and water. The wounds looked clean and the discharge healthy. At 9 p. m. I saw the patient and was told that the bowels acted copiously after the first enema, and a second action oc- curred three hours later voluntarily. The faeces were darker than normally, but no pus was seen with either stool. The pa- tient suffered no pain, and expressed herself as being greatly relieved. 16th.-The strength was greatly improved. She was able to turn upon the left side, which she had been unable to do be- fore, and this relieved the pressure upon a large bed-sore over the sacrum. The flow of pus from the groin was very scanty. The drainage-tube would no longer remain under Poupart's liga- ment, and, after I removed it, I inserted the index-finger into the canal and could feel the bottom of the pus cavity in the iliac fossa. 17th.-The internal surface of the vastus-externus muscle, which was entirely dissected from its attachment to the deeper structures, showed no indication of granulation, and I applied a sixty-grain solution of silver nitrate to it, as well as to all of the exposed surfaces of the other muscles. I then bound the mus- cles of the thigh firmly together with adhesive straps. 18th,-1There was a profuse flow of healthy pus, and the 10 A LARGE PASCAL ABSCESS. edges of the wounds were red and (edematous. The most diffi- cult task had been to strap the parts firmly enough together to keep the granulating surfaces in close contact without causing swelling and pain in the foot and leg. The thigh was so much wasted that it was of not half the size of the healthy one. 20th.-1The bowels had acted daily, and some days two or three times. The stools were natural. The discharge from the iliac had fossa ceased entirely, and a soft catheter could not be passed under Poupart's ligament. The femoral hernia was nearly obliterated by the cicatrization just external to it. 22d.-The wounds in the thigh showed no signs of union, and I applied naphtholin freely to all of the parts with a powder- blower. I then bandaged the foot and leg firmly with a roller and applied a dozen straps of adhesive plaster to the thigh. These were removed one by one and fresh ones applied in their places as required, but the surfaces were always kept in close contact. The naphtholin caused no pain when applied, but, three hours later, a burning sensation was complained of which lasted for an hour. 23d.-There was much swelling of the thigh between the adhesive straps. There was also a free flow of thick pus. She appeared to be gaining strength fast. The appetite was good and all of the functions were properly performed. 28th.-All of the edges of the wounds were adherent to the subjacent structures. There was a wound on the outer part of the thigh about eight inches long (over the middle third) and from one to three inches in width, caused by sloughing. This was healing by granulation. 31st.-The adhesive straps were removed and a roller band age were applied instead for comfort. She was able to move the limb by placing the toes of the other foot under it. August 7th.-Manipulation of the muscles of the thigh was ordered while the wounds were cicatrizing, to prevent contract- ure. The leg was fully extended several times a day. 15th.-Since the last note the patient had improved steadily. She had been put upon the sofa each day since the 10th inst. There was no wound open except the one healing by granula- tion. A LARGE FJECAL ABSCESS. 11 20th.-She had for several days walked to the easy-chair by the aid of a cane, and could fully extend the leg. 30th.-On this date I saw her walk to an adjoining room without the aid of a cane. The superficial wound that was healing by granulation was all healed. The patient was gaining flesh and strength rapidly. My reason for reporting this case is its features which have been of particular interest to me, which are, briefly stated, as follows: It has been seen that the patient was suffering with very severe symptoms when I first saw her, but that they entirely disappeared after a free evacuation of the bowels two days later. This was followed by a period of over two weeks, during which time nearly all of the symptoms were of a negative character, when suddenly it became evident that the contents of a faecal abscess were burrowing down the thigh. The pus and faeces made their exit from the abdomi- nal cavity under Poupart's ligament along the course of the anterior crural nerve, passing under the sartorius and rectus muscles, and, being directed by the inner surface of the vastus-externus muscle, pointed in the popliteal space. No fluctuation could at any time be detected, on account of the thigh being so tensely swollen, until the abscess ap- peared under the knee, although the nature of the process going on within was suspected, and the parts were frequently examined with much care. When the abscess was opened there was a free escape of faeces and flatus, which became more scanty gradually until it had entirely ceased at the end of eight days. One week afterward the bowels re- sumed their normal function, which they have since con- tinued to perform daily without interruption. A peculiar idiosyncrasy of the system was met with in its perfect intolerance of iodoform, the patient being twice poisoned by that drug. The first time it was caused by ap- 12 A LARGE F2ECAL ABSCESS, plying eighty grains to the wounds in the thigh, and the second time by using only twenty grains. Each time the symptoms were all of the same character, and they quickly disappeared after the iodoform was removed to prevent further absorption. Finally, the wounds had healed and she had fully recov- ered the use of the thigh, notwithstanding the extensive sloughing of the parts that had occurred, just three months from the time her disease began. 31 West Twenty-fifth Street, November 21, 1885. The lew York Medical Journal, A WEEKLY REVIEW OF MEDICINE. Published by Edited by 0. Appleton & Co. ffijlRiS ^ank p- Foster, The New York Medical Journal, now in the twenty-first year of its publication, is published every Saturday, each number containing twenty- eight large, double-columned pages of reading-matter. By reason of the condensed form in which the matter is arranged, it contains more reading- matter than any other journal of its class in the United States. 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