CHAPTER XVI.

PERFORATION OF INTESTINE FROM WITHOUT. ABSCESS IN ABDOMINAL PARIETES EXTENDING INTO THE INTESTINE. FECAL ABSCESS.

IT is usually believed, that next to the small intestine the perforation of the coats of the stomach ranks in the order of frequency; the colon is, however, from varied causes not unfrequently perforated, and this is a more common occurrence than is generally supposed. These perforations divide themselves into two great classes-1. Those which arise from disease commencing in the intestine itself, and to which we have referred in numerous instances, as perforation of the ileum in fever and struma; of the cæcum and its appendix; of the colon in dysentery, in cancerous disease, and in several forms of insuperable constipation. On the contrary, in a second division the perforation is from without, or from the extension of disease from adjoining structures. These constitute an important and an exceedingly interesting class of diseases.

1. From the peritoneum, as in strumous peritonitis.

2. From disease of the stomach, as ulceration or cancer, extending into the transverse colon.

3. From the liver-hydatids, or abscess, obtaining an exit by means of the small or large intestine.

4. From the gall-bladder, calculi thus escaping.

5. From abscess in the spleen.

6. From abscess in the kidney.

7. From abscess in the abdominal parietes, or loins.

8. From diseased ovary communicating with the cæcum, colon,

or rectum..

9. From cancer in various structures.

10. From extra-uterine fœtation.

11. From one portion of intestine opening into another, as the appendix into the rectum.

12. From blows, or external injury.

In many of these forms of disease last enumerated, various and characteristic symptoms precede the perforation of the peritoneum or of the intestine; thus, the signs of cancerous disease of the stomach arise some time before fæcal vomiting or eructation indicate extension into the colon. In hydatid disease of the liver there is the presence of a rounded tumour, of slow formation, having often a peculiar vibratory thrill, and without general disturbance, before the occurrence of local peritonitis, or the discharge of hydatids, either by the mouth, or with the evacuations per rectum.

In gall-stone we have very severe pain in the region of the gall-bladder, with vomiting or jaundice, before intense peritonitis, from rupture into the general cavity of the abdomen, or obstruction by its impaction in the jejunum or ileum takes place.

In abscess of the spleen the symptoms are more obscure, and constitute part of a general constitutional disturbance, till perhaps the discharge of pus by stool indicates that a communication has been formed with the transverse or descending colon.

In abscess of the kidney, or pyelitis, there is purulent urine; but where there is suppuration external to the tunic of the gland the symptoms are more obscure.

In ovarian or cancerous tumours tactile examination will detect growths of those characters with more or less cachexia. Some of these forms of disease are more obscure than others, but where fæcal abscess is the result there is considerable uniformity, severe local pain and tenderness, hectic and prostration, which steadily increase; and where the abscess is not limited by adhesion very rapidly fatal.

Suppuration in the parietes of the abdomen is frequently presented, and simulates deeply-seated mischief; for a short time considerable obscurity may attend it. The symptoms are generally of an acute character; considerable pain and febrile excitement precede inflammatory œdema of the skin, and while the effused products are bound down by firm fascial investments the symptoms closely resemble cæcal disease, or local peritonitis, &c.; in fact every part of the abdominal parietes presents us with disease on

the surface, resembling deeper injury. In the hypochondriac regions suppuration connected with the costal cartilages, or ribs, simulates abscess of the liver, empyema, hydatids, diseased gallbladder, or corresponding disease of the spleen; in the right or left iliac regions abscess in the parietes may be mistaken for affections of the cæcum, or sigmoid flexure; in the lumbar regions for renal or spinal disease; in the umbilical, for strumous or cancerous disease; and, lastly, in the hypogastric region, pelvic cellulitis, for ovarian or uterine disease.

Simple suppuration in the parietes generally tends to the surface, is opened or discharged spontaneously, and in many cases does well, unless connected with pyæmia, or in cachectic subjects; at other times, on the contrary, it is less limited; it spreads extensively among the muscles, extends also in depth, and gradually produces local peritonitis, or discharges itself into some of the viscera. Thus abscess about the kidney opens into the colon, that in the iliac regions into the sigmoid flexure, or cæcum.

The most fertile source of these forms of parietal suppuration are blows and falls. I have observed them after blows, or pressure on the abdomen, falls on the back, &c. In pyæmia and cachectic subjects apparently very trifling causes appear to be sufficient to lead to it.

Diagnosis. The pain will generally be found to be very superficial; but in many instances, at an early stage, before any inflammatory œdema has been produced on the skin, and whilst the disease is confined beneath the fascia of the abdomen, there is much obscurity. In reference to the treatment, this obscurity is of no great moment, for at that period local depletion, by leeches, rest, warm cataplasms, are equally applicable to local peritonitis as to parietal inflammation. Where suppuration has actually taken place the sooner the pus is evacuated the less likely is it to burrow among the flat muscles and fascia of the abdomen; and even in abscesses, fæcal or otherwise, extending secondarily to the parietes, unnecessary delay is sometimes made in discharging their contents. The rule is, I believe, a correct one, to open these abscesses very early.

CASE CLIII.-Suppuration external to the Sigmoid Flexure of Colon. Communication with the Intestine and the Anterior Abdominal Parietes.

Elizabeth R, æt. 39, a widow who had supported herself by dressmaking, was admitted into Guy's under my care, March, 1855. Till a fortnight before admission she had enjoyed good health, when she felt pain in the back, which extended to the shoulders and knees. The greatest pain, however, was in the course of the ilio-hypogastric nerve. These symptoms were accompanied with considerable febrile excitement.

Saline medicines with colchicum, etc., were prescribed. In a few days the pain, which had simulated rheumatism ceased, and she appeared to gain strength under the use of decoction of bark with carbonate of soda.

On March 26th, three weeks after admission, she complained of pain in the left iliac fossa, and a firm tumour about the size of a hen's egg could be felt deeply in that part. There were no tenderness in the spine, numbness in the legs, or other symptoms of disease of the spine. An examination per vaginam was made by my colleague, Dr. Oldham, but did not give any evidence of disease of the ovary. The bowels were easily acted on by hydrarg. cum cretâ, by castor-oil, and by enemata; but this action did not affect the size of the tumour or alleviate the symptoms. The urine was normal, and there was no indication of renal disease. The pain gradually increased in severity, but was considerably relieved by the repeated application of leeches, by taking iodide of potassium, bichloride of mercury, and occasional doses of morphia. It was believed that the malady consisted in disease of the sigmoid flexure of the colon, with local peritonitis.

on.

May 10th. The pain had returned with much severity, and hectic came The tumour increased in size; it could be felt extending to the quadratus lumborum; and also reached the anterior abdominal parietes, which, at the left iliac fossa, were red, oedematous, and exceedingly tender.

19th. The bowels were acted upon three times freely, and a considerable quantity of purulent mucus discharged. The examination of this discharge could detect no cancer cells. The pain and hectic continued, the patient becoming pale and exhausted; the left thigh and leg became swollen and tender, afterwards the right; and there was excessive pain in the course of the femoral veins. Nourishment and stimulants were administered as the patient could take them. Quinine and opium, or morphia were given.

June 8th. The inflammatory œdema of the anterior abdominal parietes had increased. My colleague, Mr. Callaway, made an incision at this part, and more than a pint of exceedingly offensive pus was evacuated. Every means were used to sustain the patient; but the discharge continued abundant, and bearing feculent odour, and her strength gave way. Her tongue remained clean and moist; but her appetite ceased, so that she became quite unable to take food. There was no pain at the scrobiculus cordis, vomiting, or thirst; but emaciation and sense of exhaustion. Bed sores formed on the sacrum; and a few days before her death, cough, which aggravated her distress. She gradually sank, and died June 24.

Inspection was made twenty-four hours after death.-The body was blanched, and the lower extremities oedematous; the pleura was healthy, but the posterior lobes of the lung were in a state of red hepatization; the heart and its valves were healthy.

Abdomen. The peritoneum was healthy, except in the left iliac region,

where the omentum, and several coils of intestine, were adherent. In this region was an abscess, situated behind the peritoneum and fascia, and containing offensive, feculent pus; it extended to the anterior abdominal parietes in front, above to the diaphragm and kidney, and posteriorly nearly to the spine. Very careful examination could detect no disease of the ilium or vertebra, or pelvic cellular tissue. The abscess communicated with the sigmoid flexure by three small openings, in close contact the one with the other; the edges not thickened, but valvular. The small and large intestines were otherwise healthy; and the opening into the intestine was evidently secondary. The uterus, ovaries, and kidneys were normal. The stomach was of normal size; the mucous membrane pale, and had undergone degeneration. The liver was more than 5lbs. in weight, and extremely fatty. The lower portion of the vena cava, and of the common iliac and external iliac veins, were filled with very firm, white, adherent fibrin, and the coats of the vein were much thickened.

The review of this case showed that the pain in the course of the ilio-hypogastric nerve arose from direct pressure upon that nerve by inflammatory effusion, that the tumour felt in the iliac fossa consisted of this effusion pushing forward the peritoneum and sigmoid flexure; that the subsequent symptoms arose from suppuration, and its extension in various directions, inwards into the colon, leading to some extravasation of fæces and of pus into the alimentary canal and into the abscess forwards, so as to reach the anterior parietes, where it was opened,-upwards to the diaphragm, and inwards to the cava and iliac vessels, which became involved and obstructed by fibrinous material. That it did not arise from diseased bone was proved by careful examination; and it appeared probable that some accidental blow had led to this suppuration, with its fatal results, or that irritation in the intestine had led to inflammation external to it, and subsequent suppuration.

After the tumour had been felt, evidence of suppuration soon arose, and the discharge of purulent mucus showed that it had formed some connecting link with the intestine, or that there was ulceration of the coats of the intestine itself. Renal, ovarian, spinal, or parietal suppuration, or cancerous disease of the sigmoid flexure, might give rise to many of these symptoms. The absence of all indication of diseased kidney was shown in the condition of the urine. Disease of the spine was exceedingly doubtful, from the want of tenderness, numbness, and the course of the suppuration. The position which the tumour assumed and vaginal