acute obstruction. On the following day Dr. A. J. Campbell, of Middletown, was called to attend him. He tried all known methods to relieve the symptoms and move, the bowels without avail, so sent the patient to the St. Francis Hospital for surgical treatment.

On admission to the hospital the patient was suffering little or no pain, obstinate constipation, frequent stercoraceous vomiting. During the night attempts were made to relieve the symptoms-all to no purpose. The following morning the patient was in a condition of collapse, abdomen distended, pulse 140 and thready, temperature 102 degrees and rapidly losing ground.

An operation was decided upon as the only possible chance; a slight quantity of ether administered, an incision made over the median line, sufficiently large to admit of exploration of the abdominal cavity.

On opening the abdomen, there was found an advanced stage of peritonitis, the bowels being badly swollen, both the intestines and peritoneum nearly black and covered with masses of blood, fibrin and exudate. No obstruction was found in the lower part of the abdomen.

The incision was then prolonged upward, when we were rewarded by finding with the finger, under the lower border of the stomach, a band of adhesions about one inch wide by one-half inch in thickness, extending across a loop of intestine and completely occluding its lumen. The band was ligated and incised. Nearby were found several loops of intestine matted together by the recent inflammation. These were carefully separated, the abdominal incision closed with drainage.

Primary union was secured with the exception of a superficial stitch abscess. The operation lasted forty minutes. The patient's condition seemed hopeless when he left the table. Restoratives were applied, the patient soon rallied, did not vomit after the operation, and made an uninterrupted recovery.

ON PERIRENAL, PERIHEPATIC AND PLEURAL ABSCESSES FOLLOWING APPENDICITIS.

BY WILLIAM H. CARMALT, M.D.,

NEW HAVEN.

I take the liberty of bringing to the attention of the Society a couple of cases on the somewhat trite subject of appendicitis, which are interesting by reason of the unusual positions in which the abscesses appeared, and as showing that we cannot always depend upon McBurney's point as a sure thing in diagnosis. The first case was the most complicated, and it was not until I had met the second that I was able to explain satisfactorily to my self, the unusual course which the pus took in the first, and in order to make it clear will report the last case, first. This occurred in a young man about seventeen years of age under the care of my friend, Dr. William J. Sheehan, of this city, who asked me to see it on account of the uncertainty which he felt by reason of the very unusual situation of the abscess, and the attendant symptoms had made it difficult to be absolutely sure of the diagnosis. There had been an antecedent history of an attack of appendicitis some weeks before which led him to think this was of a similar nature, but the symptomatology of this attack was not distinct, and it is not a safe rule to follow that because a man has appendicitis once, that every other abdominal il must of necessity be appendicitis also. This young man was taken sick on April 17th of this year with sudden and severe pain in the epigastrium and he vomited once only; his bowels were loose, he had had frequent movements during the day, and he complained of pain in the right loin, extending upwards and backwards to the region of the right kidney; his pulse was 84, his tempera

ture 102; his abdomen somewhat tender. He was watched carefully; anodynes were kept away from him, and unless disturbed he did not suffer much pain. His temperature, however, persisted high-100° to 102°-and his pulse ran slow; his spleen became enlarged, so it could be felt below the border of the ribs; but there was no pain or even tenderness at the McBurney point nor any where else about the right iliac fossa. His blood was examined twice by the Widal test with a negative result; the enlargement of the spleen suggesting malaria,— search was made for plasmodia, also negative. After he had been sick this way for some twelve days, the pain continuing in the loin more than anywhere else, a tumor was detected in this position. I saw the patient on the 29th of April; his axillary temperature was then varying between 100° and a fraction, and 102°; his pulse between 112 and 130, its tension was rather soft; he was having frequent urination, every three or four hours, and his bowels were moving three or four times a day; he was taking strychnine-1-30 of a grain every four hours hyperdermically; his countenance was somewhat pinched and anxious, his eyes a little sunken and he had marked emaciation. On examination of his abdomen

it was found slightly tense; no localized pain on pressure, no rigidity of walls, but there was a perceptible fullness in the right hypochondriac region, and a tenderness in his right loin, in which was also a soft spot just below the end of the twelfth rib; pressure upon it and the surrounding loin brought the fullness that could be seen in front more prominently to view, and an indistinct sense of fluctuation could be made out between the fingers placed over the tumor in front and behind in the loin. There was no doubt in either Dr. Sheehan's or my mind that there was a collection of pus deeply situated in his right loin, but there was a very considerable doubt as to its point of origin. The attack that he had had some months previously was,

unmistakably, appendicitis, but the diagnostic features of that disease were absent now. Typhoid fever and malaria had been eliminated by the examination of the blood; the location of the tumor and the frequent urination indicated a renal complication, and I, looking at the case for the first time, was in doubt whether or not he had a perinephritic abscess of renal origin; perinephritic it apparently was, but whether of renal or appendiceal origin was the question. The indications for operative interference were, however, unmistakable, and on the following day (the 30th of April), I operated, making the incision somewhat farther upwards and towards the flank than the usual incision for appendicitis; the fact being that I made the lower end of the incision to correspond with the line between the anterior superior process and the umbilicus. This brought the deeper portion of the wound well outwards toward the reflection of the peritoneum, and the opening in the abscess well on the side instead of in the groin. On opening the abscess, pus was found of the usual foul-smelling odor of appendiceal abscesses, extending up, apparently, behind the caecum. With some difficulty I was able to find the appendix, the tip ulcerated and firmly attached to the posterior wall of the caecum, from which it could not be separated without doing some injury to the wall. Continuing the search for the position of the appendix, I found it stretched out its entire length along the posterior wall of the caecum and ascending colon, which latter was very close to the abdominal wall. About onethird of the proximal portion appeared to be unaffected. lying outside of and beyond the abscess cavity; and this was all that seemed to have a mesentery. It was nearly four inches in length, had no bends or kinks in it--was simply stretched up behind the caecum with the distal extremity attached to it. The abscess itself extended still farther up towards the right kidney and had burrowed somewhat under the psoas muscle. The lower

end of the kidney could be felt distinctly at the upper part of the abscess, the wall of which appeared to be formed partially by the kidney. A counter-puncture was made in the loin, a drainage tube introduced, bringing it out of the wound in front of the lower end. It is not worth while to describe the subsequent course of the case, further than to say that on the second day after the operation there was a profuse fecal discharge coming out through the tube at both its anterior and posterior openings, caused undoubtedly by a rupture in the wall of the intestine at the situation where the tip of the appendix had been so firmly united to it. This fecal fistula closed spontaneously; the patient is now almost well.

The other case I owe to the courtesy of Dr. Barnum, of Kent, in whose care the patient had been for a month before I saw it. It was in a lad of twelve years of age who was taken sick while in school with violent pains in his abdomen, and vomiting. The pain soon localized itself in the right iliac region, in which there was a wellmarked tumor on the first day that Dr. Barnum saw the patient-which was the 26th of February of this yearabout a week after the beginning of the attack. The child continued sick, the tumor increased in size, and the doctor advised operative interference, but circumstances were unfavorable for its performance at the patient's home, and it was deferred. I saw him first on March 27th, just month after the tumor in his abdomen was discovered. At that time his abdomen was tense throughout; he complained of pain everywhere on pressure over it; his pulse was about 160; his breathing anywhere between 40 and 70. A horribly fetid odor exhaled with his breath-so fetid as to make the room almost unbearable; he coughed on the slightest exertion; he could lie only on the right side with his legs drawn up. This extremely critical condition had been present only for the last twenty-four hours, although for the