October 6, 1888. CASES OF DISEASE OF APPENDIX AND CAECUM. BY WILLIAM OSLER, M.D., Communications. 419 THE anterior surface of the kidney, close to the |hilus, and its apex is in close proximity to ithe under surface of the right lobe of the liver, being distant 134 inches by measure- PROFESSOR OF CLINICAL MEDICINE IN THE UNIVER-/ ment from the gall-bladder.”’ SITY OF PENNSYLVANIA. _ [ have recently had occasion to look over my notes of cases of disease of the caecum and appendix, and the following records illustrate the anatomy of some of the com- moner affections of these parts: Anomatizs oF Postrion.—The appendix is extremely variable in position and may be found very far from the right iliac fossa. I have seen it in every region except the left hypochondriac and the left lumbar. Case J.—Phthisis. Cecum, appendix, and the first parts of the ascending colon unattached. The caecum with a short appendix was turned up and lay in close contact with the gall-bladder, separating it together with the edge of the liver from the right costal margin. There were no adhe- sions; it could readily be replaced. Case 1/.—Cirrhosis of liver. Man, aged 31. The appendix passes behind the caecum and is adherent on the peritoneum covering the right kidney. There had been an old localized peritonitis. Case /7.—Pneumonia. Woman, aged 4o. Appendix long and descends into the pelvis, where it is firmly attached to the broad ligament, near the ovary, forming a noose, about an inch in diameter. Case /V.—Male, aged 68. Old peritoneal bands join several of the coils of intestine together. The caecum and appendix with the ascending colon are drawn up and to the left, the caecum folded on the colon, and the valve and appendix occupy a position corresponding to a point 134 inches below and a little to the right of the navel. Case V.—Typhoid fever; perforation. Woman, aged 25. A long appendix passes vertically down into the pelvis and is attached to the wall of the pelvis not far from the ovary. I dissected two cases recently, at the Philadelphia Hospital, in one of which the appendix was adherent to the ovary, and in the other to the broad ligament. Case VI.—Appendix very long, passes behind the cacum and ascending colon, and the lower end of the right kidney, reaching almost to the pelvis of that organ. Case VIJ.—Typhoid fever. ‘In removal of intestines the appendix is found to occupy a very unusual position. It passes behind ULceration.—This is a not uncommon lesion in phthisis and typhoid fever. No doubt the following list would have been greatly increased had a more systematic examination been made of the appendices in all cases. Case [.—Girl. Phthisis—pneumothorax. Ulcers in cecum; appendix dilated ; mucosa extensively ulcerated. Case /f—Phthisis. Male, aged 18. Much recent swelling and ulceration of Peyer’s glands in ileum, The appendix large, the mucous membrane swollen, con- gested; it presented one small ulcer. There were three oval fecal concretions in the tube. Case 1/[.—Typhoid fever. Girl, aged 17- Many ulcers of ileum, and small ones in cecum. Several small ulcers at, and just within, the entrance of the appendix, the mucosa of which was greatly swollen. Case [V.—Man, dead of typhoid fever. Extensive ulceration of caecum. ‘‘ In appen- dix vermiformis, mucosa at distal end muclr swollen, and there is an ulcer the size of a five-cent piece with the slough still adher- ent.”’ : Case V.—Phthisis. Woman, aged 29. No ulcers in ileum, cecum, or colon. Appendix large, swollen, and unattached. Tt contains soft feeces, and half an inch from the end there is an irregular ulcer the size of a five-cent piece. Case V7.—Phthisis. Woman, aged 19. Ulcers in ileum and one in czcum at valve. Appendix dilated and large, particularly the distal end. When slit open, mucous mem- brane swollen. Two tuberculous ulcers at the extremity. Case Vi/.—Phthisis. Male, aged 36. Ulcers in ileum, caecum (very extensive), and colon. Appendix large and thick, adherent on iliac fascia. Several ulcers, and at its extremity a small localized abscess the size of a walnut, due to perforation of one of the ulcers. Case VIT7.—Ann W., aged 22; typhoid fever. Caecum lies in pelvis, no attach- ment; the peritoneum covers it completely ; the appendix ascends from tip of caecum to the margin of the pelvis and ends in a fibrous cord just under the meso-colon. Much ulceration in caecum; in appendix several ulcers with adherent sloughs ; mucous the cecum and ascending colon, along the | membrane much swollen. 420 Case 7X.—Ellen R., aged 16; phthisis. Extensive ulceration in ileum and cecum; appendix swollen ; mucous membrane tumid and extensively ulcerated. Case X.—Male, aged 28; typhoid fever. No ulcers in the cecum. In the appendix, which is long, the mucous membrane is swollen, and there are two ulcers with! adherent yellow sloughs. Case X[,—Male, aged 35; phthisis; Uni- versity Hospital, 1886. Ulcers in cecum and ileum; appendix swollen, and presents two tuberculous ulcers. OBLITERATION OF THE LUMEN OF THE APPENDIX.—This may be partial or com- plete, and is more frequent, I think, than the scanty number of cases in my records would indicate. When complete, it may be regarded as advantageous, but obliteration of the cecal end is a serious danger, as many cases of inflammation and perforation result from the retention of secretion and dilatation. The distended tube may be as thick as the thumb, or even as large as a sausage. Case —Typhoid fever; man, aged 29. Tube of appendix partially obliterated. Case [7.—Typhoid fever; male, aged 4o. Appendix obliterated for half an inch of its cecal end; dilated in the distal part, one inch in length. _ Case Ill,.—Male, aged 33; dead of phthisis. The appendix vermiformis oblit- erated and represented by a firm fibrous cord, one and a half inches in length. There was no, special thickening or adhe- sions in the neighborhood. . Case /V.—Woman; death from a large burn. ‘Appendix is small, and the lumen completely obliterated.”’ Forricn Bopres.—I have never met with a foreign body in the appendix; but I was once brought four or five apple pips which had been removed from the tube in a sub- ject in the McGill College dissecting-room, and Dr. William Sutherland, while acting as Pathologist during my absence in 1884, has recorded a case in which six or eight snipe-shot were found in the appendix of a man dead of Bright’s disease. -Moulds of feces are not uncommon, shaped like a date-seed. Sometimes these form concretions and may cause ulceration. Jt is rather surprising, considering the sit- uation of the appendix, that we do not more often find foreign bodies in it. PERFORATION WITH PERITYPHLITIC AB- scEss.—Case .—J. B. N., aged 20, admitted October 4, with peritonitis. Notes not Communications. ° available. Death on the 8th. Body well Vol. lix developed. In abdomen, omentum is glued to the anterior wall, and beneath it much creamy pus. The tip of the omentum is closely adherent in the neighborhood of the right internal ring, and here the coils of intestines are matted together. There is general peritonitis and an unusual quantity of thick pus. The ileum, carefully removed ' and slit open, shows no disease of the mucosa. It contained numerous hard dry faecal masses. The cecum looked normal, was placed low, and adhered to the iliac fascia. The mucous membrane was not ulcerated. The appendix passed down toward the internal ring, and adhered closely, covered by the omentum. A probe passed into it enters directly a small abscess near the ring. Slit open, a perforation is seen near the end, on the under side, which leads into the abscess. There was no foreign body. Case Z7.—C., male, aged 28, patient of Dr. George Ross, in 1882. Sudden acute pain in right iliac fossa, with great tender- ness and high fever. After leeching, the pain subsided, and for several days the con- dition improved. Then he hada chill, with increased fever. Most careful exploration ° of the affected region failed to determine any fulness, fluctuation, or signs of localized tumor, and yet it was clear that the patient had a septic process from some acute abdom- inal affection. Several consultations were held with a view of operation, but the absence of local symptoms determined against it. He had repeated chills, and death occurred from septicemia. At the autopsy, two quarts of turbid fluid in peri- toneum; intestines covered with recent lymph and matted together. The trans- verse colon was adherent to the ileum, two inches from the valve. About the cecum the parts looked natural, except at the inner margin, where there was considerable pig- mentation. The cecum itself was normal. On slitting open the appendix, the mucosa for half an inch was healthy; the remainder of the tube was dilated and presented two perforations, the larger of which was the size of a five-cent piece, and communicated with an abscess situated in the angle between the czecum and ileum, and was partly covered by both these structures. The sac of the abscess, which had the size of a small apple, was closed; had thick dark walls, and con- tained two ounces of creamy pus. There was an extensive abscess of the mesentery, with suppurative phlebitis of the veins. The portal vein and its branches contained dark greenish-yellow pus. The orifice of the splenic vein was closed with a thrombus. October 6, 1888. Case IIf.—I. L., aged 42. Had typhoid fever, from which he never recovered com- pletely ; septic symptoms developed, signs of pleurisy, and finally acute general peri- tonitis. Duration of illness, three months. Autopsy. — General peritonitis; eighty ounces of turbid exudation; much lymph on the intestinal coils. The appendix passed out at right angles to the caecum and lay directly upon the promontory of the sacrum. _ It had about the length and size of the index finger, and was much swollen and soft. The cascum was normal; prox- imal end of appendix closed; a probe passed a couple of lines beneath the mucous membrane, and then met witha firm obstruc- tion. Beyond this the tube of the appendix was dilated, and, when opened, showed a perforation one-third of an inch in diam- eter, which communicated with a small localized abscess cavity on the promontory of the sacrum. No foreign body; no con- cretion; extensive abscess of mesentery ; liver enlarged; ,portal vein and branches distended with pus; empyema of left pleura. Case 1V.—J. P., aged 26, patient of Dr. F. W. Campbell. Inflammation of cecum in July, from which he partially recovered. Recurrence in September: pain in abdomen and local symptoms; then chills and sweats. Death suddenly, October 10. Autopsy.—Body emaciated. nitis. Intestines very dark-colored. Caecum healthy. Orifice of appendix closed and the tube obliterated for a quarter of an inch; distal portion dilated. On the upper sur- face, which was covered by peritoneum, there was a localized slough, not extending through the coats. ‘The mucous membrane of the tube was dark-colored and swollen, but not ulcerated. Extensive abscess of mesentery, chiefly in the mesenteric veins. The suppuration extends into the gastric and portal veins, the branches of which on the liver were dilated and full of a creamy greenish-yellow pus. Slight perito- Case V.—The following case illustrated“ tery and ilerm in most: unusual mode of termination, hemorrhage from the bowels: Male, aged 45. Hada “*‘ bilious attack ’’ in February, lasting three weeks. Fourteen months later, another attack vomiting, flatulence, and constipation; very slight abdominal pains. The motions became offensive, there was irregular fever, and he began to lose flesh. Suddenly, one morn- ing, he passed a large amount of blood in ‘the bed, and the hemorrhage recurred through the day and proved fatal the same vizZ., Communications. | evening. 421 The autopsy showed a smooth peritoneum. The lower coils of the ileum were matted together on the promontory of ithe sacrum, upon which lay a large flat ‘abscess. The czcum and colon were ‘normal. The appendix passed out at right _ ‘angles and was attached to the abscess fon the sacrum, with which it communi- |cated by two openings at the apex of the ‘tube. There were two perforations from the l abscess cavity into the ileum. The hemor- irhage had evidently come from this part, put the precise locality could not be deter- imined. . | Case V7—Patient aged 50; was the “subject of right inguinal hernia, and on ‘Sunday evening, February 27, was seized ‘suddenly with intense pain in the lower ‘abdominal region. He vomited, and the imext day the abdomen was swollen. The pain persisted. On Wednesday he had ‘diarrhoea, and the pain continued to be ‘very severe. On Friday, when admitted to. ‘hospital, the belly was tympanitic, vomiting very urgent, and the pain severe. He ‘refused surgical interference, and died on iSaturday night. At the autopsy, the ‘cecum was found adherent to the iliac fascia and passed into the ring, and was ‘attached for at least two inches to the ‘wall of the canal. The ileum was normal, ‘and the finger passed freely through the ‘valve. On searching for the appendix, the ‘proximal orifice was found at the extreme ‘end of the hernia of the czcum, in the ‘inguinal canal. It then curved upon itself, ‘passed back into the abdomen immediately ‘behind the terminal portion of the ileum, - crossed to the left and became adherent to the wall of an abscess cavity lying to the ‘right of the promontory of the sacrum. The lumen of the tube was free; the ter- ‘minal three-fourths of an inch had sloughed ‘and communicated directly with a small ‘circumscribed abscess-sac with pigmented and indurated walls. This’ opened into a ‘larger pus-cavity, bounded by the mesen- in front, and the sigmoid flexure and peritoneum behind. PpRITYPHLITIS FROM CacaL DISEASE.— The following cases of round ulcer of the ‘caecum are of interest, as the condition is ‘not common : Case .—M. G., aged 19, a well-built young man, was in hospital for four days with symptoms of peritonitis ; at first it was ‘thought to be obstruction. Three weeks previously he had had an attack of what was supposed to be internal strangulation, from which he recovered. 422 Communications. Vol. lix “The autopsy showed recent peritonitis, | first two inches of the ascending colon, and most intense in the right iliac fossa. There! just admitted the tip of the little finger; were evidences of bygone peritonitis in the! when cut through, the appearance of the form’ of opacities and puckering on the’ mucous.surface is that of an open cancerous serous surfaces. The cecum was adherent! ulcer. At the posterior wall, this has per- closely to the iliac fascia. When opened in forated and communicates with a large situ, an ulcer was seen on the outer wall,' abscess by an orifice admitting the index and a large perforation over an inch in| finger. The abscess extends behind the diameter, leading into a localized abscess! psoas muscle, and has eroded a lateral pro- in the iliac fossa. The peritonitis had {cess of one of the lumbar vertebre ; above, evidently started at this point, though there/it extends for a short distance behind the was no sign of rupture of the abscess. The| kidney’; and externally it reaches the crest appendix was normal. It seems probable|of the illum. The appendix was not that in the first illness, three weeks before | involved. the fatal attack, the perforation occurred, with the formation of the localized abscess. Case I7.—I. T., aged 38, patient of Dr. Armstrong. Symptoms at first were those of perityphlitis. A septic condition supervened, lasting 15 days; repeated chills. There was dulness in the right lumbar region, due, it was thought, to a tumor of some sort; but on aspiration a clear fluid was obtained. _ Autopsy.—Body much emaciated. No tumor or fulness to be felt either in the right iliac fossa or in the lumbar region. In abdomen, intestines very dark-colored ; two coils of ileum adherent to the cecum ; two pints of turbid serum in the peritoneum. The czecum closely adherent by its posterior wall; tissues about it dark, and look thick- ened. Between the caput czci and the psoas muscle, lying thus to the inner side of the bowel, was an abscess cavity the size of a small apple, its walls rough, irregular, and shreddy. It contained only a small quan- tity of a thin sanious pus. The colon and cecum were opened zz sétu. On the pos- terior wall of cazcum, was a dark-colored area, in the centre of which was an ulcer the size of a ten-cent piece, which commu- nicated with the abscess cavity by a perfora- tion which would admit a quill. The appendix was unaffected. There was a small ulcer on the lowermost Peyer’s patch of the ileum. Tuberculous and cancerous disease of the cecum not infrequently lead to perforation and extensive suppuration in contiguous parts, as illustrated by the following case: Case I77.—Middle-aged man.. Il for some months; symptoms of obstruction, and latterly of septic poisoning... Autopsy.—In abdomen, the czecum and appendix were seen to be large and dis- tended, and the bowel is constricted just above the entrance of the ileum. The colon-and czcum opened zx sifu. . A strict- ure, with thick hard walls, involved the!