APPENDICITIS COMPLICATED WITH LEFT SIDED ABDOMINAL ABSCESS AND LEFT PYOTHORAX.
DR. STEWART reported a second for which his thanks were due to Dr. Morton for the privilege of operating upon and reporting. A man, aged nineteen years, was admitted to the Pennsylvania Hospital, November 7, 1899, after having suffered five days with abdominal pain. There had been no chill, vomiting, or constipation. Nothing relevant in either the family or previous history could be ascertained, except that he had been struck a smart blow over the appendix several days before the onset of pain. He had had the opportunity to observe several patients who attributed their appendiceal trouble to injury. Small (Medi cal Record, September 10, 1898) reports thirteen cases of appen dicitis with a clear history of trauma. The temperature was zoo° F.; respirations, 28, and pulse, wo. Both recti were hard, the pain active, and tenderness most marked at McBurney's point. No mass could be felt and no dulness elicited, although, as was afterwards ascertained, the appendix lay just beneath the abdomi nal wall. An incision in the right semilunar line was immediately made, opening a large abscess which was completely isolated from the surrounding peritoneal cavity. The appendix measured three inches, pointed directly inward, the tip adhering to the parietal peritoneum just to the left of the midline, and the outer two thirds was gangrenous. During enucleation the distal extremity was ruptured. There was no foreign body and no fmcal concre tion. The abscess cavity was loosely filled with gauze. On the third day the temperature reached and thereafter varied between 99° and until the second abscess was opened. On the ninth day he had a chill, the discharge which had been profuse became scanty, and a mass was detected in the lower left abdomen ; this was opened on the twelfth day, cvacuating several ounces of foul pus. The patient was comfortable and the temperature nor mal for twenty-four hours, when, after feeling chilly, the tempera ture arose to 103°. As the discharge from the abdominal wounds decreased, the symptoms of sepsis increased. On the twentieth day there was another chill, followed by a tempera ture of and this by a profuse sweat. On the twenty-first he suddenly expectorated a large quantity of foul pus containing the bacillus coli communis, severe axillary pain followed, and at the end of twenty-four hours the expectoration had ceased, the left chest had become flat, and the heart had moved to the right. The pleural cavity was opened through the seventh interspace and a rubber tube inserted. From the foul brown liquid which escaped cultures of the colon bacillus were obtained. The temperature fell to normal and recovery seemed assured, when on the thirty first day he began to complain of increasing abdominal pain. He became constipated, peristalsis could be seen above the wounds. and fever again appeared. It was feared that adhesions ob structed the fecal current and that a fourth operation would be come imperative, but the bowels were finally induced to move, and on the thirty-fifth day, four days after the onset of abdominal pain, he was again comfortable. He was discharged on the thirty eighth day, with a small tube still in his chest and both abdominal wounds closed. Since leavingthe hospital there have been several attacks of pain, with transient constipation.
A pronounced feature of this case was the rapidity of abscess formation and the remarkable recuperative power, both general and local, which was exhibited. The primary abscess promptly closed when the second was opened, which in turn rapidly healed when the pus migrated to the thorax ; the pulmonary abscess dis charged through the mouth only twenty-four hours, and sixteen days after the empyema was drained the patient was able to go home. And this, with the absence of joint, liver, and endocardial inflammation, would seem to indicate that the suppurative process extended by contiguity rather. than by the blood channels, as in pyxmia. There were no symptoms of diaphragmatitis, and the abdominal abscess apparently did not extend as high as the ab dominal dome.
In Edebohl's (Ibidem) article there are recorded nine cases of appendicitis with lung complications,—four of these were em pyemas, three perforation of the lung by abscess, one gangrene of the lung, and one pneumonia. Weber (Deutsche Zeitschrift für Chirurgie, February, 19oo) reports nine cases of subphrenic ab scess; in six of these right-sided pyothorax developed, and in one of these perforation of the diaphragm was found. Jeanmire (Gazette Hebdomadaire de Midecine et de Chirurgie, March 1, 'goo) puts on record a case of appendiceal abscess opening into a bronchus and followed by recovery.
DR. JOHN B. DEAVER said that he thought the report of these two cases to be very strong arguments in favor of early inter ference and against delay in operating upon appendicitis. He had seen cases similar to those described by Dr. Stewart time and time again. They are always late cases. This left-sided condition of the appendix is not an uncommon condition. He took the credit of first calling the attention of the profession to pain in the left side as indicative of a southerly position of the appendix. In these cases he always took the appendix out and had never made an incision on the left side of the abdomen. He did not think for one moment that this was originally a case of enteritis. It was appendicitis from the start.
In operating, he incised over the seat of the appendix, that is the normal position of the appendix, and worked his way down into the pelvis and removed the appendix, drained, etc. Although it is the practice of some physicians to tap them through the rectum, and, in a few cases in the female, through the vagina, this practice he highly disapproved of. These cases demonstrate the ravages of appendiceal pus. He had seen pus make inroads in cases where the physician in attendance did not recognize the con dition. He had seen a number of cases where appendiceal ab scesses had ruptured into the lungs, and by way of the bronchus escaped through the mouth. These are not very uncommon con ditions in late cases. There is very much that can be said on the subject, but nothing against early interference, interference at the earliest possible moment.