LEFT-SIDED APPENDICEAL ABSCESS.
DR. FRANCIS T. STEWART reported the case of a boy, aged nine and a half years, who entered the Pennsylvania Hospital, August 8, 1899, suffering with diarrhcea and slight fever. There was nothing in the family or previous history bearing on the case. Four days before, after eating candy and pop-corn, he began to vomit, and complained of abdominal uneasiness. The bowels readily responded to a laxative, the loose movements persisting. On admission the abdomen was slightly distended and the lower right quadrant tender. The walls, however, were flaccid, and no mass could be felt externally or by rectum. He was sent to the medical ward with a diagnosis of enteritis. At the end of two weeks the tenderness had disappeared, the abdomen had become flat, and some induration could be palpated between the umbilicus and the left anterior superior iliac spine. On the nineteenth day, the mass having increased considerably in size, an incision through the abdominal wall was made by Dr. Le Conte, and a large quan tity of foul pus evacuated. The abscess cavity was trabeculated and completely shut off from the general peritoneal cavity by firm lymph. The appendix was not found, nor was it diligently searched for. Six weeks later the wound had practically closed.
Dr. Stewart said that this case might be regarded as one of enteritis, followed by appendicitis travelling from the base out ward to the tip, which lay to the left of the mesial line ; the sup puration being caused by a migration of the bacteria rather than by a perforation, as there was neither gas nor fecal concretion in the abscess cavity. The pus was thought to be appendiceal from its character; but that the infection originated primarily on the right side is probable, because of the situation of the initial tenderness, as there was no transposition of the viscera, and be cause of the rarity of left-sided appendicitis. Edebohls (New York Medical Record, November 25, 1899), who has made a very exhaustive study of the literature of appendicitis, says, "As re gards left-sided appendicitis, the only genuine case thereof on record is that of Biegi (Med. Moderne, 1897, viii, p. 643), which occurred in a soldier who died of appendicitis, and was found on autopsy to have a complete transposition of all the viscera. The case of Bontecou (Transactions of the Medical Society of New York, Albany, 1873, lxvii, pp. 137-139), in which death resulted from ulcerative perforation of the small intestine into the left iliac fossa ; that of Traube (Medical News, 1893, lxiii, p. 604), of a perityphlitic abscess pointing on the left side ; and the three cases reported by Fowler, in which the cmcum and appendix were displaced to the left, all originated primarily in the right iliac fossa. So did the case of Coates (" Manual of Pathology," 1895), in which empyema of the left chest followed perforation of the diaphragm from an abscess of appendicular origin."