mmm 
 
 IMAGE EVALUATION 
 TEST TARGET (MT-3) 
 
 k 
 
 A 
 
 
 
 ^(2 
 
 /- 
 
 1.0 
 
 I.I 
 
 _ i^ lllllli 
 
 *r ^ 12.2 
 
 
 sKi IIS 
 
 11-25 11.4 
 
 1.8 
 
 1.6 
 
 
 
 PhotogiBphic 
 
 Sciences 
 
 Corporation 
 
 ^ 
 
 a? 
 
 \ 
 
 iV 
 
 N> 
 
 % 
 
 V 
 
 
 
 c> 
 
 23 WEST MAIN STREET 
 
 WEBSTER, N.Y. 14580 
 
 (716) 872-4503 
 
 ^ 
 
 ■^ 
 
CIHM/ICMH 
 
 Microfiche 
 
 Series. 
 
 CIHIVI/ICIVIH 
 Collection de 
 microfiches. 
 
 Canadian Institute for Historical IVIicroreproductions / Institut Canadian de microreproductions historiques 
 
Tachnical and Bibliographic Notaa/Notas tachniquaa at bibiiographiquaa 
 
 Tha Inatitute haa attamptad to obtain tha baat 
 original copy availabia for filming. Faaturaa of thia 
 copy which may ba bibliographically iiniqua, 
 which may altar any of tha imagaa in tha 
 raproduction, or which may significantly changa 
 tha uaual mathod of filming, ara chackad balow. 
 
 □ Colourad covars/ 
 Couvartura da coulaur 
 
 □ Covars damagad/ 
 Couvartura andommagia 
 
 □ Covers rastorad and/or laminatad/ 
 Couvartura rastauria at/ou pellicula 
 
 D 
 
 Covar titia miasing/ 
 
 La titra da couvartura manqua 
 
 I I Coloured maps/ 
 
 Cartes giographiquaa en couleur 
 
 □ Coloured ink (i.e. other than blue or black)/ 
 Encre de couleur (i.e. autre que bleue ou noire) 
 
 I — I Coloured plates and/cr iiluatrations/ 
 
 D 
 D 
 
 D 
 
 □ 
 
 Planches et/ou illustrations en couleur 
 
 Bound with other material/ 
 Relii avac d'autras documents 
 
 Tight binding may causa shadows or distortion 
 along interior margin/ 
 
 La re liure serrie peut causer de I'ombre ou de la 
 distortion le long de la marge int6rieure 
 
 Blank leaves added during restoration may 
 appear within tha text. Whenever possible, these 
 have been omitted from filming/ 
 II se peut que certainas pages blanches ajoutiaa 
 lore d'une restauration apparaissant dans la texte. 
 mais. lorsque cela 6tait possible, ces pagea n'ont 
 pas iti filmias. 
 
 Additional comments:/ 
 Commentairas supplimentaires; 
 
 L'Institut a microfilm^ le meilleur exemplaira 
 qu'il lui a iti possible de se procurer. Les details 
 da cat exemplaira qui sent paut-dtre uniques du 
 point de vue bibliographiqua, qui pauvent modifier 
 une image reproduite. ou qui peuvent exiger una 
 modification dana la mithoda normaia de filmage 
 sont indiquto ci-dessous. 
 
 □ Coloured pages/ 
 Pagea de couleur 
 
 □ Pages damaged/ 
 Pages endommagias 
 
 r~~| Pages restored and/or laminated/ 
 
 D 
 
 Pages reataurias et/ou peliiculies 
 
 Pagea discoloured, stained or foxei 
 Pages dicolories. tachat^es ou piquies 
 
 Pages detached/ 
 Pagea ddtachias 
 
 Showthrough/ 
 Transparence 
 
 Quality of prir 
 
 Qualiti inigala de I'impression 
 
 Includes supplementary matarii 
 Comprend du material supplimantaire 
 
 Only edition available/ 
 Seule MItion disponible 
 
 rri Pagea discoloured, stained or foxed/ 
 
 I I Pages detached/ 
 
 I I Showthrough/ 
 
 I I Quality of print varies/ 
 
 r~n Includes supplementary material/ 
 
 I — I Only edition available/ 
 
 Pagea wholly or partially obscured by errata 
 slips, tissues, etc., have been refilmed to 
 ensure the best possible image/ 
 Les pages totalament ol partiellement 
 obscurcies par un fauillet d'arrata, une pelura, 
 etc., ont iti film6es d nouveau de fapon A 
 obtanir la meilleure image possible. 
 
 This item is filmed at the reduction ratio checked below/ 
 
 Ce document est filmA au taux de reduction indiquA ci-dessous. 
 
 10X 
 
 
 
 
 14X 
 
 
 
 
 18X 
 
 
 
 
 22X 
 
 
 
 
 26X 
 
 
 
 
 30X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 y 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 12X 
 
 
 
 
 16X 
 
 
 
 
 20X 
 
 
 
 
 24X 
 
 
 
 
 28X 
 
 
 
 
 32X 
 
 
Is 
 
 u 
 
 ifier 
 
 ne 
 
 ige 
 
 ata 
 
 ilure. 
 
 3 
 
 2X 
 
 Th« copy filmad h«r« haa b««n raproducad thanks 
 to tho gonarosity of: 
 
 MMiical Library 
 McQill University 
 IMontreal 
 
 Tha Imagaa appaaring hara ara tha baat quality 
 poaaibia considaring tha condition and lagibiiity 
 of tha original copy and In kaaping with tha 
 filming contract spacificationa. 
 
 Original copiaa In printad papar covars ara filmad 
 baginning with tha front covar and anding on 
 tha laat paga with a printad or illuatratad impraa- 
 sion. or tha back covar whan appropriata. Ail 
 othar original copiaa ara filmad baginning on tha 
 f irat paga with a printad or illuatratad impraa- 
 aion, and anding on tha laat paga with « printad 
 or illuatratad impraaaion. 
 
 Tha laat racordad frama on aach microficha 
 shall contain tha symbol — »> (moaning "CON- 
 TINUED"), or tha symbol V <maaning "END"), 
 whichavar applias. 
 
 Mapa. plataa, charts, ate, may ba filmad at 
 diffarant raduction ratioa. Thoaa too larga to ba 
 antiraly inciudad in ona axpoaura ara filmad 
 baginning in tha uppar laft hand cornar, laft to 
 right and top to bottom, aa many framaa aa 
 raquirad. Tha following diagrama illuatrata tha 
 mathod: 
 
 1 
 
 2 
 
 3 
 
 L'axamplaira film* fut raproduit griea i la 
 gAniroaitt da: 
 
 Medical Library 
 McG'll University 
 Montreal 
 
 Laa imagaa suh/antaa ont 4tA rafsroduitaa avac la 
 plua grand soin, compta tan^ da la condition at 
 da la nattati da Taxampialra film*, at an 
 conformiti avdc laa conditiona du contrat da 
 filmaga. 
 
 Laa axamplairaa orig ;aux dont la couvartura 90 
 papiar aat imprimte sont filmte an commandant 
 par la pramiar plat at w tarminant soit par la 
 darnlAra paga qui comporta una amprainta 
 d'impraaaion ou d'illuatration, soit par la sacond 
 plat, salon la cas. Tous laa autraa axamplairaa 
 originaux sont filmis an commandant par la 
 pramiAra paga qui comporta una amprainta 
 d'impraaaion ou d'illuatration at an tarminant par 
 la darnlAra pagM qui comporta una talla 
 amprainta. 
 
 Un daa symbolaa suivants apparaftra sur la 
 darnlAra imaga da chaqua microficha, salon la 
 caa: la symbols -^ signifia "A SUiVRE ", la 
 symbols ▼ signifia "FIN". 
 
 Laa cartaa, planchas, tablaaux, ate, pauvant Atra 
 filmia d daa taux da rMuction diffirants. 
 Lorsqua la documant aat trop grand pour Atra 
 raproduit an un saui clichA. II aat filir.^ A .oartir 
 da I'angla supAriaur gaucha, da gaucha Jk droita, 
 at ffa haut an baa, an pranant la nombra 
 d'Imagas nAcaasaira. Laa diagrammas suivants 
 illustrant la mAthoda. 
 
 1 
 
 2 
 
 3 
 
 4 
 
 5 
 
 6 
 
'ka-f- 
 
 6iJ- 
 
 (X/y\AA-. 
 
 % 
 
 Reprinted from the Jilontrml Medical Journal, August, 1896. 
 
 NOTES UPON A CASE OF MULTIPLE ABSCESSES OF THE 
 
 LIVER, ASSOCIATED WITH PURULENT BRONCHITIS 
 
 AND INTERSTITIAL PNEUMONIA ; ABSCESSES 
 
 IN THE SPLEEN AND PANCREAS. 
 
 BY 
 
 J. G. Adami, M.A., M.D., 
 Professor of Pathology, McGill University ; PatholoKist to the Royal Victoria 
 
 Hospital, Montreal. 
 
 The case about to be recorded is in the main of interest because of 
 the relationship lietween the morbid conditions n(jted in the title of 
 this article. For the clinical report I am indebted to Dr. W. G. 
 Reilly, Resident Physician to Di". Stewart at the Royal Victoria Hos- 
 pital. 
 
 The patient, a man aged 88, had been a labourer and exposed to all 
 sorts of weather. He gave an alcoholic history. Six years ago he 
 suffered from a left-^ided pneumonia aud pleurisy. From this attack 
 he never completely recovered ; he managed to perform his daily 
 duties, although unable to do heavy work, and he was trouljled with 
 a coup-h. Two years ago he practically gave up work altogether, but 
 kept up and about, although his condition was steadily becoming 
 worse. In November last he took to bed, the cough had been very 
 troublesome and the expectoration profuse, while there was pi'ogres- 
 sive weakness and loss of flesh. In the last few months the patient 
 had repeated chills, followed by sweats, especially at night. 
 
 Upon admission to the hospital (March 10th, 1896,) the patient was 
 emaciated and haggard, sleeping poorly on account of the cough, with 
 difficult respiration and a horrible fetor of the breath. There was 
 well marked clubbing of the fingers. He complained of no pain. The 
 left side of the chest was found much flattened, witli very little move- 
 ment, and there was a dull note upon percussion. On the right side the 
 breath sounds were harsh, but otherwise normal ; on the left side the 
 breathing was feebler than normal at the apex, blowing in the axilla, 
 while all kinds of moist rales accompanied respiration. The sputum 
 was profuse, purulent and fetid, containing no recognisaljle tubercle 
 bacilli. The odor of the breath was so foul that prolongued exami- 
 nation of the patient was a severe task ; even when he v^as placed in 
 an isolation wai'd the odour from him spread over a wide neighbour- 
 hood. Nothing very definite was discovered in connection with the 
 digestive system ; examination of the abdomen gave negative results ; 
 the bowels were regular. 
 
There was progressive failure until death ensued upon the ninth 
 day after admission ; the temperature had continued febrile with 
 slight remissions, the respirations remained about 34, the pulse varied 
 between 112 and 130. 
 
 At the autopsy performed. 28 hours after death, the body was found 
 to be that of a verj' gaunt, emaciated male adult. The fingers were 
 clubbed ; the left side of the chest was flattened above the 4th rib. 
 The riyJd iivvfj was firmly adherent along the line of the 3rd and 4th 
 ribs, but the apex was free. The upper lobe presented multiple 
 lobular abscesses, with gangrene. The middle lobe was less involved, 
 the lower lobe was crepitant, congested, but free from foci of pus so 
 far as could be seen by the naked eye ; there was some bronchiectasis, 
 and foul grey fluid poured out of the cut bronchi. Weight of lung 
 880 grammes. 
 
 The left Lung was much heavier (weighing 1345 grms,) with exten- 
 sive and firm adhe.sions from the fifth rib upwards all along the pos- 
 terior aspect, up to and including the apex. The upper lobe was 
 greatly disorganized, with humerous cavities and areas of breaking 
 down. Close to the apex, in fact right above it, was a fairly large 
 smooth-walled cavity which was evidently extra pulmonary, its walls 
 being formed by the pleura, both visceral and parietal, with the 
 adhesions between the two ; this communicated with the underlying 
 intrapulmonary cavities. The heart presented little worthy of note, 
 beyond brown atrophy. The right bronchus, near its origin, presented 
 a well marked linear ulceration eroding to the cartilage, the peri- 
 bronchial and perioesoaphageal glands were greatly enlarged, dark and 
 moderately firm ; there was no sign of caseation or other evidence of 
 tuberculosis in them. Upon opening the abdomen there was evidence 
 of old general adhesive peritonitis, with a displacement of the colon, 
 stomach and liver. Between the spleen and the stomach there was 
 necrotic tissue with abscess formation and adhesions. On separating 
 these adhesions while removing the spleen, pus exuded from this area, 
 and there was further seen a small perforation of the size of a quill, in 
 the stomach, around which were some moderately firm adhesions, 
 preventing the escape of the gastric contents. Another area of per- 
 foration, about 3 cm. in diameter, was present where the spleen 
 impinged upon the diaphragm. This extended into the substance of 
 the spleen, and superficially into the diaphragm, but not through it. 
 The spleen was soft and flabby, its upper extremity presented a large 
 subcapsular abscess, the size of a walnut, and from this there were a 
 few branching tracts of suppuration, leading a few centimetres into the 
 spleen tissue. Thus smaller foci of pus were ranged about the main 
 
abscess. Tills subcapsular abscess communicated with the suppurating 
 area between the spleen and diaphragm, and the arrangement of the 
 various parts was such that evidently the abscess had started within 
 the spleen substance, and secondarily had burst through or extended 
 through the capsule, the atfection of the diaphragm being rehitively 
 recent. The spleen gave the amyloid rejiction (sago spleen). The 
 pancreas was large, somewhat reddened and contained within its sub- 
 stance a large abscess, 1.5 cm. in diameter, situated near to the tail of 
 the organ and clo.se to the splenic vessels ; a .soft clot existed in the 
 splenic vein alongside of which was situated the abscess. The liver 
 was large, weighing 2340 grm., the upper aspect of the right lobe 
 presented two slight fluctuating nodules situated towards the left side 
 of the lobe. A similar but larger bulging mass was present at the 
 lower extremity of the enlarged right lobe. From the lower a.spect 
 of the lobus spigelii was a similar discoloured patch with fluctuation 
 On section the organ in tl lain was modei-ately pale, and presented 
 very numerous large and .^mall abscesses filled with glairy pus, in 
 some the colour was grayish, in others bright yellowish -green. The 
 largest mass of these abscesses was an aggregation beneath the upper 
 surface of the right lobe, forming in some parts cavities the size of a 
 walnut ; in others, characteristic aggregations of smaller cavities, 
 surrounded by very deeply congested liver tissue, and having an oval 
 outline. On further dissection, many of these larger cavities could be 
 seen to be arranged along definite tracts and in close proximity to the 
 bile ducts. 
 
 Fresh preparations of the pus showed only a moderate number of 
 pus cells present, with fat globules and crystals A large number of 
 various kinds of cocci and bacilli were present. The other organs of 
 the body presented little calling for remark ; the portal vein was free ; 
 the kidneys showed a condition of parenchymatous nephritis, with 
 but slight amyloid reaction in the cortex. 
 
 A microscopical examination of the various organs showed that 
 the lungs were the seat of well marked interstitial pneumonia, with 
 numerous foci of necrosis. There was no sign of tuberculosis in any 
 of the numerous portions exauiined ; the spleen presented a very 
 advanced condition of amyloid change. Sections through the pancreas 
 in the neighbourhood of the abscess showed a very interesting c<jndi- 
 tion. There was a lateral thrombus in the splenic vein of a suppura- 
 tive nature ; while the wall of the vessel immediately beneath this 
 showed extensive infiltration, with small round c^Us. Whether this 
 thrombosis is sufficient to explain the production ot an abscess in the 
 pancreas immediately outside the vessel, or not, I feel a little hesita- 
 
4 
 
 tion in statinj,^ positively. Such is possible, but I should have 
 expected to have found the thrombus prfsenting a more extreme 
 pyflemic condition than was noticeable in this case. The pancreatic 
 tissue itself, lu^yond showinjr a richly nucleated condition of the 
 alveoli, presented two or three foci of adenomatous change — suuill and 
 limited areas presenting the appearance of a medullary carcinoma, 
 with singularly small amount of interstitial stroma. I speak of these 
 as being adenomatous, inasmuch as I have met with somewhat similar 
 little foci in other cases in which, as in this, there has been no evi- 
 dence of malignant disease in other organs. 
 
 The liver showed in parts great congestion of the capillaries with 
 atrophy of the cells and further evidences of retention of bile pigment. 
 Scattered through the substance were moderately small abscesses, 
 whose centres showed comphite necrosis of the cell elementa ; while 
 at the periphery of each was a thick zone of small cells with frag- 
 menting nuclei. The paucity of cells in the pus from these abscesses, 
 to which reference has already been made, was evidently due, not tc 
 the fact that there had L^en little migration of leucocytes, but to the 
 ensuing necrosis. 
 
 Remarks. — It would appear that all the conditions here described 
 are closely connected, and that we have in this case a chain of condi- 
 tions following one after the other from a condition of delayed resolu- 
 tion with acute lobar pneumonia. The condition of the lungs, instead 
 of being as suspected, one of tuberculosis (although it must be acknow- 
 ledged that the failure to discover the tubercle bacilli had rendered 
 this a doubtful diagnosis) was one of interstitial pneumonia and 
 bronchiectasis, passing on to f(t>tid bronchitis, gangrene and gangrenous 
 cavitation. Sections of the lung tissue showed no evidences of 
 tubercles. Following upon the destruction of the lung tissue there 
 had finally been developed not ordy the amyloid degeneration of 
 spleen and kidney, due to the chronic purulent bronchial discharge, 
 butr also a condition of general sepsis, with, it would appear, septic 
 embolism in the spleen and development of the splenic abscess which 
 eventually extended so as to become subdiaphragmatic also ; from 
 this abscess the suppui'ative micro-organisms found their way along 
 the splenic vessels, setting up, it may be by the lymph channels, 
 abscess formation in the tail of the pancreas, and by the vein leading 
 to septic embolism in numerous branches of the portal vein. It is 
 difficult to state, indeed impossible to state positively, what was the 
 organism associated with these abscesses, the autopsy having been 
 performed too long after death. Not improbably the pyogenic cocci 
 were the cause