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Un daa aymboiaa auhranta apparaftra sur la damlAra imaga da chaqua microfieha, salon la caa: la symbola — »• signifia "A SUIVRE", la symbola ▼ signifla "FIN". Mapa, piataa, charta, ate., may ba filmad at diffarant reduction ratioa. Thoaa too large to be sntirely included in one expoaure ara filmed beginning in the upper left hand comer, left to right and top to bottom, aa many framea ae required. The following dlagrama iiluatrate the method: Im oartae, pianchea, tableaux, etc., peuvem Atre fllmAe i dee taux da rMuction diff irants. Lorsqua la document eet trop grand pour Atre reproduit en un seui cliche, 11 est flimA i partir da Tangle supArieur gauche, do geuche A droite, et do haut en baa, an prenent le nombre d'Imagea nAcaasaire. Lee diagrammes sulvants iilustrent la mithoda. 1 2 3 1 2 3 4 5 6 a-T= ^(^natc^^voIa; \\Ii '^?^ ^^y< "% PYOPNEUMOTHORAX SDBPHRENICUS, (LBYDBN.) By WM. GARDNER, M.D., Prof. Medical Jurisprudence and Hygiene, McGill University ; Attending Physician University Dispensary for Diseases of Women, &c. (lie-printed from the '' Canada Medical d- SurgicalJoumtd, Montreal, December, 1880.) CASE Oir- PYOPNEUMOTHORAX SUBPHRENICDS. (LEYDEN.) By WM. GARDNER, M.D. Prof. Medical Jurisprudence and Hygiene, McGill University ; Attending Physician University Dispensary for Diseases of Women, &c. [Read b^ore the Medko-Chirurgical Society of Montreal.] J. S., aet. 28, dark complexion, medium stature, slimly built, delicate-looking, sent for me for intense pain in the right iliac region. He gave a history of delicate general health, defective appetite, habitual constipation, and frequent attacks of pain in the region already referred to, the right iliac, with more than usually troublesome constipation and general malaise. These attacks frequently lasted for four or five days, and confined him to bed, but he was not in the habit of seeking medical advice for them, and this was the first time that I had seen him. The pain was intense, caused him to groan, and was referred princi- pally to the right groin, but radiated upwards and backwards to the right loin and downwards to the scrotum, but there was no retraction of the testicle. There was no tympanites, no tumor, as of fgecal impaction, to be felt ; the bowels had been moved a short time previously, there was no vomiting, and no elevation of temperature. The pain was with difficulty relieved by hypo- dermic use of Battiey's sedative solution of opium. These symptoms within a few hours developed into those of perityph- litis and then of general peritonitis : general abdominal pain and tenderness, marked tympanites and elevation of temperature. The patient was now leeched and had applications of turpentine epithems and poultices to the abdomen, the hypodermic use of opium being continued. Within forty-eight hours from the time when I was first called to him, the symptoms became aggravated to such an extent that Drs. Fenwick and Buller, who saw him in consultation, agreed with me that he could not survive more than ten or twelve hours. The pain and tender- ness had indeed subsid 3d to a large extent, but the pulse was very feeble and rapid, approaching 150 per minute, the eyes sunken, the general surface cold and bathed in a profuse clam- my sweat ; in short, a condition of collapse. After remaining in this condition for twenty-four hours, he gradually rallied, all the general symptoms becoming more favorable, and the pain, gen- eral tenderness of the abdomen and tympanites disappearing. There remained, however, persistent tenderness in the right iliac and lumbar regions. A feeling of fullness, not very marked, developed itself, but at no time was there to be felt anything that could be called a tumor or any fluctuation. The general condition improved correspondingly, the temperature fell, the patient was able to take some food, and the bowels moved spon- taneously. Within a few days a stitch-like pain, with slight cough, developed in the right side of the chest in front, involving the lateral and front parts up to the fourth rib. The was no dullness on percussion, no pleuritic friction sounds to be heard, but weak respiration sounds over the anterior and lateral parts of the right lung. This pain was easily controlled, but recurred several times. The hoped-for convalescence was slow in coming, the temperature occasionally rose, especially towards evening. There was no vomiting, but the tongue was red and smooth in centre, and furred at its edges. Slight diarrhoea was a frequent symptom. The patient remained very weak, being unable either to raise or turn himself in bed, from a lame- ness or general tenderness of the right side of the trunk. Gradually dullness on percussion developed in the base of the right chest, both back and front. Suddenly, about the end of the seventh week of his illness, and two weeks before he died, in the night, with sudden sharp pain in the right side, he began to cough up what was, from the description, probably pus, but was certainly soon replaced by what was shown me, a thin brownish fluid, having all the other characters of thin faeces. This continued to be ejected for some hours at short intervals, actual vomiting being occasionally excited by the ill taste and odor of the matters coughed up. When I saw him next day he was in a condition of semi-collapse, with a very frequent, weak, thready pulse, and cold, clammy sweats. On physical examin- ation of the chest a remarkable change had taken place. The physical signs of air and fluid in the right thorax had developed t!-3mselves, in, however, a somewhat modified form. As the patient lay on his back, percussion of tho right side gave forth from the third interspace downwards to the lower edges of the ribs in front and at the side a clear tympanitic note Above the third interspace the note approached in character the ordi- nary healthy note. At the dependent part of the chest, as he lay on his back, the note was perfectly dull. By turning the patient on his left side, the limit of tympanitic note on percus- sion was altered. All the parts of the right chest now upper- most were tympanitic when percussed, showing the presence of air and a liquid. Nowhere, in any position, could the liver, dullness be discovered ; neither could the liver be felt by palp- ation. On auscultation, weak, amphoric respiration was pres- ent from the third interspace downwards ; on coughing, splashing sounds. Above third interspace the respiratory sounds ap- proached in character the vesicular murmur of health. There was considerably diminished mobility of the right chest wall, which was quite sensitive to the pressure of the stethoscope. A normal condition of the intercostal spaces obtained. During the last fortnight that he lived, the patient coughed up at intervals pus, and the thin, brown, stinking fluid above de- scribed. His general condition varied considerably, but was for the most part one of great debility, with frequent diarrhoea, the physical signs varying only in the character of the respira- tory sound, which was not always amphoric, but occasionally distantly blowing in character. On the morning of the day he died, my friend. Dr. Ross, saw him, and after examination agreed with me in the diagnosis I e liad made, viz., perityphlitic abscess communicating with the bowel, creeping up behind the peritoneum and perforating the diaphragm, and thus gaining access to the cavity of the chest and subsequently perforating the lung. His general condition was then more favorable than it had been on any day since the set- ting up of the pulmonary fistula. The same evening the cough and expectoration, which, indeed, was now rather a gulping up of the thin, foetid fluid, returned, and in this paroxysm he died, exhausted and asphyxiated. Autopsy, fifteen hours after death, performed by Dr. Bichard McDonnell : Emaciation extreme ; a bed sore over the sacrum ; rigor mortis moderately well marked ; chest and abdomen only examined. On opening the abdominal cavity the first thing noticed was the absence of the liver from its natural position. It was pushed upwards, backwards and in- wards towards the spinal column, completely away from the right lateral and anterior chest wall, thus explaining the impossi- bility of either feeling or discovering it by percussion. To the outside and behind the caecum an abscess cavity was discovered, having on its inner wall the appendix vermiformis containing a number of masses of inspissated, quite hard, faecal matter. Two or three openings existed between the caecum and this cavity, one of them being large enough to admit the little finger. This cavity communicated by a narrow neck-like prolongation, extending upwards behind the peritoneum, with a very large cavity, pro- bably as large as a child's head, bounded above by the diaphragm pushed up to the level of the third interspace ; externally and anteriorly by the ribs, as far as their free edges ; below and on the inner side by the right lobe of the liver, whose upper surface and free edge compressed, flattened, and ren- dered quite obtuse, formed part of the wall of the abscess cavity. The contents of this cavity were not pus, but a thin, brown-colored, stinking fluid containing flakes of curd of milk, and gas or air. The stomach was somewhat pushed over to the left. The transverse colon was somewhat displaced downwards. The right lung was much compressed, its lower lobe collapsed a nd closely adherent to the diaphragm ; a series of perforations ♦/