IMAGE EVALUATION TEST TARGET (MT-3) 1.0 1.1 LilM |25 •IS BS u 2.0 I ^^ lla& L25 i U 1111116 7 4V/ Photographic Sciences Corporation # \ iV <^ 4 33 WiST MAIN STREET WEBSTER, N.Y. MStO (716)873-4503 .^^% CIHM/ICMH Microfiche Series. CIHM/ICMH Collection de microfiches. Canadian Institute for Historical Microreproductions / Institut Canadian de microreproductions historiquas V Technical and Bibliographic Notos/Notas tachniquas at bibliographiquaa Tha Instituta hat attamptad to obtain tha baat original copy availabia for filming. Faaturaa of thia copy which may ba bibliographically uniqua, which may altar any of tha imagaa in tha raproduction. or which may significantly changa tha usual method of filming, ara chackad balow. □ Coloured covers/ Couverture de couleur r~n Covers damaged/ D D D D D Couverture endommagAe Covers restored and/or laminated/ Couverture restaurAe at/ou pellicuMe |~~l Cover title missing/ Le titre de couverture manque □ Coloured maps/ Cartas gAographiques 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/or illustrations/ n Planches et/ou illustrations 9n couleur Bound with other material/ RallA avec d'autrea documents Tight binding may cause shadows or distortion along interior margin/ La re liure serrie peut causer de I'ombre ou de la distorsion la long de la marge intftrfeure Blank leaves added during restoration may appear within the text. Whenever possible, these have been omitted from filming/ II se peut que certainas pages blanches ajouttes lors d'une restauration apparaissent dans le texte. mais. lorsque cela Atait possible, ces pagea n'ont pas it6 film^as. AdditionsI comments:/ Commentaires supplimentaires: L'Institut a microfilm^ le meilleur exemplaire qu'il lui a Ati possible de se procurer. Les ditaiis de cet exemplaire qui sont peut-Atre uniques du point de vue bibliographiqua. qui peuvent modifier une image reproduite, ou qui peuvent exigwr une modification dans la mithoda normale de filmage sont indiqute ci-dessous. Tha tott f~~| Coloured pages/ D Pagea da couleur Pages damaged/ Pages endommagias Pages restored and/oi Pages restaurias et/ou pelliculAes Pages discoloured, stained or foxet Pages dicolories. tacheties ou piquies Pages detached/ Pages ditachies Showthrough/ Transparence Quelity of prir Qualiti inigala de I'impression Includes supplementary materii Comprend du material supplimentaire Only edition available/ Seule Mition disponible r~1 Pages damaged/ nn Pages restored and/or laminated/ ^T^ Pages discoloured, stained or foxed/ r~~| Pages detached/ r~^ Showthrough/ r~1 Quelity of print varies/ nn Includes supplementary material/ n~1 Only edition available/ Tha posi ofti filml Grig bagi tha sion othi first sion or 11 The shal TINI whii Mai diff< anti bag righ raqi mat Pages wholly or partially obscured by errata slips, tissues, etc., have been refilmed to ensure the best possible image/ Les pages totalement ou partiellement obscurcies par un feuiliet d'errata, une pelure, etc., out M filmies A nouveau de fapon h obtenir la meilleure image possible. This item is filmed at the reduction ratio checked below/ Ce document est filmi au taux de rMuction indiqu* ci-dessous. 10X 14X UMl 22X 26X 30X / 12X 16X 20X 24X 28X 32X Th« copy filmed h«r« has b««n raproduetd thanks to th« ganaroaity of: Mmlical Library McQill University Montrsal Tha imagaa appaaring hara ara tha baat quality poaaibia eonaidaring tha condition and lagiblllty of tha original copy and in Icaaping with tha filming contract spaeiflcationa. Original coplaa In printad papar covars ara filmad beginning with tha front covar and anding on tha laat paga with a printad or illuatratad impraa- •ion, or tha bacic covar whan appropriate. All othar original coplaa ara filmad beginning on the first page with a printad or illustrated imprea- slon. and anding on ttie laat paga with a printad or illustrated impreaalon. L'axempiaire filmA fut reproduit grice i la g^niroalt* da: MMlicai Library IMcGill Univtrsity IMontrMi Lea Imagaa suh/antae ont 4t* reproduitee avae la piua grand aoin. compta tenu de la condition at da ie nettet* de i'exemplaira fllmA. et en conformity avac lea eondltlona du contrat da fllmage. Lea exemplairee originaux dont la couvarture en pepler eat Imprim4e sont fiimis en eommenqant par la premier plat et en terminant soit par la darni^re pege qui comporte une empreinte d'impreaaion ou d'illuatration, soit par la second plat, aalon ie eaa. Toua lea autres axamplairaa originaux sont fllm4s en commen^ant par la premlAre page qui comporte une empreinte d'impreaaion ou d'illuatration at en terminant par la dernMre page qui comporte une telle empreinte. The laat recorded frame on eech microfiche shell contain tha aymbol — ^ (meening "CON- TINUED"), or the aymbol V (meening "END"), whichever eppliea. Un dee symbolea sulvanta apparattra sur la damMre image de cheque microfiche, selon Ie caa: lo aymbola -^ signlfle "A SUIVRE", Ie symbols ▼ signlfle "FIN". Mapa, plataa, charta, etc., may be filmed at different reduction ratioa. Thoaa too lerge to be entirely included in one expoaure are filmed beginning In the upper left hand comer, left to right and top to bottom, aa many framee aa required. The following diegrama llluatrate the method: Lea cartea, planchaa, tableaux, etc., peuvent *tr« fiimAe i dee taux de reduction diff^rents. Lorsque Ie document est trop grand pour Atra reproduit en un seul clich4, 11 est fiimA A pertir de Tangle aupMaur gauche, de gauche k droite, et de haut en bee, an pranant la nombra d'imagea nAcaaaaira. iLaa diagrammea sulvanta illustrant la mAthoda. 32X 1 2 3 1 2 3 4 5 6 t3 O/V A RARE FORM OF SCBDIAPHRAGMATIO ABSCESS. BY PROFESSOR J. G. ADAMI, M.A., M.D., From the McGill Pathological Laboratory. Reprinted from the Montreal Medical Journal, March, 1894. < '•< A RARE FORM OF SUB-DIAPHRAGMATIC ABSCESS * By Fbofessor J. G. Ada^u, M.A„ M.D. (From the MoGill Pathological Laboratory.) It is not a little noticeable how silent are even the best and most modern text books upon the subject of sub-diaphragmatic abscess, with a silence that is out of proportion to its diagnostic and clinical interest, and it may be added to its relative frequency. Doubtless the fact that the subject cannot be treated under the heading of any one special organ, leads to its being neglected in well-ordered text books, so that infor- mation has still to be gathered from scattered papers. Thus it happens that although I am acquainted with a fair number of cases in which the original disturbance has originated in con- nection with the liver, kidney, spleen or stomach, I have been able to find none presenting the anatomical features of the case here recorded, though such must exist. f The patient, L. F., sixty-five years old, was received into the General Hospital, under Dr. Molson, upon October 3rd, in a state of semi-collapse. All that could be ascertained as to his previ- ous history was that for the past four or five days he had been suffering from pain in the epigastrium, thirst, restlessness and pains in the joints. He died within twenty-four hours, before time had been allowed for a full diagnosis. The pulse was almost imperceptible, there was a large area of cardiac dulness, the heart sounds could scarcely bo heard, while no murmur could be detected. Over the region of the liver in front there was acute pain upon pressure. The respiratory sounds were tubular. A provisional diagnosis was made of pericarditis. At the autopsy performed upon October 5th, the following were the more important conditions observed. The skin of the whole body had a slight yellowish tinge. The pleural cavities contained about eight ounces of clear serum. The lungs were * Read in abstract before the Montreal Medico-Chirurgioal Society, Nov. 3rd> 1893. t Petri, Dissertation, Berlin, 1868, quotes a case of sub-diaphragmatic perforation of the oesophagus following upon cancer, but of the extent of the succeeding in- flammation I cannot clearly learn, not having the original by me. :•■•>« ,,f ^\ 8 very oedematous, showed some slight signs of anthracosis, and in either apex were found evidences of an old and cicatrised tuberculous condition. The pericardial cavity was enormously distended, the fluid was milky with numerous flocculi floating therein. The heart was covered over with a layer of inflam- matory lymph ; and its cavities were filled with well-formed clots, firm and rather pale, together with some fluid blood. The lower and inner half of the parietal pericardium was thickened, and upon cutting into it, down upon the diaphragm an abscess cavity was exposed lying between diaphragm and pericardium. This was of irregular shape and contained a quantity of thick creamy pus. Upon inspecting the abdomen, a large abscess was found beneath the diaphragm, having in its centre the abdominal end of the oesophagus and the cardiac end of the stomach. This extended to the left edge and under the surface of the left lobe of the liver on the one side ; on the other it almost touched the splenic flexure of the colon and the surface of the spleen. It was filled with a thinner greyish pus, and communicated through the diaphragm with the supra- diaphragmatic abscess. The cardiac orifice of the stomach was dii^covered to be greatly stenosed and ulcerated. Further inspection revealed that there was a ring of cancerous growth implicating the gastric mucous membrane, and forming a ring varying in breadth from 2 to 3 cm. around the cardiac orifice ; the growth extended a short distance up the oesophagus. Micro- scopical examination showed the cancer to be primarily gastric — that is to say, it was of the nature of a columnar celled carcinoma. It infiltrated all the coats of the stomach. No actual perforation of the stomach or oesophagus was to be discovered. It would seem evident that the history of the case was one primarily of cancer of the cardiac orifice of the stomach leading to stenosis ; ulceration of the cancer, and extension of the septic process through to the serous surface of the organ — or, it may have been, perforation above the stenosed area by a fish bone or other fine spicule, the passage closing behind the foreign body ; suppuration around the termination of the oesophagus .1 ■ i leading to a sub-diaphragmatio abscess ; extension of the process through the diaphragm ; inOammation of some little standing of the outer layers of the parietal pericardium ; extension through the pericardium ; purulent pericarditis ; death. Judging from the condition of the sub-diaphragmatic abscess, and the want of well-defined boundary, this had of late been extending rapidly. There is a possible alternative that the supra-diaphragmatic abscess with its more creamy pu^ was of the earlier origin, but this I think is improbable. The presence of the gastro- oesophageal carcinoma in- such characteristic relationship to the surrounding sub*diaphragmatic abscess, renders the former the more likely course of events. "f >-'\'S '.-. rU \.ivV •' a ■^ r * c