A RARE FORM OF 
SDE-DIAPHRAGMATIG 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 Professor J. G. Adami, M.A„ M.D. 
(From the McGill 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 be 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 sth, 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-Chirurgical 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. 3 
very oederaatous, 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 
discovered 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 4 
leading to a sub-diaphragmatic abscess ; extension of the process 
through the diaphragm ; inflammation 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 pus 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.