Compliments of the Author SUBPHRENIC ABSCESS BY CARL BECK, M.D. Professor of Surgery, New York School of Clinical Medicine; Visiting Sur- geon, St. Mark’s Hospital, German Poliklinik, West Side German Dispensary, Etc. . Reprint from the Medical Record, February ij, 1896 NEW YORK THE PUBLISHERS’ PRINTING COMPANY 132, 134, 136 West Fourteenth Street 1896 SUBPHRENIC ABSCESS.1 By CARL BECK, M.D., PROFESSOR OF SURGERY, NEW YORK SCHOOL OF CLINICAL MEDICINE ; VISIT- ING SURGEON, ST. MARK’S HOSPITAL, GERMAN POLIKLINIK, WEST SIDE GERMAN DISPENSARY, ETC. But few years have elapsed since subphrenic abscess was granted a place in medical literature. It is there- fore not surprising that even the most modern and complete text-books lack a description of this impor- tant condition. So far as my knowledge goes, R. F. Weir,2 S. J. Meltzer,3 A. L. Mason, and Osier are the only ones in this country besides me who have published cases. Notwithstanding surgery owes most of its recent de- velopment to advances of the natural sciences, espe- cially bacteriology, yet here surgery has been the donor by disclosing to pathology as well as to internal med- icine the mysteries of this disease. It was reserved to the genius of a Richard von Volkmann 4 to show, as early as 1879, that abscesses situated below the diaphragm can be reached and cured by the knife. His bold yet successful procedure of opening the pleural cavity and incising the dia- phragm called the interest of the whole medical world to this new subject. In the following year Leyden 6 published his views upon this condition from the standpoint of general medicine, and to him is due the credit of having 1 Read at the stated meeting of the New York Academy of Medicine, February 6th, 1896. 2 Medical Record, February 13, 1892. 3 Internationale klinische Rundschau, 1893, Nos. 29, 31, 34. 4 Verhandlungen der Deutschen Gesellschaft fur Chirurg'e, Bd. 8, 1879, p. 19. 6 Zeitschrift fur klinische Medicin, Bd. 1, p. 320. 2 offered the first clear and simple methods for its diagnosis. How much the knowledge of this subject has increased is evident from the fact that, while from 1879 to *890 only twenty-eight operations were per- formed for subphrenic abscesses, the period from 1890 to 1893 shows thirty-two cases. The record has since risen to one hundred and seventy-nine cases, seventy- five of which were operated upon.1 Notwithstanding the long array of cases, there are many points con- cerning the origin of subphrenic abscess that still remain obscure. This is the more to be deplored in that here, as in many other suppurative processes, early diagnosis is essential to successful surgical treatment. Even the most thorough observers some- times meet with great difficulties in diagnosis, diffi- culties which can be overcome only by clearing up the manifold etiological factors. A noteworthy effort in this direction was recently made by K. Maydl,3 who classified subphrenic ab- scesses into twelve groups, according to their anatom- ical point of origin. At the same time the primary disease causing the abscess was considered, whenever possible. Since diagnosis and prognosis, as well as therapy, are naturally dependent upon the seat of the primary affection, anatomy has served also as the basis for my own deductions. It is fitting, therefore, be- fore going further, to consider the topography and pathological anatomy of the disease as the foundation for diagnosis, prognosis, and therapy. Topography.—The subphrenic space, in which sub- phrenic abscess forms, is bounded by the epigastrium and the two hypochondria. The right hypochondrium contains the right lobe of the liver, the sharp lower margin of which is overlapped by the gall bladder in the region of the cartilages of the ninth and tenth ribs. Below the liver is the right half of the transverse 1 W. Sachs, Centralblatt ftir Chirurgie, May 25, 1895. * “ Ueber subphrenische Abscesse,” Wien, 1894. 3 colon. The right suprarenal capsule and the upper margin of the right kidney, which always leaves a Fig. i.—Vertical Section through the Human Body, one inch to the right of the External Margin of the Jfu|yWRectus Abdominis. slight impression upon the liver, occupy the most de- pendent part of the right hypochondrium. The left hypochondrium containing the fundus ven- 4 triculi, covered by the larger portion of the left lobe of the liver. A little further below lies the spleen, con- nected with the curvature of the stomach by the liga- mentum gastro-lienale and the vasa breviora. In front of the spleen lies the left part of the transverse colon. That part of the epigastrium adjacent to the anterior abdominal wall contains a part of the left lobe of the liver, separated from the wall of the abdomen by the suspensory ligament. The pylorus and a portion of the duodenum are below the liver. About on a level with the lower margin of the nip- ple (lower margin of ninth to eleventh dorsal vertebrae posteriorly), the diaphragm forms a figure-of-eight, whose knot is situated between the oesophagus and the pericardium. The peritoneal coat of these organs is incomplete at three portions: i, at the suspensory lig- ament of the liver; 2, where the lobus Spigelii touches the minor omental bursa, at the lower surface of the liver; and 3, at the portion situated between the end of the bursa omenti and the posterior end of the peri- toneal cavity, which adapts itself to the liver from in front. Fig. 1 shows the upper half of the anterior surface of the left kidney covered by peritoneum, while the lower half is not covered by serosa, and is separated behind the stomach from the great omental bursa by the suprarenal capsule and the pancreas. The ante- rior surface of the stomach has a serous coat which faces the great peritoneal cavity, while its posterior serous'coat forms the anterior wall of the great omen- tal bursa. The posterior portion of the same covers the anterior surface of the pancreas and the end of the duodenum. The serous coat of the stomach running downward covers the transverse colon. The upper portion of the transverse mesocolon passes over to the pancreas, thereby forming the posterior wall of the great omental bursa, while the lower portion passes over into the mesentery of the small intestine. 5 These anatomical facts show that, with the exception of the cardiac region and the junction of the great and Fig. 2.—Vertical Section through the Right Rectus Abdominis. small omental bursa, the stomach does not anywhere 6 adapt itself directly to the subphrenium, but touches it with a serous coat which comes from another organ. Consequently the stomach may be the medium of in- traperitoneal as well as of extraperitoneal subphrenic abscess. Extraperitoneal abscess could also originate from the left lobe of the liver, if it perforate alongside the triangular ligament into the subphrenic space. On the right side (see Fig. 2), the whole diaphrag- matic cavity is filled by the right lobe of the liver. Posteriorly the right kidney slightly indents the liver, touching the diaphragm with the upper half of its pos- terior surface and the psoas muscle with the lower half. The liver is covered with peritoneum from its lower margin up to the hilus. The posterior surface of its convexity, as well as its posterior margin and the posterior half of its lower surface, are not covered with peritoneum toward the median line, but have a peritoneal coat laterally. Only the upper surface adapts itself to the diaphragm directly. In front of the lower surface of the kidney is the duodenum, partly covered by the serosa of the small omental bursa. In front of it is the pyloric portion of the stomach, whose anterior surface is coated with the serosa of the lower anterior surface of the liver. The transverse colon is often found in front of the pylorus, while neither the transverse nor the ascending colon has ever been found between the convexity of the liver and the anterior abdominal wall, as the external convex- ity of the liver always lies close to the abdominal wall. The peritoneal coat of the liver sometimes embraces the gall bladder completely, forming a mesentery for it, from which it hangs; sometimes it merely passes over its under surface and binds it closely to the undersur- face of the liver. The pancreas is separated from the posterior surface of the stomach by the great and small omental bursae, and lies very close to the diaphragm. Pathological Anatomy. — Subphrenic abscesses 7 (synonyms: hypophrenic abscess, subdiaphragmatic abscess, subphrenic empyema, empyema hypophre- nicum, pyopneumothorax subphrenicus, perigastric abscess, perigastritis, false pneumothorax, localized tympanites, suppurative perihepatitis, suprahepatic abscess, pneumoperforative peritonitis, subperitonitis) are divided into intraperitoneal and extraperitoneal. In the first variety the abscess lies wholly within the peritoneal cavity. In the second variety the ab- scess wall may or may not be formed in part by peri- toneum, but in any case only by its external surface. An important differential point in these conditions is, that, since an extraperitoneal abscess never detaches the peritoneal serosa of the diaphragm from it, it is perforce confined within narrow limits and conse- quently does not fill the subphrenium so completely as does one of the intraperitoneal variety. Another characteristic feature of the extraperitoneal form is that it has a greater tendency to perforate into the thorax, especially into the pleural sac. Intraperitoneal subphrenic abscess asumes an en- tirely different significance according as it is located on the right or the left side of the falciform ligament. This ligament forms the median line between the right and left subphrenium. As the whole right subphrenic space is filled by the liver, the lower wall of an ab- scess situated on the right side is formed by the upper convexity of the liver; while on the left side the stomach, as well as the spleen, the transverse colon, and the left lobe of the liver, may form a wall. Extraperitoneal abscesses are most frequently found on the right side. This is quite natural, since clinical as well as post-mortem observation has very often traced their source to the caecal region. Rarely this form of abscess arises from the kidneys or ribs. Diagnosis Regarding differential diagnosis, three questions most frequently arise, namely: Is the condi- tion one of pyothorax, subphrenic abscess, or sub- 8 phrenic pyopneumothorax? The diagnostic points of these three conditions, as first advanced by Ley- den, almost invariably remain authoritative. In sub- phrenic pyopneumothorax deep percussion above the retracted lung yields resonance. From the third rib downward it is generally full and tympanitic. In- stead of liver dulness on the right thoracic margin, a profound and full sound is present. Below the right costal arch the liver is pushed far into the abdomen, and its lower border is easily recognized by palpation and percussion. Auscultation shows the absence of respiratory mur- mur from the third rib downward. Amphoric breath- ing and metallic tinkling take its place. In auscul- tatory percussion, metallic phenomena are noticed. There is no vocal fremitus on the lower part of the right thorax. The succussion sound can be heard by shaking the patient. If the effusion can be made out by percussion on the lower thoracic portion, it is found to change its seat easily and quickly, whenever the patient is turned. If the effusion is situated on the right side, the heart will be slightly displaced toward the left, and vice versa. It must be remembered, furthermore, that an admix- ture of gas is a characteristic feature of subphrenic pneumothorax. This gas is the product of putrid de- composition, and seems to give the pus a capacity for rapidly eroding the surrounding tissue. An explora- tory puncture reveals ichorous pus of offensive odor. It is superfluous to say that when the admixture of gas is recognized by an exploratory puncture, a most valu- able point for differential diagnosis is obtained. The history is often an important guide as to the location of the abscess. In subphrenic abscess there is often a history of previous abdominal disturbance. On the contrary, there is no history of cough and ex- pectoration. The heart is little, if at all, displaced, and there is no ectasy of the thorax or of the intercos- 9 tal spaces. In the lungs, vesicular breathing is found below the clavicle. Pectoral fremitus is also clearly perceptible. There is a well-marked limit to the re- gion of vesicular breathing, below which the expira- tory murmur is replaced by amphoric sounds. Deep inspiration pushes the boundary line of the region of vesicular breathing much farther down, into areas in which formerly no respiratory murmur could be per- ceived. This would indicate a well-marked separation Fig. 3.—Left-Sided Pyopneumo-thorax. between the lungs and the abscess cavity, the boundary line of the lungs protruding toward the abscess cavity during deep inspiration. It is sometimes impossible to distinguish an en- cysted pleuritic effusion from a subphrenic abscess. The pathognomonic signs of such pleuritic effusions urged by Leyden were, absence of cough and expec- toration, slight displacement of heart, and rapid change of note if the patient is rapidly turned. But, accord- ing to my observations,1 pleuritic effusion, particu- 1 “ Pyothorax and its Treatment,” Medical Record, May 19, 1894. 10 larly pyothorax, sometimes occurs without these symp- toms. In reference to the absence of thoracic ectasy and the inversion of the intercostal spaces as pathognomo- nic of subphrenic pyopneumo-thorax, it must be said that Herrlich holds precisely the opposite view, and claims that ectasy of the lower thoracic sphere is a de- cided characteristic, of the presence of this condition. The motions of the exploratory needle, introduced Fig. 4.—Left-Sided Subphrenic Abscess (containing' gas). into the abscess, were also regarded as pathognomonic by Fuerbringer. But, bearing in mind that in sub- phrenic abscess the function of the diaphragm is greatly impaired, and that, furthermore, the point of the exploratory needle may be fixed by the diaphragm as well as by the abscess membrane, neither the pres- ence nor the absence of the motions can be regarded as determining pathognomonic factors. If the diaphragm, being pushed up high, tightly ad- 11 heres to the thoracic walls, the needle may invade the subphrenic abscess without being fixed by the dia- phragm. Consequently, even if the diaphragm should still be able to make respiratory movements, the nee- dle would not necessarily be moved by them. The value of Litten’s diaphragma-phenomenon is not yet established. Jendrassik asserts his ability to note a well-marked concave undulating curve parallel to the costal margins in the mammary as well as the axillary line during deep inspiration. In one of his cases he based the diagnosis of subphrenic abscess upon this phenomenon. The correctness thereof was demonstrated by subsequent operation. All these points go to show that, aside from the his- tory, there are but few absolutely reliable pathogno- monic data for the diagnosis of subphrenic abscess. Practically, however, it will make little difference to the surgeon whether pyothorax or subphrenic abscess is present, as the essential part of the treatment of either condition is free opening. The main question will always remain as to the presence of an abscess. Whenever suspicion exists, the introduction of the exploratory needle is a matter of course. The same aseptic precautions should be observed as in any other operation. The skin of the patient, as well as the hands of the surgeon, should be rendered clean, and the syringe and needle thoroughly sterile. If the first trial be negative, the needle should be introduced several times into different portions, as the pus cavity may either be of small extent, or may contain a cheesy accumulation, or, finally, may be divided into several minor cavities by adhesions. In the first event the cavity may be missed alto- gether by the exploratory needle, and in the second the needle, being introduced into the solid cheesy mass, can draw no pus. After each negative result, there- fore, a wire should be pushed through the needle (which must not be of too small a calibre). Thus 12 some pus, which had remained adherent to the innei surface of the needle, will become attached to the wire. Occasionally it will be useful to fill the syringe with sterile water after the operation, and force the water through the needle into a Petri dish. In case cheesy masses are present, small particles are some- times drawn into the calibre of the needle which can- not be perceived by the unaided eye; but which, by being mixed with the sterile water, can be recognized under the microscope. In case the microscope does not give sufficient information, resort should be had to cultures of the fluid. Prognosis.—Experience leads me to conclude that the prognosis of subphrenic abscess, except those of malignant origin, such as carcinoma pylori for in- stance, depends almost entirely upon early diagnosis. It has been my good fortune to lose none of the four cases I operated upon. This indubitably is owing to my cases being of a more favorable etiology than those generally found. I am confident that I shall meet with a higher mortality rate as soon as I have oppor- tunity to see more cases. Still I may say that the mortality rate of fifty per cent., as given by Maydl, is much too high. Considering that Scheurlen’s mor- tality rate was 82.5 per cent., while Sachs, in a series of six cases, lost none, it can clearly be seen that the kinds of cases reported differ notably. Furthermore, it must be considered that very few of the cases re- ported in the unfortunate series were operated upon. An approximate judgment can be based only on a large number of well-defined cases. Spontaneous healing of subphrenic abscess is ex- tremely rare, as is that of pyothorax. Perforation may take place into a hollow organ, like the stomach, or a bronchus, or the bladder. Literature shows spon- taneous healing of subphrenic abscess six times in one hundred and four cases. As the mechanism of such natural healing is unknown to us, and therefore cannot 13 be controlled by any medical therapy, it can only be by chance that a cure is thus effected. Since the pathology of appendicitis has been more widely recognized, poulticing and opium have ceased to be the panaceas. The expectant treatment of sub- phrenic abscess also will be discarded as soon as the condition has been more closely studied. I have already said that the important point in prognosis is the source of the abscess. Microscopical and bacteriological examination of the aspirated pus gave no prognostic aid in my cases. But it may fairly be assumed that with greater in- terest in this disease and the higher development of our examining methods, more valuable information on these points will be obtained. It is to be regretted that, according to the reports of reliable investigators, most of the pus-culture experiments made so far were negative. Probably the microbes are dead, since even the pus taken from the subphrenic abscess of tubercu- lous patients has repeatedly failed to produce reaction when injected into rabbits. Thus far the pus of these abscesses has been found to contain the staphylococcus pyogenes aureus, strepto- coccus, bacillus coli communis, bacillus pyogenes foe- tidus (Passet), micrococcus tetragonus, various species of proteus (Hauser), saccharoinyces, and diplococcus citreus conglomeratus. As the analogy with pyothorax is obvious, it may be remembered that the pus of that condition show's streptococcus, bacillus tubercu- losis, typhus bacillus, staphylococcus aureus and al- bus, and diplococcus lanceolatus (Fraenkel). In 109 cases of pyothorax Netter found streptococcus 50 times, pneumococcus 32 times, saprogenous micro- organisms 15 times, Koch’s bacillus 12 times. The presence of pneumococcus in subphrenic abscess would suggest a pulmonic origin. We know that the presence of streptococcus in pyothorax seems to favor the formation of solid masses in the effusion, and, 14 furthermore, that this coccus has a predilection for the infectious, diseases of adults, whereas Fraenkel’s coccus shows the most benign character of all microbes found in pyothorax. Whether this is accidental or not, and how much the analogy can be utilized for the prognosis of subphrenic abscess, the future must show. Undoubtedly the prognosis is also influenced by the extent of the accumulation, the consistency, appear- ance and odor of the pus, the age and the constitution of the patient, the pulse, the temperature, and, perhaps the most important of all, the stage of the disease. Early operative interference will certainly reduce the percentage of mortality considerably. If the percent- age of successful operations, as reported in literature, is still far from being satisfactory, it can be due only to disregard for this principle and to the fact that the unsuccessful cases are the result of a defect in diag- nosis quite as much as in operative procedure. In all these cases the autopsy showed the pres- ence of another abscess, so that the essential condi- tion for success, a thorough evacuation, was not ful- filled. In six cases, besides subphrenic abscess, pyo- thorax was present. In nine cases abscesses were present in adjacent organs, i.e., in the spleen, liver, kidney, etc. In four cases the additional disease was suppurative peritonitis. In ten cases there was pneu- monia, in addition to pyaemia, tuberculosis, actinomy- cosis of vertebrae, etc. In several cases an incision was made, but the abscess was not detected during life. Varieties classified according to source.—By far the greater number of subphrenic abscesses are the re- sult of pathological processes in the stomach. There may be direct perforation into the subphrenium, due to an ulcer or a neoplasm, or infection may occur through the lymphatics which drain that part of the stomach involved in the pathological process. Most of the cases reported, however, point to simple ulcera- tive processes as etiological factors. The intestine is nowhere attached to the diaphragm. Consequently other conditions prevail here than in those organs which are in direct contact with the dia- phragm. The experiments of Saenger very clearly illus- trate the manner in w'hich a subphrenic abscess may arise from the intestine. This author noticed that when he injected a solution of Berlin blue into the re- trocaecal tissue, only a trifling amount of the colored solution could be driven around the caecum and along- side the linea innominata down to the inguinal canal. But the liquid column rose behind the ascending co- lon, formed a considerable fluid collection around the right kidney, and, passing the inferior horizontal por- tion of the duodenum, reached the dull margin of the liver and the diaphragm. Little fluid reached the transverse mesocolon, and none at all the mesentery of the small intestine. From this experiment the rule may be deduced that subphrenic abscess is more apt to arise from perforation of the caecum, ascending colon, or duodenum, than of the small intestine or transverse colon. The experience gained from autopsies is in en- tire accord with this theoretical assumption, as in thir- teen intestinal cases, reported by Maydl, perforation of the duodenum wras found eight times; of the colon, four times; while perforation of the ileum was found only once, and that, too, near the colon. It is of interest to notice that the etiological factor of these perforations of the gut, with the exception of one case which was caused by a foreign body, were all ulcerative processes. Traumatism could never be made out as a primary source. The ulcers of typhoid fever, since their favor- ite seat is the small intestine, cannot, according to Saenger’s experiments, enter into the formation of subphrenic abscesses. Autopsies have shown that ap- pendicitis causes subphrenic abscess by perforation from the appendix into the retroperitoneal space, the resulting abscess extending up behind the kidney and liver to the subphrenium. From the anatomical situ- 16 ation of the appendix, such abscesses are generally found on the right side, but in a few cases they passed from behind the right kidney, over the vertebrae, to the left kidney. The great advance in the therapy of appendicitis, however, leads us to hope that the future will give us very little opportunity to study its sequelae on the au- topsy table. We seldom see a case of echinococcus in this coun- try, but in Germany, Austria, France, and England, where it is more common, it sometimes figures as a cause of subphrenic abscess. Of the subphrenic ab- scesses due to this cause, seventeen were operated upon, with the result of seven deaths. No case re- covered after perforation of the abscess into the pleura, except those treated by operative means. The starting-point is generally an echinococcus cyst, formed in the cellular tissue between the dia- phragm and the liver. Such a cyst may, however, be developed between the diaphragm and the left kidney or the spleen, since both these organs are occasionally the seat of the parasite, and are both in contact with the diaphragm. Simon-Brown, Mosler, and Fiaux have reported abscesses from this source. In what manner subcutaneous traumatisms give rise to the formation of subphrenic abscess is not always manifest. The explanation may be that trauma origi- nally causes a simple extravasation, into which pus- producing organisms emigrate from the neighboring intestine. These microbes are usually abundant in the gut and are found in tissues whose vitality has been lowered by trauma, a most favorable soil for their fur- ther development. It is also conceivable that trauma producing a capil- lary separation in the continuity of kidney, pancreas, or liver, causes oozing of the secretions of these or- gans, which may then irritate and infect the adjacent tissue. Or a more extensive rupture of one of these organs may cause the formation of an abscess with- in it, which later on might burst into the subphrenic space. Sometimes trauma may be produced by an appar- ently insignificant amount of force. Simply lifting a heavy weight, for instance, is reported to have done it. Literature has seventeen cases with this etiology, six of them recovering after operation and two spon- taneously. The gall bladder and the intra- and extra-hepatic bile ducts naturally offer marked opportunities for the formation of subphrenic abscess. Bearing in mind that the anterior surface of the gall bladder adapts it- self to the right inferior insertions of the diaphragm, it seems easy for inflammation of this organ to extend by means of the lymphatics, or by ulcerative perfora- tion to the lower surface of the diaphragm. It may be that a stagnation in the flow of bile favors infection of the gall passages from the intestine. Retention cysts containing bile may originate in the liver itself as well as on its surface, and may burst and discharge into the subphrenium. Thus subphrenic abscess may arise from purulent cholecystitis terminating in ulcera- tion and perforation, or from cholangiectasia due to obliteration of a large gall duct, or from cholangioitis terminating in purulent hepatitis, or from purulent in- flammation of the ductus communis choledochus itself, followed by rupture. There are reports of sixteen cases of cholangioitic origin (mine excepted). Of these, fourteen were not recognized until the autopsy, while two were operated upon successfully. In several of the cases gall stones were found. In all of them, naturally, the subphrenic abscess was located on the right side. Every one of the patients had complained of well-defined acute pain in the right hypochondrium. The anatomical situation of the kidneys gives them an important relation to the formation of sub- 18 phrenic abscess. According to Hyrtl’s anatomy and to Maydl (Figs, i and 2), the kidneys are situated in the lumbar region of the abdominal cavity, and are cov- ered in front by peritoneum. The right kidney lies in contact with the ascending, the left one with the de- scending, colon. They are bounded behind by the lumbar portion of the diaphragm, and above by the suprarenal capsules. The left kidney extends a little higher into the pleural domain, so to speak, than the right, so that in perforation from the renal sphere into the pleura, the left side is more frequently concerned than the right. The most frequent cause of perinephritic abscess is a primary perinephritis, arising from a contusion in the renal region or from one of the infectious diseases. Another cause may be pyelonephritis calculosa, sup- purativa, or tuberculosa. Repeated exposure to cold can scarcely be considered an etiological element. Since suppurative pyelonephritis is most often the outcome of disease of the uropoietic apparatus, viz., prostatis, stone, carcinoma of the bladder, etc., it will be wise to reflect upon the possibility of the formation of a subphrenic abscess in all such conditions. The lower border of perinephritic subphrenic ab- scess is generally formed by the ascending or descend- ing colon, sometimes by the duodenum. In reference to diagnosis, it is maintained that if the abscess occupies the whole anterior or posterior surface of the kidney, there is generally tenderness or pain, swelling and oedema on the anterior surface of the abdomen. My own experience, however, does not accord with this, as, with the exception of pain, I found no local symptom in one of my own cases (Case II.) even seven weeks after the onset of the disease. If the abscess has formed on the upper surface of the kidneys, pleuritic symptoms, combined with oedema of both legs, jaundice, ascites, and vomiting may be observed. Of eleven such cases reported in literature, only one was saved, the unfavorable course probably being due to delayed diagnosis. Perhaps, too, the kidney is so much affected in this condition that nephrectomy should be added to the operation for evacuation of the abscess. Subphrenic abscess originating in the ribs (from a tuberculous focus, as a rule) is of rare occurrence. If situated on the right side it may easily be confounded with cholangioitic subphrenic abscess. In the cases reported in literature, the tuberculous process was local- ized, and there was consequently quick recovery. The great tendency of subphrenic abscess to perfo- rate into the thoracic cavity has been alluded to be- fore. On the other hand, there are subphrenic ab- scesses of true thoracic origin. The most frequent purulent affections of the thoracic cavity are pyothorax and abscess of the lung. Suppurative pericarditis is rare. A circumscribed pyothorax may perforate di- rectly, while abscess of the lung will first produce an inflammatory adhesion of the adjacent visceral and dia- phragmatic pleurae. Free pyothorax has a tendency to perforate the middle of the diaphragm. Of nine cases reported in literature, one case re- covered spontaneously by perforating into the gut; one after surgical operation; three died with, four without, surgical interference. Metastasis is another important etiological factor, but is, as a rule, observed only in the tropics. It has been found after trauma in connection with pyaemia (septic phlegmon of the forearm and tuberculous coxitis [Godlee]) ; following ulcerative processes in the diges- tive tract (perforation of fishbone into the vena portae); and associated with fistula ani and gangrene of the appendix. Abscess of the spleen, perforating into the portal branches, as well as suppurative processes in the mesentery and mesenteric glands, may cause ab- scess of the liver. Malaria, enteritis, and dysentery may do the same. In tropical dysentery Koch 1 could always prove the presence of amoebae in portions of the intestine, and regarded them as the etiological factor. Abscesses of the liver were also demonstrated by von Bergmann. Other authors claim that such amoebae are not the cause of the abscess, but only the characteristic admixture of the secretion transported from the seat of ulceration to the liver. An attempt was made to obtain cultures from the pus of thirteen cases of dysenteric abscess of the liver. In eight cases the results were negative. Among the positive results staphylococcus pyogenes aureus was found twice; staphylococcus albus, bacillus pyogenes foetidus and proteus, once each. But in sections and cover-glass preparations amoeba? ware found in every one of twenty-two cases. In ten cases they were mixed with bacilli. Of eleven cases reported in liter- ature, ten died. In one case recovery was obtained by surgical interference. Only two of the fatal cases were operated upon. A wound inflicted directly in the diaphragmatic space may also in rare instances cause subphrenic abscess, somewhat as do the subcutaneous traumata defined above. The wound is generally produced by a bullet. There are in the literature reports of autop- sies in four cases. The liver, kidneys, and thoracic cavity may be involved at the same time. Besides the varieties described above, another group of subphrenic abscesses must be mentioned, whose original sources either are questionable or cannot be discovered. Eleven such cases are reported in litera- ture. In three of them successful operations were performed. One recovered after perforation into a bronchus. The other seven died under expectant treat- ment. In one case actinomycosis of the vertebra was found, while there was pyosalpinx in the case w;hich finally perforated into a bronchus. 20 1 Gaffky, “ Reports on Investigations of Cholera,” 1883. 21 Tn those cases of subphrenic abscess originating in diseases of the female sexual organs, e.g., endometri- tis, pyosalpinx, perimetritic exudations, the route to the subphrenium is through the retroperitoneal space. Course.—As said above, subphrenic abscess may arise from infection carried from an area of suppura- tion by means of the lymphatics. It oftener originates in an abscess of an adjacent organ, which bursts into the subphrenium. The fistulous tract representing its route may then become obliterated, or may remain and gradually grow larger. If perforation of a subphrenic abscess into a lung has taken place, the rusty sputa and their offensive odor, as well as that of the breath, together with the microscopical demonstration of elastic fibres, point to a limited gangrenous process as the initiative factor of the perforation. The cough, which then is always present, generally brings up fetid pus, in which particles of food, such as starch grains or margarin crystals, can be seen by the naked eye or demonstrated by the microscope. This would, of course, point to a gastro-intestinal or cholangioitic source. While in a small number of such cases recovery is obtained by the perforation, the majority of patients succumb either to the shock of the perforation itself, or to a foreign-body pneumonia later on. The symp- toms of perforation into the pleura consist in intense pain, rapidly developing dyspnoea, and collapse; while those of perforation into the peritoneal cavity are identical with the well-known symptoms of the general type of peritoneal perforation. Therapy.—The treatment of subphrenic abscess must be surgical. Before the days of asepsis, the sur- geon very properly hesitated to open the chest or ab- domen, but now such fear need no longer prevent him from procuring timely evacuation. Such evacuation can be thoroughly effected only by wide opening. 22 This can usually be secured by resecting a piece of a rib, as the subphrenic abscess is generally within the extent of the ribs. Very exceptionally, it must be approached below the costal arches or the xiphoid process. I cannot agree with those authors who pronounce it a misfortune for the patient when the abscess is reached by the transpleural route. On the contrary, it seems to me that no other route, except- ing the lumbar, offers so many advantages in after- treatment, as a rule. While for prognostic purposes it is important to know whether the pleurae are adherent or present a cavity filled with serum or pus, so far as surgical pro- cedures are concerned it makes very little difference. The adversaries of the transpleural route maintain that to open the pleural sac, if it be in a normal state, would expose it to the dangers of pneumothorax, as well as to infection from the atmosphere or from the escaping pus. Regarding the first objection, pneumothorax, it must be borne in mind that in subphrenic abscess the aspirating power of the diaphragm is greatly impaired. As is evident by the dulness on percussion, the dia- phragm is pushed so far up toward the thoracic cavity as to be pressed against the thoracic walls to a consid- erable extent, and to have its summit brought into per- manent contact with the costal pleura. It may even have been so overstretched as to be entirely paralyzed. Furthermore, the lower part of the thorax itself is gen- erally expanded, thus diminishing its aspirating power. When pneumothorax does occur after the exposure of the pleural sac, and a feeble patient suffers shock, final incision and evacuation may be deferred until the following day. In reference to atmospheric infection, I may refer to Petri’s and Cleves-Symmer’s experiments, w'hich dem- onstrated bacteriologically what had long appeared probable from clinical observation, viz., that the mi- 23 crobes contained in the atmosphere are non-patho- genic under ordinary circumstances. Furthermore, I do not see why the pleura should be more inclined to become in- fected than other parts of the body, provided thorough aseptic pro- phylaxis has been ob- served. While the incision should be made in the centre of the dull area, the exploratory needle will always indicate its ultimate route. The technique of the opera- tion is practically the same as that of resec- tion of a rib for pyo- thorax. As a rule, the eighth, ninth, or tenth rib is selected. I pref- erably choose the me- dian axillary line, as thence the abscess walls can be reached equally well in front and behind. It also enables the patient to be brought to the edge of the table during the operation, and permits him to assume the dor- sal decubitus; whereas, if the incision were made farther back, he would be obliged to lie on the healthy side. us rendering evacuation more difficult. Fig. 5.—Resection of Rib (rib riding on the elevator). 24 If, however, the dull area, as sometimes occurs in ab- scesses of small extent, is situated distant from the median axillary line, the resection must take place at the point where the aspiratory needle revealed the pus. It goes without saying that thorough aseptic precau- tions must be taken. Particular attention must be given to the skin of the patient and to the hands of the surgeon, scrubbing with green soap for three or four minutes, then washing with alcohol or ether, and subsequently with bichloride (i to 500). To ster- ilize the skin of the patient thoroughly, it is advisable to cover the field of the operation for from ten to twenty hours with a large poultice of green soap, and allow this to remain until shortly before the opera- tion. Should this tend to produce a dermatitis, a bi- chloride fomentation should be substituted. All the paraphernalia needed at the operation must, of course, be sterilized; the instruments, ligatures, etc., in boiling soda-solution, and the towels, sponges, etc., in steam. If no sterilizer be at hand, towels, sponges, etc., can also be sterilized in boiling water. The incision, about four inches in length, should be made directly down to the periosteum of the rib selected. Its direc- tion must, of course, be parallel to the margin of the rib. An incision is then made along both borders of the rib, and the periosteum both in front and behind is raised by means of an elevator. Having freed the periosteum, the elevator is pushed beneath the rib, between it and its posterior perios- teum, and allowed to rest on both edges of the wound (Fig. 5). With a blunt hook the tissues are retracted along the rib toward the axilla, and by means of the bone scissors the rib is then cut beween hook and ele- vator. Next, the elevator is pushed toward the ster- num, forcing the rib from the last fragment of adher- ing periosteum; the retractor is inserted into this end of the wound, and with the scissors the same ma- 25 noeuvre is executed. If my own elevator shears 1 are used, nothing is needed but to tear away the con- nection between the periosteum and the rib and di- vide the rib, the in- strument being of such a shape as to keep the tissues prop- erly retracted. One blade, if separated, can be used as an ele- vator, so that, with nothing else at hand than a knife and these shears, practically the whole operation could be performed. A piece three inches in length, or at least large enough to allow in- troduction of the fin- ger, usually suffices for the purpose of drainage. It is impossible to strike the intercostal artery during these manipulations on account of its anatomical sit- uation, while in performing simple incision this acci- dent has frequently occurred (fatal hemorrhage was reported in Billroth’s clinic). A saturated solution of iodoform in ether is then spread upon the wound surface, to form a protection against the pus. The very thin thoracic fascia and the costal pleura are now incised, and if the pleural sac be found empty the pus cavity is located by means of the exploring needle, and an opening is made through the diaphrag- matic pleura just large enough to permit the introduc- tion of a grooved director. Before this aseptic tam- pons are packed into the pleural sac to occlude it from the escaping pus. This precaution renders oc- Fig. 6.—Thoracic Opening in Subphrenic Abscess. 1 Osier, Centralblatt fUr Bacteriologie, Bd. 7, No. 23. 26 elusion of the pleural cavity by suturing unneces- sary. As soon as pus appears in the groove of the director, a small Pe'an forceps is introduced and the opening gently dilated. Evacuation of the pus should take place slowly (it may consume twenty to thirty minutes). A sponge should be pressed against the opening from time to time to interrupt the stream, so as to avoid too rapid expansion of the lungs. If the condition of the patient permit, the finger is now introduced and any solid masses, such as fibrin- ous lumps or necrosed tissue adhering to the abscess wall, are w iped out with the index finger or with a blunt spoon made for this purpose. For inspection, my dilating speculum 1 can sometimes be used to advan- tage. If hemorrhage should occur or if signs of shock present, such procedures may be deferred for a day or two, as may also irrigation of the cavity with a sterile normal salt solution, which is used to secure thorough evacuation. When malodorous pus is found, an antiseptic wash, preferably bichloride, i to 5,000, is used for this once, instead of the sterile salt solution. The pleura or the edges of the diaphragm are stitched to the skin with four silk sutures (preferably iodoform silk), one at each end of the wound and one on each side, with strong Hagedorn needles. Thus the w'ound surface is entirely covered and the adjacent tissues protected against infection. At the same time secondary hemorrhage is thereby prevented and the wound kept open. Then the cavity, if of small ex- tent, is packed with iodoform gauze. In pyothorax about one ounce of an emulsion of iodoform glycerin (one-half ounce in children) is in- fused into the cavity besides. But if the cavity be very large, a drainage tube, five-eighths to three-fourths of an inch in diameter, is introduced and secured by two large safety pins arranged in the shape of a cross. 1 Beck, “ Modern Theory and Technique of Surgical Asepsis.” Saunders, Phila., 1895, p. 213. 27 (In pyothorax I refrain from introducing it immedi- ately after operation, for I have seen much hemorrhage follow its immediate introduction. No doubt the con- stant motion of respiration produces friction against the drain, which accentuates the irritation already pro- duced by contact of the wound with the air; whereas, after the tissues have in a measure recovered from this shock and granulations have begun to form, /.