ï~~U; a VOLUME 72 NUMBER.12. ABDOMINAL COMPLICATIONS-BEALS ET AL. 851 After the first inflammatory reaction, a streptococcus infection:is prone to proceed even to the point of a large amount of purulent exudate with onlya few localizing symptoms or signs. Extensive exudate in the chest cavity is at times found only after the most critical routine examination when there are no signs or symptoms referable to the chest. Similarly a diffuse purulent peritonitis may be present as a part of a generalized infection without attracting especial attention to its presence through the symptoms usually associated with this condition. In five of the six cases of peritonitis that were found at necropsy, a diagnosis of such a complication was not made during life, although these patients were carefully and repeatedly examined with the possibility of abdominal lesions in mind. The peritonitis was not secondary to any demonstrable abdominal focus, but apparently was merely one manifestation of generalized infection, which frequently was- also evident in pleura and pericardium. Suppurative peritonitis was not found in necropsies in the early' filminating cases of 'the'epidemic, 'but appeared as 'a part of the late postpneumonic' complications, five of the six' cases being'foundin the last thirty necropsies. The early occurrence of deaths 'did not afford time for the development of this condition. A similar group of cases was noted during the severe infections in the early part of 1918. SUBPHRENIC ABSCESS Two 'cases occurred during the latter portion of the present epidemic which show the necessity of thorough routine examinations: REPORT OF CASES CASE '1.-A soldier, admitted, Oct. 8, 1918, with bronchopneumonia involving the right and left lower lobes, complained, November 25, of severe pain in the left upper quadrant of the abdomen. There was slight distention but no rigidity. November 26, 425 c.c. of amber fluid were aspirated from the left pleural cavity, cultures from which showed no growth. November 29, 75 c.c. of pus were aspirated from the same pleural cavity and showed a pure culture of staphylococci. The following'day the left chest was again aspirated and a serohemorrhagic fluid obtained through the ninth inter-' costal space, between the posterior axillary and scapular' lines. On pushing. the aspirating needle slightly deeper,, a thick yellow pus was obtained. Roentgenoscopy had revealed the presence of fluid in the left pleural cavity; hence the outline of the diaphragm on this side could not be seen. A costectomy was performed over the area from which the pus had been aspirated, and 1,500 c.c. of serohemorrhagic fluid were evacuated. The diaphragm v.:s seen to bulge upward and, for this reason, the presence of a subphrenic abscess on this left side was suspected. December 4, the roentgen ray revealed a dense shadow from the sixth rib downward on the left side, and the domes of the diaphragm on the two sides' were at about the same level. The normal clear area below the left dome, due to the gas bubble in the stomach, was absent. The tenth rib was resected in the midaxillary line after exploratory puncture had confirmed the diagnosis of a subphrenic abscess. Following the needle, which had been left in situ as a guide, the pleural reflection was pushed upward,.an incision made through the muscles of the diaphragm, and 125 c.c. of a dark pus were evacuated. The soldier had no recurrence of elevated temperature and is making an uneventful recovery. CAsE 2.-A soldier, admitted, Oct. 8, 1918, with a' diagnosis of 'bronchopneumonia of all lobes of the right lung, in whose ase, October 27, an additional diagnosis was made of acute cholecystitis and cholangeitis, developed a facial erysipelas, the following day, and remained in.a very septic=conditior until November 23, when he was seen by a surgeon in consultation on account of pain in the left upper quadrant. There was dulness over, theanterior portion of the left side of the chest in the mammary. line justabove the costal arch, and an obliteration of Traube's semilunar space. There -was also very slight 'excursion of the left lowere lobe into the costophrenic angle. There was also evidence of free fluid in the peritoneal cavity, but no rigidity or tenderness. Roentgenographic examination revealed a shadow in place of the normal gas bubble beneath the left dome of the diaphragm, and displacement of the heart toward the right. The right half of the diaphragm showed such a degree of elevation that a right subphrenic abscess was thought of; but on exploration with a needle, no pus was obtained. Pus, however, was obtained over the left lower chest in the anterior axillary line, and about 90 c.c. of chocolate colored pus were evacuated through an incision in the eighth interspace from the left subphrenic region. The symptoms of a generalized sepsis supervened, and the patient died a few days later. At necropsy. the lower lobe of the right lung was found adherent to the diaphragm, and that of the left lung was covered with a thin yellowish exudate. Throughout the liver were scattered many small abscesses. A generalized peritonitis with 1,500 c.c. of free greenish yellow fluid confirmed the clinical diagnosis. 'The left subphrenic region was walled off, and the origin of the pus obtained at operation was seen to be from an extensive suppurative pylephlebitis. There had evidently been a direct infection of 'the left subphrenic region froonrupture of one;of'the abscesses 'in:theleft lobe of the liver. The gallbladder and the appendix showed at this time. no evidence of disease. A number of the mesenteric lymph nodes contained abscesses. A gram-negative bacillus which,did not give the typical reaction of the colon group was obtained from the lungs, liver and peritoneum at necropsy. JAUNDICE The incidence of jaundice as seen postmortem has been about what one is accustomed to-find in fatal' cases of lobar pneumonia. Jaundice, in most cases with a marked discoloration of the skin and the mucous and serous membranes, has been present in 7 per cent. of 140 necropsies. In all except one, a bacteremia was demonstrable; Streptococcus hemolyticus was present in three, Streptococcus viridans in three, and pneumococcus Type IV in two cases. In only one case was there swelling of the ampulla of Vater. In this instance the mucous membrane of the gallbladder and' the d16's4vas' slightly swolen and inflamed, being most marked in the cystic duct. The swelling was not sufficient, however, to interfere with the free passage of bile' to the duodenum: In' nall ases thd intestinal contents showed that bile was freely passing into the intestine, and stools examined during life gave no evidence of obstruction to the flow of bile. SPLEEN The spleen in the majority of cases was but very little enlarged. It was moderately firm on section and red. Microscopically a rather marked congestion was the predominating feature. KIDNEY Cases of true acute nephritis were extremely rare. Acute congestion of the kidneys was frequent. In one case, multiple abscesses of the kidney were a part of a hemolytic streptococcal septicemia, which had also caused a severe 'infection of one of the toes. Pyelitis demonstrated by ureteral catheterization was occasionally found. Both renal and 'perirenal localization may be so severe as toendanger life, either during the stage, in which some pulmonary condition is present,.or independently of any other demonstrated focus, as is well illustrated in the following case of perirenal infection: