TWO CASES OF SUBPHRENIC ABSCESS

W. E. THOMPSON
1909 Journal of the American Medical Association  
As has been said, the abducted or pronated position of the foot is the weak position, and in practically all cases in which the individual has a weakened foot it will be found that the foot falls into a pronated position during sleep. The foot may have been kept in a correct position during the day by braces and shoes, but during sleep, which is usually about one-third of ti e time, the foot is allowed to assume the pronated or abducted position, and it can easily be understood what an
more » ... od what an influence this must have on treatment. Fig. 3.-The strap (d) is to fasten into the buckle (e) of the ankle support, and, when tightened, draws the foot into a flexed and adducted position. In some cases it may be of advantage to incorporate a piece of elastic webbing-into the strap. The strips of spring brass fastened to the apparatus by their leather covering serve to stiffen it and cause the pull of the apparatus to be applied at the right points. Fig. 4 .--A modification of the waist band that can be used when, hallux valgus is present. The hand (a, b, c) around the waist of the foot is as in Figures 1 and 2 , but there is a prolongation (d, e), along the inner side of the big toe. This prolongation is strengthened by a strip of spring brass and corrective force can be brought to bear on the toe by bending this strip. In order to overcome this faulty position during sleep and to aid the process of growth, the apparatus, outline drawings of which are here shown, has been devised. By a slight change in. the apparatus it can be used to great advantage as a night support for clubfeet. This is done by simply changing the strap and buckle to the outer side. Tightening the strap will now tend to hold the foot in a flexed, pronated or abducted position, just the reverse of the position in ordinary equinovarus. Hair Dye Poisoning.-Dr. J. H. Mackay, Norfolk, Neb., reports a case in which the eruption extended beyond the scalp to the face, shoulders and arms, with itching, burning, redness and puffing. The eruption was similar to ivy poisoning, but with larger individual pimples. There were constitutional symptoms suggestive of arsenic poisoning. The diagnosis was confirmed by three attacks during a period of six months, concurrent with the ipplication to the hair of "Mrs. Potter's Pure Walnut Juice." The following case is reported because we believe, that, even in the face of a rapidly increasing literature, it is appropriate to draw attention to the not infrequent condition of subphrenic abscess following appendicitis and to the condition of empyema and lung abscess following subphrenic abscess, even when an appendiceal abscess is drained and occasionally after the removal of a non-suppurating appendix. Patient.\p=m-\W. P., aged 26 (family history immaterial), was operated on at Omaha for appendicitis, two years before the date of first examination. He believed it only a drainage operation. A year and a half later an abscess opened externally in the right iliac region. The patient was shortly removed to a hospital, where two attempts were made to close the resulting fistula. At this time there was a swelling of the lower part of the chest on the right side. Later he began suddenly to cough and to expectorate large quantities (two to four pints) of very foul pus, the swelling in the liver region gradually subsiding. Examination.-March 23, 1909: Patient admitted to the hospital, emaciated, dyspneic, with rapid breathing, no expansion of the right thorax. Temperature, 102 F.; pulse, 110; bulging of the right thorax, dulness extending up into the axillary space, area of dulness changing with posture. Amphoric breathing and other cavity signs of right lung. Diagnosis-In the order of occurrence: Appendicitis, subphrenic abscess, empyema, lung abscess. Operation.-March 23, under ether, which the patient took poorly, resection of sixth rib was done, evacuating about one quart of pus; breathing was easier. By a linear incision in outer border of right rectus, we opened the subphrenic space and demonstrated a sinus leading from the appendix to the right lung, through which air escaped in breathing as it also did in the thoracic opening; drainage of openings was effected. Postoperative History.-At no time after operation was there any drainage through the old sinuses in the appendieeal legion. On the second day the drainage was removed from the subphrenic space, with closure of the wound twelve days after operation. The thoracic discharges gradually lessened until on April 7 the discharge had ceased and the wound about closed. The patient was up, gaining in weight; his cough was negligible. The next case is reported because of the long train of symptoms, and widely separated septic conditions that may follow a seemingly mild and non-suppurative appendicitis after apparent recovery; also because of the obscure symptoms present due to the small amount of pus and its many locations; and because of the fact that the pus must have been present for a long time and the tissue reactions excellent to produce such a completely organized pus. Patient.-W. F., male, aged 28 (family history not obtained; early history negligible), in 1904 worked in the tropics where he had a "fever" which left him with large stellate scars on the back. He complained of not having felt well for some time before the examination. He could remember no very severe pain but some colic. Examination.-March 18, 1909: The patient was a muscular male, not markedly emaciated, with face flushed, rapid breathing, rapid pulse, temperature 102 F., an area of consolidation in the left upper lobe of lung, and no marked signs oi extensive pneumonia. The sputum contained Friendlandcr's bacillus and numerous cocci; it was slightly blood-stained. We made a diagnosis of pneumonia. Course of Disease.-The patient next morning was removed to the hospital, at which time his temperature was 95 F., pulse 110; the other conditions were unchanged. The patient had had no chills and gave no history of chills but had chilly sensations. During the next day he complained of severe pniri in the diaphragmatic area on the left side. Next day the pa-Downloaded From: http://jama.jamanetwork.com/ by a University of Iowa User on 05/27/2015
doi:10.1001/jama.1909.25420460027002d fatcat:6qx6psged5gq7fobfncztysk2u