previous seventy-two hours he had been getting decidedly worse. I could feel no tumor in his abdomen which could easily be explained from the rigidity of the abdominal wall. The examination of his chest brought on violent spasmodic coughing, so violent that I feared suffocation at the time; his lips became livid, and his condition looked dangerous. The examination was therefore unsatisfactory, but I made out dullness on both sides, and yet on the right side of the chest below, and still over the liver, the dullness disappeared and the percussion note was highly tympanitie; there was also entire absence of respiratory sounds over the dull and tympanitic areas, but they could be heard at the apex where there was resonance on percussion and the vocal resonance was exaggerated. It should have been stated that the child's temperature had varied considerably be tween 99° and 104°; his condition forbade any extensive operative procedure; it was not possible to give him an anesthetic. I did not feel positive as to the presence of pus in his right iliac region at the time, though the history did not allow me to doubt the correctness of Dr. Barnum's diagnosis. His respiration required immediate relief, however. I could not feel sure that he did not have a pyemic abscess in his lung, but the stench certainly suggested gangrene, and that there was fluid and air in the lower portion of his chest I was certain, and decided to evacuate this. I introduced a small exploring trocar in the mid-axillary line in the seventh intercostal space and withdrew a small quantity of pus emitting the same foul odor that was present in the breath which was that of appendiceal abscesses. Local anesthesia by the chloride of ethyl spray was produced and an incision with a bistoury sufficient to introduce a large drainage-tube. A large quantity of the same horribly smelling pus mixed with air or gas was evacuated, deluging the bed.

No further attempt to explore either chest or abdomen

was made at that time, but I advised if he should survive this, that a further operative exploration should be made later. Within twenty-four hours his temperature fell to nearly normal, and he immediately improved in all respects. In the course of about two weeks he was brought to the New Haven Hospital. His chest was discharging from the opening that I had made through the tube a considerable amount of pus, which, however, had lost its fetid odor within a few days after the operation, and the boy's general condition improved markedly. He was brought to the Hospital for the purpose of getting a better drainage, and for that purpose, on about April 20th, I excised a portion of the eighth rib. After removing the rib, and stilling all hemorrhage, the incision was carried through the soft parts beneath, expecting to enter into the pleural cavity, but instead came directly upon the upper surface of the diaphragm; I then endeavored to make a communication through this incision here with the cavity of the abscess in which the drainage-tube was situated, but found I could not until I had divided quite a thick layer of tissue which I took to be the thickened diaphragmatic pleura lifted up from the muscle.

This case I acknowledge was an enigma to me. I had never before known of an appendiceal abscess in the chest, and could not restrain the fear that it was metastatic; that the condition was really pyemic. The course of the temperature was suspicious of this condition, and I experienced a very decided relief upon hearing subsequently that the temperature had soon resumed the normal character. It was not until I met the second case, however, viz., the one herein first described, that I was able to explain, satisfactorily to myself, what had probably been the course of the pus. Never had I before found an appendix lying so directly posterior to the caecum in what I now regard as outside the peritoneal cavity in between the folds of the meso-colon. As we know, there

is occasionally no meso-colon, the caecum lies more in apposition with the abdominal wall-connected with it by loose connective tissue, the reflections of the peritoneum being fairly wide apart. When this is the case, the hepatic flexure of the colon is in immediate contact with the lower portion of the kidney, and it is possible for the pus to burrow into the para-nephritic space and simulate a perinephritic abscess. The further progress of the unevacuated pus in the direction of least resistance is under and behind the liver, and we have perihepatic and subphrenic abscesses; still unevacuated, it is possible, by burrowing, to enter either the thoracic or pleural cavities by different routes. It may perforate directly through the diaphragm to my mind the least likely of any; or it can insinuate itself underneath the ligamentous arches of the diaphragm as they pass over the psoas muscle, or again through alongside of the vena cava. The latter is situated so far forward above the vertebral column that it seems to me more likely that the route would be by way of the ligamentous arches above mentioned, and the way in which this lad lay in bed on his right side with his legs drawn up, with the psoas muscle therefore relaxed, favors this view.

I regard these two cases as fitting into each other like the articulations, of a dissecting map. If one will compare the figure in the Reference Hand-Book of Medical Science, Vol. VI., Page 305, of the peritoneum by Dr. Frank Baker, of Washington, D. C., I think this explanation will prove satisfactory. This figure is a diagram illustrating the posterior wall of the abdomen viewed from in front with the viscera entirely removed showing the lines where the parietal layer of the peritoneum is reflected upon the viscera. In it one sees where the channels of loose connective tissue are to be traced up from the caecum to the hepatic flexure and the transverse colon, and knowing as we do that the kidney is sometimes but loosely attached to the abdominal wall, the route up to the diaphragm is but slightly obstructed.

Since I have begun the preparation of this paper, an abstract of a paper in the Revue de Chirurgie by Dr. Lapeyre, of Tours, on "Perihepatic and Pleural Complications of Appendicitis," has appeared in the Annals of Surgery of the present month, which he considers as taking place in a similar way to the one given above.

The course of the abscess after entering the thoracic cavity may be either sub-pleural-lifting the pleura from the diaphragm-or it may penetrate the pleural cavity and be a veritable empyema. The condition of things which I found at the second operation on the lad upon whom the excision of the eighth rib was made would favor either view. When the rib was removed, though it was the lower boundary of the intercostal space through which the pus had been evacuated three weeks before, I did not this time enter into a pus cavity, but came directly in contact with the upper surface of the diaphragm; and the situation of the pus at the time he entered the New Haven Hospital two weeks after the first operation was almost entirely in the anterior portion of his chest; practically there was no cavity-simply a sinus; nothing more came away in washing it out that would be expected from a sinus. At this time, two months from the first operation, the lad has gone home quite well.

DISCUSSION.

In discussing this paper, Dr. McKnight said it recalled a case which was under the care of Dr. Storrs, Dr. Wainwright and himself. In those times it was called perityphlitis. Dr. Storrs made repeated punctures, but no pus was found. The patient vomited up large quantities of pus and then his symptoms were better. They became worse, when he again coughed up another lot of pus with improvement of symptoms. After two or three years he died. Adhesions were found throughout the intestines and diaphragm. He always had thought it was inflammation of the diverticulum. It could hardly have come from the appendix.

UNUNITED FRACTURE OF THE TIBIA.

JOHN F. DOWLING, M.D.,

HARTFORD.

During my term of service at St. Francis Hospital, on September 14, 1901, Timothy S., aged 22, of Windsor Locks, was admitted, having been sent in by Dr. Joseph A. Coogan, to be treated for ununited fracture of the leg.

He gave the history of the injury as follows: About five weeks previous to entering the hospital, while playing a game of base-ball, he collided with an opposing player and was thrown violently to the ground. Being unable to continue the game, a physician was summoned, who found a fracture, and placed the leg in splints. The physician called every day or two until Dr. Coogan was consulted, and he advised going to the hospital at once.

The condition of the leg on entering the hospital was as follows: There was found an oblique fracture of the tibia, in the upper and middle thirds of the bone, about four inches in length. The fragments were overriding, the point of the upper one almost protruding through the skin. There was no union, the fragments being freely movable, the movements causing no pain nor discomfort. There was also an oblique fracture of the fibula about parallel to the fracture of the tibia; this was also ununited. The shortening by measurement and comparison with the right leg, was two and one-half inches.

A consultation of the staff was called, and it was advised trying extension and applying a plaster cast, before resorting to operative measures. I did not think favorably of this treatment for several reasons. The young man had already remained in bed nearly six weeks, and, naturally, was anxious to get on his feet. Simple extension and putting on a cast would mean five