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sub-phrenic abscess. The author had reported nine cases in a series of 500 cases of appendicitis and this prob- ably did not overstate the frequency of the complica- tion. Diffuse subphrenic suppuration was much less often found in this type than in any of the others. Gas- tric and duodenal ulcers frequently caused subphrenic abscesses, but these rarely perforated the disphragm. â– With this condition in amebic dysentery there was fre- quent involvement of the pleura and lung with infre- quent subphrenic abscess. Left-sided subphrenic ab- scess usually originated from ulcer, although suppura- tive appendicitis, acute pancreatitis, suppurative chole- cystitis, and amebic liver abscess might be the starting point. The mere presence chinese viagra pills of subphrenic abscess must not be taken to establish its abdominal origin. Dr. Thomas H. Hawkins had reported one case in which an abscess resulting from a suppurative salpingitis finally evacuated through the lung. Archibald's figures indi- cated that about four per cent of cases of subphrenic abscess originated from the intrathoracic infection. The lymphatic distribution was such that the invasion chinese viagra pills from the abdomen was vastly more frequent; the right pleura and lung were therefore involved much more frequetly than the left. Appendicitis and suppurative involve- ment of the right lob of the liver caused most of the instances of subphrenic suppuration which brought about the involvement of the resniratory tract. Yet it was possible that the spread of the process beneath the diaphragm chinese viagra pills might cause involvement of the pleura on the side opposite the original abdominal affection. The most frequently found bacterial infection in sub- phrenic abscess was that of the colon bacillus. The diag- chinese viagra pills nosis of subphrenic abscess often viagra for sale philippines depended upon the recognition of some possible cause in the abdomen. In empyema, unless it was entirely evident that the affec- tion followed immediately after acute pneumonia or broncho-pneumonia, the history should be taken with special care to overlook no chinese viagra pills evidence of viagra for sale philippines prior abdominal disease. When one had obtained a history of appendi- citis, amebic dysentery, gallbladder disease, or other similar affection, and symptoms such as irregular fever, irregular chilis, sweats, leucocytosis, perhaps cough, dyspnea, pain, and even in neglected cases bulging, redness, and edema of the chest, he could feel quite certain that he was dealing with subphrenic abscess. The heart might be displaced to the opposite side. Ten- derness and deep pain and discomfort were common. The diaphragmatic movements were abolished. Push- ing downward of the liver in rieht side involvement, or of the spleen upon the left side, should be noted. Mus- cular rigidity below the costal arch was probably always present. The higher line of dullness over the liver and pushing upward of the diaphragm behind suggestive of pleural effusion were reliable evidence of the presence of an abscess. The .c-ray plate demonstrated the shadow of chinese viagra pills the effusion and might prove it to be subdiaphrag- matic in location. The fluoroscope revealed the absence of respiratory excursion of the diaphragm. Feeble respiratory sounds, a lessened vesicular murmur and even slight dullness might be detected. Pleural friction was occasionally to be heard, less frequently pericardial friction. Splashing was decidedly less frequent in chinese viagra pills pyo- pneumothorax subphrenicus than in the usual form above the diaphragm. Increased area of dullness in the lateral region of the chest was to be found if the abscess was of much size. The displacement of liver dullness by tjTnpany if gas was present was of extreme impor- tance in diagnosis, and was usually associated with mov- able dulness. Subphrenic abscess rarely broke exter- nally. In one of the writer's cases it broke into the colon with fatal results. Given such a history and some of the findings described and they were ready to consider the possible invasion viagra for sale philippines of the region above the diaphragm. This probably occurred in 25 to 35 ner cent, of the neg- lected cases. It was more frequent in extraperitoneal type than in the intraperitoneal abscesses. The gen- eral symptoms after pleural involvement were much the same as those of subphrenic abscess. If in doubt as to subphrenic absces or pleural effusion the needle must be used freely, the patient being prepared for opera- tion, and in serious cases an anesthetic should be used. The greater danger of using an exploring needle on the left side and the need of emptying the stomach by means of the tube before aspiration, should be borne in mind. One was likely to be satisfied if he found one kind of fluid in one place in the aspiration of the chest, hence it was well to recall that when effusion above the dia- phragm existed with subphrenic abscess, the latter was too frequently overlooked. Acland stated that in case of doubt, clubbing of the nails pointed quite definitely to the supradiaphragmatic location to the disease. There were notable features in the amebic hepato-pulmonary abscess. Extensive destruction of lung tissue was not infrequent, and expectoration of the products of tissue diintegration might be noted. In case of perforation into the lung death might occur from the pneumonic process, from abscess, or from gangrene before the abscess emptied itself through the bronchus. In fact the latter process was probably a function viagra for sale philippines of the milder infections only. The most striking phenomenon in the whole general process was the sudden breaking through of the abscess into the bronchus, with expectoration, of foul piis. Pulmonary embolism was spoken of as a complication of subphrenic abscess, coming from the thrombotic process in the veins of the abdomen, but a much more striking variety of embolism might occur in the cases of perforation of the lung bv the subphrenic abscess. One of the author's cases described elsewhere had septic chinese viagra pills embolism of the popliteal artery, survived am- putation, and suffered two other embolic attacks. The source was evidently the thrombosis in the branches of the pulmonic vein around a large cavity demonstrated in the lower right lobe. There were rare instances in which the abscess ruptured into the pericardium. Peri- cardial friction and even splashing might be noted. This complication was of extreme gravity. In cases of sub- phrenic abscess with lung involvement complete recov- ery was most exceptional. Yet the author could chinese viagra pills not agree with Rolleston's statement that death commonly resulted in two or three months, since he had had three patients who had lived from one to ten years, and two of Oct. 2, 1915] MEDICAL RECORD.