Patient.—Mrs. A. N., aged 39, recently entered Professor Dock's clinic on account of an abdominal tumor, which had been present for more than fourteen months ; weakness, loss of PARAVERTEBRAL TRIANGLE OF DULNESS weight, abdominal pain of no distinct type and ascites ( ? ). (GROCCO'S SIGN) History.—Thirteen years ago the right ovary was removed for an enlargement of the nature of which she is ignorant. IN A CASE OF ABDOMINAL MULTILOCULAR CYSTADENOMA. Was married at 27 ; was never pregnant ; still menstruates FRANK SMITHIES, M.D. regularly. Shortly after ovarian operation, hernia developed at side of and wears a stout truss. Instructor in Internal Medicine and Demonstrator of Clinical Medi- incision, patient History cine, University of Michigan. otherwise negative. a noted in It ANN ARBOR, MICH. July, 1906, mass was left hypochondrium. grew rapidly larger, and in October, 1906, was tapped, and a In various conditions complicated with collections of amount of fluid removed. Since that time she has been in the large fluid pleural sacs, the clinical observations of tapped fourteen times. At present the abdomen is as large Grocco,1 Baduel and Siciliano,2 Rauchfuss,3 Thayer and as it ever was. Apart from the abdominal condition she has Fabyan,4 Ewart,5 Morison6 and others, have established been in fair health. the constancy of an area of percussion dulness, Examination.—A rather cachectic woman of medium build. roughly somewhat triangular in outline, lying along the on the oppo- Thorax : Anterior, short, but fairly broad ; expansion spine, but shallow; no distinct Lit- site side to that on which the fluid is found. This para- poor, symmetrical; respirations ten's on either side. border at fourth space vertebral area of dulness to have a sign Liver-lung triangular appears in the mid-clavicular line; dulness in left axilla begins at the as a between distinct value point in differential diagnosis sixth and continues downward into the abdomen ; of space conditions pulmonary consolidation, mediastinal Traube's space dull. Auscultation: Negative, except for harsh growths, etc., and conditions, associated with pleural vesicular breathing over both uppers. Heart: Apex beat in effusion. It has even been suggested7 that the paraver- fourth i. c. s. about 51/, cm. beyond the left sternal edge. tebral triangle of dulness is pathognomonic of the ordi- Sounds rather weak; no arrhythmia. Thorax: Posterior— nary type of pleural effusion. Recently, however, atten- Upper thoracic region negative. For percussion outlines of lower thorax 1. There were no or tion has been called to the fact that areas of see Figure percussion triangular evidences of free fluid in either pleural sac. With dulness may be the in affections auscultatory percussed along spine the on the edge of the bed and loaning forward where the thorax is not the seat of the patient sitting pathologic proc- a paravertebral area of dulness, somewhat triangular in shape, ess. Ewart5 now admits that in cases of ascites, could readily be percussed to the left of the spine. It will be Grocco's sign may be present, and Beall8 cites a case of seen by consulting the figure that it was low for its breadth subpbrenic abscess, on the right side where "there wau at the base. The spinal dulness extended from the eighth to an easily definable paravertebral triangle on the left." the tenth dorsal spine, a distance of about 4 cm. At the He suggests that the sign may occasionally be expected level of the tenth rib the base extended to the left for a dis- tance of about 6% em. from the midvertebral line. The in other subphrenic conditions, such as tumors and cysts of the etc. hypothenuse of the "triangle" was" rather markedly convex out- liver, abscesses, the lower of the line somewhat The the ward, portion descending patient furnishing material for this report abruptly to meet the base line. The limit of thoracic resonance exhibited the unusual findings of an encapsulated collec- to the left of the triangle was at the tenth space. On the tion of fluid, apparently wholly within an abdominal right the liver dulness was made out at the ninth rib. This tumor, that was in no way intimately connected with was about 1% em. below where the dulness on the. spine began. the diaphragm or organs lying adjacent to the dia- The shape as well as the size of the paravertebral dull area phragm; there was a well-marked area of paravertebral was little influenced by changes in the patient's position. When the leaned forward, with the head on the knees, the dulness, but no demonstrable exúdate in either patient pleural triangle was somewhat more sharply defined; sitting erect or sac. Evacuation of some of the fluid from the abdominal leaning backward produced a rather smaller area of dulness; tumor was accompanied by distinct changes in the area leaning to the right produced no perceptible alterations. Lying of paravertebral dulness. Bemoval of the tumor mass on the left side brought out more marked spinal dulness, but promptly brought about the disappearance of the dul- no changes in the base line of the triangle. Auscultation: No breath sounds could be made out over the dull ness lying to the left of the spine in the thoracic region. paravertebral area; to the left of the the breath sounds were some- A few details of the clinical of the case will suf- triangle history what harsher than at of the above or to the left in to out the points lung fice bring interesting features. the axilla. There were no alterations in the voice transmission. Abdomen: Markedly globular; bulged in the flanks and rose From the Clinic of Internal Medicine of Professor George Dock. abruptly from the base of the xyphoid. Was rather fuller in 1. Riv. crit. di clin. med. Firenze, Nos. 13 and 14, 1902. the left than the the fulness 2. Ibid., 1904. upper quadrant right, continuing 3. Deutsch. Arch. f. klin. med., 1906, lxxxix, 186, 219. upward beneath the lower ribs. The abdomen measured at 4. Am. Jour. Med. Sciences, January, 1907. the level of the tenth ribs, 102 cm.; at the level of the iliac 5. Lancet, Lond., 1907, ii, 49, 189. crests (about level of navel, also) 106 cm.; from navel to pubis, 6. Lancet, Lond., 1907, ii, 112. 17 from navel to base of 32 On 7. Ewart: Progr. Med., 1907, ix, 40. cm.; xyphoid, cm. palpation a mass 8. The Journal A. M. A., Dec. 28, 1907, p. 2148 large, smooth, rather globular could be made out filling

Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/01/2015 the lower three-fourths of the abdomen and extending upward The cause of the dulness in this case to the left paravertebral more than the right. There was distinct fluctuation appears to be due to the of the at any of the abdomen, but more at the level of the navel. primarily presence large, part abdominal Just in what manner this Stomach: Inflation revealed slight displacement to the right cystic, neoplasm. new the in the thorax can and downward. Colon: Very capacious in the ascending and growth produced changes only be It would seem that in cases where descending portions. The transverse portion was displaced up- conjectured. para- ward. vertebral dulness exists from causes that are extra- mere of the Progress of Case.—The patient was tapped by Professor thoracic, something more than displacement Dock two days after entering the hospital, and eleven and mediastinal tissues (as suggested by Baduel and Sicil- one-half liters of slightly opalescent fluid were removed. Ex- iano2 in explanation of Grocco's triangle) must take amination of the back after tapping showed dulness as place. In the case herewith described, the positions of the in Figure 2. There was dulness on the spine at the level of heart, liver and with the absent Litten's the ninth and tenth vertebrae. The base of the to the spleen, together triangle on both to a rather marked left measured about 2% cm. The and sign sides, certainly point percussion auscultation upward displacement of the diaphragm. It might be suggested that on account of the support offered the diaphragm by the liver on the right side, locally, the dia- phragm was pushed upward to a greater extent to the left. In this manner one might fancy that some dis- placement of the mediastinal tissues took place, and that . the lung on the left was pushed from the spine. One must not forget, however, that displacement upward and to the left of the liver itself could produce paraver- tebral dulness. The prompt disappearance of the dul- ness to the left, after extirpation of the tumor, enables one to rule out secondary growths in the mediastinal tissues or in the lung, and also speaks against the possi- bility of an unrecognized pleural effusion.

THE DIFFERENTIATION OF BACILLUS COLI COMMUNIS FROM ALLIED SPECIES IN WATER. D. M.D. Fig. 1.—Outlines of percussion dulness. A, upper limit of liver ; RIVAS, B, flatness in Hanks and lumbosacral regions ; D, lower border of Bacteriologist to the Department of Health of the State of thoracic resonance on left: C. paravertebral dulness, base 6y% cm.; Pennsylvania. about cm. vertical spinal dulness, 4"!4 PHILADELPHIA. It is not the purpose of this report to deal with the old and controversial question of the significance of Ba- cillus coli communis as an indication of pollution in drinking water, nor to go into details upon the typical or atypical biologic characteristics of the organism; but especially to determine a constant biologic feature by which it can be differentiated with certainty from the allied species of the colon group. It is common knowl- edge that B. coli communis presents such extensive varia- tions that often cultures isolated from water and re- ported as identical with this micro-organism will, if studied more closely, be found to have very little or no relation at all with it. The hypothesis that the acceptance of such variations in B. coli communis is responsible for the unsatisfactory results often obtained in the bacteriologic examination of drinking water has been the basis for undertaking the following studies. I believe B. coli communis, like B. typhus, B. diph- theri[ill],B. anthracis, etc., is a single micro-organism, not a group ; and if its and features of dulness one hour after biologic morphologic Fig. 2.—Outlines percussion tapping are (11.5 liters fluid removed). A, upper limit of liver; B, flatness sufficiently studied, is not to be confused with others. in flanks and lunibosacral region ; D, lower limit of thoracic reso- It is true that sometimes an atypical reaction is seen, but nance ; C, small triangular area of paravertebral dulness; base '¿y2 this if will be found cm. ; vertical spinal dulness about 3 cm. irregularity carefully inquired into to depend, not on the colon bacillus itself, but on the in which it has been of the adjacent lungs were negative. A large mass, of dis- condition placed. The colon ba- tinctly cystic feel, could be made out definitely in the abdomen. cillus is commonly regarded as an acid-producing micro- The patient was transferred to the gynecologic clinic and Prof. organism. The reaction, however, depends entirely on Reuben Peterson removed an enormous multilocular cystad- the presence of sugar in the culture media ; and in plain enoma. Examination of the back four days after operation neutral bouillon the reaction of the culture will be alka- revealed absolutely no evidences of paravertebral dulness on line. either side. The liver was at the ninth rib in the right mid- The lower limit of thoracic resonance to the scapular line. Reported from the Pennsylvania State Department of Health left was at the tenth rib, and continued inward to the spine. Laboratory, University of Pennsylvania.

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