242 POSTGRADUATE MEDICAL JOURNAL May 1953

Cramps in the affected leg are quite common andpersistent although sciatic pain may have dis-appeared completely.A small proportion of patients develop a true

recurrent prolapse (prolapse from the same disc)months to years later. This varies in individualstatistics, but is probably in the neighbourhood of4 per cent. to 5 per cent. These recurrent attacksof sciatica, due to a further protrusion, are dealtwith in the same way as the primary attacks,except that one will tend to persist with conserva-tive treatment for a much longer period before sub-jecting the patient to a second laminectomy.There is also a 2 per cent. risk of developing afurther disc prolapse at another level.

Results of SurgeryTable i gives the results in disc surgery at the

hands of experienced surgeons. The figures arean average gathered from several large series.The overall results of treatment of sciatica or

TABLE I

TABLE SHOWING THE RESULTS OF OPERATION FORPROLAPSED LUMBAR INTERVERTEBRAL DISC

Percent.

Completely relieved of sciatic or back pain.. about 40Greatly improved, mild sciatic or back

pain; at full work ..V .. .. 30Improved, more severe sciatic or back pain;

at full or light work .. .. .. 20No improvement, or worse; unable towork . .. .. .. .. ,, 10

back pain can now be summed up. Out of 0oopatients about 80 will be improved or cured oftheir symptoms by the conservative measures ofbed rest or plaster immobilzation, and 20 will failto respond. Of these 20 who will eventually cometo operation i8 will be made fit to return to work,and of these eight will be completely relieved ofsymptoms. Two patients will fail to derive anybenefit from surgery.

SUBPHRENIC INFECTIONBy A. B. BIRT, F.R.C.S.

Norwich

The pathology and surgical importance of sub-phrenic infection cannot be fully understood with-out a thorough appreciation of the anatomy of thesubphrenic space.AnatomyThe subphrenic space is defined as being that

portion of the abdomen which lies between thediaphragm above and the transverse colon andmesocolon below.The space is divided into two parts by the liver;

the supra-hepatic and infra-hepatic portions.The supra-hepatic portion is divided into right

and left sides by the falciform ligament of the liver.The right side is itself divided into an anterior andposterior space by the right lateral ligament of theliver. The left lateral ligament of the liver runsvery close to the posterior margin of the left lobeof the liver so that it does not divide the left supra-hepatic area but forms the posterior part of theboundary between the supra- and infra-hepaticparts on the left side. There is, therefore, only onesupra-hepatic space on the left side, In addition

there is one small extra-peritoneal space in thesupra-hepatic part, namely the bare area of theliver, between the leaves of the lateral and falciformligaments. The supra-hepatic portion of the sub-phrenic area therefore contains two intra-peritonealspaces on the right and one on the left and onesmall extra-peritoneal space. These spaces areusually referred to as the right superior anteriorsubphrenic space, the right superior posterior sub-phrenic space, the left superior subphrenic spaceand the bare area of the liver.The infra-hepatic portion is divided into right

and left parts by the free edge of -the lesseromentum and the descending part of the duo-denum. There is only one space on the right inthe infra-hepatic region, but on the left there aretwo spaces, an anterior one and a posterior one,being separated from each other by the stomachand the lesser omentum. All the infra-hepaticspaces are intra-peritoneal, there is no extra-peritoneal space below the liver. The infra-hepatic portion of the subphrenic area thereforecontains one space on the right and two spaces on

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BIRT: Subphrenic Infection

the left. These spaces are usually referred to asthe right inferior subphrenic space, which is thesame as the hepatorenocolic pouch of Morrison;the left inferior anterior subphrenic space, oftencalled the perigastric space; and the left inferiorposterior subphrenic space, also referred to as theomental bursa or lesser sac of the peritoneum.From the surgical point of view the space most

commonly infected, and therefore the most im-portant, is the right superior posterior space,which is difficult of access both for diagnosis anddrainage.AetiologyThe commonest cause of subphrenic infection

is any infective process occurring in the peritonealcavity, but less commonly the infection canoriginate from a more distant focus.The subphrenic region may be infected by the

following methods:I. Direct extension. This is by direct spread of

infection from contiguous organs, such as per-forated peptic ulcers and the gall bladder.

2. Distant extension. The commonest cause ofinfection of the subphrenic region by this means isthe appendix or any suppurative lesion in thepelvis. The infection probably spreads mainly bymeans of retro-peritoneal cellulitis, although retro-peritoneal lymphangitis may be the method ofspread in some cases. Distant intra-peritonealfoci of infection can also infect the subphrenicregion by direct intra-peritoneal drainage of in-fected material especially if the patient is supine.The diminished incidence of subphrenic infectionsresulting from the nursing of pelvic infections inFowler's position probably results from the pre-vention of this method of spread of infection.

3. Rupture into the subphrenic space. This isthe rupture of an adjacent abscess into one of thespaces, such as rupture pf a liver abscess.

4. Extension from the thorax. This is not acommon source of subphrenic infection, althoughit certainly does occur. It is probable that thepath of spread is by means of retrograde lymphaticextension rather than directly through the dia-phragm.

5. Blood stream. In these cases the subphrenicinfection is a metastatic infection resulting fromsepticaemia or pyaemia which has itself resultedfrom some distant infective focus. This causeaccounted for 8 per cent. of a series of 25 casestreated at the Norfolk and Norwich Hospital from1948 to 1952.

6. Direct implantation. By this method or-ganisms are implanted directly in the subphrenicregion. In wartime this most commonly resultsfrom missiles, and in peacetime from aspirating

needles inadvertently traversing the diaphragm inthe course of the aspiration of an empyema.

In dealing with the actual source of the sub-phrenic infection most series of cases have shownthat about 88 per cent. followed suppurationwithin the abdomen, about 6 per cent. were blood-borne, about 3 per cent. resulted from extensionfrom the thorax and the remainder were due to avariety of rare causes. Of the causes of abdominalsuppuration, most writers report that about 30per cent. of all subphrenic infections result fromthe appendix, about 30 per cent. from perforationsof the duodenum or the stomach and about I2 percent. from infections of the liver and biliarypassages, the remainder being much less common,from the kidney, pancreas, traumatic, etc.

In a series of cases of subphrenic infectiontreated at the Norfolk and Norwich Hospital,Norwich, from 1948 to 1952, no less than 44 percent. resulted from perforated peptic ulceration,while appendicitis only accounted for I6 per cent.of the cases. It is of interest that, in this series,there were two cases in which subphrenic infectionresulted from osteomyelitis of the spine.The actual infecting organisms vary according to

the source of the original infection, but most pub-lished figures show that B. coli and streptococciaccount for almost 40 per cent. of cases each, andstaphylococci for about 20 per cent. of cases. Notuncommonly the infection is a mixed one.

DiagnosisIn subphrenic infections the safety and recovery

of the patient depends to a great extent on thecorrect diagnosis being made. The presence of asubphrenic infection can usually be diagnosed ifthe possibility of its existence is kept well/in mind.In any patient with an unexplained fever, andespecially following abdominal suppuration, thelikelihood of subphrenic infection should be con-sidered. and kept constantly in mind. There is nosingle test or investigation which will establish thediagnosis. It is only by viewing the case as a wholegind keeping the condition constantly in mind thatthe diagnosis will be arrived at in the early stagesand so allow treatment to be started early and thuslower the very high mortality with which thiscondition has been associated.

Subphrenic infection results in a fever of theswinging type and general toxic signs and symp-toms which may result in rapid deterioration inthe patient's general condition. The patient maycomplain of pain or discomfort in the upperabdomen or over the lower ribs posteriorly.Tenderness on pressure may be present but itsabsence by no means excludes the infection. Asa rule the tenderness is in relation to the ;2th rib

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244 POSTGRADUATE MEDICAL JOURNAL May 1953

posteriorly, or below the costal margins in anteriorspace infections.The most useful and constant physical:sign is

some limitation of movement on respiration, of thelower part of the chest on the affected side. Thisis usually most easily detected from behind and isdue to limitation of diaphragmatic movement onthe affected side. Apparent increase in the liverdullness may be noticed. There may be signs of abasal pleural effusion, usually of a sympatheticnature, on the affected side or of basal lobular pul-monary atelectasis. The white blood count, notunnaturally, shows a polymorpho-nuclear leuco-cytosis. The most useful aid to diagnosis isthe use of X-rays, and examination under thefluorescent screen is usually more valuable than bymeans of films. The most constant X-ray findingis that the diaphragm is raised on the affected sideand that the range of movement on respiration isdiminished compared with the normal side. It maybe possible to see an accumulation of gas in theupper part of the subphrenic abscess with a hori-zontal fluid level below it, but this is not nearly socommon as writers in the past have tended tosuggest. The gas is usually due to the fact that the

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FIG. i.-X-ray film showing a right-sided subphrenicabscess containing gas. The fluid level within theabscess cavity is well shown. Note the raising of theright side of the diaphragm and the degree of rightbasal pulmonary atelectasis,

subphrenic abscess has communicated with ahollow viscus, such as in the case of perforatedpeptic ulceration, rather than to the presence ofgas-forming organisms within the abscess (seeFigs. i, 2 and 3).The X-ray diagnosis of left-sided subphrenic

infections may be aided by filling the stomach withbarium. This may show the stomach being in-dented by the abscess at one point with the pro-duction of an apparent rounded filling defect ofthe stomach. Diagnostic pneumo-peritoneum hasalso been used in the investigation of subphreni-infections. Normally an X-ray after a pneumocperitoneum has been induced will show the air tohave risen and be situated under the diaphragm,whereas in the cases of subphrenic infectionsadhesions in relation to the area of infection pre-vent the entry of the air to the sub-diaphragmaticregion. Diagnostic aspiration is mentioned only tobe condemned, as there is a very great risk that theinfection will be spread along the needle track toresult in an empyema or spread to other parts ofthe peritoneum from which it has been success-fully walled off by adhesions. Some surgeonsadvocate aspiration at the time of operation, butthe writer does not agree with this view because ofthe grave risk that the pleura may be traversed.

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1FIG. 2.-Lateral view of the same case as Fig. I,

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May 1953 BIRT:.Subphrenic Infection 245

Course of DiseaseAs has been stated above, the majority of sub-

phrenic infections are due to some focus of intra-abdominal suppuration. Shea and Holden (1948)investigated a large number of cases of subphrenicinfection and observed that the average time fromthe onset of the abdominal suppuration to thesuspicion of the presence of subphrenic infectionwas 15 days.

In considering the course of subphrenic in-fections it must be realized at the outset that themajority of infections never proceed to suppura-tion. Those cases which never go on to suppura-tion remain as a cellulitis of the subphrenic spaceand then resolve completely, those which do notsubside proceed to the formation of an abscess.Ochsner and Graves, in I933, reported that about70 per cent. of subphrenic infections subsidespontaneously and about 30 per cent. proceed tosuppuration. It is important to note this observa-tion which was, of course, made before the dayseven of sulphonamide therapy. It will, therefore,be appreciated that about two-thirds of all casesof subphrenic infection will recover completely ontheir own without any form of treatment of theinfection.

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FIG. 3.-X-ray film showing a right-sided subphrenicabscess-_without any gas and consequently without? fluid level within the abscess cavity.

In considering those cases which have gone onto suppuration it must be stressed at the outsetthat their prognosis without treatment is poor, andthat with energetic and correct treatment themortality, can be lowered very greatly. It isdifficult to be certain of the present mortalityfigures since the advent of antibiotics and chemo-therapy, but Ochsner and Graves found that themortality in cases of suppuration was as high asabout 90 per cent. without surgical drainage, andthat with drainage the mortality was lowered toabout 33 per cent.

These figures are sufficient evidence to show theimportance of early diagnosis and correct surgicaldrainage in all cases which have resulted insuppuration.

Although no really accurate figures are availablesince the advent of antibiotics, there seems to belittle doubt that the use of these drugs has pre-vented as many cases from proceeding to suppura-tion as was the case formerly, more cases havingundergone resolution in the stage of cellulitis.

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FIG. 4.-This lateral view X-ray shows one of the com-plications of subphrenic abscess. The subphrenicabscess was drained at the site of the lower tube.The patient then developed an empyema which wasdrained at the site of the upper tube. This film wastaken towards the end of treatment after the tubeshad been progressively shortened in length andshortly before their removal.

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POSTGRADUATE MEDICAL JOURNAL

Once suppuration has taken place, the importanceof early and adequate surgical drainage is just asgreat as before, but the use of the antibioticscertainly seems to have done a great deal todiminish the intense toxaemia from which thesepatients suffered, presumably by diminishing theactivity of the organisms within the abscess. Thereis no doubt, clinically, that cases of subphrenicabscess coming to operation today under anti-biotic therapy are in a much less toxic state thanwas the case before the days of antibiotics.

ComplicationsThe most common complications of subphrenic

infections are those affecting the pleura and lungimmediately above the part of the diaphragmwhich is overlying the area of infection. Theraising and immobility of the diaphragm results ina high incidence of basal lobular atelectasis of thelung on the affected side, and the atelactatic lungnot infrequently becomes infected and results inbroncho-pneumonia, which itself may give rise toa lung abscess. Shea and Holden stated thatbroncho-pneumonia accounted for about 50 percent. of all the complications resulting from sub-phrenic infections. Pleural effusions develop notinfrequently owing to inflammation of the pleurathrough the diaphragm. These usually resolvebut may go on to give rise to an empyema (Fig. 4).The other complications are comparatively rareand consist mainly of hepatic abscess, septicaemiaand pyaemia. In very rare cases a subphrenic-pleuro-bronchial fistula may develop, in whichcase the patient coughs up the pus from the sub-phrenic abscess.

TreatmentIt cannot be stated too strongly that the mor-

tality of subphrenic suppuration can only belowered by early diagnosis of the condition, sothat the correct treatment can be instituted.There seems to be little doubt that the in-

stitution of antibiotic therapy once the diagnosis ofsubphrenic cellulitis has been made will prevent atleast some cases from proceeding to suppurationand so will aid resolution of a higher proportion ofpatients. Furthermore, even in those cases whichdo not resolve, the patient's clinical conditionusually remains so much better generally than itdoes without the use of antibiotics.The majority of infections are due to streptococci

and staphylococci, and penicillin is, therefore, themost useful of the antibiotics for routine use; butit must be remembered that a large number of in-fections are due to B. coli and to other organismsso that if penicillin produces no response, strepto-mycin, chloromycetin or aureomycin must be usedin addition.

Occasionally the antibiotics will apparently aidresolution of the infection so that the patient seemsto be perfectly well and the infection overcome.The administration of the antibiotics is stoppedand, after a lapse of time, the infection againmanifests itself. In one case, under the writer'scare, this actually happened and the patient wasdischarged from hospital only to return a fewweeks later with a return of his pyrexia so thatdrainage ultimately became necessary. This isdue to the fact that all the organisms were notkilled in the first place and were therefore able toflare up again, and serves to illustrate the necessityof continuing antibiotic therapy for a sufficientlylong time after the infection has apparently beenovercome.Once suppuration has occurred, resolution will

only take place in rare cases, and if the highmortality associated with the condition is to beavoided, surgical drainage of the abscess must beundertaken.

Surgical approach of a subphrenic abscess canbe either trans-thoracic or trans-abdominal, and ineither case the approach can be trans-serous orextra-serous.Any form of trans-serous approach is to be

condemned as this will result in infection of theserous cavity traversed in a high proportion ofcases, giving rise to an empyema or peritonitis.

Drainage must, therefore, be carried out by anextra-serous route. Originally this was achievedby the trans-thoracic method, either below thereflection of the pleura or by mobilizing the pleuraof the costo-phrenic angle, but in either case therewas a grave risk of tearing the pleura and so in-fecting it. Other methods were tried, firstlysuturing the two surfaces of the pleura together,which was not successful as infection spreadthrough the suture holes; and secondly by thetwo-stage method of preliminary exposure of theparietal pleura and packing down to it so as topromote the formation of adhesions in the pleuralcavity and then a few days later draining theabscess through the area of adhesions. This lastmethod was not satisfactory as it meant delayingthe actual drainage of the abscess for several daysduring which time the patient's condition wasdeteriorating.The great advance came in 1933 when Ochsner

and Graves described the method of trans-abdominal, extra-serous approach to a subphrenicabscess through the bed of the I2th rib. The rightsuperior posterior subphrenic space is the mostcommonly affected, and the approach to this spaceis described. A horizontal incision is made at thelevel of the outer third of the 12th rib which isthen resected periosteally. The dissection is thencontinued through the outer end of the bed of this

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May 1S53 DONALD: Resuscitation of the Newborn 2

rib, lateral to the attachment of the arcuate liga-ment of the diaphragm. The dissection must,therefore, be below the diaphragm and behind theperitoneum. Dissection upwards and forwards inthis position must lead to the subphrenic space.This method can also be used on the left side forthe approach to a posterior subphrenic abscess onthat side.

Anterior subphrenic abscesses are approachedby means of subcostal incisions which will leaddirectly to the abscess cavity extra-peritoneally, asadhesions will have walled off the abscess from thefree peritoneal cavity below.The importance of carrying out drainage by an

extra-serous approach is shown by Ochsner andGraves. They found that the mortality of sub-phrenic abscesses drained by an approach whichdid not contaminate any serous cavity was about21 per cent., while in those drained trans-pleurallythe mortality was 39 per cent. and in those drainedtrans-peritoneally it was 35 per cent.

SummaryI. The anatomy of the subphrenic region has

been described.2. The aetiology of subphrenic infection has

been discussed; most cases follow intra-abdominalsuppuration.

3. The diagnosis has been considered. The

condition will only be diagnosed early if the sur-geon is continually on the look-out for its presence.There is no single method of diagnosis althoughthe radiological findings are of great help.

4. The course of the disease and its main com-plications have been described. It is to be noted thatabout 70 per cent. of cases will resolve on theirown without going on to suppuration.

5. The use of antibiotics in the treatment of theinfection has been described, together with themethods of drainage of the abscesses. The im-portance of an extra-serous approach to theabscess is stressed and the method through thebed of the resected I2th rib is described.

AcknowledgmentsMy thanks are due to my colleagues on the

Staff of the Norfolk and Norwich Hospital forpermission to make use of the notes of cases treatedby them and for so kindly allowing me to reproducesome of the X-ray films from their cases.

BIBLIOGRAPHYBAILEY, H. (1948), J. Int. Coll. Surg., II, 377.FRIEDMAN, P. S. (1950), Radiology, 55. 36.GROSS, H. T. (1948), Ohio St. Med. J., 441I005.OCHSNER, A., and GRAVES, A. M. (I933), Ann. Surg., 98, 961.SHEA, P. C., JUN., and HOLDEN, W. D. (I948), Arch. Surg., 57,

843.THOREK, P. (I947), Surgery, 31, 739.

RESUSCITATION OF THE NEWBORNBy IAN DONALD, M.B.E., M.D., B.A., M.R.C.O.G.

Reader, Institute of Obstetrics and Gynaecology, University of London

At no time is a baby likely to be as near death asit is within the first 15 minutes of extra-uterine life.The first few breaths demand a well co-ordinatedeffort to produce the necessary pressures to openup the lung alveoli. Experimental attempts toinflate collapsed lung artificially usually requirepressures of over 40 cm. of water at first. Afterthe lung has once been expanded, lower pressureswill succeed in keeping the alveoli open.

For a child to be equal to this effort it must befit enough to react adequately to the stimuli whichthe birth process inflicts. The stimuli are of twosorts. Firstly, there are those from skin andjoints which crowd in upon the baby's conscious-ness. Secondly, these are reinforced by thephysiological anoxia of delivery. In animals the

foetus often falls on to its snout and this providesa very powerful stimulus to respiration.The carotid sinus, too, plays an important part

in respiration as a receptor organ for stimuli, bothpressor or chemical, and it is known that breathingis markedly depressed following sinus denervationin experimental animals. An accumulation ofcarbon dioxide will thus stimulate the carotidsinus, but only where it is functionally capable ofreacting. Previous anoxia may diminish theresponse, especially in cases of prematurity andcerebral compression.Aetiology of Neonatal Asphyxia

In extreme prematurity, alveolar developmentmay not be sufficiently far advanced to sustain

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