GENERAL OBSERVATIONS ON SEA-SICKNESS AND THE LABYRINTHINE THEORY
Authors: T. G. Maitland
Journal: BMJ (1931)

JMEDICAL JOURNAL venture offensive brown pus was found.Then, through an oblique incision, the termiinal half of the last rib was removed aInd the diaphragm cut horizontally; it was thickened and inflamed.Forceps were passed upwards and forwards along the needle into the abscess cavity, which was the size of an orange, and lying chiefly behiind the right lobe of the liver.It was drained throughI a large tube, and the patient made a good and rapid recovery. CASE IIIT. B., a male aged 59, lhad had indigestion and attacks of vomiting for years.On November 1st, 1922, he was seized with sudden severe abdominal pain, accompanied by vomiting, and was admitted to Guy's Hospital on November 4th.The right upper quadrant of the abdomen was rigid, and there were signs of compression of the base of the right lung.The x-ray report stated: " Right diaphragm is greatly elevated and completely immobile.Left diaphragm moves well.Gas bubble above right lobe of liver."This abscess was explored trans- pleurally by resecting the tenth rib in the mid-axillary line, four and a half pints of fluid being removed.The patient died on December 11th, and at the post-mortem examination a large right empyema and collapsed lung were found.The subphrenic abscess.was secondary to a perforated duodenal ulcer.CASE IV 1. G., aged 33.A gastric ulcer was operated upon seven hlours after perforation, suture of ulcer being done with supra- pubic drainage.Eight days later pain was complained of below the left costal margin, and examination proved a "rub" at the left base.A strawv-coloured fluid was aspirated.On the eleventh day a left subphrenic abscess was drained by incision below the last rib.On the fourteenth day there was rib resection for left-side empyema; the patient died on the twenty-eighth day.McC., aged 62 years, was admitted to Guy's Hospital oni May 2nd, 1925, with a fifteen-hour history of acute pain in the upper abdomen.Laparotomy revealed a perforated duodenal ulcer.Suture with drainage of the peritoneum was performed.Three weeks later he had pyrexia with pain over the lower ribs on the right side.The white blood count was 20,000.X-ray report: " Right leaf of diaphragm is slightly elevated, movements greatly diminished.Slightly indefinite opacity at right base suggestive of pleural thickening, but no effusion seen.Left base and left diaphragm show no abnormality."Pus having been found by an exploring needle on Juune 11th a portion of the eleventh rib was resected on thle right side; the lower margin of the pleura was found and sutured to the diaphragm.The diaplhragm was then opened subpleurally anid the abscess drained.He made a satisfactory recovery, and was discharged a fortnight later.CASE VI K. S., aged 38, was admitted to Guy's Hospital on September 12th, 1927, withi fourteen days' history of pain in the left loin, with pyrexia.There wa-s tenderness in the left loin and dullness at the left base of the lung, but x rays showed no abnormality.An exploring needle inserted through the tenth space located pus apparently.below the diaphragm.A portion of the eleventh rib was resected and the pleural cavity opened; no pus wras present.The pleura was closed and the diaphragm incised andl a subdiaphragmatic abscess drained.One month later the pyrexia was still present, and pus was found by an exploring needle in the left pleural cavity; this was drained through the original wound.After a prolonged, conivalescence the patient left the hospital with a discharging sinus.CONCLUSIONS A review of the causes, symptoms, and diagnosis of the subphrenic abscess is given.The treatment is discussed, and the posterior subpleural method of approach is advocated in order to avoid pulmonary complications-.Cases are cited i-Rustrating the complications following the trausleural route.Cases II and' V show the advanltag,es o.f the subpl3eu-ral route.