Lyman A. Brewer

Subphrenic abscess: A thoracoabdominal clinical complex: The changing picture with antibiotics☆

D ESPITE the effectiveness of antibacteria agents in peritonitis and pIeuropuImonary infections, the present day incidence of subphrenic abscess has not appreciabIy decreased in our experience, while the empIoyment of antibiotics is steadiIy increasing. In fact, the use of antibiotics has added to the diffIcuIties of diagnosis. We beIieve that the diagnostic probIems wiI1 be simpIified if one considers subphrenic abscess as a thoracoabdomina1 cIinica1 compIex. It is truIy thoracoabdomina1, because there is usuaIIy invoIvement of both regions of the body with a dominance of the thoracic or abdomina1 findings in any given case. Furthermore, this subject has received IittIe attention in the medica Iiterature since the advent of antibiotics. Therefore a review of 125 cases of subphrenic abscess has been made on the Loma Linda University SurgicaI Services at the Los AngeIes County Genera1 HospitaI to study the vaIidity of our concept that subphrenic abscess is a thoracoabdomina1 cIinica1 compIex and to bring us up-to-date on the changing picture with antibiotics.

A Comparative Study of Cardiopulmonary Bypass with Nonblood and Blood Prime

Abstract A prospective study of cardiopulmonary bypass in adult cardiac surgical patients undergoing similar types of operations compared 50 consecutive perfusions utilizing a clear, balanced, electrolyte-protein prime with 50 consecutive perfusions utilizing a solution containing 1,000 ml. of blood. Significant findings were: The oxygenation and perfusion capabilities during bypass were similar and satisfactory in both groups. The postoperative coagulation studies were essentially the same. The postoperative plasma hemoglobin was 83 mg. per 100 ml. with nonblood prime and 138 mg. per 100 ml. with blood prime; and 12 hour postoperative blood loss was 353 ml. with nonblood prime and 455 ml. with blood prime—22% less in the nonblood prime group. Total blood requirements during hospitalization averaged 1,500 ml. in the nonblood prime group and 3,500 ml. in the blood prime group. The use of nonblood prime and autotransfusions reduces postoperative blood loss, demands on blood bank facilities, risk of serum hepatitis, transfusion reactions, and coagulation abnormalities.

Strangulating Diaphragmatic Hernia

Abstract Understanding that strangulated diaphragmatic hernia is a thoracoabdominal complex consisting of distinctive gastrointestinal and cardiorespiratory features will facilitate earlier diagnosis and treatment. Strangulated diaphragmatic hernia is a fatal condition unless promptly recognized and surgically treated. The abdominal manifestations of the acute complex include sudden excruciating upper abdominal pain and tenderness, nausea and vomiting, and gastrointestinal bleeding or shock or both. The thoracic portion of the complex is characterized by severe lower chest or substernal pain with radiation to the neck or shoulder. Dyspnea and cyanosis result from a mediastinal shift produced by massive distention from herniated viscera or pleural effusion or both. A gastrointestinal series should be obtained in all patients with crushed chest injuries, multiple rib or pelvic fractures, or severe blows to the lower thorax or upper abdomen before discharge from the hospital. The thoracic approach is preferred for left-sided strangulated diaphragmatic hernia, but the abdominal route may also be satisfactory. The thoracic approach is essential for proper management of strangulated hernia occurring on the right side.