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SUBPHRENIC ABSCESS
674
agitation, insomnia, bad taste in the mouth, and brown furring of the tongue; rashes have occurred occasionally but have not been severe. Disturbances severe enough to necessitate cessation of treatment have been decidedly rare. Nevertheless there has been anxiety in some quarters, and this has particularly concerned the possibility of injury to the foetus during early pregnancy. In the United States particularly the doubts persist, and they have been explained in this country in the Drug and Therapeutics Bulletin.3O The Bulletin points to the fact that in laboratory animals metronidazole has shown an unusual range of toxic effects for a drug to be used clinically for the treatment of a disease which does
of reports of severe toxic effects, it is perhaps surprising that the Federal Drug Administration in the United States has only lately authorised this remedy. Nevertheless the case for extreme caution in the use of metronidazole in early pregnancy cannot be denied, and the manufacturers have been wise to recommend that at present it should not be used in the first three months of pregnancy. SUBPHRENIC ABSCESS
THE hoary subject of subphrenic abscess takes on a fresh appearance in an account by Moore1 which throws doubt on the accepted anatomical boundaries of these abscesses and, hence, on the surgical procedures traditionally dictated by these. Barnard’s2 apparently not threaten life. The effects have included testicular definitive description has acquired the aura of gospel; and damage with disturbance of spermatogenesis, and of students have been taught the six spaces in neurological disorders such as ataxia and tremor. It generations which can collect between the diaphragm and the pus should be said, on the other hand, that testicular damage transverse colon and mesocolon. resulted from very high dosage in rats and did not develop Moore makes the substantial point that to talk of a on repetition of the experiment with lower but still high left-sided abscess is unrealistic. When a dosage. The neurological disorders resulted from over- cadaver is subphrenic radiographed in the erect position after a dosage in dogs and did not occur in other animals; they has been induced, the subphrenic pneumoperitoneum may have reflected an unusual susceptibility of this species. on the left is seen to contain no organ that cannot space Some concern was also expressed about the possibility of blood disorders, since the drug is an imidazole bearing the readily be displaced. Hence an accumulation of pus in this region is not truly subphrenic or within the thoracic nitro-group, and similar drugs have caused these toxic effects. It is true that studies of effects upon the white cage at all, and the abscess can readily be drained through blood-cells have been few, but they have given no cause an anterior abdominal approach. By contrast, the right for alarm. Serial white-cell counts have usually shown no lobe of the liver is large and remains (except for its inferior surface) within the thoracic cage when air is significant changes, and no cases of serious blood dyscrasia introduced into the abdominal cavity. The area immedihave been reported. The Bulletin recommends that metronidazole should not be used during pregnancy ately below the liver on the right, therefore, is abdominally because the action on the human fcetus is unknown, and placed, and abscesses here will produce a palpable mass, whereas collections above the liver are closely related to also that it should not be taken by nursing mothers because it is excreted in breast-milk and its effect on new- the diaphragm and do not give rise to a mass which can be born infants, and especially premature infants, is also seen or felt. Such collections can be revealed early only by unknown. It is true that full data are not available on means of radiography. The triangular ligament of the liver is generally these matters. Robinson and Johnson 31 treated 100 pregregarded as a barrier separating the right subphrenic nant women giving each 500 mg. of the drug daily for space into anterior and posterior intraperitoneal compartten days, and none of the 93 infants born before their ments. Moore shows clearly that the triangular ligareport was published suffered adverse effects which could be attributed to treatment; but the stages of pregnancy at ment is situated so posteriorly that for all practical which the patients were treated was not stated. Scott Gray purposes only one large area above the right lobe of the liver can rightly be regarded as subphrenic. An abscess et al. 32 showed that metronidazole was excreted in breastmilk in concentrations comparable with those found in the above the liver on the right side is subphrenic; but the blood-serum. None of the infants whose mothers received right posterior subphrenic abscess, hitherto assumed to be the drug suffered ill-effects, but each mother had been a sequel to extension of suppuration from the appendix, is a figment. given only one tablet of 200 mg. Crowther 33 gave metroniThe practical conclusions are obvious. Moore points dazole to 2 premature infants with trichomonal vaginitis, out that direct and adequate drainage cannot be in a dosage of 50 mg. three times daily for five doses in achieved on the right side by an anterior or posterior 1 case and for seven days in the other. Both responded approach: it must be lateral. But the lateral exposure has well to treatment and neither had toxic effects. Fluker 34 described the case of a pregnant girl who swallowed been frowned on, because the pleural cavity must be and infection here may lead to empyema. twenty-one 200 mg. tablets of the drug at one time. -Apart traversed, Moore believes that the risk is exaggerated. The from transient disorientation there were no ill-effects on is as resistant to infection as the peritoneum. If the mother or foetus, but the stage of pregnancy at which the pleura will resist the surgeon temptation to intervene too early tablets were taken was not stated. will avoid multiple needle punctures which are likely Caution is certainly desirable; but the question arises (and to spread infection) the adjacent pleura will adhere to the whether caution can be taken too far in assessing a valuable, Even if the pleura is not adherent, no harm and indeed unique, remedy for a condition which can be diaphragm. need follow operation through the midaxillary line and severe and distressing and does not respond satisfactorily resection of the eighth or ninth ribs, provided that the to other remedies. In view of the four years’ experience lung is kept expanded. Since the advent of antibiotics, with many thousands of cases and the complete absence subphrenic infection often resolves without operation; 30. ibid. 1963, i, 1116. when operation becomes necessary, surgeons will do well 31. Robinson, S. C., Johnson, D. W. Canad. med. Ass. J. 1961, 85, 1094. to adopt Moore’s sensible approach. 32. Scott Gray, M., Kane, P. O., Squires, S. Brit. J. vener. Dis. 1961, 37, 278.
33. 34.
Crowther, I. A. Lancet, 1962, i, 1074. Fluker, J. L. Brit. J. vener. Dis. 1961, 36,
280.
1. 2.
Moore, H. D. Ann. Surg. 1963, 158, 240. Barnard, H. L. Brit. med. J. 1908, i, 371.
agitation, insomnia, bad taste in the mouth, and brown furring of the tongue; rashes have occurred occasionally but have not been severe. Disturbances severe enough to necessitate cessation of treatment have been decidedly rare. Nevertheless there has been anxiety in some quarters, and this has particularly concerned the possibility of injury to the foetus during early pregnancy. In the United States particularly the doubts persist, and they have been explained in this country in the Drug and Therapeutics Bulletin.3O The Bulletin points to the fact that in laboratory animals metronidazole has shown an unusual range of toxic effects for a drug to be used clinically for the treatment of a disease which does
of reports of severe toxic effects, it is perhaps surprising that the Federal Drug Administration in the United States has only lately authorised this remedy. Nevertheless the case for extreme caution in the use of metronidazole in early pregnancy cannot be denied, and the manufacturers have been wise to recommend that at present it should not be used in the first three months of pregnancy. SUBPHRENIC ABSCESS
THE hoary subject of subphrenic abscess takes on a fresh appearance in an account by Moore1 which throws doubt on the accepted anatomical boundaries of these abscesses and, hence, on the surgical procedures traditionally dictated by these. Barnard’s2 apparently not threaten life. The effects have included testicular definitive description has acquired the aura of gospel; and damage with disturbance of spermatogenesis, and of students have been taught the six spaces in neurological disorders such as ataxia and tremor. It generations which can collect between the diaphragm and the pus should be said, on the other hand, that testicular damage transverse colon and mesocolon. resulted from very high dosage in rats and did not develop Moore makes the substantial point that to talk of a on repetition of the experiment with lower but still high left-sided abscess is unrealistic. When a dosage. The neurological disorders resulted from over- cadaver is subphrenic radiographed in the erect position after a dosage in dogs and did not occur in other animals; they has been induced, the subphrenic pneumoperitoneum may have reflected an unusual susceptibility of this species. on the left is seen to contain no organ that cannot space Some concern was also expressed about the possibility of blood disorders, since the drug is an imidazole bearing the readily be displaced. Hence an accumulation of pus in this region is not truly subphrenic or within the thoracic nitro-group, and similar drugs have caused these toxic effects. It is true that studies of effects upon the white cage at all, and the abscess can readily be drained through blood-cells have been few, but they have given no cause an anterior abdominal approach. By contrast, the right for alarm. Serial white-cell counts have usually shown no lobe of the liver is large and remains (except for its inferior surface) within the thoracic cage when air is significant changes, and no cases of serious blood dyscrasia introduced into the abdominal cavity. The area immedihave been reported. The Bulletin recommends that metronidazole should not be used during pregnancy ately below the liver on the right, therefore, is abdominally because the action on the human fcetus is unknown, and placed, and abscesses here will produce a palpable mass, whereas collections above the liver are closely related to also that it should not be taken by nursing mothers because it is excreted in breast-milk and its effect on new- the diaphragm and do not give rise to a mass which can be born infants, and especially premature infants, is also seen or felt. Such collections can be revealed early only by unknown. It is true that full data are not available on means of radiography. The triangular ligament of the liver is generally these matters. Robinson and Johnson 31 treated 100 pregregarded as a barrier separating the right subphrenic nant women giving each 500 mg. of the drug daily for space into anterior and posterior intraperitoneal compartten days, and none of the 93 infants born before their ments. Moore shows clearly that the triangular ligareport was published suffered adverse effects which could be attributed to treatment; but the stages of pregnancy at ment is situated so posteriorly that for all practical which the patients were treated was not stated. Scott Gray purposes only one large area above the right lobe of the liver can rightly be regarded as subphrenic. An abscess et al. 32 showed that metronidazole was excreted in breastmilk in concentrations comparable with those found in the above the liver on the right side is subphrenic; but the blood-serum. None of the infants whose mothers received right posterior subphrenic abscess, hitherto assumed to be the drug suffered ill-effects, but each mother had been a sequel to extension of suppuration from the appendix, is a figment. given only one tablet of 200 mg. Crowther 33 gave metroniThe practical conclusions are obvious. Moore points dazole to 2 premature infants with trichomonal vaginitis, out that direct and adequate drainage cannot be in a dosage of 50 mg. three times daily for five doses in achieved on the right side by an anterior or posterior 1 case and for seven days in the other. Both responded approach: it must be lateral. But the lateral exposure has well to treatment and neither had toxic effects. Fluker 34 described the case of a pregnant girl who swallowed been frowned on, because the pleural cavity must be and infection here may lead to empyema. twenty-one 200 mg. tablets of the drug at one time. -Apart traversed, Moore believes that the risk is exaggerated. The from transient disorientation there were no ill-effects on is as resistant to infection as the peritoneum. If the mother or foetus, but the stage of pregnancy at which the pleura will resist the surgeon temptation to intervene too early tablets were taken was not stated. will avoid multiple needle punctures which are likely Caution is certainly desirable; but the question arises (and to spread infection) the adjacent pleura will adhere to the whether caution can be taken too far in assessing a valuable, Even if the pleura is not adherent, no harm and indeed unique, remedy for a condition which can be diaphragm. need follow operation through the midaxillary line and severe and distressing and does not respond satisfactorily resection of the eighth or ninth ribs, provided that the to other remedies. In view of the four years’ experience lung is kept expanded. Since the advent of antibiotics, with many thousands of cases and the complete absence subphrenic infection often resolves without operation; 30. ibid. 1963, i, 1116. when operation becomes necessary, surgeons will do well 31. Robinson, S. C., Johnson, D. W. Canad. med. Ass. J. 1961, 85, 1094. to adopt Moore’s sensible approach. 32. Scott Gray, M., Kane, P. O., Squires, S. Brit. J. vener. Dis. 1961, 37, 278.
33. 34.
Crowther, I. A. Lancet, 1962, i, 1074. Fluker, J. L. Brit. J. vener. Dis. 1961, 36,
280.
1. 2.
Moore, H. D. Ann. Surg. 1963, 158, 240. Barnard, H. L. Brit. med. J. 1908, i, 371.