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smoking interferes with the healing of a peptic ulcer andhelps to maintain its chronicity.We are grateful to Miss Keena Jones, Mrs. M. M. Glyn, Mrs. B.

Kenchington, and Mrs. R. Bird, who recorded the smoking historiesof the patients, and, in particular, to Miss Jones for assistance in thestatistical analysis of the results.

REFERENCES

Batterman, R. C. (1955) in The Biologic Effects of Tobacco (edited byE. L. Wynder). London.

— Ehrenfeld, I. (1949) Gastroenterology, 12, 575.Brown, R. G., McKeown, T., Whitfield, A. G. W. (1957) Brit. J. prev. soc.

Med. 11, 162.Doll, R., Friedlander, P., Pygott, F. (1956) Lancet, i, 5.

— Hill, A. B. (1950) Brit. med. J. ii, 739.— — (1952) ibid. ii, 1271.— — (1956) ibid. ii, 1071.— Price, A. V., Pygott, F., Sanderson, P. H. (1956) Lancet, i, 70.— Pygott, F. (1952) ibid. i, 171.— — (1954) ibid. ii, 1200.— — (1958) To be published.

Hammond, E. C., Horn, D. (1957) Paper read to the American MedicalAssociation, New York City, June, 1957.

Jamieson, R. A., Illingworth, C. F. W., Scott, L. D. W. (1946) Brit. med. J.ii, 287.

Registrar General (1951) Classification of Occupations, 1950. H.M.Stationery Office.

Segi, M. (1957) Paper read to the International Society of GeographicalPathology, Paris, July, 1957.

DIAPHRAGMATIC HERNIÆ DUE TO

BLUNT TRAUMA

A. W. FAWCETTM.B. Edin., F.R.C.S.THORACIC SURGEON

JOHN B. DASM.B. Madras, F.R.C.S.

THORACIC SURGICAL REGISTRAR

ROYAL INFIRMARY, SHEFFIELD

DIAPHRAGMATIC hernix (apart from those through theoesophageal hiatus) may be traumatic or congenital. As aresult of two world wars, and the increase of road acci-dents, diaphragmatic hernia of traumatic origin is

steadily becoming commoner (Carter et al. 1951). We

present five cases in which the diagnosis was made sometime after the injury.

Case-reportsCase 1.-A boy, aged 12 years, was admitted in August,

1950, shortly after a motor accident in which he was hit in theside. He was cyanosed and dyspnoeic. There were bruisesover the scalp and right elbow, besides upper abdominal

rigidity. Skiagrams showed a subluxation of the right acromio-clavicular joint and slight displacement of the right olecranonepiphysis; the X-ray film of the chest showed what appearedto be a high cupola of the diaphragm with partial collapse ofthe left lower lobe, and multiple large gas bubbles below it(fig. 1). Traumatic diaphragmatic hernia was suspected, butfluoroscopy showed a paralysis of the left cupola. The bone

injuries were treated with Robert Jones strapping.The general condition improved, and further X-ray films of

the chest showed a gradual return of the left diaphragm to amuch lower position (fig. 2a); but the collapse of the lower lobepersisted. He continued to have pain in the epigastrium, leftchest, and shoulder, relieved by resting, and dyspnaea on exer-tion. A barium-meal examination confirmed the earlier diag-nosis of traumatic diaphragmatic hernia, and showed the mainbody of the stomach (which had undergone volvulus) in theleft lower chest (fig. 3). Unfortunately, the boy was lost sightof till October, 1951, when he came into hospital with increas-ing symptoms. He also

complained of "fluidsplashing in the chest"when he ran. The left lowerchest was hyperresonant an-teriorly. Breath sounds werediminished over this area;gurgling could be heard.At left thoracotomy, a

large amount of small gutand transverse colon, as wellas the stomach, were foundin the left chest. There wasa rent in the left diaphragm,10 cm. long, parallel to thelateral chest wall, and run-ning forwards from just infront of the cesophageal

Fig. 3-Case 1: Barium-mealexamination.

hiatus: there were a few adhesions at the anterior end of therent. The gut was returned to the abdomen with some

difficulty, and the hole repaired with nylon. The postoperativecourse was smooth.

In this case, though traumatic diaphragmatic hernia wassuspected early, hasty interpretation of the fluoroscopyfindings led us astray. The lateral view of the chest filmtaken two months after the accident (fig. 2b) shows thatwhat was presumed to be a high cupola was in fact theupper margin of the herniated stomach; the arch-likeshadow falls short of the anterior chest wall anteriorly.Case 2.-A man, aged 43, was admitted to the Royal

Infirmary in September, 1952, with epigastric distension after

Fig. 1-Case 1: Posteroanterior view of the chestsoon after the accident, showing the collapse ofthe left lung, and areas of translucency in theleft lower chest.

(a) (b)Fig. 2-Case 1 : Posteroanterior (a) and left lateral (b) views of the chest, a fewmonths after the accident. Although the left lung is better expanded, the gas bubblesin the left chest persist.

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food, worse on lying down. He had been buried by a fall ofcoal in a mine in August, 1951. Since the accident, he hadhad epigastric fullness soon after a meal, partly relieved byvomiting. Dieting gave very little relief. Clinical examinationshowed a hyperresonant zone in the left lower chest. Barium

meal and follow-through confirmed the diagnosis of diaphrag-matic hernia.

At left thoracotomy, the stomach, spleen, and omentumwere found to have herniated through a rent, 20 cm. long,across the left cupola, extending posteriorly up to the crura.The abdominal viscera, including the spleen, were returned tothe abdomen, and, after the edges had been freshened, therent was repaired with interrupted silk. Postoperative progresswas uneventful.

Case 3.-A man, aged 28, was first seen in July, 1957, com-plaining of epigastric fullness and pain after food, worse onreclining. He had been involved in a motor-cycle accidentfour years previously, when he sustained simple fractures ofboth bones of the left forearm, and a fractured pelvis. The

epigastric pains had come on a year later. Clinically, therewas no abnormal physical sign in the chest or abdomen. A

Fig. 4-Case 3: Barium-meal examination shows the volvulus of thestomach inside the left chest, with the cardia and the pylorus stillbelow the level of the diaphragm.

barium-meal showed a diaphragmatic hernia, the stomach,which had undergone a volvulus, was in the left hemithorax(fig. 4).At left thoracotomy, the stomach, left lobe of the liver,

small gut, and omentum were found to occupy the left chest;they were attached to the rim of the rent across the left cupola.These organs were freed, and returned to the abdomen. Therent was repaired with interrupted silk sutures. The post-operative course was without incident.

Case 4.-A man, aged 33, was first seen in September,1942, because of epigastric pains (chiefly soon after meals, andsometimes after exertion), and severe eructations. The epi-gastric pains had come on soon after a fall in January, 1942.Clinically, nothing abnormal was found in the chest or abdo-men. A skiagram of the chest showed the left diaphragmobscured by dark shadows, " not unlike distended bowel " inthe left lower chest. A barium-enema examination showedthese shadows to be due to the splenic flexure of the colonlying above the level of the diaphragm.

At left thoracotomy, the splenic flexure of the colon wasfound in the left chest, having come through a rent across theleft cupola. The colon was returned to the abdomen, and therupture repaired. Further progress was smooth.

Case 5.-A man, aged 27, was buried by a fall of coal in acolliery in January, 1940, and treated in a plaster-of-paris castfor a spinal injury. Soon after the accident, he started havingsharp pains in the left anterior chest and epigastrium, worse onexertion or bending, and after meals; this was associated withshortness of breath as well. When we first saw him in Septem-ber, 1949, the chest and the abdomen appeared normal clini-

Fig. 5-Case 5: Left lateralview of the chest 7 yearsafter the accident; confu-sion with localised even-

tration of the diaphragmis easy.

cally. An X-ray film of thechest had revealed the stomach inthe left chest (fig. 5), with a largefluid level; a barium meal con-firmed this. The stomach had

undergone volvulus.At left thoracotomy, the left

chest was found to contain the

stomach, spleen, coils of small

intestine, and the splenic flexureof the colon. There was a rent inthe diaphragm, right across thecupola, lateral to the oesophagealhiatus. The abdominal organswere returned to the addomen;the margins of the rent were

freshened, and the diaphragmwas repaired with nylon. Theimmediate postoperative course

was marred by a segmental collapse in the right lower lobe.

Discussion

The diaphragm, along with the transversi sterni et

abdomini and the levatores ani, is primarily a compressorof the caelomic cavity. Its respiratory function is of onlysecondary significance (Wood Jones 1946). Therefore it isreasonable to expect all the compressors to take the strainat the moment of impact, when a sudden compressionforce is applied to the lower chest or upper abdomen orboth. The bursting force is expended on the relativelymobile diaphragm, whose periphery (the costal element)is protected by the lower thoracic cage; hence it is the

cupola that splits-at or near the musculotendinous junc-tion, as in rupture of other muscles. The right dome iswell protected by the solid and elastic liver, while the leftone has no such protective buffer-on the contrary, it isweakened because the left leaf of the central tendon issmall, and the musculotendinous junction is sited acrossthe very vertex of the cupola. The rent rarely if ever runsbackwards into the oesophageal hiatus, for the crural slinghas a tendency to pull away into the comparative safetyafforded by the lumbar spine. If the rent is large, massiveherniation of the abdominal viscera follows, giving rise toimmediate symptoms. With small rents (which are com-moner with penetrating injuries), omentum may plug thehole, which later enlarges, helped by associated infarctionof the diaphragm at the time of the original accident.Strangulation is the catastrophic sequel to these lesserdeficiencies. A subsequent trivial trauma, which increasesthe intra-abdominal pressure facilitates this process.Carter and Giuseffi (1948) found that 90% of strangu-lated diaphragmatic herniae were traumatic in origin.Clinical Types

Immediately after trauma.-Besides signs of shock, theremay be epigastric pain and distress, radiation of pain tothe shoulder-dyspncea, and cyanosis (as in case 1).Physical examination may show a contralateral mediastinalshift; dullness or hyperresonance will be evident in the

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involved hemithorax. There may or may not be symptomsand signs of incarceration of gut.

Latent group.-The symptoms are vague and bizarre,with periodic bouts of epigastric distension and dyspncea,relieved by vomiting.

Strangulated hernix.-The signs and symptoms are thesame as in stran ulated congenital diaphragmatic herniae; -,signs of strangulation, without obvious evidence of the site,are the rule. The early symptoms are pain in the upperabdomen or lower chest, vomiting, and hiccups. Upperabdominal rigidity is soon evident, but abdominal dis-tension is never great. The closed-loop obstruction insidethe chest leads to rapid distension, and a bloodstainedpleural effusion. Deterioration of the general condition isequally rapid, with increasing dyspnoea. The radiographicappearances are equally confusing.

Radiographic AppearancesThe common findings are:1. Contralateral mediastinal shift;2. High " cupola " (actually the upper margin of the herni-

ated gut simulating an exaggeratedly high diaphragm);3. Abnormal gas-bubbles or solid-viscera shadows in the

hemithorax; and

4. Areas of collapse in the adjacent lower lobe.

Fluoroscopy may "confirm" the mistaken diagnosis ofparalysed diaphragm. Barium-meal or enema examina-tion or both will clinch the diagnosis; and make easythe differentiation from eventration of the diaphragm,subphrenic abscess, and pleural effusion.

Treatment

The treatment of traumatic diaphragmatic hernia is

surgical; when they are complicated by strangulation,urgent operation is mandatory. The transthoracic

approach is ideal, because it leads one directly to theinvolved area; further, as the herniated viscera are alwaysadherent to the diaphragm or the lung, mobilisation underdirect vision is possible; and, last but not least, accuraterepair is easy, after freshening up the edges. Interruptednon-absorbable sutures are used. In strangulation neces-sitating resection of gut, the thoracic approach is just aseasy as the abdominal. But, where colon is strangulated,the possibility of twin-loop obstruction should be bornein mind-the cxcum and ascending colon distal to a com-petent ileocsecal valve act as a second closed loop, rapidlydistend, and are in imminent danger of perforation, unlessrecognised early. It may be necessary to extend therent in the diaphragm radially, to free the incarceratedviscera.

SummaryFive cases of diaphragmatic hernix, caused by blunt

trauma and treated by surgery, are described. Oneillustrates how easily, on X-ray films and fluoro-

scopy, herniated viscera may be mistaken for a highdiaphragm.The treatment is surgical. In strangulation, operation

is urgent.We are grateful to Dr. J. Wilkie (Royal Infirmary) and

Dr. E. K. Abbott (City General Hospital) for the radiographsand interpretations.

REFERENCES

Carter, B. N., Giuseffi, J. (1948) Ann. Surg. 128, 210.- - Felson, B. (1951) Amer. J. Roentgenol. 65, 56.

Wood Jones, F. (1946) Buchanan’s Manual of Anatomy. London.

ANTI-GLOBULIN CROSS-MATCHING TESTITS USEFULNESS FOR URGENT

BLOOD-TRANSFUSIONS

E. E. FRENCH *

M.D. McGill, D.C.P.

VOLUNTARY RESEARCH ASSISTANT, DEPARTMENT OF HÆMATOLOGY,POSTGRADUATE MEDICAL SCHOOL OF LONDON

* Trainee, National Institute of Arthritis and Metabolic Diseases,U.S. Public Health Service.

As the use of blood-transfusion increases, more andmore patients develop specific immune isoantibodies.If a patient requires a blood-transfusion very urgently,is it worth while to try to detect incomplete antibodiesby a short-cut anti-globulin cross-matching procedure, ormust one take a chance and give blood matched only forABO compatibility or, to patients in extremis, unmatchedgroup-0 Rh-negative blood ?

Ideally, a cross-matching test should include a tubetest for ABO compatibility carried out by mixing at roomtemperature the patient’s serum and a saline suspensionof the donor’s cells, and an anti-globulin (Coombs) cross-matching test carried out at 37 C. The saline matchingtest can be done without long standing if the tubes arecentrifuged at slow speed to allow closer contact of

antigen and antibody (Jennings 1954, Grove-Rasmussenet al. 1954). Thus a saline cross-match can be read,employing centrifugation, in 5-30 minutes. A direct

matching at 37-C of the patient’s serum and the donor’scells suspended in serum or albumin is probablyunnecessary if the anti-globulin cross-matching is done.However, the anti-globulin cross-matching is usuallyconsidered to need incubation at 37-C for at least 1 hour,preferably 2 hours, before testing with suitable dilutionsof anti-human-globulin serum.The present investigation was undertaken to find out

how far one can shorten the incubation time without

missing dangerous circulating antibodies. Sixty-nineantisera were tested to determine the time required forred-cell sensitisation and the factors which affected the

speed and degree of sensitisation.

ProcedureSeraThe following human sera, containing incomplete and

occasionally in addition low-titre complete, antibodies weretested: 30 anti-D, 6 anti-C, 3 anti-c, 4 anti-E, 1 anti-e,4 anti-Lea, 11 anti-K, 8 anti-Fya, 1 anti-S, and 1 anti-Jka.Some of the sera were fresh; most had been stored at -20°Cfor periods of up to 2 years.

Anti-globulin (Caornbs) TestThe anti-globulin cross-match was carried out as recom-

mended by Dacie (1956). One drop of a 30% cell suspensionin saline solution was added to 4 drops of serum, undiluted ordiluted (see below), in an 8 mm. test-tube, and placed in awater-bath at 37"C for 1, 5, 15, 30, 60, or 120 minutes. Afterthe prescribed time of incubation the tubes were removedfrom the water-bath and the cells washed three times with a

large volume of saline at ordinary room temperature.After the saline had been decanted and washed, the cells

were resuspended in the remaining saline, making an approxi-mately 30% suspension. One drop of this suspension wasthen mixed, on an opalescent tile, with one drop of suitablydiluted anti-globulin serum, rocked gently for 5 minutes, andthen inspected over a strong light without the aid of magnifica-tion. The reactions were scored as follows: _-4_-, just detectablegranularity; -I-, uniform easily visible granularity; ++,granularity with moderate aggregation into clumps; -1+++,