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A TREATISE
OH
DIAPHRAGMATIC HEENIA;
BEDCG
AN ACCOUNT OF A CASE OBSERVED AT THE MASSACHUSETTS GESERAL HOSPITAL
FOLLOWED BT A NUMERICAL ANALYSIS OF ALL THE CASES OF THIS AFFEC-
TION, FOUND RECORDED IN THE WRITINGS OF MEDICAL AUTHORS,
iettoeer) tt)e ()e^k*3 1610 qod 18if6.
BY HENRY I. BOWDITCH, M. D.,
OXK or TBB PBTBIC1AK8 OF THE MASSAOHUSEm OS5KRAL HOSPITAL; MEMBER OP THE SOCIETIES tO^
MEDICAL OBSERVATION OP PARIS AHD OF BOSTON.
BUFFALO:
PRINTED BY JEWETT, THOMAS k 00.
1858.
V\oo
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x/#\/%
PREFACE.
This monograph sufficiently explains itself. Suggested by a case, acci-
dentally met with at the hospital in this city, I prepared the memoir, some
time since, for the Boston Society for Medical observation. It has already
lain many years among my papers, and doubtless would have rested there
many more, had not my friend Dr. J. C. Dalton, Jr., induced me, a few
months ago, to present it to him for publication in the Buffalo Medical Jour-
nal, of which he was, at that time, acting editor. A few copies are now
republished from that periodical.
I have prepared it in a • strict accordance with the numerical system, as
expounded by Louis. It claims to give, in exact language, the precise state
of our knowledge of Diaphragmatic Hernia, so far as that knowledge can be
gained from the records left us by authors. It is founded on an analysis of
eighty-eight cases, that being the number of recorded facts of this nature,
found in Medical Literature during the period from 1610 to 1846. This is
a larger number than has ever before been collected by any American or Eu-
ropean writer on the subject I hope that the memoir will be useful to
the future student of Diaphragmatic Hernia, but the examination of it can
never afford any one a tithe of the pleasure or profit the original preparation
of it afforded me.
H. I. B.
Boston, July 4, 1863.
DR. J. BIZOT, OF GENEVA, SWITZERLAND.
Boston, July 4, 1853.
Mt Deab Bizot,
Allow me to dedicate thid monograph to you, as one who will fully appreciate
the labor undergone, and the pleasures experienced during its preparation. It may
serve to remind you of La Piti6 and of the many delightful hours we spent there
under the eye of our venerated master, Louis.
I remain, my dear Bizot,
Most sincerely your friend,
H. I. B.
CONTENTS.
leiO AKB 1B46.
Historical Bummarv of the litanttrae of
Diaphragmatic Hernia,
ClageiDcalion of tbc SulQects coctained
in tlie Monograph,
■ On wMcli dda of die Dinpliragm waa
the Hernial opening modB, 15
Talilal.iUnstnitiveofthiBBubject, 15
KeagonB vbj it is found ofteuer at the
left than the right,. 15
Hemia of the right ade, 16
Sacs chiefly on this aide, Table a, IG
Why so. Table 3 17
Modoof tonnatjon of Sacs, 18
Plate iUuHtntiTe of the ReaaonB irhy
Sacs are fonnad at the right aide, .. . 19
Oont«DtB of tb& Saci 19
Table4, 20
Hernia of both sides of the Diapbm^, 20
Diaphragm and Mediastinani waotiDg, SI
Diaphragm pushed up into theCheat,. 21
» Absence of the UodioBtinun], &c,, 21
Conditioo of the Diaphragmatic Open-
ing. as
Table 5, Inferences there&om, 32
Hernia through the CEsophageal Aper-
ture, 34
Do. Intercostal Serve Aperture, 24
Adhesion of Organs to the Aperture in
the Diaphragm, S5
Are the Organs strangulated by it ? 25
Hernia through iliuacular or Tendooons
part of the Diaphragui, S6
|"{)}^Mniu8traHTe of this topic,...- 26
L Table S, Showing what Orffana were
most commonly into tho Thoras and
on which Bide Uiej were found, 27
ABDOMEN,
stomach. Con tents, Situation, S6
Do. Injuries of ; Inflammation, 2
(Esophagus, Channo of its CJoutae, 2
Small lotestineB, Contents, Inflamma-
Ooion,' .'...' !.![."..'.!!!! 3
Liver, compreBsed, atrangnlated, Ao.,.. 3
Gall-bladder, Bile Ducts, compreBBed,. 3
Spleen, tom, ijic, rarelT disturbed, 3
Pancreas, rarely diBturbed, 3
Kidneys, rarely disturbed, 3
Omentom often displaced, Inflaoied, . . 3
Mesocolon. 3
Table 9, Showing the various combina-
tions of Abdominal Organs found in
the Thoras, 3
Abdomen, Collapaed, Distended, £c.,.. 3
Muscular System, , . 3
Utenw, 3
IBOBA£.
Thoras. Eiterior, 3
Lungs compreased, 3
Table 10, Showing amount of compres-
sion 3
Lungs, Adhesions, itc., 3
Pleurre, 3
Mediostiniim absent^ tom, Ac, -. 3
Ensiform CartilBgo, 3
Thj.muB Gland, 3
Pericardium, 8
Heart disptamJ, 3
Aorta and TeinB, i
Cranium _ 4
Symptoms, ttntMedetU loihe/iUal ailaek. II
Cephalic, rare, _._ 41
PulmDoary, dyspn<Ea, 41
Causes of dyspuosa, _ 42
Cough, rare, _ 43
Pains in the Ohest, 43
Peculiar "crawling" in Chesty 44
FilHofSuffixBtioD, ..- 44
Cardiac, _ 4i
Abdominal, vomiting, colics, 45
State of Skin, Ac, -- 46 (
VIU
OONTENTS.
PAOB.
Symptoms during the fatal attaeJe, 47
Cephalic, 47
Pulmonarv, dyspnoea, 48
Oouen, sputa, 49
Hiccougn, of common occurrence, 49
Pains in tibie diest, voice, 50
Physical Signs, 50
Inspection, Remarks on, 51
PiJpation, position of heart, <fec.,.. 51
Mensuration, 52
Auscultation, absence of murmur,. 52
borborygmi,tinkline^, 52
rMe, heart displaced, 53
bellows murmur, 53
Percussion, dull, tympanitic, 53
Pulse, Fever, Lividity, <fec., 54
Abdominal, Thirst, 54
Nausea, Vomitings, 55
Pains in the Chest and Abdomen, 56
Dejections, 56
Condition of the Abdomen, 57
Urine, 57
Omentum, 57
Skin and General condition, 57
Restlessness, 58
Countenance, <&c., 58
CAUSES OF THE HERNIA.
Table 11 showing causes, 59
Table 12 showing causes of &tal attack, 59
Inferences from Table 11 and Table 13, 60
AOE, SEX, PBOFESSIOX, dkO., OF THOSE AF-
FLICTED WITH DIAPHBAO. HERNIA 61
Table 14, Professions, »... 61
DURATION OF LIFE.
In Congenital cases, 62
Table 15| 62
In Accidental cases, 63
PAOE.
DURATION OF LIFE IN THE FATAL ATTACK, 63
DIFFERENT SPECIES OF DIAPHRAQ. HERNIA 64
Three usually given by authors, a fourth
suggested, g.
Table 16, relative frequency of the va-
rious species, g^
DIAGNOSIS.
65
Of Congenital cases, gg
1. In those dying at biptti7.'"JI'.I gg
2. In those living a few years of
suffering, gg
3. In those arriving at adult age)' ' 67
Of those having sacs— difficult if not
impossible, g-
Of Accidental cases, gg
1. Immediate deatii, ! . 1 . ' 68
2. Recovery and fatal results after-
'^'^^^ 68
Diffsrential Diagnosis of Diaphragmatic
Hernia and Aisthma, Pneumo-thorax
Phthisis, Cardiac disease. Colic, Cal-
culi, Inguinal Hernia, <fec, 69
PROGNOSIS,
TREATMENT,
70
71
Prophylactic, important^ ^o
Proiession, Dietetic rules, '.'.'.. \ 73
Treatment during fatal attack, 73
Venesection, possibly useful, ,.'/.[ 73
Leeches, '/' 74
Cathartics, Emetics, prejudicial, [.[ 74
Opiates, useful, ll[ 75
Bathing, useful, *'" 75
Ether, useful, [\\ 75
Operation, [[ 75
List of Works quoted from in preparing
Monograph, 7g
EECOKD or THE CASE,
The following, imperfect, notea of the case were oblaineil from the leeortls
kept by the snrgeons of the hospital. I examined the youth on tlie day of
hU entrance, in order to observe the effects produced on the action of the
I lieart by bo severe an injury aa fracture of the spine. I was much surprised
to find the signa detailed below, and was satisfied that the inteatines were in
< the left pleural cavity. I supposed thai there had been rupture of the dia-
I phragm at the time of the accident. On aeveral subsequent examinations,
every one, 1 believe, coincided with me in this diagnosis, as to the fact
of the altered position of the alimentary eana!. The case, I believe to be
wholly uniqiif, in certain particulars, viz., in the preservation of life and tol-
erably good health for so many years, whereas it appears from recorded
eases, that death usually supervenes, either immediately after birth, or at n
very early age, in the vast majority of such cases.
Sept. 20, 1846. F. L, Kt 17, laboier, entered the hospital with fracture
of the apine. It appeared that when a child he was surprised, on comparing
bis chest with those of his school-fellows, to find that his heart did not beat
u theirs did, but to the right of the aternum. He had been troubled all hia
lifetime with palpitations of the heart, and by frequent "stitches" in the left •
mde; and often had attacks of total unconsciousness, by which he was for
some time wholly disabled.*
Sept. 25. While resting from his worlt of raising a piece of limber, the
derrick he had been using, broke, and fell, striking him about the middle
of the hack, and fracturing the spine.
The manner in which the blow was received cannot be exactly ascertained.
The only facts obtained are, that he was sitting down at the time, when the
derrick swayed, broke, and struck him on the back, probably not directly.
The effects of the accident were temporary loss of consciousness, paraplegia,
and imperfect an.-csthcsia below a line, drawn around the body through the
10 DIAPHRA6MATI0 HERNIA.
umbilicus, and severe pain in the left chest and abdomen, which diminished
after two days. The accident occurred at Gloucester, where he received
medical treatment A catheter was passed twice daily, and two or three
cathartics given. On the fourth day, he was brought to the hospital on a
litter.
On examination. Intellect unaffected. Skin hot. Pulse 132. A pro-
tuberance on the back, occasioned by the spinous processes of the three
lower dorsal and first lumbar vertebrae. Complete paralysis of lower extrem-
ities, with slight degree of insensibility. Fullness and dullness on percussion
at hypogastrium.
Pulsation of heart natural, but entirely to the right of median line. Res-
piration thoracic Right chest laboring more than left. Left chest more
prominent than right, both in front and at side. On percussion, left front
chest highly resonant as far as a line dropped from anterior boundary of ax-
illa. Beyond that, dull, even on the back as far as median line. Right
chest natural.
On auscultation. No respiration over whole of left chest except from the
clavicle down to the space between the second and third ribs. In its place a
mixture of gurgling, whistling, and blowing sounds was heard, like those heard
over the abdomen, and produced by flatus and intestinal motion. These
were not generally affected by cough or inspiratory effort, though ROinetimes
excited by either. No bronchial or amphoric sound. Metallic tinkling occa-
sionally. Voice natural. Impulse and sounds of heart most distinct at right
of sternum.
Diagnosis, Probably rupture of diaphragm and intestines in left chest.
Catheter was passed. Elixir opii., gtt. xxx. given, and patient left for the night.
Sept. 30. Slept well. Had no pain. Pulse 132.
Oct, 1, Lies quiet ; makes no complaint except of flatus. Enema; laxa-
tive diet.
Oct, 13. An amphoric sound, with metallic tinkling, is occasionally heard
in left front chest, most intense over cartilages of fourth and fifth ribs. It
seems rather stomachic than pleuritic, or pulmonic, its tone being very sharp;
it is but slightly affected by the respiratory act.
Oct, 15. Respiration labored. Cough frequent Throat is clogged
with mucus, which he raises with great difficulty. Urinary bladder seems
to contain air. It is resonant up to umbilicus, but found contracted on the
catheter being used.
" t 17. Very feeble. Does not readily answer. Appetite quite good.
tatory sounds the same. Mouth sore.
DIAFURAOMATIO HERNIA. 11 H
Oet. 18. As jGSlenJay. Urine passed freely by catlieter. Bladder is ]
felt in IiypiogEiBtriuin as a saiall, hard, round tumor.
Tiie above detail of Bjniptorna is Bufficieot for my purpose. The patieut
died OcL 20. J
The post-mortem esamination was made very liuniedly, owing to circum- I
stances lieyond our control. The trunk presented no uniiaual appearanu'e in I
front Abdomen moderate in size, certainly not distended. On raising tha I
sternum, the stomach, the major part of the colon, and several folds of the 1
small intestine, with the omentum, were found in the loft chesL These of- I
gans were much distended with fl.itus, hut appeared perfectly healthy, Ku I
trace of recent lymph or injection about them on the pleura. The King was I
compreMed to the greatest degree and looked like a lung that hud been con- I
fined by a pleuritic effusion, save that it had not the usual Milden aspect I
obserred in pleui-isy. The heart van pressed to the right side, but th.tt, with i
the right lung, was healthy. The liver, resting upon the right side of the I
diaphragm, was normal. The spleen was healthy, and in its usuhI situation I
under the left ribs. The bladder was seen above the pube-s anil contiiitied I
about half a pint of purulent, flaky-looking, very offensive uiine. A told of I
smail intestioe was a<!hereut to its Hindus, by soil adhesions, an 1 e.tlended I
from there to the umbilicus, and was much distended with air. The coals J
of the bladder were dark and gangrenous. The diaphragm was jiflrfectly I
healthy at the right side, but was almost wholly wanting at tha left. It eon- 1
sisted — lat. Of u triangular piece extending from front backward. This 1
was 5i inches long from stcrnurt) to spine, and only 2j inches broad at it»- 1
base, which was attached to the sternum and cartitagus of ribs. Toward the ' I
Bpina St presented an opaque, whitish, rounded, somewhat cord-like aspect* 4
On examination it was fouud composed of a muscle, and on each side was 1
serous membrane, viz., pleura and peritoneum. Near the sternum and ver- 1
tobras, for the space of about an inch, these two membranes were united, and |
smoothly so, the hne of demarkation in the part near the spine being invid- I
ble, whild in that toward sternum thoy were joined by a cellular structure. 1
The intervening space showei! the muscle about ^ inch ihitk, and the two 1
inarabranes firmly attached to it. 2d. There was a small semilunar portion |
only of the diaphragm near the spleen, lying by the side and a little umler- I
neath the intestines, that had passed into the tii<Tax. But over the whole of I
the breast and a good part of the side, the peritoneum and pleura seemed 1
continuous, forming one large smuoth cavity. k
It was evidently a fcetal arrest of devclcpmenL fl
12 DIAPHRAGMATIC HERNIA.
ANALYSIS OF CASES REPORTED BY AUTHORS.
The preceding case having been one of exceeding interest to me, I deter-
mined to investigate the whole subject, as I might find it displayed upon
the records of medical science of the past and present (1846) times. The
results of that investigation, I propose now to lay before the society. .
The earliest writers of our art believed that a wound of the diaphragm
must inevitably be fetal Even the celebrated Dr. Fothergill, in a letter that
he wrote to Dr. Mead about one hundred years ago, and in which he gives a
very interesting account of a case of Diaphragmatic Hernia, thus exclaims:
"Every one skilled in medicine, I think, will suppose, from the history, that
the disease was a new one. But who would ever have conjectured that the
diaphragm (septum transversum) was divided asunder, and that a large por-
tion of the stomach and intestines had rushed through this opening into the
breast ?'' And again, in his naive enthusiasm, he says : '* Behold ! a sight
never, that I am aware of, seen before I "*
Unfortunately, Dr. Fothergill's learning failed him on this point, as I shall
now proceed to show.
A century and a half, or thereabouts, before the above letter was written,
we find two cases reported in the quaint but still admirable Opera Chirur-
gica of the father of French Surgery, old Ambrose Pare. One of them
proves the incorrectness of the above mentioned opinion of the older writers,
that a wound of the diaphragm is necessarily fatal.f
Following him, I find a letter written in most barbarous Latin, by Sen-
nertus to Fabricius Hildanus, in which a melancholy tale is told of a soldier,
who, in despondency of heart, fell upon his sword. It entered about the
fourth and came out at the ninth rib, wounding the diaphragm in its course ;
as was proved six months afterward, at which time hernia was discovered.!
Still later, comes to my notice a case of congenital disease of this kind,
mentioned by Riverius. The suflferer, he tells us, was a pensive youth, 24
* Works of John Fothergill, Ac. By John K. Lettsoni. London, 1784.
'• Opera Chirurgica ah Ambrose ParsBO. Franckfort. 1610. Ch. 30, p. 230.
}era Gulielmi Fabricli Hildani Franckfort, 1646, cen. 2, obs. 33, p. 108.
'1 works of the " most exculliiDt
t pupil of Vulaalva, and
years of age, and one lung waa almost wLolIy compressed in consequence of
hernin of some of the organs of the abdomen;*
Other cases nppear in the Philosophicnl Transactions, | Memoirea de
I'Academie Francaise;! but the firat person who altflmpted a regular treatise
on the subject was Kii'schbaum, a little before the middle of the last century.
He has collected seventeen cases from his own observation, and from the
works of others. His dissertation is well worthy of the times and of the
plnce in which it is now found ; namely,
Haller."§
Not long after this, that extraordinary
upon the fame of whose genius Italy might well have rested a century, —
Oiambattista Morgagni took, as the subject of a part of one of his letters, tli9
question of diaphragmatic rupture. He treated ii, as ha always has treated
his aubjects of investigation, in a most accurate and manly style. ||
Passing through the numerous, though biieily related and tantaliKing,
cases, recorded hy Lieutnud.^^ tlie interesting observations by Dr. McAulay**
and others by Vioq d'Azyrff and Portal.lJ we come to lie great surgeon
of modern times, and his magnificent work on the general subjfct; I
aJlude to Sir Asiley Cooper and to his work on Hernia.§§ To this gentle-
man we owe the first systematic and thorough discussion of the various
forma of this complaint, although I think that one more class may be justly
added, consisting of only two recorded cases, to which I shall allude at a
future time.
Since the publication of Mr. Cooper's works, many isolated cases of this
complaint have been published, and maybe found in the various journals
of the day. Admirable treatises have been written upon it by Lawrence,U||
• Lazaii Riverii Opera Med, UiUTor. London, 1698, Obi Oont. Quart, oba. 67. ,
t PhiloH. Trans. Abridg. 1594 to 1703, vol, iv, 630. Sir Charles Holt.
} Meinoires de I'Academie, 1129, pages 1 1 and 124. Cusea by Chauvet and Senac.
i Dissert CLIiurg.. loL iii,, p, Q17, lauBaliDe, llbb,
II Seats and Causes of Disease, voL iii,. Letter 54.
V Hisluria Anntamica Jdedica Auct,, Joseph Lieutaud, vol, i,, obs. 20B, itc.
■■ Medici! ObaerratioUB aiid Inquiries, ti>1. i. London, 1771.
it Memoirea de I'Academie Francaisc, 1772. Second part, p. 81.
tl Coor d'Aoatomie Medicale, par Antoine Portal, Turn, v., p. 82. Paris, lt03.
^$ A Treatiee uu tleniii), by Astley Cooper, dtc. London, 1834.
II U On Ruptures. London, 5th edition. 1S3B.
14 DIAPHRAGMATIC HERNIA.
Cloquet and Berard* Percy,f Stierling,J Dreyfus,§ Auzellyl and
Mehliss.^
Upon 88 cases, some collected by these various authors and others found
scattered through medical journals published since the commencement of the
present century, I shall rest the results that I shall present. I have sub-
jected them to a strict numerical analysis. This is the largest number ever
collected for this purpose, and although some of them, especially the earlier
ones, are not quite so much in detail as we could wish, I think some curious
results may be obtained from the whole mass. This seems to be a small
number of observations; but I know that I have carefully examined many
works and journals from 1610 down to 1846, and I am convinced but few
more can be found. Every one, also, who consults his own experience, must
feel assured of the infrequency of this occurrence. Curling says only two
cases have occurred in ten years at the London Hospital, 1000 patients being
annually admitted.
CLASSIFICATION OF THE SUBJECT.
I propose to treat the subject under the following general heads
1st Anatomical Characteristics.
* Dictionnaire des Sciences Medicales, in 30 vols., 1835. Art. Diaphragm.
t Dictionnaire des Sciences Medicales, 1818. Art Diaphragm.
t Dissertatio Inauguralis Anatomico-Chirurgica de hernia diaphragmatis cum tabulas
iii. Auct Hub. Griff. Stierling, Heidelberg, 1834, in 4to. See Archives Gen*les de
Medecine, second scries, vol. xii., p. 387.
$ Abhandluiig ueber die Biueche des Zwerchfells in beziehung auf gerichtliche arz-
neikunde, <fec., Ac. Tubingen, 1829. Journal des Progres, (vide below.)
March 15, 1847. I have not been able to procure copies of tlie two last mentioned,
but of one of them, at least a very full account is given in the Journal des Progres des
Sciences et Institutions Medicales, 1829. Paris, Tom- 17, p. 125. With the results of
this author I shall frequently compare my own, because his paper purports to be an
analysis of facts.
H These pour le doctorat en Medecine, presentee et soutenue le 30 AcOt. 1842, par
Aristode Raymond Auzelly.
^ Die Kraukheiten dea Zwerchfells des Menschen von C. W. Mehliss, M. D. Eisle- .
ben, 1845. (B. and F. Med. Rev.)
DIAPHRAGMATIC HERNIA. 15
2d. Symptoms,
dd. Causes.
4th. Ages, sex, profession, (fee, of patients.
5th. Duration of life in congenital cases and in those produced by wounds,
6th. Do. during fatal attacks.
7th. Different species of Hernia.
8th. Diaornosis.
9th. Prognosis.
10th. Treatment.
I. ANATOMICAL CHARACTERISTICS.
On which side of the diaphragm was the hernial opening found ?
Table 1.
It was observed in the left side of diaphragm
" right "
" both "
Diaphragm was wanting
" and mediastinum were absent
" was pushed up into chest on one side.
Mediastinum wanting, with double rupture,
Doubtful which side of diaphragm was ruptured,
88
Why is it that rupture of the diaphragm occurs so much oftener on the
left than on the right side? There are many reasons why this should
happen :
1st. Among the more obvious, it may be mentioned that the great mass
of the liver, partially united, as it is, to the diaphragm, becomes a kind of
bulwark to defend the right side of this muscle from undue pressure.
2d. The right crus of the diaphragm is longer and stronger than that of
the left side.
3d. There are two fibrous bands at the right side of the diaphragm, which
do not exist at the left.
4th. We have in addition to all these means of support for the right side
41 times.
18
u
3
((
1
u
1
u
2
ii
1
u
21
<i
16 DIAFHBAOMATIC HERNIA.
the exposed condition of the left side of the diaphragm, and two minor points
of interest, bearing on this subject, viz : two distinct pouches in the left side,
one for the spleen, the other for the cul-de-sac of the stomach to rest in.*
These reasons appear to me more than sufficient to account for the fact
that hernia of the right is less frequent than that of the left side. But great
as it is, the numbers <lo not give so strong a view as the expression by Schel-
ler, of Berlin, who says that " the hernia of the right side is excessively rare."f
Nevertheless, although the proportions given by my numbers may not be
entirely accurate, owing to the comparatively small number of cases analyzed,
they are a greater approximation to the truth than any general assertion.
EXAMINATION OF THE PECULIABITIES OF HERNIA OF THE RIGHT SIDX.
Hernia into the right side of the thorax occurred 18 times. Of these
cases, 1 1 presented the very unusual form of hernia with a complete sac,
formed by the pleura and peritoneum. So rarely has this form of the affec-
tion been observed that all writers on the subject have noticed its infrequeiicy.
Cloquet and Berard said,| in 183^, that in all the Annals of Medical Science,
they could find but two such facts. Though they were in error, when they
made the number § of recorded facts so small, they were right on the general
proposition that sacculated diaphragmatic hernia is very seldom met with.
Lawrence speaks to the same purpose. || Sir Astley Cooper had never seen
a case.^ .
But a still more curious fact is this, viz: that these 11 cases of hernia of
the right side compose more than five-sevenths of all the cases of sacculated
hernia that can be found in the records of ancient or modern time. To make
this more plain I shall give another table.
Table 2.
Hernia was found 41 times at the left, and sacs existed 3 times.
** "18 " right, " 11 "
* For these various anatomical details, I am indebted to the great work by Bom^ry
and Jacob. Anatomie Elementaire en 20 planches. Paris, 1836.
t Archives Gen'les de Medecine, 3d Ser., vol. 18.
\ Diet des Sciences Medicales, 1835. Art Diaphragm.
$ At least five I have found in authors who wrote before 1835.
II On Ruptures. London, 5th ed. 1838.
^ Yet Mons. Auzellj (These pour le Doctorat en Medecine, Paris, 1842,) would
limit the definition " hemie diaphragmatique " to such cases only.
I
The menlion of sa additional fact will mnke this tabular stateiaent yet
more prominent 2 i>f the 11 cases had 2 aaca each, making 13 sacs on the
right side of ihe diaphragm, while only 3 have existed at the left aide of tUe
median line.
The eausei of the greater prevalence of sacs at the right side than Jit the
left side are, I think, as follows :
1st. Jnat back of the ensiform cartilage, the diaphragm^ whe:
contact with the raediastiniim, is thinner in its fibrous structure than else-
where, and eel I ulo- vascular openings separate this fascia from the cartilages
of the seventh rib* Cloquet and Berard say: The anterior fibres, (of the
diaphragm,) often leave a triangnlar space behind the ensiform cartilage,
through which the cellular tissue of the mediaslinura is continuous with
that of the anterior parietes of the abdoir.en.| Wilson J gives the following
plate, (Fig, 1,) and it is illustrative of this sub-
ject. It lepresenta the anterior part of abdom-
inal surface of the diaphragm. 1. Section of
ensiform cartilage; 2,2. Right and loft portions
of muscles of D.; 3. " A thin fasciculus which
arises from the ensiform cartilage, leaving a
small triangular space on both sides which is
completed only by the serous membranes of the abdomen and chesL" It ia
exactly at these weak points, I believe, that sacs usually commeDce. I have
been able to make a small numerical statement in support of this idea. In
7 of the 11 cases in which sacs were found at the right side of the dia-
phragm, the part through which the hernia had taken place wa.s noticed as
in the following table:
" to Ihe right of die ensiform c^Knage/'
"just back of the ensifopar^rtilage."
" through the agt^iSr fibres."
'T^oneurosis,"
muscular structure."
^r words, !n 5-7 of the cases, the rupture took place as indicated
I do not, however, quote these remarks as proving what I say, or ai
* Bouigcry and Jacobs, ElcmenB, &a,, ut supra
t DictionBiri) di:s SoJCBCea Medicak-s, 1835.
X Anstomist's Vade Mecitm. London, 1B40.
18 DIAPHRAGMATIC HERNIA.
being of any great weight in themselves ; but I believe it to be a rule of
common sense, as well as of the highest reason, that a small fact sometimes
becomes highly significant when conjoined with others, whereas, isolated, it
is of little or no value.
2d. These sacs form gradually, and not unfrequently in the following
manner: Small portions of fat, situated about the ensiform cartilage, are
gradually pressed through the thin, weak spots on each side of the muscular
fasciculus just described as existing back of the ensiform cartilage. Gradually,
a small fold of the intestine follows after, pressing forward the fat and keep-
ing it at the bottom of the cavity. Such sacs may vary from the size of a
thimble to one capable of holding the liver, and in one case on record there
were appendices, as it were, to the main sac, each containing small quantities
of fat.* In some cases the sacs are represented as having passed up into the
mediastinum and thence into the right pleura. And this last fact brings us
to the final reason why they tend to the right rather than the left.
3d. In the annexed figure we have an ocular demonstration why, after
a sac begins to form under the ensiform cartilage; it first presses into the me-
diastinum, and thence much more readily goes to the right than to the left
side of the thorax.
A glance at this plate shows how much more it is likely for hernia, that
comes on by degrees, to occur at the right than at the left. The right pleu-
ral cavity is, in fact, much nearer the median line A B, than the left one is,
and 2d, the left is compressed to about one-third the size of the right.
* The following case by Berard, Jr., (Supplement to Scarpas,) illustrates these views:
" The opening of the diaphragm was caused by tlie non-insertion of its anterior fibres into
ensiform cartilage. There were two sacs, one at the right three inches long, of the size
of the intestine ; other at left, size of thimble. The mouths of these were smooth and
round, and a little smaller than the fundus. At the bottom of the smaller one was a
small globular body of fat. The mediastinum was distended with fat, and from both
sides of it were protruded several little fatty tumors like appendices epiploicoo."
20
DIAPHRAGMATIC HERNIA.
Tahh 4.
The omentum was found in it
The colon ; usually a part of it,
** An enormous mass of intestine,"
Right end of stomach and part of the duodenum.
Appendices epiploicoe,
A mass of fat was at the bottom of one and floating )
in the cavity of the pleura, J
Part of liver, stomach, colon and spleen, .
6 times.
5
i<
((
a
«
t(
i(
u
u
a
Usually one or more of these parts were found into the same sac, and in
<me case, were parts of the stomach, duodenum, omentum and arch of the
colon.
In two of the cases, it is expressly mentioned that there was no adhesion,
and the parts could be easily drawn out
In one case, there was an adhesion of the liver to the interior of the sac;
and in two more, there were adhesions to the contents, and likewise, exter-
nally, to the ribs, causing the parietes to be drawn in with each act of
respiration.
Nature of the Sacs, They were invariably composed of the two serous
membranes, peritoneum and pleura, with, at times, some thickened cellular
membrane over them ; they were usually rounded, or conical, smooth at the
fundus, and at times wrinkled near the mouth. The mouths were usually
smaller in circumference than other parts ; they were rounded, like the pylo-
rus, and variable in thickness; at times, quite thin.
RUPTURE OF BOTH SIDES OF DIAPHRAGM.
There were, as we have seen, three cases of this kind. (Table 1.) It
must be, therefore, a very rare affection, except, perhaps, in very malformed
subjects.
Two of these cases were congenital, and in one the child never breathed ;
in the other, life was sustained ten months, but with very severe symptoms,
(dyspnoea, vomiting, (fee.;) and the third was that of a man who, at the
storming of a certain citadel, was thrown down from a high rock and killed
almost instantly.
From these facts, though small in number, we may certainly be confirmed
I
I
KIAPHBAGUATIO HBRHU. 21
in the idea, whicb would naturally arise, that with a double hernia it is im-
possihle to have a comfurtabte life, and usually death superreuea immediately.
At the same time, however, the second case wholly seta aside the opinion
that children, born with hernia of the diaphragm, oven of a moat serere
character, invariably die. As we proceed we ehall find otber cases in con-
firmation of tliia suggestion.
DIAPHIUGM AlTD MBniABTUTUM WAMIIHQ.
This ia a very rare affection. Only once have I found it recorded. (Ta-
ble 1.) Unfortunately this case is given, with very few details, by Lieataud,
as having been noticed previously by Dienimerbrock.* But, strange as the
fact may appear, the child, tlius wanting in two of the most important parts,
lived to the age of seven years; always suffering, however, "&om chronio
asthma and frequent cough."
The mediastinum was wanting in one case, given by Sir Cbaa, Holtf The
child lived two months, moaning, and with constant dyspncea. Absence of
mediastinum, and hernia of the loft side were observed at the autopsy.
:hed uf into thb chest.
This is likewise of very rare occurrence, only two spedraens of it having
been observed among the 88 cases. (Table 1.) Strictly speaking, there is
hernia in the case, the whole muscle on one side being thrust upward,
' and thereby compressing the corresponding lung. One was the case of a
soldier to whom, after a debauch, an antimoninl emetic had been given, and
death was the result At the autopsy, the diaphragm was found pressed
strongly up into the cheat. Of this ease, however, a penon may hare some
doubt; hut I do not see th^'t any one can doubt about that related by 3enac.|
In that, the right side of the diaphragm was greatly pushed upward, almost
to the clavicle, and (he right lobe of the liver was in the space. The lung,
of course, roust have been as much compressed, as if there bad been a. rup-
ture of the diaphragm.
AnSBNCB OF THE UEDIASTINVM WITH DOUBLB HERNIA.
I have found only one case of this kind. (Table 1.) It ia quoted by
•Historia Anatomica MaUca, Paris, 17G7, VoL i., page 100, obs. 793.
t Phitosuph. TmnB., at supra,
t McmoircB de I'Acadumiu FraucBisc. 1729, page 134.
22
DIAPHRAGMATIC H£RNIA.
Kirsclibaum,* and by Lieutaud,f having been originally recorded by
Becker.J It is one of the most extraordinary in the annals 'of medicine.
The subject of it was a child, five years old at the time of its death, and who,
from the age of two years, had had gradually augmenting dyspnoea, with
forcible elevation of the chest, great liability to cough, and some dyspeptic
symptoms. At death, the heart and liver lay in the right, the spleen and
stomach in the left pleura. Verily it seems hardly possible for a human being
to have lived, even a moment, under such circumstances, and yet, supposing
that the organs were (some of them at least) thrust into their abnormal po-
sitions not immediately after birth, the symptoms distinctly showed that the
major part of. the disease must have been afi'ecting the little patient for
months, perhaps years, before death.
CONDITION, SITUATION, &0., OF THE OPENING IN THE DIAPHRAGM, <t0.
NOTICED IN SEVENTY-SIX CASES.
Table 6.
It was described
as roundy
19 times.
u
a lunar arch, . . , .
4
u
u
oval, ......
1
((
u
smooth,
5
u
u
large, .....
19
u
u
cartilaginous, ....
2
it
((
thick, callous, ....
3
n
i(
opahe, yellowish, firm and even,
1
u
<i
" muscular.
1
M
<(
thin, soft edges, ....
1
u
i(
large and recent,
10.
a
t(
edges uneven, red, fringed.
2
((
it
u u
1
u
u
torn from sternum and side of chest.
3
u
u
" attachment near oesophagus, 1
it
•
u
owing to deficiency of fibres, .
5
u
u
through oesophageal opening.
3
ii
u
aperture for intercostal nerves,
2
ii
* Haller's Diss. Chirurg. (as above,) vol. ill., 217.
t Hist. Auatom. Med., vol. i., obs. 216.
X Acta Erudita Lips. A 1706, Apr., p. 17.
DIAPIIHAGMATIO HERNIA.
Pleura and pentoiioiiiTi were united
PeritoneiHn abruptly lerminiited
A valvular apparatus formed by pleura, .
It was in the muscular structure .
" front of " ...
" beliiud steraum i rained lately.
Narrower than the sacs ....
BXAMIHATIOK C
i INFERENCES 1
The rounded, oval, or semi-circular tendency of ihe openings is very man-
fest, (24 timoa.) Tliis has heen observed previously by aulliora, and a mo-
ment's consideration of the anatomical structure of the diaphragm will lead
na to the reasons for this form. The muscular fibres ruu somewhat in a cir-
I «ular direction; hence tlieir contraction would tend to the production of,
W'^it, a rounded aperture, modified, perhaps, by accidental circumstances, into
d-circular or oval ; and second, we learn from this structure of the
I dinphragm the almost total impossibility of a closure of the wound, in case
I of any injury of tlie diaphragm, causing a rupture of its coats.
The smooth and polished or carlUaginous and thick aspect, is very mani-
I feat from the table, (10 timeH.) In fact, I have no doubt that this number
I eipresaes too small a proportion. The long-continued, though, perhaps, gen-
' ile polishing by the vermicular movemeut of the alimentary canal, must
inevitably tend to this result. Authore have noticed it before. It was very
mwifest in our case at the hospital, where there muist have been less friction
than in the majoi'ity of the cases. The same remarks may be made in regard
to thickness.
In only one case of a chronic cliaracter were the edges described as thin
and ao/l.
The opening is represented as large in 19 cases. Of these, 11 were the
I «ffecta of recent severe injuries, such as fails, severe pressure, wotrnds, &c,
libllowed either instHntly, or in a few days, by death. The remainder were
I either congenital or of several years' duration. This would seem to indicate
(lliat even a large rupture of the diaphragm, though eventJiolhj, usually fiital,
) necessarily fatal at the time of accident as one would at first sight
lituppose. I do not, however, lay n
n this
^ult, because si
eof
B may not have been sufBoiently explicit, in regard to the eiaot si
24 fiUPHRAGMATIO HERNIA.
only a few of them having been measured^ and the word large being in itself
very indefinite.
It was uneven and fringed in three cases, two of which were from severe
injury and from labor pains and evidently recent The other was an old case
of accident. Serious symptoms and signs of enteritis supervened, and death
took place a year afterward ; but there was nothing at the autopsy to explain
the cause of this unevenness.
In two of the above cases, there was a bloody appearance of the edges and
parts about, from the extravasation of blood.
The diaphragm had been largely torn from the sternum and ribs in three
cases, from the parts near oesophagus in one. In two of these, one arising
from over-exertion under difficult circumstances, and the other from a fall
from a cabriolet, death was instantaneous. The two others were congenital
or of a year's duration, thus confirming what we have said above, that some
cases, at heast, may not result in instant death, even though a very extensive
rupture take place.
Among the five in which there was " a deficiency of muscular fibres,^
three presented it at the posterior part, forming in one a *♦ chasm." In the
third the fibres were absent in such^ way as to allow of a sac being formed.
The first three were cases — 1st, of a still-born child ; 2d, of one who lived
three-quarters of an hour only; the last was that of an adult man.
DILATATION OF (ESOPHAGEAL OPENING.
The cases of dilatation of the oesophageal opening were very cnrious.
They were three in number. They were all in adults ; two of these were
drunkards. In one, only, a small part of the ileum had entered into the
chest; in two others a much larger quantity, viz., stomach, epiploon, duode-
num, jejunum, and part of ileum. Unfortunately, few details are given.
DILATATION OP AN INTERCOSTAL NERVE OPENING.
There were two cases of dilatation of the passage made by one oftheinter*
costal, nerves. The details are too indefinite for analysis. In both, how-
ever, the pancreas and a part of the colon were the parts that had passed into
the chest, and in one the pancreatic vein was ruptured. The cause of these
organs being thus forced upward is undoubtedly their position^ directly under-
neath the hernial opening.
The statistics in regard to the union or otherwise of the pleura and peri-
toneum do not afford, as I think, a just idea of the usual condition of these
DUPBOAOUATIO BBBNU.
membranes. Nor can I state anf geoeral rule in regard to it.
pital case, and at a hastj examination, these two membranes seemed to pre-
sent a uniform smooth surface over the major part of the ribs from the Blernam
to the side; but oa the muscalar mass that extended from the sternum to
spine, tbe two were nnited at both extremities for half an inch ot thereabouts,
and in the intervening space, tbey were separated by a cellular membrane.
In one of the cases in the table, it was impossible to diatinguiah the dividing
i line. This was that of a child, twenty months old, On the contrary, in one
[ of the severest and most chronic cases on record, given by Sir Afltley Cooper,
L die peritonenm terminated abruptly at the orifice.
25 H
our hos- ^1
ADHESIOirs OF OIITXBBMT ORaANB TO 1
The fact of adhesion is mentioned only eight times, and although this may
I not express the exact number, I have no doubt, from other statements, made
I by authors in regard to the smooikneas, roundness, &c,, of tbe aperture, that
this conveyK a tolerably accurate idea of what really happens. In one case,
I these adhesions were very strong, requiring the scalpel for their removal. In
' the others they seem to have been more slight.
The omentum adhered in three cases, the spleen and colon, each, once;
j and finally, the pleurte were adherent around the edges of the aperture in
B ORQANS BTRANotTLATBD C
; AT THE OFENIKO f
The facts relating to this topic are twelve, of which five are described as
ases having an entire freedom from strangulation, and allowing an easy re-
[' turn of the organs from the cheaL In the other seven there was a very close
I grip by the aperture upon ita contents. Very serious effects were visible as
I "consequences of the strioture. In all but two of them, the stomach or intes-
1 tines thus caught were highly inflamed, usually dark or livid, and once gan-
I grenons and ruptured. In two, pentonilb in various parts was observed, and
f ■ bloody fluid was found in the peritoneum.
Of the five cases in which there was no constriction, two presented noth-
I JDg remarkable in the parts adjacent to the aperture, and in the remainder
Kibere was only a slight degree of inflammation, and this very limited in ita
latent,
it we must beware of inferring that there is no strangulation before
K'Seath, when we find no great constriction af^er death. We all know that
le abstraction of the vital force must diminish very much the constriction
26
DIAPHRAOMAnO HSRVIA,
in cases of common internal strangulation, and as we shall be well aware»
when investigating the symptoms, that almost all the patients die with symp-
toms of such strangulation, we may reason upon both species of hernia in
the same way, and make deductions, somewhat more genera], than statistical
data would, at first sight, seem to warrant
DOBS HBRNIA OCCUR THB MORB FRBQUBNTLT THROUGH THB MUSCLBS
OR TBNDON OF THB DIAPHRAGM?
Authors have left this question undecided, and we must do the same.
For out of twenty-seven cases, in which mention is made of the part through
which the opening occurred, we have as follows :
Table 0.
Through lAuscular part, ....
15 times.
" tendonous part, . . . .
11 "
" ** chiefly ; a little in muscle,
1 "
Again,
Table 1.
In those where the muscular portion was ruptured, the
hernia was
In those where the tendonoui structure was ruptured,
the affection was
ACCIDENTAL.
7 times.
8 "
OOIfOKMITAL.
2 times.
1 time.
From these tables I infer that the tendon and muscle are nearly equally
liable to rupture from accident The numbers, however, are too limited for
very great accuracy.
DlAPHRAQltATIO HERKU.
27
WHICH 0^ THE ABDOMINAL ORGANS WAS MOSt VBEQUENtLIT VOUKD IN TfiB
THORAX, AND ON WHICH SIDE DID THET USUALLY LIE?
TahU 8.
THORAX.
LKFT.
BtOHT.
DUUBTPUL*
The stomach was found in the
34
\ * %
4
• » • •
The small intestines, part of »
M M it
■ % • •
21
4
6
• • %
4
The large intestineS) . » . .
(C «
» » • k
26
5
a (c
» » • •
8
The liyer> part or whole,
8
7
The gall bladder, ....
1
The pancreas, .....
« ((
....
The spleen, «
« «<
....
4
11
2
2
The omentum ".....
24
» • . •
3
« «
3
The mesentery, " ....
M «
Contents of stotiiach found in
1
1
1
The mass of the floating intestines, .
" in chest, especially at R.
The kidney,
Blood or bloody fluid,
Fluid,
1
2
7
1
2
2
1
o
1
1
" or fetid gas, ....
1
142
31
28
The gross results of this table amply confirm what we have previously
26 DIAPARAGHATIO HERKIA.
proved, in regard to the greater frequency of rupture of flie diaphragm at
the left than at the right side.
But it will be useful to examine the facts less in detail. The relative fre-
quency of hernia of the different organs is as follows, viz : Stomach, (44) ;
large intestine, (39); omentum, (30); small intestine, (29); liver, (IV);
spleen, (13); pancreas, (6); mesentery, (2); kidney, (2).
This result agrees very well with that obtained by Dreyfus.* In exam-
ining 55 cases he found the stomach had penetrated into the chest 37 times;
the colon, 24 times; omentum, 19 times; small intestine 14 times; spleen,
11 times; pancreas, S times; duodenum, 6 times; and liver, 4.
CONDITION OF THE VARIOUS ABDOMINAL ORGANS. *
STOMACH.
This organ was most frequently displaced, (46 times in 82 cases,) but these
numbers do not represent the exact proportions, because some of the report-
ers of cases have not mentioned the organ. Dreyfus makes it 37 in 55 ca8es.f
It was wholly in the chest in 32 of the cases; the greater part of it was
there in 5 ; cul-de-sac in 4 ; large curvature and right end of do, and pyloric
half, each once.
CONTENTS OF THE STOMACH.
The contents were recorded eleven times. They were chiefly gaseous in
seven cases, and once the stomach was said to be enormously distended by air.
This flatus was mixed with some fluid in three cases, and food in one case.
The organ contained a dark, fetid matter in five cases; in one of which it
had acid, and in two, reddish characters. Half-digested food was found in
two cases. In two, half-coagulated blood was the chief substance contained
in the organ.
SITUATION OF STOMACH.
Its position was, at times, much changed. In three cases it was turned
up into the chest, the large curvature being bent upward toward the clavicle
the pyloric and cardiac orifices nearly level with the diaphragm. In an-
other, the pylorus was on a level with 3d rib, the large curve toward the me-
diastinum ; and in a fourth there was a still greater change, viz., the pylorus
' Abhandluug, (&c. Journal del Progres, 1829, Tom xvii.
f Journal des Progres, &c, 1639, roL xvii., p. 130.
DIAPHHACIUATIC HERNIA. 2»
I near the clavicle, while the cardiac oiiGce remained at the diaphragm,
-where in one case it was said to be constricted. In another, exactly the re-
verse took place, viz., ihe cardiac orifice was thrown up. In one case it was
inverted forward, while the large curve was adherent to the left of the dia-
phragm. It was compressed in one case under the concave surface of the
liver, and thrust to the right side in another.
Any one of these situations we can readily imagine wonld be liable to pro-
[ duce some difficulty in the digestive functions. 1 shall allude to this subject
I '■gain when treating of the symptoms.
I
1
I
I
It was wounded in two cases.
It was torn in the cul-de-sac, letting its contents into the thorax, in one-
trhis occurred under a beating during a drunken frolic. The rupture was
one and a half inches long.
It had a small serai -circular opening in one case where it was strangulated,
and through this blood had oozed into the chest.
Though these numbers are few, I cannot but think that they indicate that
the stomach is but rarely injured in these cases. The organ is such a con-
spicuous one, and has been examined so many times, that so grave a lesion
u rupture could hardly have escaped nodce had it existed.
CONOBSTION AND IHTLAMMATIOK, 40.
The mucous membrane was said to be dark colored, (port wine color in
one,) in five cases; and it was easily scraped off in one; sufficiently firm in
another. The organ presented, on its peritoneal surface, marks of recent in-
flammation, where in contact with the intestines, in a case of general peri-
tonitis. It was purplish outside, in another; and firmly adherent in a third.
It seemed well, but more vessels than usual were seen under the peritoneum,
in one. It was emphysematous, toward its splenic portion, in one.
Finally, the organ was larger, paler, and thinner, in one case.
TUB lEeOFHAOnB.
It presented a very abrupt change of its course in all the cases, (3,) in
which it waa noticed. In all it descended through the diaphragm as usual,
but turned back toward the left to enter the abnormal aperture caused by the I
hernia, and to join the stomach in the chest. 1
DiAPmuaHATiG I
the right Gide, back of the reoa cava ftod diaphrBgm, in
SMALL INTESTINES.
Contents. They were inflated with air in ^x cases. The amount of tat
varied, but it was in great quantity ao as to enurmouajy distend the canal in
tbrea cases. Otherwise, the conteQts presented nothing remarkable.
Situation. The duodenum, in one case, was so pulled out of place, that it
bent the common biliary duct and almost closed it. Of courae, the changes
in thia respect depended entirely on the parte of the small intestine carried
into the chest. The part nearest the aperture was most frequently changed
in iu position. Hence the duodenum was more frequently in the chest than
other parts, but a great part of the convotutions were at times found thera.
(See Ubie 8.)
In seven cases the small intestines were represented as inflamed, &c.
In only one case, however, was there anything like general peritonitia.
In all the others, there were merely lines or patches of congestion, of an acute
character. In one, where a mass of colon was greatly constricted, the paria
were dark, soft, and ruptured. In another there was an old partial adheiioD
of the intestines.
I think we may infer from these few facts, that anything like general peri-
tonitis, to hasten the death, must be of very rare occurrence.
The colon, however, presented evidence of more serious trouble than the
imall intestines, a fact which coincides with our previous results. (Table 6.)
We proceed now to its examination.
I
The transverse colon, or parts of it, was most commonly found in the chest. .
It was said to be distended with air, in 6ve cases. In one of these tbs
walla of the intestine were thickened by the strangulation. This distention, of
course, varied with the degree and point of stricture of the canal. The canal
was empty and contracted in the parts be!ow and at the stricture, and before
it, dilated. In one case it was full of meconium, and in the chest. It was
in a still-born child, and it was pushed between the cesophagus and aortJ^
carryi[jg the mediastinum before it.
In one case, it was contracted; in another, it was twisted upon itself.
I
It was either iajlamed or dark, soft, and at times very livid in eigb.t cases,
and twice ruptured. The arch of the colon was adherent to the parte adja-
cent to it; twice to those within the thorax, and once to the opening of the
diaphragm. The rupture appears to have been caused by severe constric-
tion by the diaphragmatic aperture; as in both case% in which it happened,
there was a great straagulation of the parts.
This organ was noticed nineteen times.
Either one lobe, (as in three cases) ; or a considerable part, (as in two
cases) ; or the whole organ, was found in. the right cavity of the chest. Parte
of the left lobe, (as in four cases) ; or the whole organ, (as in one case,) were
found in the left cavity. Of these ten, six were cases of coijgenital hernia,
and the patients were still-bom, or death supervened soon after birth. In
one it was the result of severe accident; the cause was doubtful in three
more.
In four cases it was much compressed in that part that passed through the
stricture; so that in two of them the parts in the thorax and abdomen seemed
almoat like distinct organs, united by pedicles.*'
It was stTangidaled, softened, and /accid, in three cases; its lefl lobe thin
and flabby in one; nodulated in one; torn in one; its veins and bile ducts
much distended in one; thrust to the right side in another; it was pushed
up into chest, without rupture of the diaphragm, in two.
Moat of these appearances were probably owing to the rupture. It is said
to have been scirrhous and gangrenous in one ; nothing remarkable in others.
The effects of the changes in the form and position of the liver must at
times produce very serious results; for example, such an obstruction of the
gall-ducts as to produce jaundice. In the case mentioned above, the child
died ten months after birth, and one of the symptoms mentioned ia, " skin
sometimes yellow," (see gall-bladder in this case,) and this is the sole case of
^e dghty>eight in which this symptom is mentioned.
rThis organ is mentioned in four cases. It was empty and collapsed in
3 in one of these the organ had been ruptured by a fall of thirty feet
* These, i^c., ut supra, by Auzell/.
DIAPHBAailA.Tia BBnSlA,
It was large and filled witb ^iss. tbick black bile ia iLe third case, owing
to the fact that the bladder ^Fas pushed up more than usual and that the
duodeDQm, being pulled out of its place, caused an abrupt turn and almoat
closure of the ductus coramunia choledochua. (See symptoms. Jaundice.)
In a fourth it was large, situated in thorax, thickened, and witb an old
cicatrix inside of it, and four calculi. The bile-ducla were thickened and
lengtliened.
This organ was mentioned sixteen times.
It was torn in teveral directions, and bathed in blood, in two cases; one
from A severe bullet wound that penetrated the diaphragm and allowed tb4
stomach and spleen to pass into the thorax ; the other from the patient being
overrun by a chaise; and in this case, the spleen and a quart of blood were
found in the thorax.
It lay lengthwise in the lower part of the cheat in one case.
It adhered to the diaphragmatic opening in another.
In one case it had been carried up hj the stomach, and lay near the
junction of the second and third ribs with the Tertebral column.
With the exception of these injuries and malpositions, the organ seems to
have been not abnormal. In fact, it would seem, a priori, as if it would be
more difficult to produce any change in this organ than in the alimentary
canal, and our statistics agree with our reasoning.
I
This organ was mentioned nine times.
It lay ivkvUy in the c/iesC in two cases. One of these was aFter drunken-
nesa and an emetic ; the other was one of congenital opening. In the former
case, the pancreatic vein had been ruptured, and the parts were bathed in
blood. A portion of ikt organ was found in the thorax in three more cases,
the rest of it being in the abdomen. In all the coses in which the side of
the chest was mentioned, (viz., three,) it lay at the left side. These &ct>
prove that, like the spleen, it is but rarely carried into the thorax.
It was pulled out of its usual situation in one other case, without being
involved in the hernia.
It had a purulent infiltration about it in one case, in which a soldier had
twice fallen on his sword.
It was said to be well in the two other cases.
1 BERmA.
e fucts I infer that the paacreaa \s rarelj diaturbed in any n
These oi^us were montioned five tiraea.
The right one lay partly in the chest, at the right side, in two cases. Id
one, it was the result of the trunk having been crushed by a heavy wagon;
in the other, of congenital mal formation.
In one case, it was ruptured; death having occurred from accident In
the otber case, the organs were well.
Similar remarka may be made in reference to this as were made above,
with regard to the pancreas and spleen. The kidneys are but rarely affected
in eases of diaphragmatic hernia.
THE OMKNTUW.
i This part was noticed ihirty-one times; it was in ite chest thirty times.
Wiie table S.)
was condensed and adherent to the storoacb in . . 2 ca^ea.
'' dark and adherent to the diaphragms tic opening, . . 1 "
" thin and with old adheaions to do, and lo sac, . . 2 "
" adherent by old bands to pleura near clavicle, . . 2 "
" of a vivid red color, 1 "
" had a purulent infillration about it, . . . . 1 "
" formed a solid cord, ...... 1 "
" condensed, . , . , 1 "
|.Thus we see that about one-third of the cases presented some of the
jdifications of inflammation, evidently showing that the omentum is irri-
i by its frequent change of position, cfec, caused by the rupture. It seems,
r, to be a part liable to slip into the thorax.
1 UGSOCOLOH,
a mentioned o
J elongated.
' I have thus examined all the organs of the abdomen that have been do*
y writers in diaphragmatic hernia. I have detailed the peculiarities,
k, of each, but there is another point of interest, viz., their combinations in
ll hernial sac or in the pleural cavities.
84
DIAPH&AGMATIO HSBNU.
The following table gives an idea of their combinationsi in the various
cases analyzed, in the cavities of the pleurae, or in the sacs, in eighty cases:
u
n
u
It
u
ii
Table 9.
The stomach alone was found 10 times.
and omentum ....
^ and colon • . . •
'< and small intestines •
The stomach, omentum, and pancreas
and duodenum, spleen, liver,
small and large intestines •
duodenum and arch of colon •
colon, pancreas .
intestines and spleen
duodenum, colon, spleen, liver
and duodenum and colon
and intestines, spleen, pancreas
and ileum, colon, ^
and small intestines and colon
and intestines, liver
and colon
and intestines
intestine and spleen ....
and spleen
" and liver ....
*' other viscera
The small intestines
tt
u
u
«
u
u
a
u
u
u
U
M
U
U
«
U
M
M
U
U
U
The colon
«
liver .
^ renal capsule
and omentum
and liver
^* and pancreas .
" All intestines " or " floating viscera '*
Intestines with mesentery
<< liver, colon, omentum .
•* « kidney .
<< omentum, spleen, pancreas
u
8
tt
u
5
tt
tt
3
tt
tt
a
tt
u
tt
u
u
u
tt
tt
tt
tt
u
u
u
tt
u
tt
tt
u
u
u
tl
u
u
u
tt
tt
it
u
tt
u
u
tl
It
u
tt
tt
tt
tt
u
tt
u
tt
tt
tt
tt
tt
tt
((
tt
tt
u
tt
a
tt
it
tt
tt
tt
OIAPHRAOtfATJO HERKIA. 3S
^'Omentum, . found 2 times.
Kidney, « 1 "
J Liver, « 1 «
"Viacern," " 2 "
i Sbc containing no viscera, but iat merely, . . . " 1 "
80
In general we may say, tbat, of single orgam nbich are liable to pass into
the thorax, the order is aa follows: Stomacb, colon. Email tnteslines, in the
proportions of 10, 7 and 1.
But tbe conibiQationa are much more frequent, and the Btomach in its
THrious connections with the other viEcera, stands pre-eminent.
The spleen, kidney, liver, and omentum, were each found once alone. Of
these the omentum and livor were contained in sacs; and the spleen and
kidney were forced th^re by violent accidents.
Id its combioatioUE, tbe stomach was conjoined with the omentum most
frequently, next with the colon, and afterward with the small intestines and
other organs.
The position of (he stomach, colon, and small intestints, are such as explain
their relative liability to hernia.
^" Noticed eighteen times.
This part wfts described as hard and contracted la one; contracted in one;
and ns hcmgjiat at the upper part of the hypogaatrium, (bas ventre,) in four
cases. See symptoms (abdomen.)
Some authors have noticed this subsidence of the abdomen as indicativB
of a loss of its usual viscera. It obviously may happen. It was not particu-
larly manifest in our case. But it is equally evident that any unusual
distention of the alimentary canal, with gas, would tend to counteract any
subsidence from the hernia. The suddenness of the death, apparently, has
something to do with this result, inasmuch aa no lime may be allowed for
inflammation and consequent distention of the abdomen.
Of the six cases meutiuDed above, three were in accidents of a most severe
characlor and causing instant death ; a fourth was from congenital malforma-
tion of the diaphragm, and death occurred in a few hours after birth ; in the
^fifth, a fatal result came from an attack thirty hours previous, although the
^^■hnia had been produced by a full a year before; in the sixth alone was
36 DIIPHRAQMATIO HKRMU.
there any time for inflammation to commence, or probable distention to
In this, tbe man lived four days after a fall, and iiad had hernia, probal
for savera! months, owing to an injory of the same kind.
The abdomen was, on the contrary, distended, swollen and tight ii
cases. In one of these the air was effused into the peritoneum from ■
Hire of the colon, and the man died on the fifteenth day, Of the
onfortunatcly, no symptoms are given.
It was of its usual size in one case.
The peritoneum was represented as congested everywhere in one case, of
long standing, but which proved fatal in thirty hours after the patient had
taken acidulated drink. This fact, in connection with what we have pravionsiy
seen, confirms our opinion that universal peritonitis is a rare occurrence in
this affection.
It was firmly united to the pleura in two casat.
£lood naa effused in five cases. All of them were the result of falls from
a height, or from the persons affected having been thrown down or ran orer
by a carriage. In this last case it was from the vena cava being lacerated
that death occurred. The quantity varied. It was slight in two; but in
one, lbs. vi, were found in the hypogastrium.
I
TBU AKD UTBRDB.
Blood was effused into the muscles in one case of a patient who h
fallen.
The uterus presented nothing peculiar to this affection. In or
contained a full grown, entirely healthy, fostus. The mother died from tf
effects of labor, which augmented all the symptoms veunlly attendant
diaphragmatic hernia, and to which she had been, for some time, liable.
CONDITION or 1
£xteriQT.
The left side of the thorax was described as larger than the right, in oi
case; in another, the thorax was more prominent generally; it wi
and narrower in a third ; and compressed transversely and very prominent
in front, in a fourth. No sufficient and accurate obaervntion has been mads
by writers upon the subject In the second case, there was a tearing of
the diaphragm in various directions, so that the intestines were forced into
■itDth cavities. I cannot
DIAPHKA6UA.T10 tIEBNU. 37
Dth cavities. I cannot but feel that this point has been much neglected,
and tbe probability is that we should frequently find as great a difference
betwe^a the two aides of the thorax, aa we find in cases of pleurisy or pneu-
—iDo-thorBx.
B^ A glance at table 8 would satisfy any reader that the lungs must be more
or less compressed in almost all the casea of diaphragmatic hernia. Of course,
the amonut of this compi-ession will depend upon the amount of extraneous
[liter introduced into the chest. I have examined all the cases, and Snd
it they may be classified as follows:
Table 10
Very much c
impressed,
Much
"
Somewhat
«
A little
f
Kot at all
"
Doubtful
"
8 times.
Whence it appears that eighty out of eighty-eight of the pulmonary organs
must have been so compressed as to have been aerioualy interfered with in
their funcljons. (Vide " symptoms " dyspncea, &c.) We shall, hereafter,
^dluda to this subject aa illustrative of the causes of some of the symptoms.
llHiiE compression may bo said to have been slmost the sole chronic difBculty
Hklucb the organs had to contend with ; for they are not described as, other-
B^ise, seriously deranged. On the contrary, in some cases of extreme com-
HiB6saion, it is stated that they could he inflated and were healthy. In only
Bne case, was any old disease noticed. In that, the man felt gradually into
^Htliisis, and tubercles were found in the lungs. The fact is interesting,
^■ureover, in leading us to suspect, (we cannot be entirely sure, because all
Khe cases are not sufficiently in detail,) that even great compression in these
Htaes does not tend to really injure the delicate pulmonary structure. This
^■nresponds entirely with our case, for in that, the left lung seemed as healthy
^n if nothing had been pressing it, when in fact the stomach, colon, and small
^Mestines had been compressing it from birth.
^B Id ft few cases, (six,) the lung was described as congested, mdemalout, he-
Hwuei^ or carnijied. In one of these cases there was so much compression
Hut the organ rested on the spine.
I
36 DIAPflR AQUATIC BBSHIA.
The lung was adherent, by old adhaaons, in three cases, I caonot s
whether ihis represents the ratio of all the cases. I fear it does not I thialu
however, we may safely infer that inflaminatioii of, and adhesion of, the diM
placed abdominal organs to the lungs, iiQ^ is not so common as on
suppose, ff priori, tliey would be. And here we see the absolute r
of having in the records of our cases, many nagaliva statements. Had eSM
the authors, whose cases I am analysing, definitely stated that there v
adhesion of the pleura, there ttoidd have been no doubt in the preeentV
instance.
The lungs were wounded in three cases.
Of the two lungs, the left was the most frequently and ohvioualy com* J
pressed. At time^ it was fairly laid upon the spine, hut the mediagtinuoi I
and heart being thrown to the opposite side, the other lung must haTe beeii'l
but poorly able to perform its own function, much less to do * douhle shs
of dutv. Hence have arisen the dyspucea, Sie.
Finally, in one case, the lungs were emphysematous, distended, did noil
collapse, and the mucous membranes wore red and filled with purifomi mit- 1
CU9. In this case the sacs were too small to produce a compreseion to a
great amount.
k
This part was noticed twenty times.
Liille is mentioned of the pleura; whence I think we may infer thatw* J
Tere general infiammalion of them is rare in this complaint. They n
however, represented as more or leas inflamed in five cases, in three of whiehJ
some recently effused membrane was observed.
There were old adhesions in nine, but all except one was of a local char- 1
acter; either adhesions (o an old cicatrix, or to the diaphragmatic opening, I
or of the omentum to the pleura, iic. In one case, however, they were so I
■trong HS to cause a drawing-in of the chest during life.
It was mentioned that tliere were no adhesions in six cases.
There was a Jluid in both cavities in one; and in two more there was |
Bome in ihe right or the left cavity. It was bloody in one. There i
great quantity of blood effused into the pleura in four cases, three times at J
the right and once at the left. This was evidently caused by the severity (
of the accident ihat produced the hernia. I think that from these facts J
ve may infer that the pleum were not usually much diseased, in any J
iDBDDer.
Jl Was noticed ten times.
It waa wlioll; absent in two cases. One wrs in a cliild who lived two
months with this trouble and a hernia, which, at the time of death, consisted
of all the int«Gtines save the rectum. The patient suffered much from dj'sp-
_«cea, resllessneEs, and Anally, pined and died. The aecond case was that
ItoVen by Lieutaud. I bare already spoken of it.
^V It was torn, to the extent of five inches, from its attachments to the sternum
^^n the case of the Boidier, who was thrown over the ramparts during the
storming of a citadel.
It was said to have been pushed ^ide by the hernia in four esses; but it
is evident that this number does not give a correct impression, If compared
either with the number ten or eighty-eight, for the fact that the lungs were
much compressed fifty-five times out of eighty-eight, and somewhat so twen-
ty-four limes more, proves that the mediastinum must have been pushed
aside an equal number of times. In one case, it was pressed, in the form of
a poucb, to the right side, between the aorta and essophagus.
^^ft ENSII'ORU CAailLAOB.
This part was turned baclcward and to the right tn one case, in which a
sac existed at the right side of the diaphragm. It was in the person of a
man xi. 60 yea
1^
^" IP
THK THYMUS 01. AND.
mentioned in only two cases; in one of these it
illhy ; in the other, as having been pushed to the left side of tha thorax.
P OIRCULATIOW.
I
The pericardium contained some yellow serum in three cases. These
wero the only times it was noticed at all. In one case there were sev-eral
ounces of fluid, but otherwise this part seemed to be but little liable to disease.
TBB HBABT.
The heart was noticed thirty -one times.
Its change of position was the most marked, and moat abnormal condi-
tion. It was ihnist to the right side fourteen times; to the left five times.
.Fosition not observed in other cases. How well do these data accord with
^■nhat we have observed as to the greater frequency of hernia of the left than
40
DIAPBRAOUATIC HBRHIA.
of the right sitle. One clasa of facts supports another. But do these nuiQ-
bera give the relative frequency of the displacement of the heart in all the
eighty-eight cases? Undouhtedly not, I think, because, according to table
10, we have seen that the lungs are very frequently and eeverolj compreBsed.
Now although the heart would doubtless remain in position while under the
influence of some compression, it must yield under much pressure. There-
fore, I think, that instead of being put out of place once in five times, it must
be displaced in more than half of the cases and probably much oftener than
that, it will he slightly removed from its usual seat.
Its dimensions are represented by the terms, empty, small, contracted, in
four cases; very large in two. Its right auricle was distended in one; and
ventricles contained thick, black blood in the second. It is described as
sufficiently large in one.
In other words, it would seem, from these statements, that any cardiac
symptoms that may arise must probably come from the displacement and
not from any organic change of the organ. This displacement, combined
with the gi'eat compression of the lungs, would seem, a priori, to point to
some cardiac symptoms. We shall treat of these hereafter.
The descending aorta was pressed to the right side, in a caae of a child in
whom the intestine, full of meconium, was pushed upon the aorta and medi-
astinum. (See mediastinum.) This cana! must, however, be very materially
altered in its position, especially about its arch, by the thrusting of the heart
BO frequently to (he right side. It seems to me that such change might be
likely to produce some change in the pulse, and perhaps a diSerence between
the two radials; but in no case was that fact mentioned.
The vena cava was ruptured in one case near the diaphragm, in conse-
quence of injury from a carrii^e passing over the body. The panereatie
vein was likewise ruptured in one case, which is given by Kirscbbaum, after
a violent emetic had been administered to relieve drunkenness. The umhiU'
cal vein was much elongated and very tur^d in a case in which there wu
hernia of the right side and a considerable part of the liver had passed into
the cheat.
This cavity has never been examined in this complaint, probably from the
paucity of cerebral symptoms and the attention of physicians having never
beea attracted to it.
n. SYMPTOMS.
In considering this subject, I sholi malio two divisions of the symptoins, viz :
Ist. Tliose notecedent to the futal nttack.
2d. Those occurring during that period.
In each one of these, I shnil endeavor lo point out thole which seem to be
Hrely accessory and accidental, and (ho^ more important ones, which are
idently dependent upon and caused by the heruio.
AITTEOBDENT TO THE FATAL ATTACK.
CaPUALtC SYMPTOMS..
(Fr,
s to fatal attack.)
ffjA priori, one would anticipate, perbap.i, some disturbance of the cerebral
DOtioDB whenever, from an; sudden exertion or exciteraont, some interrup-
tion should take place in the even tenor of the already labored respiration.
But, on consulting authors, I find less to sustain this idea than I could have
anticipated. The cephalic eyraptoms are mentioned but twice, and th«ee, with
my own, afford no data whereby to judge the question. In our own case,
the lad was liable to swoon on any violent exertion, Aud to be unccmsciouB for
some time. I explain it in the same way that we explun syncope in diseases
of the heart.
This is the only symptom that can, by possibility, bb I think, be referred
to the disease. In the two other ca.ses, there was a fetid discharge behind
the ears, in
Hildanua.*
tnd a deprei
aind i
the other described by
PDLMONART SYUPTOMB.
(Pr.
'■s to/atal attack.)
These symptoms were noticed in twenty-nine cases.
Dyspnoea. This symptom was observed in sixteen out of nineteen cases.
This proves the great prevalence of this symptom, and accords very well
with the fiict that the lungs are ao frequently compressed and the heart put
out of place.
t
* Op. Hildani si abole.
42 DUPSRAQHAtIO BBRSIA.
It was great in two; eonsUnt in two; the chest was forcibly elevated,
dyEpncea apgrnenting till death, in one; it was worse at nigbt, and *]
the clothes wore wrapped closely around the trunk of the body, also
iQ a recumbent than when id a Bitting posture, in one. This was the
ciasi of cases. It was milder in others, viz., like "chronic asihtna," io two;
constant in sotoe degree, and very much augmented on enerlion, in two;
occasional, in three; sudden, evanescent, and without evident cnuse,
one, the patient being at other times free and easy; not great or none at al^
in two,
I endeavored to classify these various degrees of dyspnoea by tie li
found after death, as it seems very natural that there would be sc
between these two ranges of facti.
lo my first endeavor to inalce these comparisons, I thought I should bej
able to give deGnite results; but on more minute examination I becftme
isGed that only the most general and indefinite deductions could be
Two of the cases mentioned had most serious lesions, viz^ rupture of the dia-
phragm and absence of the mediastinum. They were in my first division,
and the patients had severe dyspncea. Generally, however, the lenoni in
the second class were not of so severe a character as this, and the symploniB
were milder. Nevertheless, our own case is a stumbling block to nicety of
diagnosis; for surely the patient could not have been very much troubled, by
s complete want of the left side of the diaphragm and compression of oh
lung, since he was able to do a laborer's work. It is possible, nheu our-
powers of diagnosis are more accurate and we recognize the disease befoNi
death, we shall be able to use this symptom as a means of nice diagoi
more than the present record of facts allows of our doing. The actual
Uca point toward what we may prove to be true some years hence,
the numerical method allow of such prophecies? That method, as I under-
stand it, has two objects: 1st The rigid deduction of laws from observed
facts, 2d. The suggestion of other laws whith it cannot prove, but which
future observatipn may confirm or annul. If, as numeralista, we cannot take
this view, we make ourselves slaves to bare statistics, and give up our reason,
thus checking that far-reaching power, which makes us men and not children.
What is the reason for the evanescent attacks of dyspncea; and why ia
posture at times a relief; why is there no dyspncea at limes?
The evanescent attacks of dyspncea, suddenly coming and at times as sud-
denly giving ofi; are to be explained, I think, by the fact that by overeier-
tJon, injury, or certain positions, &c., a larger quantity of the intestinal canal
s forced upon the lungs, or perhaps the part already in the chest becomes
DIAPBrtAGUATIO HERNIA. 4<!
J«uddenly distended with gas. Whatever may be tbo circumstances, we can
•«afii]y conceive that tliey may be very transitory in tbeir nature.
That posture sbould be Ukely to bave raucb influence upon suob a case as
)ur own, we can easily conceive. Gravity would, wbi!e the patient was in
I ■an erect posture, tend to relieve the symptoms by taking from the eompres-
1 aion of the lungs, and this was the fact in the observation given by Dr. Foth-
rergi!!.* It was in his case such a remarkable feature, that the little Bufli:rer,
■ during the ten montbs of its life, never could lie down after the first nap, but
f slept in the nurse's arms, bo that if during the first sleep in a horizontal posi-
tion, too great an amount of intestine fell through the larjfe opening into
totb pleorse, the same might tend to fall back again while in a more erect
posture. One person could not be on his buck without dyspncea.
Finally, why is not dyspnosa constant? In the first place, it is doubtless
e general than ournurabers would make it. But second, there are some
1 record in which the amount of hernia is so slight as scarcely to be
I lira o ugh to produce pressure on the lungs; and again, in some professions,
I (as that of a student,) there may be such slight exertion made as that the
' ' dyspncea will be imperceptible or of the most trivial amount. Finally, the
opening may be lai^ enough in the diaphragm to allow commonly a free
;eto the organs. Hence, somelirae?, there would be compression; and
it others, entire freedom of the thoracic organs.
(f,.
a to fatal aCtack.)
This symptom is mentioned six times.
It was represented as either fiequeni, or as nearly constant from the time
of the accidect or from birth, in congenital cases. It waa spoken of as dry in
one case. I cannot believe that this fairly represents tlia relative prevalence
L of this symptom. However, from our facts, we cannot deduce more.
A slight expectoration is mentioned once.
PAINB IK THE CRBST.
(Previous to fatal attack.)
. These were noticed in five cases.
• Worlts, 1784. (See above.)
44 DlAPHIUaMATIC HKRHIA.
They were always in these eases in the left side, and in one of them they
extended to the shoulder. In this last, a full meftl aggravated it, and in one
of the others it came on and disappeared so suddenly that it was supposec
to be spasmodic. In al! these case?, the opening in the diaphragin was a
the left side. The symptom did not seem connected with any apertures !■
the diaphragni of peculiar size or shape, nor with the amount of abdominal j
viscera in the chest The colon was displaced in all the cases, alone and only
to the size of the fist, in one; it was connected with omentum in another
with the stomach in the third, and with the stomach and omentum in two
PB CO LIAR BYMPTOM.
I
(Previous to falal atlaclr.)
In the case mentioned by Sir Charles Holt,* there was an appearance of J
a very peculiar character, viz : " an odd sort of working of the breast, a crawl-
ing around the ribs of both sides, as if a knot of worms were there." In this I
case, there was a congenital, hernial opening on the left side, and the medi- j
astinum was wanting.
I presume this motion was caused by the vermicular movements of the *
alimentary canal within the chest. It has some analogy to what our pnlien^ I
observed, who felt air pass, at times, from a spot high up on the left breast 1
down to the pubes. This symptom is well worth attention as a means of 1
diagnosis, and it becomes of more importance, as we may sometimes excite it, I
by allowing the patient to swallow while we are auscultating.
PITS OP BUFFOCATION.
(Pr,
s lo fatal attack.)
These occurred, in one case, viz., that of a child who lived ten months,
was, in fact, a kind of access of dyspncea. While nursing, the little patient j
would fall into a violent Gt of passion. The crying and extra-exertion would I
produce an access of suffocation which, from its severe induence upon the i
whole system, instantly subdued the temper of the child, by causing phywcal I
prostration.
cARDiAO aTUPTOua.
(Previous to fatal attack.)
The pulse was always "disturbed, small and tremulous," and very rapid,
in the only case in which it was mentioned.
The heart beat to the right of the sternum in one case. Theaa data evi-
dently give no accurate results. For a discussion of this point, see article
"Pulse during attack."
i
^H (Previous to fataJ atlacJc.)
^1 Noticed thirteen times.
^^ VomiHng. This was observed seven times; the tendencies usually com-
menced after the injury or soon after birth, and continued, with more or less
liability on the part of the patient, until the ffttal attack. It was augmented
in three cases, hy over-eating; and in one case, even the smell of food, or
acescent food, tended to produce it.
The matters vomited are not mentioned, save in one case. In thnt, (a
nursing child was the palienl,) it was a kind of fetid, purulent pap.
I In all these cases the stomach was found either wholly, or in part, in the
Aefit. (See symptoms during attack, article vomiting.)
The other stomachic symptoms were as follows; weakness of it in one;
Sability to oppression in two ; troubled by acescent food in one ; dyspep^ in
Que; nausea and desire to vomit in one; fullness after eating, one.
These combined with the vomiting, make ten cases, out of the thirteen in
ifhich the stomachic symptoms were observed, and they seem to me to prove
thai the slflmach is very frequently the sufferer in diaphragmatic hernia.
This will be still more evident when we examine the same subject, aa it
relates to the symptoms during the fatal attack.
Abdominal pai»3 or eolies were noted in nine cases, or in tbree-fourlhs of
the cases in which any abdominal symptoms were observed. Tliey wera
usually of a violent character, and lasting from birth or the time of injury;
oeonrring at irregular intervals, and were frequently brought on by esceta in
eating. They were so particularly liable to affect a worthy soldier, described
by Ambrose Pare, that he was obliged wholly to forego his wonted 9 o'clock
■upper, after his apparent recovery from a bullet wound in the ihorai. They
Hi^eetn generally to have been felt at the upper part of the abdomen near the
4 6 DUFHRAGMATIO HBRNU.
diapbragm, or ibey were referreJ to the stomach. In only one case was it
in the left bjpochondriam. I think we may regard this eign as an important
one for ibe future diagnosis of any cose.
I endeavored to learn wbetber any particular state of the diRphragmatic
affection, or of the parts in the hernia, would account for these paina. I
found that in four of tbe cases, in all of which the colics were severe, the
apertures in tbe diaphragm were small. In two more, the opening was pos-
sibly a little larger, one being two and a half inches in diameter; the other,
having tbe cesopbageal aperture opened. In one case the liver and stomach
&e^ were in both sides of tbe chest; in a second, the stomach and omentum
re condensed into a ball inside of tbe thorax ; and in the third, the dia-
phragm bad been torn from the spine near one of its crura.
Perhaps at a later period of the paper, in tbe article " Paina, &c., during
fatal attack," we may be better able lo decide this question.
Tbe other abdominal symptoms were as followa: a dragging sensation, as
of something attached to the right side and referred to tbe region of the
stomach. This was noticed in one case, in which the stomach was thrust to
the right side of the abdomen, " Enlerilis " occurred in one case, in which
lan fell from a great height, and recovered after suffering some time froiD
i disease. Another person had an " abdominal difBculty ;" probably, tu-
berculosis. One was described as ba^i□g attacks of strangulated intestine;
and of two remaining, one had diarrkixa; the other, costivenesa. It is plain
that we can deduc« only the most general conclu^ons from these isolated
BTATK OF Eonr, SKIN, diC.
(Pre
t (0 fatid attacle.)
The skin was wrinkled, and sometimes yellow, in one case of a child aged
ten months, affected with congenital hernia, and in whom the common bile
duct was almost closed by a change of position of the duodenum, (Sea
gall-bladder, page 31.) There was a vesicular eruption, (accidental, I pre-
sume,) about tbe mouth, in another.
The lips were of a violet hue, and cheeks of a deep red, in two congenital
sases, in which death occurred after two and ten months; tbe patients were
always restless and uneasy, and, in one, Accompanied with much pining until
death. One was " weakly and little."
la one c/iae, a man, ten years after an accident, fell into phthisis and bectia
mi. i7
l«ymptoms. In the case of oue innii, iL wan said that thougli unhealthy he
Wta ahle to work at his trade of masoD. One, otilt', was said to be weS.
The details of thia csf^e, however, as given by Morgangi, are scarcely aoffi-
rietit to allow ub to lay much stress on it. But our owu case is a proof that
the greatest degree of hernia may exist on one side and the patient may be
muictdar and able to do the hardest work, though liable to accesses of dysp-
ncea, Ac. In two of the eases recorded, the patients were said to be very
useular. This fact is quite in accordance with what is seen in other condi-
Ktions, where the disease consists of a merely local disturbance without the
B^DBtitution being necessarily affected.
Table 14 supports this idea; for out of twenty-five cases in which the
ccupatioDS of the patients are given, twenty-four were engaged in business,
quiring activity and eiiertion of strength.
-, that of fifteen individuals of whom any mention is made
f the amount of development of the muwular and adipose texture, there
Jrere of women, five either fat or inclined to be so, only two thin ; of in en
) robust and muscular. Had only one thin. (It may be remarked
FHiat this last was the only case iu which phthisis was discovered) ; of chil-
dren, three, and all of them were lliin. It seems to me that from these facts
we may infer that, although the patients suffering from diaphragmatic her-
a may have troublesome, and at times, dangerous symptoms, nevertheless,
^en they arrive at aditlt age, there is nothing to prevent a full development
if the muscular and adipose tissues.
They are noticed five times.
' Convulsions were observed in a child who died a few hours sStet birth. The
4raordinary dyapncea seemed to be the cause of it. At the autopsy, a con-
iderablc portion of the liver was found in a hernial sac. This symptom was
seen likewise in the case of a man, in whom death occurred in a few hours,
after having been preceded by the "greatest degree of dyapncea." In him
the hernia consisted of the colon, omentum, and pancreas, with blood from
Bajpture of the pancreatic vein.
^v Qrmding of the keth was noticed in the case of a child, who died in
^■farelve hoars, and in whom the stomach and omentum only were in tlie
i
48 DIAPHRAOMATIO HERNIA.
Delirium occarred in but a single case ; and in that, I think it may have
been more owing to a comminuted fracture of the 1^ than to the hernia.
There waa numimess^ without paralysis of the legs, in one case.
I think we may safely infer that cerebral symptoms are ancommon in this
affection. The result above obtained corresponds — 1st With the fact that
authors have never examined the head after death, which they certainly
would have done sometimes, if any serious symptoms had occurred ; and 2d.
With what I have stated above, when treating of symptoms that occur pre-
vious to the fotal attack.
THORACIC SYMPTOMS.
(During the fatal attack,)
Noticed in thirty-six cases.
PULMONART SYMPTOMS.
Of the thirty-six cases in which mention is made of any pulmonary symp-
toms, in twenty-seven there was some labor in the respiration. This large
proportion proves that some modification of labored breathing must take
place in at least three-fourths of all affected with diaphragmatic hernia, and
I am inclined to believe that this is a small proportion, because from our
previous investigations we have seen — Ist. That the lungs are compressed
in a larger proportion of times, and I cannot conceive of there being so much
pressure without a corresponding dyspnoea 2d. The results, upon this point,
in our investigation of the antecedent symptoms confirm this view of the
case. We meet, in our daily practice, with cases of dyspnoea which, at the
first glance, are not very obvious; it is rather breathlessness than dyspnoea,
and I presume some such cases have been omitted.
This symptom varied in its degree. It is described in one case as orthop-
noea; as the greatest dyspnoea, or dyspnoea; breath interrupted; frequent
and labored; very imperfect; suffocative on lying down; much oppressed,
confined; panting; short and quick; in the other cases.
I endeavored to find out if possible, as when looking at this question
previously, whether this symptom in its different degrees of severity bore
any relation to the amount of disease in the diaphragm, or of the hernia of
the abdominal organs into the chest, but I found it to be impossiUe.
It seems to depend on causes which are not indicated in the cases. More
thoroughly detailed cases may elicit more on this subject than can be done
at present.
DIAPHR AQUATIC I
49
se, the respiration is said to have been always free. It was the
case of a drunliard, and he seems to have sanli with vomiting; and purging
after initnuderate drinking, aud possibly may not have died so mucli of the
I hernia as of his bad habits.
r COUGH.
w This symptom is spolten of in only eight of the thirty-six cases. Possibly
k some cases the record of it is omitted, altboiigb this symptom really
bcurred. In fact, I can scarcely believe that it should occur so seldom,
althoQgh this result is similar to that which we obtained from examination
of antecedent symptoms. We have examples, however, of a similar absence
of cough in various diseases, involving the pleura and parta adjacent to the
lungs. Pleurisy, for example, very frequently produces very little cough
It seems to me that we ehoidd he allowed to deduce, (1st, From the infre-
quency of its being noticed in diaphragmatic hernia; and 2d. From the
Kiracter of the symptom when recorded,) that as a symptom, diagnostic o f
I disease, it is of very little importance. The cough was said to lie fre-
ent in three cases; and in one case, there was an inability to cough, owing
to pain being caused by it. In other cases it was noted without any
qualification.
tThis symptom confirms what we have said in regard to the cough. It
Is mentioned but three times and always as having occurred after a fall.
|i two, in which extravasations of biooJ were found in the abdomen, a little
bod was raised, but as the lungs vr^ia found simply compressed I doubt
hether it came from the pulmonary structure. In the third there was a
1 raising of mucus. May we not infer that, if this symptom does
i nevertheless rather an accidental than necessary
times, or in nearly one third of the oases, and
iportant symptom of the affection. It was usually
In one case it existed during the last nine days of the
constant; in another it was loud and the immediate
It somedmea resembled sobbing, and in one case, a
three-fourths of an hour, and expired.
Id examining it with reference to the morbid analgioy, i found it o
:i'.rrM
50 DIAPHRAGMATIC HERNIA.
twice in cases in which the right side was ruptured, nine times in hernia of
the left I did not find this sign connected with rupture of any particular
structure of the diaphragm, or hernia of any particular number of organs, or
bulk ; for, in one case, there was only a small part of the ileum in the aper-
ture, and in another were the greater part of the small intestines, omentum,
spleen, and pancreas; while the remainder of the cases presented every
variety between these two.
I might cite, as another reason for admitting this as an important sign in
this affection, the well known fact that hiccough is generally considered
one of the symptoms of any disease of the diaphragm.
PAIN IN THE CHEST AND SIDES.
In regard to this symptom I refer the reader to the article " Pains, <fec., in
the abdomen.
VOICE.
In one case, (of a child that died half an hour after birth,) I find recorded
that there was difficulty of breathing from birth, that some time elapsed be-
fore the patient cried, and that when it did so, there was a peculiar note to
the voice. I know not whether the very peculiar state of the parts, found
after death, will explain this symptom, but the coincidence is a curious one.
In this case alone have I found that the colon, full of meconium, was pushed
up between the aorta and spine, and was pressed upon the trachea as high
as the first rib.
PHYSICAL SIGNS.
These signs have been almost wholly neglected. Laennec*^ has stated that
they would prove of much service in this affection, but, as he had never seen
a case, he merely makes the suggestion that it may be recognized by absence
of the respiratory murmur and the presence of borborygmi in the chest Mr.
Lawrence, so far as I can discover, is the only person who ever, (before our
case at the hospital,) recognized the hernia by these signs,f or, as I may add)
by any other, save by the morbid appearances after death. It may have
been suspected, but never definitely diagnosed.
I proceed now to name them, and under each head I shall, in addition to
' * * Trait4 de P Auscultation Mediate. Paris.
• -t' London Lancet, Sept &; >835.
DtAPI]tUGU<LTIC BBRHIA.
giving the usual aouljsia of facta,
make su^estions in regard to soi
notictid.
Inspection. This was used &
the chest was dilated ; a round
hieh in thia particular will be very meagiu,
le that must liave been present though not
Ino
eth
Dg our own case. Id three
of the affucted side being
1 g a, med luxated inward; and in
VI d awn p nd down with each inapica-
([uietness of the whole side. I may allude
Bsciibed above, viz, a " crawling round the
not much confidence in its being observed ire-
niarked ii
another, the abdominal parif
tioR. Id our case, there wa
here to the peculiar symptor
ribs," which, although I hav
quently, may, however, occasionally occur.
So much for the records of science. But may we not step now beyond
these narrow limits and declare tliat, according to known physical laws, there
must be in the majurity of cases, a prominence and a partial or complete
immobility of the side of the chest in which the hernia exists? In looking
at Table 10, I find that in fifty-five out of the eighty-eight cases the lungs
were miich compressed, by which terra it is meant that the stomach or intes-
tines, or other of the abdominal viscera, occupied the place of a major part
of the lung. If wo remember that (by Table 9) only in four cases of seventy-
nine was there a single small organ in the cheat, hut that in seventy-three
cases out of the same seventy-nine, either the stomach or some of the intes-
tines were there, with some one or more organs; if we recollect likewise that
aentary canal, when thus ijicarcerated, often become
1 readily believe that the side of the thurax will be
mmovable. This prominence and immobility must
n front, because the lung would tend to be pushed
the portions of the alin
much distend I
distended and partially ii
Ukewise be most u
up and backward in consequence of its natural attachments to the spinal
column. These considerations induce me to believe that in a great ma-
jority of the future cases of this kind, prominence and immobility of the
thorax will be important aids to diagnosis.
Palpation. I am not aware that this was used at all except, perhaps, to
recognize the changed position of the heart Yet as physical laws exist
there must be a different vocal fremitus on the two sides of the chest, when
tile lungs are forced back by an intestine distended with gas, and the walls
of the chest are thereby more expanded than usual. What difference there
ihouid he I camint say. That a difference would exist I have no doubt.
I have alladed to the use of this method in recognising the changed
position of the heart, but as auscultation will do this more effectually, I must
refer to that
62 DHPHRAQMiTIO HBRNIA.
MenmiraiioH might be used very frequently, aod as usefully as we emplov
it in pneunio-thorajL, pleurisy, <fec, but I do not think it has evar been UMJ,
and probably in cases of recent rupture, we shall generally be unwilling to
use it, owing to the sufferings of the patient.
Avicttllation, This was used in six, possibly in seven cases. I likewise
recognised tbe affection chiefly by the use of this mode of examination.
Mr. Lawrence* found little or no renpiratory murmur on the affected aida.
In this case, a large part of the intestines, the whole oincntuin, part of ths
spleen and the whole pancreas compressed the lungs to the size of a man's fiift
Dr. Reidf found " a respiratory murmur" in the left side in his ease, sod
yet there were more than six pounds of fluid with one foot of colon and
omentum in the pleural cavity. It is to be regretted that Dr. B, did not
give a more detailed account of this case, and one is led to doubt whethw
the sound may not have been transmitted from the other lung; because th«
lung of the diseased side was found pressi'd back against the spine anj
attached to the diaphragm and "conUining no air." Possibly the soaad
may have resembied that heard in cases of large effusions into the cheat.
In our case, and one other, there was ahstnce of the reapiralortf nuirmttf
on tbe diseased, with puerile respiration on the healthy side. But inonroase,
when the patient took a deep inspiration, the murmur was heard perfaollv
Teaicular and pure to tbe second rib. A full breath increased certain hof-
barygmi, which had taken the place of the respiratory murmur below thii
point To the inesperienced ear they seemed to form so completely a part
of the act that they were, at times, supposed to be in the lungs. But the?
had exactly the charactenatice of the sounds heard over the abdomen in cas^
of intestinal disturbance, a mixture of gurgling, whistling and blowing, and
though excited at times by the act of respiration, they could be heard, evan
when the patient held his breath. It seemed as if the distention of 1^
lung eioited the vermicuUir motion. But this was not always the case, be-
cause often I could not excite them, either by a forced cough or inspiratioD.
Occasionally a metallic tinkling was heard, such as we sometimes hear
over the stomach. One day, an amphoric sound was heard, quite intense,
over the cartilages of fourth and fifth ribs, seeming to be stomachic though
affected slightly by the act of inspiration. Might we not excite these various
sounds (borborygmi, etc.) by making the patient driuk some stimuUtiog
liquid J
■ Lauoet, Sejit ."i, 1835.
t Bdinbuifli llL-dicalauJSurgicalJoumnl, Jan., 1840.
niAPHBAGUATIO HERKIA. Q3
» The voice Appeared natural in our case, and in one that occurred in Uuy'a
Hospital. I do not find that it has been noticed in others. Jt deserves
attention, for I believe some modification of it maj often he present.
In three cases, a siibcrepitant ^le was heard, twice in the back, once in
front and npper part of the back. Bronchophony, likewise, was heard in one.
In all, pneumonitis was found at the autopsy, and these modilicalions of the
respiratory murmur and voice were owing to this accidental eiroumstanca.
It seems to me very probable that some auscultatory phenomena might
he produced by pressing suddenly on the abdomen, and thus foR-ing air into
the intestines while in the pleural sac; or by disturbing the contents of the
intestines and thus causing peristaltic action.
The pulsations of the heart were noticed in four cases, and in three of
them they were to the right of the sternum. In our hosjiital case, it was
heard there Hkewise. These numbers give, I know, a very inadequate idea
of the real number of times that the sounds will be heard out of theif usual
situation.
When treating of the pathological anatomy of the heart, I remarked on
the probable frequency of this displacement. I would likewise refer now to
what I stated when speakiog of inspection; for the argument, drawn from
Table 9, applies to this subject as well as to prominence of the chL'Sl. This
dislocation of the heart must be considered an important element in the
diagnosis.
May not I suggest that not infrequently a bellows murmur will be heard,
owing to the constrained position of the heart ? It has never been noticed,
but were I to peroeiva it I should be very careful of inferring from ita exist-
ence any serious lesion of the organ.*
Permission, This method was used five times. There was dullness four
times at the back of the chest, in three of which there was either pneumonia
or pleuritic effusion; and in the other, the liver, colon, and omentum, were
in a sac. In one there was good sound, in which, though there was a slight
degree of pneumonia, there were the stomach and colon to distend chiefly
the left side of the thoraic Finally, in our case there was decided tympan-
ites. This result, I believe, conveys a very inaccurate idea of the real use of
• Since writing tMs, I have seen a record of a cose in wliicli a Honffle was obsorved
ibout tlie ruuts of tlio bronclii. Thu hcait in tliis case was pushed stiuiigly to tlie ^^^^
Icflby aBac at the right side. (Bui. de la Society Anatoinique,AuEeltj'sTli€siB.t) ^^^H
f TbAse puur la docturat ea M^decine. Paris, 1S49, par Aristide — Raymoml ^^^^^|
54 DIAPHRAGM ATIO HBRMTA.
percussion in this complaint. For in seven only of all the cases was there
sufficient fluid to cause dullness; in only six were the lungs camified or
hepatized, &c. On the contrary, by reference to Table 9, we find that in
seventy-two out of the eighty cases, either the stomach or some portion of
the alimentary canal was in the chest. Now, although in some of these cases
only a small portion of the canal was in the chest, or perhaps if in the thorax
it was contracted, — this is not the usual resuli; but the stomach or intestines
are distended with air. This distention must cause tympanites as in our
case, and generally in front of the chest, especially at the left side of the
same. There may be, also, a removal, toward the right, of the usual dull-
ness observed over the heart, owing to the organ being pushed out of place.
FULSB AND FBTER.
The pulse was noticed eleven times.
Its increased frequency was remarked in all but two of the cases. It was
small or feeble in eight; tremulous in two; firm or hard in two; soft in one;
strong and full in one ; and intermitting in one. It has evidently been
omitted in a majority of the records, and we cannot make any deductions,
except, perhaps, that an increased frequency seems not uncommon, but of
this we cannot be certain, because, as the time of the examination is not
mentioned, except in two cases the record may have been made of the latest
hours of life only.
Fever was spoken of but twice, but cold, clammy sweats were observed
five times. This part of the subject needs further research.
The skin was cold and livid about the chest, abdomen or extremities, in
six cases. It was covered with cold, clammy sweats, in three.
ABDOMINAL SYMPTOMS, <bO.
(During the fatal attach,)
Noticed in thirty-five cases.
Tongue and throat, dtc. They were not mentioned but twice. In the
case of the former it was clean and moist at one time, and only had a little
brownish coat on another occasion.
In one case there was great distress in the throat, but the post-mortem
appearances did not account for it.
Great thirst is mentioned in one case. A grinding of the teeth occurred
D1AFHRAQMA.TI0 UEBRIA. 55
H anotber. Anorexia and cardialgia occuri'ed in & beer drinker, wlio died,
in cansequence of an immoderate di'aiiglit of his favorite liquor.
TLere was rejection of food before it reached the atoniach, in one case, In
this the stomach was wholly inverted in the pleura, so that food must have
found access to ii with, difficulty.
IL Nausea or retching, or ineffectual efforts at vomiting, were noticed six
tjmes. I found that these symptoms were not particularly caused by the
abnormal position of (he stomach; at least, to produce them it was not ne-
cessary for the stomach to be confined in the chest, for, in two out of the
three cases in which nausea was mentioned, the stomach was not above the
diaphragm. In two cases of ineffectual efforts at vomittiip,* the same gen-
eral result was obtained. In one of Kirchbanm's cases, I find the expresaon
— weakness of the stomach — which, I presume, indicates a similar symp-
tom. In this case there was likewise vomiting, and the stomach had passed
into the chest
But the principal symptom in the disease, connected with the stomach,
was vomiting. Mention is made of this twenty-two times. Add to these
four cases of retching, die., and four more of whom it was said that the indi-
viduals died of iliac passion, and who probably had vouiidng, we have thirty
cases out of thirty-five who had either a disposition to vomit or actual
vomiting.
This, then, becomes a very important symptom for the diagnosis. In fact
no other, save dyspncea, can be compared with it. Their combination in any
case, of course, is still more important. We shall discuss this point at a
future time. (Vide Diagnosis.)
This symptom not merely existed; but in the majority (fourteen out of
twenty-two) of the cases, it is recorded as severe, very severe, constant or as
" vomiting of every thing."
The matters vomited were mentioned in eight cases. They were dark and
foetid in three cases; it was a kind of purulent pap, acid and fcetid in one;
a brownish mucus, probably altered blood, with .sarcinula veotriculi in one;
it was distinctly blood in one; an'd slercoraceous in two, toward end of life.
In one of the above which had altered blood, the matters vomited gave an
acid reaction, had no taste, and was covered with a jeasty froth.
56 DIAPHRAGMATIC HSRMIA.
On comparing this symptom with the post-mortem appearances, I found
that the stomach, in one case, was merely violently pressed up against the
diaphragm; in three others, other abdominal organs were in the chest; in
the remainder (eighteen in twenty-two) this organ was either wholly or in '
part in the chest.
PAIKS ABOUT THB ABDOMEN AND CHEST.
These pains were noticed seventeen times in the abdomen. In two cases
they were described as great distress at precordia; in ten they were very
severe, intolerable, excessive or violent pains or colics; in four they were
chiefly limited to the left side; in two to the right, one of which of last had
a dragging sensation at the right ; in one it was confined to the upper part
of the abdomen ; in another, chiefly to hypochondrium. Finally, in one
case, it was stated that there was no pain in the region of the stomach, but
there was a violent pain at the lower part of the sternum.
Pains were " in the side " or chest in eight cases, but four of them were
among the seventeen who had pain in the abdomen. These pains were
generally severe and acute, and never recorded as dull.
In comparing these results with the post-mortem appearances, I have been
foiled, as heretofore, but there seemed to be more severe and intolerable
pains in those cases in which a small part of the intestines was firmly strao*
gulated than in others, where there was a larger quantity of viscera in the
chest I cannot lay much stress on this point as the number of facts are too
small and records too indefinite.
ALVINX DISCHARGES.
Noticed eleven times.
Costiveness, usually of an obstinate character, was reported seven times.
These prove that this symptom occurs frequently. But it is to be regretted
that we do not find more detail in the cases given by authors, because I be-
lieve that the character and frequency of the alvine discbarges would have
presented interesting points for diagnosis and prognosis. Sir AsUey Cooper
says that in diaphragmatic hernia, we have the usual symptoms of internal
strangulation, combined with those of asthma. As costiveness is very com-
monly the accompaniment of this strangulation, we must, I think, meet with
svmptom ofUner than our numbers would seem to indicate.
DIAPHRAGMATIC HERNIA. 57
The bowels were loose, with foetid dejections, in four cases; they were
flatulent in one.
ABDOMEN.
tt was tense and sore^ on pressure, in one casa This was one in which
general but not severe peritonitis existed.
It was tympanitic in 2 (^^ses.
" retracted " 2 "
« tense u 1 «
« hard or rigid « 2 **
** depressed and drawn inward at each inspiration « i «
These facts are important from their very meagreness. It confirms the
inferences which I drew wheu treating of the pathological condition of the
abdomen. In the diagnosis of the disease it is of some importance for
the practitioner to feel assured that, in the vast majority of the cases, there
is no general peritonitis.
URINS.
This was noticed only once. It was free, without blood ; scanty, turbid
from lithates, with purple sediment The state of the kidneys are not men-
tioned in the autopsy.
OMENTUM.
This was protruded through the abdominal parietes in one case, in which
there were two wounds about the ensiform cartilage.
SKIN AND GENERAL STATE OF PATIENT.
Mentioned in twenty-three cases.
Great lassitude or faintness in five cases. In two a wound had been in-
flicted. In one there was great depression after vomiting came on. In two
casea^ the patients were able to walk some distance after accidents which
ruptured the diaphragm. Que of them rode in a coach nearly 150 miles,
'Without any complaint, though he became ill soon after his arrival, more
^han twenty-four hours after the accident
That great lassitude should be likely to happen in case of so severe an
^ocident as rupture of the diaphragm, seems very probable. I therefore
5
58 DIAPHRAGMATIC HERNIA.
doubt whether our numbers express very accurately the number of those who
are prostrated by it. But it is an extremely interesting fact that a man is at
times able to sustain himself for so long a period as twenty-four hours after
a rupture, in which one-half the stomach was forced through the diaphragm
and some blood eflfused.
RESTLESSNESS, dtC.
This feature of the affection was observed eight times. Once it was sim-
ple "discomfort." The left lung was in this case very much compressed.
There was a starting and shuddering at birth, so great that "fits" were feared,
and death took place in one and a half hours after birth. A third was un-
able to lie on the right side. In the remainder there was great restlessness,
patients sometimes tossing about in agony at the intensity of their sufferings.
COUNTENANCE.
The eyes were found open, haggard, or starting from their sockets, in three
cases. All three cases were the results of severe falls. The face was pale in
three cases; it had an anxious look in three more. It was expressive of
great suffering in two; it was red, after having been livid previously, in one.
After death it had a smiling aspect in one; it was natural in another; the
veins of the forehead were distended, the commissures of the mouth were
drawn apart showing the teetli, and the lips were covered with a bloody fluid
in another ; it was drawn to one side, as from paralysis, in one.
I think that we may infer from these few facts that the countenance fre-
quently indicates the severity of the disease. The last two cases are the only
ones in which I find notice of what some authors say is so very common in
this and other affections of the diaphragm, viz., the sardonic smile. I do not
believe that it is of such frequent occurrence as has been stated.
INCIDENTAL APPEARANCES.
In ten other cases there were various conditions, not connected, save inci-
dentally, with the hernia, viz., fractures, redness of skin, vesicular eruptions,
&c^ but of these I need not to speak.
DIAPHRAGMATIC HERNIA. 69
III. ORIGINAL CAUSES OF THE HERNIA
I have made the followiDg table for sixty-eight cases :
Table 11.
It was
congenital
in
26
cases.
It was
from drunkenness and debaucheries
•
3
u
a
<c
bullet wound ....
((
3
u
ti
u
stabs with sword or lance
u
•
9
u
u
il
"wounds" ....
u
3
u
ti
u
absence of diaphragm .
•
1
u
it
a
falls
(t
13
u
a
u
labor pains .
2
u
ii
u
sudden strain ....
u
1
u
«
t(
blows .....
4
u
C(
it
being run over
«
2
tt
u
u
fracture of the rib .
ti
•
1
u
68 cases.
By the above table we perceive that the congenital cases of diaphragmatic
hernia are about one-third of the whole number. There is another class of
cases of which, until the last year, we might have anticipated few examples
in this country, viz., those in which the hernia is caused by stabs or bullet
wounds; but, probably, among the military who have fallen on the plains of
Mexico, we should find not a few pathological specimens of this kind. Some
one or more of the survivors of that unholy war may be bearing even now
the results of it, in the form of hernia of this nature.
IMMEDIATE CAUSES OF THE FATAL ATTACK.
These causes are noticed by writers thirty-four times.
Table 12.
By a fall in 9 casess
" violent emetic <* 3 '*
" laxative medicine a \ u.
** drunkenness " 5 "
" inordinate use of cabbage and vinegar . « i «
** " cold acidulated water . . . •' 1 "
** 1
a
" 1
a
•* 3
u
« 1
u
« 1
u
** 8
u
« 1
u
** 2
u
« 1
u
34
cases.
60 DIAPHRAOMATIO HKRHIA.
** excess at a ball ....
** ballet wound ....
"stab
« blow
** strain, violent and sudden
** being run over ....
" violent crying ....
^ labor pains ....
^ a long walk
In eleven cases tbe bemia was congenital and almost immediately fatal;
making in all forty-five cases in whicb the causes of fatal attack were given.
INFERENCES TO BE DRAWN FROM THE ABOVE TABLE.
The table is interesting in many particulars. It may be again classified,
whereby we shall bring out four great classes of causes of the fatal attack.
Table 13.
1st. Pressure either from internal or external causes, . . 17
2d. Indigestible and irritating substances taken into the stomach, 12
3d. Wounds, 4
4th. Congenital, 11
5th. Great fatigue from a long walk, 1
45
From the second class of causes we have important indications for prophy-
lactic treatment; and of this I shall treat more fully hereafter.
The compai-ison of the number of fatal results immediately after birth in
congenital cases, with the absolute number of congenital cases on our record,
proves very conclusively that congenital hernia of the diaphragm is by no
means so necessarily immediately fatal in its consequences as some authors
would have us believe — eleven in twenty-six of those aflfected with it, or a
little less than one half having died at birth.
diaphragmatio hernia. 61
IV. AGE, SEX, PROFESSIONS, &a, OF THOSE AFFECTED
WITH THIS HERNIA
The average age of seventeen males was 35}!^, or 36 years nearly, the old-
est being 60 and the youngest 19.
Of three females the average age was 25 years, the oldest being 28, the
youngest 19 years. In addition to these, we have the indefinite but expres-
sive phrase ** old woman " applied to one of the patients.*
There were four under V years of age, with sex unknown, and nine still-
born infants, sex, likewise, unknown ; finally six, whose age and sex are alike
unknown.
The relative number of the sexes was as follows: out of seventy cases in
which the sex is named, there were
Of males, 63
Of females, 17
It may be a question why there should be this great difference between
the sexes in their liability to this disease. A glance at table 13 will readily
solve the question. We see that of the five classes of causes, only two apply
with equal force to males and females, viz., second and fourth ; whereas the
other three, viz., first and third, are almost exclusively liable to affect the male
sex, from the fact that the males are the laborers and warriors of the race.
The professions of those suffering from this complaint, are interesting as
indicating the amount of real deterioration to health caused by it. In only
twenty-five cases is any record made, and the result is as follows :
Table 14.
Common soldiers, 7
Officers, (military,) 3
Masons, 2
Shoemakers, 2
Sailors, 4
Husbandmen, 1
* Since this was written I have found the case of a female, aged eighty. It is evi-
dent, therefore, that a gi eater number of facts is needed before we can decide the
question. j
62 DIAPHRAGMATIC UERNIA.
Slater, 1
Conductor of Diligence, 1
Postillion, I
Laborer, 1
Carpenter, 1
Student, 1
25
Total. Laborious professionsy . . 22
Light do. (student and shoemaker,) 3
26
Ten of these twenty-five died in consequence of their injuries, either in-
stantly, or after a few days. The remainder lived a greater or less time
afterward, and performed some of the most laborious duties of life. For
example : a sailor went several India voyages ; a husbandman died at a good
old age; a postillion cracked his whip for ten long years, and at length died
of a second fall; a shoemaker kept himself busy at his last for a great while;
all enjoyed a comfortable degree of health but were liable to those symptoms
to which I have alluded in another part of this paper. (See symptoms ante-
cedent to fatal attack.) Our hospital case was a striking illustration of the
fact that a man may have diaphragmatic hernia and yet be able to perform
much hard work. He was in fact a most beautifully proportioned youth, a
sort of Antinous, as he appeared, when his trunk and limbs were laid bare
during the examination of his fractured spine. All his muscles were fully
and gracefully rounded, and their undue prominence was prevented by a
certain quantity of adipose matter indicative of perfect health.
V. DURATION OF LIFE.
I shall consider this subject under two points of view, viz., the duration of
life in congenital and accidental cases. Under the latter term I include all
except the congenital.
There were twenty-six congenital cases, and of these persons
Table 15.
11 died within two hours after birtk
6 within two years.
DIAPHRAQMATIO HERNIA. 03
1 at seven years.
8 not until the adult age.
Duration of life in the accidental cases, thirty-one in number.
Death was instantaneous in four cases; (arising, on^ from falls; one from
a severe blow ; one from a violent and sudden strain ; one from labor pains.)
It took place within twenty- four hours in twelve cases; (viz., two from
wound; one from fall; two from being run over; one being beaten and
drunk; one from drunkenness; one from crying violently; two after an
emetic ; one from cabbage taken ; one from labor pains.)
It occurred within a week in seven cases ; (one from a stab ; two from a
fall; one being run over; one cold water; two from drunkenness.)
It took place within a year in five cases ; (two from wound ; one from
drunkenness; two from falls.)
Life lasted more than a year in three cases; (viz., two from wounds; one
from a fall.)
In one of these last cases life was prolonged thirty-eight years.
The shortest time was about two years.
It will be seen by the above statements that
28 died within a year after the accident
3 lived beyond that period.
This proves, conclusively, that accidental diaphragmatic hernia is much
more liable than congenital soon to destroy life. Or to express the same in
in numbers: about one- tenth live more than a year in accidental cases; a
little more than one-half live beyond that period in congenital cases.
VI. DURATION OF LIFE IN THE FATAL ATTACKS.
In twenty-seven cases the duration of the attack is mentioned. The aver-
age of all of these is two days and fifteen minutes. The shortest time was,
of course, instantaneous death ; the longest was nine days. The causes that
operate the most quickly are those which produce sudden and violent strains,
such as blows, falls, <fec. : the next in order may be ranked all indigestions,
from having taken too much of substances that are prejudicial to the stom-
ach. But it is impossible to make a definite classification. The avera
duration proves the fearfully rapid course of the fatal attack.
64 DIAPHRAGMATIC HSRNIA.
VII. DIFFERENT SPECIES OF HERNIA.
Sir Astley Cooper* made three species, and that division has been usuallj
followed by authors, in England and on the continent, since his days. They
are as follows :
Ist In the first species we find the parts, of which the hernia consists, are
forced through some one of the natural openings of the diaphragm; for ex-
ample, that of the aorta, vena cava inferior, an intercostal nerve or the oesopha-
gus. May we not also consider the sacs, of which I have heretofore spoken,
as the result of enlargement of small apertures naturally existing between the
anterior mediastinum and the cavity of the abdomen ? It seems to me as
reasonable to classify this set of facts under this head, as it is to put those
cases there in which it is said that an intercostal nerve passage is dilated.
2d. In this species, are included all hernias resulting from a mAlconstruc-
tion of the diaphragm.
3d. Hernias from accidental wounds or lacerations of the diaphragm.
To these I would add a fourth kind; although, in the opinion of some,
the cases are not, strictly speaking, cases of hernia.
4th. Those cases in which one side of the diaphragm is violently forced
up into the chest, so that the lung is compressed, and all the signs of the
affection, as seen in the other classes, are observed.
In a former part of this paper I have investigated some of the points con-
nected with this subject.
Of the relative frequency ef these four classes, I obtain from sixty-eight
cases the following:
Table 16.
Hernia from accidents, 41
" " malconstruction, . . . .20
" " dilatation of natural openings, . . 6
" ** diaphragm being pushed up, . . 2
68
* On Hernia. London. FoL 1804.
ntAPHKAOMATIC HERKI*. 65
These numliere agree with tbe opiuions advanced by Sir Astley Cooper-
Pf the first three, he says, the Ihird is of very rare occurience. He had
evet seen one,
r The eeconil kiDil he says is more frequent.
p The-tirst kind is the most common, but as most of the nccidcnla are, in
le opinion of Sir Aslley, caused by the small sword, this class will, of course^
b and flow according to the character of the age.
Vlir. DIAGNOSIS.
) recognilion of this disease has usually been made only ai
me writers have gaid that it would be impossible to discover it during life.
J, in fact, been recognized, I believe, but a very few times before death.
i only two recorded inalancea, vin., that by Mr. Laurence, of London,
)ur own case, recognized by myself and others, at the MaGsachusetta
nieriil Hospital, The reason for this apparent difficulty in the diagnosis ia
I extremely infrequent occurrence of the affection. No man can hope
le more than one case during his lifetime, and therefore, as his attentioD
it drawn to the subject, he is unable to recognize the affection when it
B under his notice. Yet, from the investigation I have made upon the
tgect, I am disposed to believe that the diagnosis of diaphragmatic hernia
B easy, as that of almost any other chronic, and, possibly I might add,
IHtu disease. The rational signs distinctly pomt to it, in most cases; the
liyaical signs will generally afford the experimeatum crucia, and definitely
ttle the c|uestiou. In our own ciise at the hospital, these signs alone proved
lie intestines or stomach must be in the left side of the thorax, and if
i good observers should have done, bad compared more accurately
e did the rational witli the physical signs, we should, I think, have
I compelled to infer that there was a congenital diaphragmatic hernia,
> simple rupture of that muscle; which latter condition we were
i to believe nas the case from the circumstances of seveiv injury in the
ick, under which the patient entered the hospital*
I ahatl treat of the subject of diagnosis under the following heads:
'•Binee writing the above, I Ipmti that the housu surgeon made this iufcrtnoe fi'wa
n the eai'ly biBtiry of tliP paticut, but whieli, from the sufferiugH of the p^aep
been uiiabli' to obtain.
First. Congeaital cases.
Second. Cases in which a
Third. Accideutal cases.
^irsl, DiAGiioBi§ c
This categnrj of facts may be atill further divided, viz; Ist. loto thos
who die at hirth or immediately afterward. 2J. Those who live for a feif
months, or years, in a slate of more or less constant ill betilth. 3d. Thoa
who arrive at the adult age, and are able to perform many of the duties o
life, even those, at limes, involving the hardest kind of labor.
Ist In the first class, nearly one half never breathe, nor can they be n
to breathe. They die at the moment of their birth. It is literally " deattl
in life" with these little creatures; for, although the placental circulatioi
may have gone on in perfect order, and the infant may be well formed, Ba?4
in the want of a part, or the whole of the diaphragm, his doom is sealed at
the moment of his Stst effort of insjiiration. He can not inspire and he dies
instanter, or with a few gasps or sighs. He may make some very feeble _
attempts at crying; and, in very rare eases, may seem to be recovering; ban
he will relapse and die within a few hours. The other functions of the bo<^M
may be, though very imperfectly, performed ; the circulation may go on, bqfl
the heart should be ausculted, for wo shall frequently find it heating out t tM
its wonted place. If it be so, our diagnosis and prognosis may be mofM
decided. The nersous system may sympathize, and shudderings or severiS
convulsions may occur, to close the scene. If with these symptoms, we fioAfl
lividity of the skin and evidently general distress, referable to trouble in tbofl
respiratory function; if auscultation and the physical signs, already detaitedfl
confirm the rational signs, we certainly may be as sure of our diagnosis, anoH
of the proper method of treatment, as we can be of almost any disease, pneitfl
monia, for example. H
In addition to these means of recognizing the affection, I wonld remaiffl
tliat any external malformation, such as spina bifida, &c, combined with tKlfl
above-named symptoms, should lead us to suspect malforraation of the diafl
phragm, upon the same principle that when signs of cephalic disease occaiH
in the course of any malignant affection, that is well marked externally, i nm
infer that the same disease has commenced in the hruin. Facts snstjn^l
my assertion, several cases of monsters having exhibited this malformati<aM
2d. Congenital cases in ivhieh the patients live months, or a few year^butl
DIAPHRAGMATIC HERNIA. 67
generally in ill-health. Dyspnoea seems to be the most prominent symptom.
It is either constant or the patient is very liable to it upon the slightest exer-
tion; the attacks come on suddenly, and as suddenly leave; sometimes po-
sition and clothing have much influence. The whole constitution of the
individual seems bad, and the symptoms generally point to a chronic diflS-
culty about the respiratory function; the little patients are at times emaciated
and feeble. Auscultation will come to our aid as in the previous case.
3d. There are some who arrive at the adult age, notwithstanding there
is a very material malccnstruction of ihe diaphragm. It seems almost im-
possible that such persons should be able to perform any hard work, but such
is the case in not a few instances, and not merely are they able to perform all
the work of hard laboring men, but they have at times a degree of embon-
point. This was particularly the case with our youth at the hospital, with
his fair, ruddy countenance, and rounded swelling limbs and chest. But
though thus generally healthy, these individuals are liable, on severe or sud-
den exertion, to violent, and at times, prostrating attacks of dyspnoea, causing,
as in our case, total 1 )ss of consciousness. These attacks may come on very
suddenly and as suddenly disappear.
The^)w/se in these cases is at times very materially altered, quickened and
tremulous, owing to the dislocation of the heart.
Pain in the side about the region of the diaphragm, is not uncommon.
Colics and costiveness are not very common.
Vomiting is frequently seen, and this is a very dangerous symptom to be
excited either by an emetic or by improper food; for it aggravates the
affection.
But after all, no symptoms of a general nature can, in these cases, be
equal in value with the physical signs.
Second, diagnosis of cases in which sacs are formed.
Some writers* have hinted that there is a distinct difference between the
symptoms of these cases, and of those in which there is a rupture, or a dila-
tation without a sac through the various layers of the diaphragm. That one
may imagine a difference, I will not deny, but that the records of science-
give any support for such an hypothesis I am disposed to doubt. My rea-
sons for this opinion are that the records are too slight wherefrom to draw
any inferences.
* Arch, Gen'les de Med., 2d ser. torn. 12, p. 387.
68 DIAPHRAGMATIC HBRNIA.
Third. DIAGNOSIS of hernia arising from accidbntal rupture
OF THE DIAPHRAGM.
This class of cases may be divided iDto those in which 1st The patient
dies immediately or in a very short time after the accident; and 2d. Those
in which the individual recovers from the immediate effect of the injury, and
rupture is discovered at death, or may be suspected during life, by the symp-
toms incident thereto.
Ist. Of those who die in consequence of the accident, some few persons*
are found, in whom no marked and very severe symptoms come on until after
the lapse of some hours after the accident. In all the cases alluded to
I have found the menf were drunk, or nearly so, and their faculties were
probably so benumbed that they did not experience the ill-effects they
would have felt, had they been clothed in their right minds and sensibili-
ties. But generally a most violent train of symptoms commences imme-
diately, varying of course somewhat according to the amount and peculiar
character of the lesion. Many die immediately after having been so
wounded by a bullet, or having fallen from such a height, as to entirely and
very promptly destroy life. About an equal number die within a few days;
nine days being the longest, and thirty-three hours the shortest period in our
cases. In these persons violent breathlessncss, orthopnoea, or simple dyspnoea
is observed most frequently. With this, pains in the thorax, or either of the
hypochondria, are likewise common. Cough is occasionally present but
more rarely, causing increased pain in the chest and abdomen. Very rarely
is there any expectoration ; but at times hoemoptysis or hoematemesis occurs,
that is if either the lungs or stomach are wounded. The pulse is very much
quickened and must be altered as in any severe affection of this nature.
Vomiting, or ineffectual efforts to do so are frequent, and in the midst of
these symptoms, coupled with the prostration that commonly follows a severe
internal injury, the patient dies.
2d. At times he recovers from the immediate effects of the injury, owing^
probably, to its being of a less severe character than in the cases already
considered. In this case the individual may have no untoward symptom^
until symptoms of some internal strangulation occur, and he dies, and at the
• '■'* Wheelwright's case, Med. Chirurg. Transac, vol. v., page 574. 1815,
i«n'lM de Med. Sept 1834.
mtopay we Bhal! find the remnants of the former injury in the shape of an
sbnormal aperture in the diaphragm, and a hernia into the chest of the ab-
<k>ininal organs. This freedom from Bymploms, until the fatal attack, is, liow-
ever, rare, and it ia fortunate for humanity that it is so, for when they occufi
and do not prove fatal, they may be of infinite service to us in our subse-
qnent treatment of tlie patient, by enabling us to preBCribe certain diet«tio
and other rules whereby the individual may possibly arrive at a green old
age, instead of being cnt off in the vigor of manhood, as WEia the case recently
in a very remarkahle example.'* These symptoms are, a liability to dyspncea
cm exertion, pains in the hypiichondria, or chest; colics, costivenesa and vom-
Ifaig. Here, too, should we nse with great care, the physical signs. In one
on record, the heart beat to the right; in ours, likewise, there was the
3 fact. If, then, we find the heart beating in a different place from usual,
tpi other rational and physical signs indicating diaphragmatic hernia, we
iL charge our patient to be cautious in every action, for tlie sword of
death hangs snspended by a huir over him. The symptoms above stated,
my be liable to recur for many years. He may have several attacks of
i«n and may recover, or he may be cut down by the first strangulation of
'%B contants of the hernia, which of course ia the cause of the severer attacks,
while those symptoms that are habitual, the dyspnoea, &c^ are owing to the
impression of the lungs, from distention of the stomach and intestines, Ac
ymally, however, death comes on, perhaps after a debauch, an emetic, or
ler accident, or it may bo without any evident cause. The symptoms
the same as those already described as precursors of death, and joined to
we may have hiccough, syncope, cold clammy sweats, and lividity.
DIFFERENTIAL DIA GNOSIS.
Idigbt not asthma, pneumo-tborax, phthisis, cardiac disease, or a case of
Biat rare disposition of the organs in which the heart is found at the right
d^ &e., could not common colic, biliary calculi, abdominal hernia, or intor-
|] rtrangulation, simulate diaphragmatic hernia ! If we examine carefully
le origin, the course and actual state of the symptonis, and do not neglect
ifl physical signs, I can scarcely C'
Aloxander Barrow, 17. 3. Senator from Louisiana, wd learn from the public pspera,
of lliis iut«nial atrangulatiun, in cnnaequonco of an old sword wound uf the dia-
Aswa shall see wben fipeiikinK of iho treatment, tbejoum'iy he was engaged
le neceaaary distarbaiioe of the whole system consequent thereupon, ruigbt ha.T*
foretold to him, had the diseoBe beea previously recoguiztd.
70 DIAPHRAGMATIC HERNIA.
Asthma, it is true, causes dyspnoea, but the symptoms are excited by
very different cause. The symptoms we recognize, likewise, at once, as the
result of a constriction of the bronchi marked by a wheezing, and by physi-
cal signs to correspond. Cough, too, is always present in asthma — rather
rare in this hernia. Auscultation would allow us to hear wheezing every
where in one case, whereas absence of respiration or borborygmi would be
discovered in the other.
Pneumo-tkorax is rarely latent and chronic; it comes on suddenly during
phthisis or some similar disease. It has but rarely any abdominal symptoms;
the symptoms occur but once, and these are usually fatal. The physical
signs may admit of doubt, but usually the borborygmi will settle the matter.
A change in the usual disposition of the organs will not commonly be ac-
companied by any symptoms. The heart may beat at the right side, but
the respiration will be pure throughout the chest
Simple phthisis or cardiac disease I cannot believe will ever afford any
serious difficulty in the diagnosis.
The passage of gal^ stones may cause severe pains about the diaphragm,
but rarely thoracic symptoms. Moreover the physical signs are different in
this case and in hernia.
In regard to the supposed similarity of abdominal hernia or internal stran-
gulation, the fact, first, that in the former there would be usually some exter-
nal tumor; and second, that in both all thoracic symptoms would most prob-
ably be absent; and finally, that we have the physical signs very different in
the two classes of cases; these facts, it seems to me, would be sufficient for
a thoroui^h discrimination of the two affections.
IX. PROGNOSIS.
We have seen that congenital cases of diaphragmatic hernia are not neces-
sarily, immediately, fatal, the number immediately resulting in death to the
whole number of congenital cases, being about one to two four-elevenths. A
similar remark may be made in regard to hernia resulting from accidents;
for we have found that a little less than one-tenth of all the cases are not
fatal, but the patients are alive more than a year after the accident.
But though death may not be the result, we shall, most probably, have a
aeries of symptoms clearly indicative of the disease. Upon this points how-
'^er, I must refer to the detailed account of the symptoms and to the
DIAPHHAGIUTIO HERKIA. 7l
chapter od Diaguosls, From these we may infer somewhat as to the probable
course of the discaee. If we can persuade a man to take rcasonsble care of
the digesiive functions, to avoid costiveness; to cease from all very violent
exerdse or employment; in fact, to do all things in such a way as most to
promote quiet health, thtn our prognosis may be favorable. If, nnfortu-
nalely, ho should he taken ill, we should avoid al! violant means, especially
those operating severely on the nlimentnry canal. If these precautions be
observed, we may enable a person to enjoy a comfortHble degree of health;
anil in case of actual strangulation, aflbrd hira a tolerably fair chance of
recovery. If, on the contrary, the individual is of irregular habits, indulges
his palate, and is generally of a dissipated life, our prognosis must be
unfavorable.
With regard to the result of the actual attack, the severity of the local
gymptoms and their effects upon the whole system, must be our guide. Fo
, example, as long as the vomiting and costiveness, and pulmonary symptom!
. are alight, and the pulse and powers of the body are not prostrated, we may
give some hope. But if the dyspnoea is intense, the vomiting stercoraeeous,
I the pains about the chest or diaphragm agonizing; if the pulse become fre-
I qaent and feeble; if the skin is covered with a clammy sweat; if the strength
I at the patient fail, our prognosis must be very unfavorable.
Finally, it must be remembered that all I have stated above is closely
I allied to, and may, in fact, be considered as absolutely dependent upon an
I. Mwurate diagnosis. This has never been made but twice, and in these cases
3 too lute to do service. We must do better than our predecessors, bet-
ter, likewise, than we ourselves have done, and recognize the affuction before
the commencement of its fatal attack. This, as we have seen, can undoii
edly be done, if we will but be accurate in our esarainalion of the rational
lUid physical signs, and connect them with previous facia in the history of the
padent, in the way indicated in various portions of this paper.
X. TREATMENT.
In considering this part cf our subject, I shall rely little upon the anal,
of the results of treatment in the individual cases recorded ; but rather upon
the suggestions that have arisen in consequence of the study, that I have
made, of the whole course of the affection. The reasons for so doing are
these: 1st. The small number of cases in whicii any I'eoords ai'e made of
72 DIAPHRAGMATIC fiSRKU.
any treatment In only thirteen, in fact, is there any record. 2d. Owing
to the ignorance of most of the observers in regard to the true nature of the
afifectioD, their modes of treatment have been entirely empirical, and gener-
ally very absurd, and not a few times absolutely hurtful to the patient. Oc-
casionally, a course of action, having a good influence, has been commenced,
but owing to this same ignorance of the actual morbid condition, all the good
has been destroyed, by subsequent exhibitions of remedies of a most perni-
cious tendency. The consideration of this question of treatment still further
naturally divides itself into the prophylactic^ and that to be followed during
an attack. Of the two branches of the subject,! consider the former the more
important
The prophylactic mode of treatment, which I shall lay down, "will, of
course, depend wholly upon what we have learned of the condition of the
parts in this affection, and of the tendencies to their strangulation under
various circumstances. I have already alluded to this when speaking of the
prognosis. Let me suppose either that a child present, from the moment of
birth, signs of this hernia, or that an adult is liable to fits of dyspnoea, or cos-
tiveness, &C., (see Diagnosis,) after a fall, or a wound in the trunk from a
sword or bullet, <fec Let me suppose that the physical signs, inspection,
have enabled us to decide which side of the diaphragm the rupture exists,
what course are we to advise our patient to pursue, in order to avoid the risk
of a fatal attack of strangulation ?
If we turn to the list of causes of the fatal attack, we shall see that there
are two conditions of the system which are particularly liable to produce
serious effects, viz : 1st Any condition that would be likely to produce vio-
lent, or sudden, or long-continued strain on the abdominal muscles; and 2d,
Any ingesta taken into the stomach which excite it into undue action. We
should therefore advise the patient to give up the practice of any employ-
ment likely to produce the first result; for example, that of a seaman, a sol-
dier, or coach driver, or even of common laborer. He should select some
more quiet, though not sedentary employment, as the least liable to produce
the results that are anticipated. This treatment I recommend, also, because,
from Table 14, 1 learn that the laborious professions seem more liable to this
disease than should be their proportion supposing all equally liable to it
But, at the same time, that he may choose a more quiet business, he must
be very careful not to select one liable to produce irregularity of the digestive
operations ; for instance, that of a tailor would not be very good for a maa ;
and the same remark may be made in regard to the business of a searastrefls
of a female. In both of these professions dyspepsia, at&d its train
DIAPHRAGMATIC HERNIA. 73
of evils, costiveness and vomiting, &c^ are apt to occur, and if they do, the
patient will narrovrly escape with his life. The business of baker, bricklayer,
grocer, servant, merchant, or either of the so-called, liberal professions, would
be the better.
2d. We should advise the patient to be very careful that his digestive
functions go on well ; we should assure him that by a debauch he runs the
risk of his life ; and that by undue eating of unusual food of any kind, a dan-
ger is incurred which no wise man would incur for the mere gratification of
the palate. He should use that food which is easiest of digestion, and which
has neither a constipating nor a purgative effect; but which will enable him to
have regular and suflScient and easy alvine discharges daily. These remarks
are suggested by Table 12. It may be further remarked, while upon this
subject, that on no account should emetics or cathartics, of a violent nature,
be prescribed for one having this hernia; for antimonial emetics, that is, any
violent emetics are very liable to produce death in these cases.
The treatment of a patient suffering from symptoms of actual strangula-
tion, is less satisfactory than one could wish. There are records in thirteen
cases only, and even if there had been notes of a greater number, they would
hardly have taught us much, for every case on record, in the annals of medi-
cine, has proved fatal, which fact presents a most conclusive argument that,
up to the present hour, at least, no course of medication has been of any
avail, or if it has been, no medical record at present existing, can prove it to
have been so. But are we to infer from this state of things, that we shall
never be able to cope with this affection ? By no means. When, by our
more accurate diagnosis we shall be able to recognize, earlij in the period of
strangulation, we may, by cautious treatment, be able to give the patient a
fairer opportunity of recovering, than nature, unassisted by art, would afford
him ; and certainly a far better chance than the various empirical methods
pursued by all previous practitioners.
I shall speak of the various remedies that have been used, and give my
own views upon the advantages, or disadvantages likely to result from each.
Venesection was used five times, and never with any effect On the con-
trary, the distressing symptoms went steadily on till death. The amount of
blood taken seems never to have been very great, only once is it stated that
§xvi. were taken. Are we to infer from this result that venesection is never
to be performed ? I think not. The cases are too few in number to author-
ize such a deduction, especially as it does not appear that in any of the cases
6
74 DIAPHRAGMATIC HKRN'IA.
deliquium was produced. Now to do much good, i, e, to produce any mat
rial relaxation of the strangulation, it seems to me a decided effect should I
produced. At the same time, however, there are serious objections to its us
viz., we deprive a man of a great portion of his life's strength by v^nesectio:
and we do so without much hope of good. I think, however, we should b
justified in bleeding ad dehquium, a stout patient, who is suffering much paii
and who has a strong pulse ; but we should be chary of such a method i
the cases of more feeble persons.
Leeches were used once without relief, and I do not beUeve they eve
would do much good.
Cathartics and enemata were given four times. This is, hkewise, a sma
number of cases whence to make any deduction. Yet I think a fai
examination of these few, and some, a priori, reasoping on the subject, wi
lead us wholly to reject these two methods as something worse than useless
The patients were never relieved by either of the methods. On the con
trary, all were great sufferers from violent spasms, or colics, or vomiting* an<
in one, at least, the vomiting was excited by the medicine, and in anothei
the pains in the abdomen were more severe after their use. And we ma
fairly, a priori, ask the question : Is not this exactly the result we shouL
anticipate? Does an able surgeon give cathartics in a case of strano-ulatei
inguinal or crural hernia? To force, by the peristaltic action, more of th
contents of the intestine into the strangulated part would be mischievous
Why, then, should we use cathartics and enemata in hernia of the diaphragm
There is no reason, but our ignorance and our disposition always to play th
hero in any case of obscure abdominal trouble resembling colics. If a mai
does so, he is liable to be the cause of the destruction, perhaps, of humai
life. I am, therefore, fully of the opinion that all cathartics, even of the gen
tlest kind, should be avoided. The only hope for the patient rests on th(
entire quiet which the intestinal canal preserves.
•
Emetics, Some may doubt about the truth of the assertion that the phy
siciaa may be the cause of death by the administration of cathartics. I fee
perfectly certain that such would be the case in the use of emetics. If w(
look at the table of causes, (Table 12>) we find that a violent emetic was th(
cause of the fatal attack in three cases. In the single case in which it wai
mentioned as having been used as a remedy, the dyspnoea became rauel:
greater after it, and death took place an hour after its exhibition. Taking
» ^«5tB into consideration, that vomiting is a very troublesome symptom
DIAPHBA6MATIC HERNIA. 75
of the disease, I think we are fairly justified in concluding that emetics, not
only do no good, but that they tend to aggravate the afiection, and, therefore,
should never be administered.
Opiates were used four times. In one case, where they were freely ad-
ministered, the patient lived until the sixth day. Though one case afibrds
but small data, whereupon to build an opinion, still as this was a severe case,
and continued longer than the average number of days before death, it seems
to me to be of some importance. In the other cases in which opiates were
administered, they were given in very small quantities and without any defi-
nite aim ; so that no marked effect was produced, save in the relief of pain.
But does it not seem reasonable that they should be of service in prevent-
ing any undue peristaltic action of the bowels, while we are using other reme-
dies for the relief of the inflammatory condition of the ring and parts adjacent.
Thus the analysis of facts and reasoning, a priori, lead us to conclusions
exactly the reverse of those to which the subject of cathartics has brought us.
Other remedies of a general and very indefinite nature, are mentioned by
authors, such as "soothing antiphlogistics ;" and "stimulants afterward, '*
"remedies for spasm of the stomach;*' "creosote,** " vesication and sinapism"
to side. But of these I shall say nothing.
Bathing was used once, for a quarter of an hour, with relief. But should
it not be used more freely ? Nothing that I know of has a more powerful
effect on the system than long-continued bathing. It evidently relaxes all
parts with which it comes immediately in contact, and I think that the cold
bathing, as used by the hydropathists, would tend, at least in a degree, so to
lower the pulse, and diminish any local inflammatory tension even of the
diaphragm, that it is worth a trial.
Ether, Were I satisfied that stricture existed in the diaphragm, I should
be disposed to use this new method freely. It would do no harm and would
temporarily relieve the pain and give relaxation to all the parts, and thus
give a chance, at least, of active relief to the strangulation.
Operation, Finally, as a last resource, might not an operation for cutting
the strangulated ring be attempted ? It never has been done, though Laen-
nec has suggested it Yet I see no good reason why it may not be possi-
ble to recognize, by the physical signs, the side at which the disease exists,
and the probable amount of the affection. Having learned these two points,
and having tried other means of relief without success, ought we not to
undertake the more serious operation of the scalpel ?
T6
Where should tUt; incision be made! Saes commence about the lower
Bud fronL part of the mediastinam ; therefore, near Cliis ia a proper place to
commence the iuciaion. Pamng along the edge of the ribs for the space of
thiee or four inchea, we should divide the muscles and come upon the peri-
Dvering the lower part of the diaphragm and reflected thence upon
iside of the abdominal nmaclea. It would be possible, (I think,) to push
aside this membrane and not enter the cavity of the peritoneal sae until we
I might be able to make out the exact place of stricture, and there a very slight
n only would be necessary. But in this operation there is, at present,
BO much of difficulty owing to the proximity of important organs, and to the
distention and alteration of position of the abdominal organs, that it will
probably have few to perform it, especially as the disease is so rare, that no
person would be likely to have mure than one or two opportunities for oper-
ating during his whole lifetime.
List of works from which the above cases were taken, or which were con-
sulted during the preparation of the monograph :
IGIO. Opera Ohinirgica. Ambrose Pare. Franltfort.
1646. Gulielrai Fahricii Hildani, opera. Frniikfort.
1698. Lszari Riverri Op. Medics Univera. Obs. 67.
170a. Pbiloaophical TransiuStionB of (bo Rojal S(H:icdty of LtmdoD : abridgment.
Paper by Sir Charles Holt
1729. Mfmoires do I'AciuISniie des Scieuces. Article by Ohauvet tb Seuao ; alto
1772, by Vioq d'Azyr. Paris.
1755. Holler's Disaertationes Cbinirgicie, vol. iii. Dissertatio de Hernia Tentri-
culi ; by Eirscbbauni. Lausanne.
Morgagni Worke, vol iii., letter 54 Seata and Caaaes of Diaease.
1767. Historia Anatomico-Medica ; Joaeplius Lieotaud. Paris, voL i.
17TI. Medical Obsercatio:^ and Inqtiiriea. London,
net Works of John FotbergilL Edited by J. R. Lctfaom. London.
1803. CoutB d'AnatnmiB Mfidieale. Autoine Portal. Paris.
1804. On Hernia. Sir Astley Cooper. London.
1807. Edinburgh Medical and SuTgical Dictionary ; by Morris ib Gendriok.
ISl.'i. Uedico-Cbirurgical Transactious. London.
IBIS. Di ctioc Dai re dea Sciences Med icalcs. Paris. Percy on Rupture of Uie Dia-
pliragiu.
182.1, '26. Edinburgh Medical and Surgical Journal, vol. xin., p. 293 and 382.
1B33. Supplement au Traits Pratique des Hemrea, par Scarpa. Paris.
15. Reme Mfidicale et Journal de Olinique, vol. icvit Parts.
!7, Jonrnal des Ptogr^s MpdicaleB. Do., 1823.
DUPHRA6MATIC HKRNIA. 77
1828. Medico-Chirurgical Review, vol. ix., p. 280.
1831. London Lancet, April ; Nov., 1834 ; Sept., 1835 ; April, 1840 ; Aug., 1843.
1832, '3, '41. London Med. Gaz., vol. x., p. 42 ; vol. xii., p. 673 ; vol. xxviii, p. 390
1834. Disscrtatio luauguralis Anatom. Chirurg. de Hernia Diaphragmatis. Huber-
tiis ; Griffioen ; Stierling. Heidelberg.
1635. Dictionnaire des Sciences M^dicales, in 30 voli«. Paris. Art Diaphragme.
Cloquet & Berard.
1838. Treatise on Hernia ; by William Lawrence. London.
1839. Archives Grenerales de Medicine, 3d ser., 19 vols. ; vol. vii. ; vol. xviii.
1842. These pour le Doctorat en Medicine, par Aristidc Auzelly. Paris.
1846. Bulletin de la Societe Anatomique. Case by Mons. Gabier.
Philadelphia Medical Examiner, vol. iii., p. 384.
British and Foreign Medical Review, vol. iv., p. 260.
Encyclographie des Sciences Med. Ser. 6, Tom. 12, p. 267.
In addition to the above works, froni which I have obtained the cases, I
have examined all the medical and scientific journals and transactions which
I could find up to the date of the paper, together with all treatises upon the
subject of hernia, to which I could obtain access.
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iB78 A treatise on dia-
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