The Roentgenologic Diagnosis of Diaphragmatic Hernia, with A Report of Seventeen Cases

THE literature on diaphragmatic hernia reveals four important facts: (1) purely clinical diagnoses have seldom been made; (2) purely roentgenologic diagnoses have often been made; (3) in routine roentgenologic examinations of the chest, diaphragmatic hernias have often been overlooked, or mistaken for other conditions, and (4) the co-operation of clinician and roentgenologist has led to the best diagnostic results. Thus far, including our series of seventeen cases, approximately 1,200 cases of diaphragmatic hernia are on record. The condition has been noted in twenty patients1 in the Mayo Clinic, an incidence of one in practically every 18,000 patients examined. Fifteen of these patients have been examined in the last two years. Protocol of Cases2 Case 1 (A55100, reported by Giffin). Mr. L. J., aged twenty years, was examined in the Clinic June 26, 1911. One year before, while working in a sand pit, the walls had given way, and he was doubled up suddenly with his head between his feet, suffering a crushing injury. Since that time he had had severe attacks of epigastric pain coming on at irregular intervals with a feeling that his stomach was in his chest. Examination. — Tympany was elicited over the lower left chest. Over this area the breath sounds were distant, and occasional tinkling sounds were heard. A clinical diagnosis of diaphragmatic hernia was made. Roentgenologic examination revealed a gas bubble above the left diaphragm. An opaque meal demonstrated the herniation of the stomach into the left chest. Operation. — An oval-shaped opening was found in the left half of the diaphragm large enough to admit the hand. The hernia contained the stomach, nearly all of the transverse colon, and twelve feet of jejunum. Tremendous traction was exerted by the chest cavity. It was impossible to determine what portion of the abdominal contents became a part of the hernia, as a result of opening the abdomen. The patient's recovery was uneventful. Case 2 (A136932, reported by Balfour). Mr. J. L. K., aged forty-seven years, came to the Clinic for examination July 27, 1915. He had sustained a crushing injury to his ribs in a railway accident in 1911, and had not been well since. He had dyspnea, burning pains in the epigastrium after meals, and pains in the left chest. Examination.—Gurgling and splashing sounds were heard in the left chest, more marked in the knee-chest position. Tympany was elicited over the left chest. Diaphragmatic hernia was suspected. Roentgenologic examination revealed the presence of the stomach and splenic flexure in the left chest. At operation a small hernial opening was found in the left diaphragm. The chest cavity contained a large part of the small intestine, the greater portion of the colon, the spleen and the stomach. Two ulcers of the stomach were found, one at the pyloric ring and one 2.5 cm. above it.