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By F. V. Bevan Brown, M.D. (Lon.), M.R.C.P, Hon. Physician Christchurch Hospital.

While diaphragmatic hernia of traumatic origin is comparatively common, especially since the war, hernia resulting from congenital defects in the diaphragm is only rarely recorded. The present case is remarkable for the apparently complete absence of the left half of the diaphragm. Tjhere was no hernial sac and the abdominal viscera passed freely up into the thorax. A still more interesting feature is that at the operation the heard could be clearly seen through the abdominal incision uncovered by pericardium, and appearing under the costal margin. The history is as follows:—

Thomas G., aged 54, cabdriver, was admitted to the Christchurch Hospital under my care on 2nd February, 1921. He complained of chronic headache, giddiness, occasional vomiting, and feeling generally out of sorts. He said that all his life he had never been able to follow any strenuous occupation, though he had never noticed anything particularly wrong with himself until the present time. Ten years ago he had been kicked in the abdomen by a horse, and two years ago he had been operated on for acute appendicitis. His present trouble commenced indefinitely a few months ago, but the vomiting dated apparently from the time he received the kick from the horse. He is a man of medium build, spare and of rather poor physique. On examination, his heart was found to be displaced so far to the right that the apex could be seen and felt pulsating in the epigastric angle under the xiphisternum. The rhythm and sounds of the heart were normal. Both brachial arteries were tortuous, and the left radial pulse was almost obliterated. The systolic pressure in the right arm was almost 185m.m. The left side of the chest moved less well than the right; tactile fremitus was absent in the axilla and diminished in front and behind. The area of normal lung resonance and breath sounds on the left side varied from day to clay, depending as it did on the degree of flatulence present. On an average it reached down to the fifth rib in front and the seventh rib behind, while laterally it was seldom obtainable. Below this lung are there was tympanitic resonance which could be elicited high up in the axilla. Over the tympanitic area breath and voice sounds were absent. The right lung was hypertrophied, and the breath sounds over it were loud and harsh. A marked gastric succussion splash could he obtained.

We considered the possibility of pneumothorax, but X-ray examination put this out. Dr. W. Bates, radiologist to the hospital, reported that the bismuth meal revealed a very large stomach rising high into the chest and lying against the heart, the fundus filled with gas and evidently pushing the heart over to the right. No diaphragm could be seen on the left; on the right it was placed rather lower than normal, owing to the hypertrophy of the right lung. The stomach had passed so high up into the chest that the pylorus lay at its lowest point, and the duodenum seemed to have lost its loop and to have been pulled out straight by the upward drag of the stomach. The bismuth rapidly entered the small intestine. When the bismuth reached the large intestine the transverse colon could be seen passing obliquely up from right to left to the splenic flexure which lay above and behind the stomach at the level, in front, of the third intercostal space.

We made the diagnosis of diaphragmatic hernia, caused, perhaps, by the kick from the horse ten years previously, but we were puzzled to know why we could not see any diaphragm on the left side. An extra degree of flatulence began to cause the man syncopal attacks—a new feature and largely of nervous origin, as he was very apprehensive of his condition. He was in so miserable a state that it was decided to attempt to reduce the hernia by operation, though the prospects of success were recognised to be rather poor.

Dr. A. C. Sandston operated. A vertical incision was made through the left rectus from costal margin to umbilicus and continued along the costal margin to the xiphisternum. On opening the abdomen no great omentum could be seen, and its lower edge was found appearing under the costal margin. The stomach passed high up out of sight into the thorax. Traction on it brought it down a few inches, but on being released it immediately returned. The transverse colon passed obliquely up towards the splenic flexure, which lay far out of sight behind the stomach and high up in the chest. Like the stomach, it could not be drawn down permanently. The left lobe of the liver reached only to the midline. No trace of diaphragm on the left could be made out. The most remarkable feature of all was the condition of the heart, which could be clearly seen and felt, lying free in the abdomino-thoracic cavity, naked of pericardium, its apex lying in the middle line of the body, under the xiphisternum. A hard white glistening cartilaginous substance covered the apex and lower two inches of the left ventricle behind, and in the region of the right auriculo-ventricular groove were three small fleshy cyst-like bodies, growing on the heart.

A second incision was made over the sixth rib in the posterior axillary line and a piece of this rib was removed. The surgeon passed his hand up through the abdominal incision to the rib incision, and nothing intervened but a thin membrane of parietal pleura.

Since there was no diaphragm on the left and no hernial orifice and no sac, there could be no hernia, and therefore the stomach and colon could not be restored to their normal position. Nothing could be done, and the incisions were therefore sutured and the man taken back to bed. For the following few days he was very blue and dyspnœic from bronchitis, but this passed off and he. returned to his former condition, though with his nervous system rather upset. At the present time, a month later, he is short of breath on exertion, and suffers some pains in his scars. His condition is otherwise unchanged. He certainly has a functioning left lung, since faint breath sounds can usually be heard in the left axilla and normal breath sounds can always be heard in front and behind in the upper part of the left chest, which moves fairly well. The lung, therefore, manages to fill and empty in spite of the apparent absence of the diaphragm, and in spite of the stomach and colon, which must lie against the lung and press on it. The condition is certainly a congenital one. Absence of the left half of the diaphragm as a congenital anomaly is referred to in Cunningham’s Anatomy and in Choyce’s Surgery, and cases are recorded in the proceedings of the Anatomical Society of Great Britain, June, 1900, and in the Journal or Anatomy and Physilogy (Vol. 34). Professor Keith, in his description of the development of the diaphragm, states that the commonest defect is a persistent dorsal pleuroperitoneal opening on the left side, which may occupy two-thirds of the left half of the muscle.

Absence of the pericardium is a much rarer condition, and I have so far been unable to find any reference to its occurrence, though no doubt previous cases have been recorded; there are few structures of the body which are not prone to congenital defects. The cartilage on the apex of the heart in the present case is probably a developmental remnant of the central tendon of the diaphragm. It will be remembered that the pericardium opposite the apex is normally attached to the central tendon. The fleshy cysts on the right auriculo-ventricular groove are, perhaps, similar remnants of the undeveloped muscular portion of the diaphragm. Absence of the pericardium raises the interesting question of the function of that structure. Evidently, as in this case, it is not an essential part of the human anatomy.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Acknowledgements

Correspondence

Correspondence Email

Competing Interests

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

By F. V. Bevan Brown, M.D. (Lon.), M.R.C.P, Hon. Physician Christchurch Hospital.

While diaphragmatic hernia of traumatic origin is comparatively common, especially since the war, hernia resulting from congenital defects in the diaphragm is only rarely recorded. The present case is remarkable for the apparently complete absence of the left half of the diaphragm. Tjhere was no hernial sac and the abdominal viscera passed freely up into the thorax. A still more interesting feature is that at the operation the heard could be clearly seen through the abdominal incision uncovered by pericardium, and appearing under the costal margin. The history is as follows:—

Thomas G., aged 54, cabdriver, was admitted to the Christchurch Hospital under my care on 2nd February, 1921. He complained of chronic headache, giddiness, occasional vomiting, and feeling generally out of sorts. He said that all his life he had never been able to follow any strenuous occupation, though he had never noticed anything particularly wrong with himself until the present time. Ten years ago he had been kicked in the abdomen by a horse, and two years ago he had been operated on for acute appendicitis. His present trouble commenced indefinitely a few months ago, but the vomiting dated apparently from the time he received the kick from the horse. He is a man of medium build, spare and of rather poor physique. On examination, his heart was found to be displaced so far to the right that the apex could be seen and felt pulsating in the epigastric angle under the xiphisternum. The rhythm and sounds of the heart were normal. Both brachial arteries were tortuous, and the left radial pulse was almost obliterated. The systolic pressure in the right arm was almost 185m.m. The left side of the chest moved less well than the right; tactile fremitus was absent in the axilla and diminished in front and behind. The area of normal lung resonance and breath sounds on the left side varied from day to clay, depending as it did on the degree of flatulence present. On an average it reached down to the fifth rib in front and the seventh rib behind, while laterally it was seldom obtainable. Below this lung are there was tympanitic resonance which could be elicited high up in the axilla. Over the tympanitic area breath and voice sounds were absent. The right lung was hypertrophied, and the breath sounds over it were loud and harsh. A marked gastric succussion splash could he obtained.

We considered the possibility of pneumothorax, but X-ray examination put this out. Dr. W. Bates, radiologist to the hospital, reported that the bismuth meal revealed a very large stomach rising high into the chest and lying against the heart, the fundus filled with gas and evidently pushing the heart over to the right. No diaphragm could be seen on the left; on the right it was placed rather lower than normal, owing to the hypertrophy of the right lung. The stomach had passed so high up into the chest that the pylorus lay at its lowest point, and the duodenum seemed to have lost its loop and to have been pulled out straight by the upward drag of the stomach. The bismuth rapidly entered the small intestine. When the bismuth reached the large intestine the transverse colon could be seen passing obliquely up from right to left to the splenic flexure which lay above and behind the stomach at the level, in front, of the third intercostal space.

We made the diagnosis of diaphragmatic hernia, caused, perhaps, by the kick from the horse ten years previously, but we were puzzled to know why we could not see any diaphragm on the left side. An extra degree of flatulence began to cause the man syncopal attacks—a new feature and largely of nervous origin, as he was very apprehensive of his condition. He was in so miserable a state that it was decided to attempt to reduce the hernia by operation, though the prospects of success were recognised to be rather poor.

Dr. A. C. Sandston operated. A vertical incision was made through the left rectus from costal margin to umbilicus and continued along the costal margin to the xiphisternum. On opening the abdomen no great omentum could be seen, and its lower edge was found appearing under the costal margin. The stomach passed high up out of sight into the thorax. Traction on it brought it down a few inches, but on being released it immediately returned. The transverse colon passed obliquely up towards the splenic flexure, which lay far out of sight behind the stomach and high up in the chest. Like the stomach, it could not be drawn down permanently. The left lobe of the liver reached only to the midline. No trace of diaphragm on the left could be made out. The most remarkable feature of all was the condition of the heart, which could be clearly seen and felt, lying free in the abdomino-thoracic cavity, naked of pericardium, its apex lying in the middle line of the body, under the xiphisternum. A hard white glistening cartilaginous substance covered the apex and lower two inches of the left ventricle behind, and in the region of the right auriculo-ventricular groove were three small fleshy cyst-like bodies, growing on the heart.

A second incision was made over the sixth rib in the posterior axillary line and a piece of this rib was removed. The surgeon passed his hand up through the abdominal incision to the rib incision, and nothing intervened but a thin membrane of parietal pleura.

Since there was no diaphragm on the left and no hernial orifice and no sac, there could be no hernia, and therefore the stomach and colon could not be restored to their normal position. Nothing could be done, and the incisions were therefore sutured and the man taken back to bed. For the following few days he was very blue and dyspnœic from bronchitis, but this passed off and he. returned to his former condition, though with his nervous system rather upset. At the present time, a month later, he is short of breath on exertion, and suffers some pains in his scars. His condition is otherwise unchanged. He certainly has a functioning left lung, since faint breath sounds can usually be heard in the left axilla and normal breath sounds can always be heard in front and behind in the upper part of the left chest, which moves fairly well. The lung, therefore, manages to fill and empty in spite of the apparent absence of the diaphragm, and in spite of the stomach and colon, which must lie against the lung and press on it. The condition is certainly a congenital one. Absence of the left half of the diaphragm as a congenital anomaly is referred to in Cunningham’s Anatomy and in Choyce’s Surgery, and cases are recorded in the proceedings of the Anatomical Society of Great Britain, June, 1900, and in the Journal or Anatomy and Physilogy (Vol. 34). Professor Keith, in his description of the development of the diaphragm, states that the commonest defect is a persistent dorsal pleuroperitoneal opening on the left side, which may occupy two-thirds of the left half of the muscle.

Absence of the pericardium is a much rarer condition, and I have so far been unable to find any reference to its occurrence, though no doubt previous cases have been recorded; there are few structures of the body which are not prone to congenital defects. The cartilage on the apex of the heart in the present case is probably a developmental remnant of the central tendon of the diaphragm. It will be remembered that the pericardium opposite the apex is normally attached to the central tendon. The fleshy cysts on the right auriculo-ventricular groove are, perhaps, similar remnants of the undeveloped muscular portion of the diaphragm. Absence of the pericardium raises the interesting question of the function of that structure. Evidently, as in this case, it is not an essential part of the human anatomy.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Acknowledgements

Correspondence

Correspondence Email

Competing Interests

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

By F. V. Bevan Brown, M.D. (Lon.), M.R.C.P, Hon. Physician Christchurch Hospital.

While diaphragmatic hernia of traumatic origin is comparatively common, especially since the war, hernia resulting from congenital defects in the diaphragm is only rarely recorded. The present case is remarkable for the apparently complete absence of the left half of the diaphragm. Tjhere was no hernial sac and the abdominal viscera passed freely up into the thorax. A still more interesting feature is that at the operation the heard could be clearly seen through the abdominal incision uncovered by pericardium, and appearing under the costal margin. The history is as follows:—

Thomas G., aged 54, cabdriver, was admitted to the Christchurch Hospital under my care on 2nd February, 1921. He complained of chronic headache, giddiness, occasional vomiting, and feeling generally out of sorts. He said that all his life he had never been able to follow any strenuous occupation, though he had never noticed anything particularly wrong with himself until the present time. Ten years ago he had been kicked in the abdomen by a horse, and two years ago he had been operated on for acute appendicitis. His present trouble commenced indefinitely a few months ago, but the vomiting dated apparently from the time he received the kick from the horse. He is a man of medium build, spare and of rather poor physique. On examination, his heart was found to be displaced so far to the right that the apex could be seen and felt pulsating in the epigastric angle under the xiphisternum. The rhythm and sounds of the heart were normal. Both brachial arteries were tortuous, and the left radial pulse was almost obliterated. The systolic pressure in the right arm was almost 185m.m. The left side of the chest moved less well than the right; tactile fremitus was absent in the axilla and diminished in front and behind. The area of normal lung resonance and breath sounds on the left side varied from day to clay, depending as it did on the degree of flatulence present. On an average it reached down to the fifth rib in front and the seventh rib behind, while laterally it was seldom obtainable. Below this lung are there was tympanitic resonance which could be elicited high up in the axilla. Over the tympanitic area breath and voice sounds were absent. The right lung was hypertrophied, and the breath sounds over it were loud and harsh. A marked gastric succussion splash could he obtained.

We considered the possibility of pneumothorax, but X-ray examination put this out. Dr. W. Bates, radiologist to the hospital, reported that the bismuth meal revealed a very large stomach rising high into the chest and lying against the heart, the fundus filled with gas and evidently pushing the heart over to the right. No diaphragm could be seen on the left; on the right it was placed rather lower than normal, owing to the hypertrophy of the right lung. The stomach had passed so high up into the chest that the pylorus lay at its lowest point, and the duodenum seemed to have lost its loop and to have been pulled out straight by the upward drag of the stomach. The bismuth rapidly entered the small intestine. When the bismuth reached the large intestine the transverse colon could be seen passing obliquely up from right to left to the splenic flexure which lay above and behind the stomach at the level, in front, of the third intercostal space.

We made the diagnosis of diaphragmatic hernia, caused, perhaps, by the kick from the horse ten years previously, but we were puzzled to know why we could not see any diaphragm on the left side. An extra degree of flatulence began to cause the man syncopal attacks—a new feature and largely of nervous origin, as he was very apprehensive of his condition. He was in so miserable a state that it was decided to attempt to reduce the hernia by operation, though the prospects of success were recognised to be rather poor.

Dr. A. C. Sandston operated. A vertical incision was made through the left rectus from costal margin to umbilicus and continued along the costal margin to the xiphisternum. On opening the abdomen no great omentum could be seen, and its lower edge was found appearing under the costal margin. The stomach passed high up out of sight into the thorax. Traction on it brought it down a few inches, but on being released it immediately returned. The transverse colon passed obliquely up towards the splenic flexure, which lay far out of sight behind the stomach and high up in the chest. Like the stomach, it could not be drawn down permanently. The left lobe of the liver reached only to the midline. No trace of diaphragm on the left could be made out. The most remarkable feature of all was the condition of the heart, which could be clearly seen and felt, lying free in the abdomino-thoracic cavity, naked of pericardium, its apex lying in the middle line of the body, under the xiphisternum. A hard white glistening cartilaginous substance covered the apex and lower two inches of the left ventricle behind, and in the region of the right auriculo-ventricular groove were three small fleshy cyst-like bodies, growing on the heart.

A second incision was made over the sixth rib in the posterior axillary line and a piece of this rib was removed. The surgeon passed his hand up through the abdominal incision to the rib incision, and nothing intervened but a thin membrane of parietal pleura.

Since there was no diaphragm on the left and no hernial orifice and no sac, there could be no hernia, and therefore the stomach and colon could not be restored to their normal position. Nothing could be done, and the incisions were therefore sutured and the man taken back to bed. For the following few days he was very blue and dyspnœic from bronchitis, but this passed off and he. returned to his former condition, though with his nervous system rather upset. At the present time, a month later, he is short of breath on exertion, and suffers some pains in his scars. His condition is otherwise unchanged. He certainly has a functioning left lung, since faint breath sounds can usually be heard in the left axilla and normal breath sounds can always be heard in front and behind in the upper part of the left chest, which moves fairly well. The lung, therefore, manages to fill and empty in spite of the apparent absence of the diaphragm, and in spite of the stomach and colon, which must lie against the lung and press on it. The condition is certainly a congenital one. Absence of the left half of the diaphragm as a congenital anomaly is referred to in Cunningham’s Anatomy and in Choyce’s Surgery, and cases are recorded in the proceedings of the Anatomical Society of Great Britain, June, 1900, and in the Journal or Anatomy and Physilogy (Vol. 34). Professor Keith, in his description of the development of the diaphragm, states that the commonest defect is a persistent dorsal pleuroperitoneal opening on the left side, which may occupy two-thirds of the left half of the muscle.

Absence of the pericardium is a much rarer condition, and I have so far been unable to find any reference to its occurrence, though no doubt previous cases have been recorded; there are few structures of the body which are not prone to congenital defects. The cartilage on the apex of the heart in the present case is probably a developmental remnant of the central tendon of the diaphragm. It will be remembered that the pericardium opposite the apex is normally attached to the central tendon. The fleshy cysts on the right auriculo-ventricular groove are, perhaps, similar remnants of the undeveloped muscular portion of the diaphragm. Absence of the pericardium raises the interesting question of the function of that structure. Evidently, as in this case, it is not an essential part of the human anatomy.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Acknowledgements

Correspondence

Correspondence Email

Competing Interests

Contact diana@nzma.org.nz
for the PDF of this article

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