Traumatic Diaphragmatic Hernia

Transcription

1 Traumatic Diaphragmatic Hernia A Review of 25 Cases John P. Sutton, M.D., Robert Byron Carlisle, M.D., and Sam E. Stephenson, Jr., M.D. I n 579 Ambrose Part [9] reported the result of a necropsy performed in 568 by Jacques Guillemeau on a French artillery captain. This individual had been shot in the left chest with an arquebus eight months previously but had healed all external wounds. He had returned to duty with only minor complaints of postprandial cramping abdominal pain until his death with large bowel obstruction caused by incarceration of a portion of the colon through a rent in the fleshy portion of the diaphragm. Bowditch [5] credits aennec with the suggestion that operative reduction of the herniated viscera should be attempted. Gibbon [2] refers to Guthrie, who in 853, while reporting a case of a soldier who had died with a diaphragmatic hernia and strangulated stomach, surmised that when corrective measures aimed at reducing intraabdominal pressure failed, surgical reduction by the abdominal route might be lifesaving. Toward the end of the nineteenth century operative procedures were being attempted for diaphragmatic hernia. Grage et al. [4] point out that in 879 Bardenheuer performed a colostomy for acute intestinal obstruction in a patient who, two days later at autopsy, was found to have a diaphragmatic hernia with strangulation of the colon. Hedblom [5] cites Riolfi, who reported the successful repair of a stab wound of the diaphragm in 886; Walker [22] in 899 successfully repaired a diaphragmatic tear in a patient hit by a falling tree. Up until recent years the majority of diaphragmatic hernias were sustained in combat and often were immediately fatal. At the present time, the majority of injuries to the diaphragm are secondary to the present emphasis on high-speed transportation or to major sidewalk social incompatibilities [8-0, 20, 2, 23. A lesser cause which is currently being seen with increasing frequency stems from the increasing numbers of thoracoabdominal operative procedures which necessitate surgical incision of the diaphragm. From the Department of Surgery, Vanderbilt University Hospital, Nashville, Tenn. Presented at the Thirteenth Annual Meeting of the Southern Thoracic Surgical Association, Asheville. N.C., Nov. 3-5, THE ANNAS OF THORACIC SURGERY

2 Traumatic Diaphragmatic Hernia CINICA MATERIA From the years 933 to 965 there have been 25 cases of traumatic hernias of the diaphragm admitted to the surgical service of the Vanderbilt University Hospital. As can be seen in Table, 2 of these hernias occurred on the left side TABE. INCIDENCE OF TRAUMA AND ONSET OF SYMPTOMS Right aiaphragm Onset of Symptoms eft Diaphragm Onset of Symptoms Type of Trauma Immediate Delayed Total Immediate Delayed Total Indirect Direct and 4 on the right side. This represents a somewhat smaller ratio than that reported by many [3, 0, 3, 8, 20, 23. The average age in this series was 34 years with the youngest patient being years and the oldest 77. This is consistent with other studies [9,, 3, 2. These hernias can be further categorized as to those produced by indirect violence and those produced by direct trauma to the diaphragm. Table also depicts the incidence of the two categories considered. All of the cases of rightsided hernia were due to indirect trauma, and all were found in males. Of the 2 hernias on the left side, 4 were due to indirect trauma; of these, 0 were found in males. This merely reflects the higher male exposure rate to industrial and automotive hazards. Table 2 presents a synopsis of all cases reviewed and again demonstrates the fact that indirect trauma was responsible for almost threequarters of all traumatic diaphragmatic hernias. Of these, the automobile was the etiological agent in 0. These data are in accordance with the consensus of the literature with the exception of a slightly lower incidence of automobile accidents [2, 0, 4, 2, 23. DIAGNOSIS The clinical picture of a rupture of the diaphragm has been divided into three phases by Carter and Giuseffi [8, 9: () an acute phase with signs and symptoms dependent on the size of the tear and the quantity and character of dis laced viscera; (2) a chronic phase exemplified by those who have had previous ab B ominal or thoracic trauma and who at a later date developed symptoms; (3) an intermediate phase that presents with the signs and symptoms of intestinal obstruction. It seems that it should be equally acceptable to categorize these hernias into those cases with immediate and those with delayed onset of symptoms. This allows the intermediate group to fall partly in the acute and partly in the chronic, thereby permitting a more liberal classification and ease of interpretation. In considering the time of onset of symptoms sufficient to bring the patient to medical attention, it is apparent from Table that there was immediate onset of symptoms in an overwhelming majority of indirectly produced left-sided diaphragmatic hernias. This was the result of the frequency of associated severe injuries as well as the character of the viscera impounded. Hernias produced by direct trauma and those of the right diaphragm demonstrated little difference in the time of onset of symptoms. In this series any significant symptom up until 4 days after injury was considered as immediate. Of those patients presenting in a delayed fashion, the shortest interval from the time of injury to onset of symptoms was two months. This was in a schizophrenic patient who was run over by a hay wagon at the State Mental Hospital. He had been initially treated in the Emergency Room and released, only to return with signs and symptoms of intraabdominal catastrophe two months later. He was found at operation to VO. 3, NO. 2, FEB.,

3 TABE 2. SYNOPSIS OF CASES REVIEWED Mode of Age & Time Diaph. Injury Sex to Opr. Inj. Operative Findings Comment on Injury Mortality. Auto M 2. Auto 42lM 3. Auto 43/M 4. Auto 59/M 5. Auto 24lF 6. Auto 20lM 7. Auto 40/M 8. Auto 38/M 9. Auto 20lM 0. Auto 8/M Total, 0 cases 8 hr. 4 hr. 3 hr. 4 days 3 hr. 5 hr. 7 hr. 4 hr. 6 hr. 3 days R ac. R. lobe liver; no visc. Pedestrian herniated No herniated viscus Sm. bowel, stom., spleen, liver in chest Stom., oment., tr. colon, sm. bowel in chest Stom., sm. bowel & rupt. spleen in chest Kid., sm. bowel, stom. in chest. Rupt. spleen Stom., colon, spleen in chest Spleen, oment., stom., sm. bowel in chest Stom. in chest. Rupt. spleen Rupt. spleen, perf. stom. in chest v. Ind. 3lM 2. Ind. 22lM 3. Ind. 20lM 2 yr. 36 hr. 3 hr. R iver, tr. colon in chest Caught between 2 mine cars. 2 yr. PTA. Init. Rx-4 weeks bedrest Sm. bowel, stom., tr. colon Miner, knocked into jackin chest knife pos. by falling rock ac. liver & torn dist. ileum, Gravel truck ran over stom. in chest abdomen

4 4. Ind. 62M Total, 4 cases. Misc. 29M 2. Misc. 8/F 3. Misc. 29M 4. Misc. 58lM Total, 4 cases. Knife 4lM 2. Knife 42lF 3. Knife 9M Total, 3 cases. Gunshot 7lF Total, case. Surg. 77lF 2. Surg. 40/M 3. Surg. 26M Total, 3 cases 3 hr. 2 yr. hr. 6 hr. 2 mo. 2 hr. 20 yr. 2 hr. 9 days 3 yr. 4 yr. 7 mo. R R Perf. stom. in chest. Rupt. spleen iver, kid. in chest Rupt. spleen and stom. in chest ac. liver in chest Strang. stom. in chest Oment. protruding from chest Spleen, flex. colon in chest Oment. in chest Perforated stom. in chest Stom., tr. colon in chest iver, colon, oment. in chest Splenic flex. of colon, oment. in chest Pinned beneath tractor 2 v hr. Buggy ran over chest at age 8 Passenger in motor boat accident Hit by falling boxcar door Run over by hay wagon,,v 2 mo. PTA; seen in E. R. and discharged Self-inflicted Prev. esophagogastrostomy; v hernia thru diaph. inc. Prev. esophagogastrostomy Prev. thoracoabdom. proc. for gunshot wound, left chest

5 SUTTON, CARISE, AND STEPHENSON have a strangulated stomach. The remainder of the patients with delayed onset noted symptoms at seven months, 4 years, 2 years, 3 years, 4 years, and 20 years subsequent to injury. One patient who was found incidently at thoracotomy for recurrent esophageal stricture to have a hernia through an incision made 4 years previously has been included in this group. Subsequent to the onset of symptoms, most patients immediately came to surgical attention. One patient, however, noticed the onset of symptoms seven months following a thoracoabdominal exploration for a gunshot wound of the left diaphragm; he had continued to complain of intermittent abdominal pain with nausea and vomiting for two months before a hernia was recognized in the left diaphragm (previous surgical incision). Similarly, another patient, who had been run over by a buggy at age 8 and had remained asymptomatic for the ensuing 4 years, complained of intermittent severe abdominal pain with vomiting for 7 years before he underwent a right thoracotomy (2 years after injury) for a supposed right lower lobe tumor and was found to have a large diaphragmatic hernia through which the liver and the right kidney were passing. As has been stated by many, a high index of suspicion is often necessary to recognize the traumatic diaphragmatic hernia [l, 24, 6, 0,. Certain signs were more prevalent than others, and these are summarized in Table 3. Evidence of pneumonic consolidation and mediastinal shift comprise the largest group of physical signs. The pathognomonic finding of the bowel sounds being audible in the chest occurred in only 7 cases. Interestingly, the chest exam was negative in 6 of the cases, and signs of intraabdominal injury were present in 2. It is felt that any individual presenting with a history of thoracic or abdominal injury and demonstrating any one of these signs must be considered a candidate for traumatic diaphragmatic hernia. A review of the chest x-rays in this series revealed that the routine posteroanterior roentgenogram was normal in only out of 23 cases. In this single case with a normal chest x-ray, a plug of omentum was eviscerated and clearly visible on physical exam. Table 4 summarizes the experience of the routine chest x-ray and contrast studies. In this series there were 4 cases in which a chest x-ray was abnormal but not suggestive of a diaphragmatic hernia and in which contrast studies were performed. These studies were beneficial in establishing a diagnosis in 3 out of these 4 cases. OPERATIVE FINDINGS Twenty-four patients came to operation. The most frequent single approach was thoracic (8 cases), but in 6 other cases in which a thoracic incision was initially made, it was necessary to add an abdominal component. In 5 cases a single abdominal approach was used, and in 4 others an additional thoracic incision was required. A simultaneous thoracic and abdominal approach was employed in patient. Figure is a cross section of the thorax viewing the diaphragm from above. That portion of the left diaphragm in the para-pericardial position extending to the esophageal hiatus has been outlined and labeled A. The remainder of the left diaphragm is then further divided into tendinous, anterior muscular, and posterior muscular portions. The right diaphragm has simply been divided into tendinous, anterior muscular, and posterior muscular portions. As is apparent from the accompanying legend, the para-pericardial portion and the anterior muscular portion represent the most frequent site of herniation on the left side. The right-sided hernia was most frequently seen through the tendinous portion. The 2 cases of direct injury to the para-pericardial portion were due to previous surgical incisions in this area. An analysis of the organs eviscerated into the chest is depicted in Table 5. It can be seen that the stomach, colon, small bowel, and spleen are most frequently found in left-sided hernia. The liver was the organ most frequently involved on the right. Only 9 of 25 cases had a single herniated viscus in this 40 THE ANNAS OF THORACIC SURGERY

6 Traumatic Diaphragmatic Hernia TABE 8. Finding Decreased breath sounds Basilar dullness Evidence of intraabdominal injury Mediastinal shift Respiratory distress Hypotension Bowel sounds in chest Decreased diaphragm excursion Hyperesonance Negative chest exam PHYSICA FINDINGS No. of Cases X-ray Finding Suggestive of diaphragmatic hernia Abnormal but not suggestive Normal Not done TABE 4A. CHEST X-RAY FINDINGS Indirect Trauma 6 - No. of Cases Direct Trauma TABE 4B. CONTRAST STUDY FINDINGS" No. of Cases Contrast Finding Diagnostic Not Diagnostic Chest abnormal but not suggestive Chest x-ray suggestive "Includes only upper gastrointestinal series and barium enema. 3 - Organ Stomach Colon Small bowel Spleen Omentum iver Kidney None TABE 5A. CONTENTS OF HERNIA FOUND AT OPERATION: ORGAN INVOVEMENT eft Hernia Right Hernia Total Single Total Single VO. 3, NO. 2, FEB., 967 4

7 SUTTON, CARISE, AND STEPHENSON TABE 5B. CONTENTS OF HERNIA FOUND AT OPERATION: NUMBER OF VISCERA PRESENT Viscera eft Hernia Right Hernia None series. Bernatz et al. 3 stated that the omentum had the greatest propensity to migrate alone; however, our data suggest the stomach as the most frequently seen single organ, with the omentum assuming second place. Slightly more than half of the cases had multiple organs herniated. Of these, the stomach was in combination with the small bowel in 7 cases, with the spleen in 6, and with the colon in 8 cases. ASSOCIATED IN JURIES Table 6 demonstrates the frequency of associated abdominal sequelae to diaphragmatic hernia. Of the depicted cases, only 3 significant complications were Indirect Direct ocation Trauma Trauma Total eft Side A B. 2 3 C. 2 D E.a 2 2 Right Side X Y. 0 Z. 0 *E. Combination OT unclassified: () y-shaped tear across diaphragm; (2) U-shaped tear across diaphragm with apex anteriorly. FIG.. Cross section of thorax and diaphragm depicting locations of hernia caused by indirect and direct trauma. 42 THE ANNAS OF THORACIC SURGERY

8 Traumatic Diaphragmatic Hernia TABE 6. ASSOCIATED VISCERA INVOVEMENT FOUND AT OPERATION No. of Cases Obstruction Stomach Colon Perforation Stomach 3 Ileum Strangulation Stomach Rupture Spleen 7 iver 3 Total 7 due to direct trauma. One of these was a thoracostomy tube being inserted into a herniated stomach, and the other 2 complications were late sequelae of incarcerated colon. Two of these patients presented with truly delayed symptoms. One of these was colonic obstruction presenting nine months following a thoracoabdominal procedure for a gunshot wound of the chest. The other was a strangulated stomach in a patient presenting two months after injury. There were several associated bony injuries commonly seen in patients with diaphragmatic hernias produced by indirect diaphragmatic trauma, some of which have previously been reported by Carlson et al. [7. Pelvic fractures (7) and rib fractures (7) were the most frequently found concomitant injuries. Only 3 cases with indirect trauma had no associated bony injuries. There were 4 hip or leg fractures, 3 facial or skull fractures, 3 lumbar spine fractures, and 2 fractures of the upper extremities. MORTAITY There were 5 deaths in this series (a mortality rate of 20%). This figure is similar to those previously reported. When blunt trauma was considered alone, there were 3 deaths (22%). Three of the patients who died did so as the result of severe and multiple injuries. Of the remaining 2 deaths, one was a 58-year-old schizophrenic who expired one month after an initial operative procedure in which a strangulated stomach was resected. His death was due to postoperative obstruction of the small bowel. The final death was a 77-year-old who succumbed to respiratory insufficiency secondary to a hernia through a diaphragmatic counterincision for an earlier esophagostrostomy. DISCUSSION Aside from the nature of the injury necessary to produce a traumatic diaphragmatic hernia, this entity is particularly serious in that it tends to perpetuate itself. The normal intrathoracic pressure is relatively negative to the intraabdominal pressure on inspiration, thereby allowing abdominal viscera to be pushed into the chest. The insertion of the muscular fibers into the tendinous dome of the diaphragm are such that any rent would tend to enlarge by contraction of the diaphragmatic muscle. In addition, Figure 2 demonstrates the fact that forces exerted on the thorax either in the anteroposterior or lateral VO. 3, NO. 2, FEB.,

9 SUTTON, CARISE, AND STEPHENSON FIG. 2. Cross sections of diaphragm showing how lateral (left) and anteroposterior (right) compression aid in production of para-pericardial rents. U directions tend, by compression of the thoracic cage and by alteration of the angle of origin and insertion of the diaphragmatic muscle, to produce the rents characteristically seen in traumatic diaphragmatic hernias. Therefore, with anteroposterior compression the muscle fibers have a more lateral direction of pull. If one assumes that the pericardium rotates slightly to the left and is compressed with the increase in lateral diameter and decrease in anteroposterior diameter, then the pull and shearing effect produced frequently results in a para-pericardial rent. Similarly, with lateral compression the pericardium is elongated and muscle pull assumes an anteroposterior direction, thereby again allowing a para-pericardial tear. It would seem that these factors would explain the rents in this area of the diaphragm, which in this series was 5 (36%) of the 4 left-sided hernias produced by indirect trauma. The anterolateral muscular portion of the diaphragm was the second most frequent site of indirectly produced rupture. Certainly the vulnerability of this position with associated avulsed attachments and lacerations concomitant with broken ribs would account for its frequency of disruption. One further factor for consideration is the fact that thoracic trauma is frequently associated with abdominal trauma. Forces that are applied abdominally must be transmitted as though through a liquid media. Since the diaphragm is a relatively weak structure when compared to the abdominal wall or perineum, in addition to the fact that it protects an area of relatively negative pressure, it is surprising that it does not disrupt more frequently [l, 0. On the right side the liver, being a parenchymatous organ, possibly acts as a buffer, although the right diaphragm may disrupt in 5% to 20% of the cases [3, 0, 3, 8, 20, 23. The majority of those individuals with diaphragmatic hernia due to indirect trauma are usually the victims of multiple injuries [2, 7-0, 5, 23. In this series only 4 (6%) failed to show associated bony injuries. Often the signs and symptoms of diaphragmatic disruption 44 THE ANNAS OF THORACIC SURGERY

10 Traumatic Dial, hragma tic Hernia are quite impressive. Thus dyspnea, cyanosis, shock, bowel sounds in the chest, mediastinal shift, and evidence of pneumonic consolidation or pneumothorax should lead one to consider serious intrathoracic injury. All too often, however, the diagnosis is not considered, and attention is turned to other injuries as evidenced by the 7 (28%) who presented with delayed onset of symptoms. These probably were individuals with small rents that enlarged with the passage of time, thereby permitting the incarceration of voluminous quantities of viscera in the chest. Certainly, a high index of suspicion must be maintained; when combined with the routine upright posteroanterior x-ray of the chest, as has been pointed out in this series and in others [2-4,6,9, 8,23, a diagnosis can be made in most instances. Carter et al. [9] listed four points in their extensive discussion of the subject of x-ray findings that should arouse the suspicion of a diaphragmatic hernia: () archlike shadows resembling a high diaphragm, (2) extraneous shadows or gas bubbles extending above the diaphragm, (3) shift of the mediastinal structures, and (4) disc or platelike atelectasis supraadjacent to the archlike shadow. These are depicted in Figures 3-5. Frequently the posteroanterior x-ray of the chest will be the only diagnostic adjunct permitted by the condition of a seriously injured patient. Fortunately it is usually sufficient to permit the diagnosis. In this series a correct diagnosis was established preoperatively in 2 of 25 cases. Only out of 23 of these had a negative chest x-ray, but omentum was visible protruding from the lower thoracic stab wound in this case. Many have pointed out that additional procedures such as upper gastrointestinal series, barium enema, pneumoperitoneum, and x-rays after the passage FIG. 3. Posteroanterior x-ray of a case of indirectly produced left-sided traumatic diaphragmatic hernia. An archlike shadow resembling a high diaphragm is seen. VO. 3, NO. 2, FEB.,

11 SUTTON, CARISE, AND STEPHENSON FIG. 4. Posteroanterior x-ray of a left traumatic diaphragmatic hernia showing extraneous shadows and gas bubbles extending above the diaphragm. Also seen is a nasogastric tube entering this extraneous gas bubble. of a nasogastric tube often aid in the establishment of a diagnosis. These adjuncts are a benefit in problem cases, such as in one patient referred to us from an adjacent city: A chest tube had been inserted in the left chest of this 7-year-old white female with a self-inflicted gunshot wound for a presumptive diagnosis of pneu- FIG. 5. Posteroanterior x-ray of a left-sided traumatic diaphragmatic hernia showing platelike atelectasis szipraadjaceiat to a high archlike shadow and mediastinal shift to the right. 46 THE ANNAS OF THORACIC SURGERY

12 Traumatic Diaphragmatic Hernia mothorax. A nasogastric tube had been inserted for ileus. Her condition worsened, and studies revealed that the nasogastric tube passed from the stomach into the chest and the chest tube passed into the stomach. This certainly is not the first case in which a supradiaphragmatic air shadow was interpreted as representing a pneumothorax. It is mentioned merely to point out the value of contrast studies. All too frequently, however, contrast studies must be limited to those individuals presenting less acutely and particularly to those presenting with late symptoms. Figure 6 shows the barium enema providing a diagnosis in a 42-year-old female complaining of frequent eructations, postprandial cramping, and constipation. She had been stabbed in the left chest 20 years prior to admission. As can be seen, the splenic flexure of the colon is present in the left chest. In general, the pathophysiological effect of a diaphragmatic hernia is dependent on two factors: () a situation analogous to a tension pneumothorax with ipsilateral pulmonary collapse, mediastinal compression, mediastinal shift, and contralateral respiratory embarrassment; and (2) the type and quantity of the viscera impounded. The first situation can oftentimes effect a situation of dire emergency and when such a patient is given a general anesthetic, hypotension and cardiac arrest often follow [7]. This was exemplified in this series by a 20-year-old patient with a ruptured diaphragm through which the spleen, left kidney, small bowel, and stomach had passed. The patient became profoundly hypotensive upon induction of anesthesia. When the left chest was opened hurriedly, the blood pressure returned to normal. When consideration is given to the type and quantity of viscera impounded, it is apparent that the clinical picture is frequently that of FIG. 6. (eft) Posteroanterior x-ray of a 42-year-old female stabbed in the left chest 20 years previously. Extraneous shadows are visible above the left diaphragm. (Right) A barium enema proves this to be splenic fiexure of the colon. VO. 3, NO. 2, FEB.,

13 SUTTON, CARISE, AND STEPHENSON an intraabdominal catastrophe. Of the 5 cases in which the stomach was found in the chest, resection or closure of perforations was necessary in 5. Splenectomy was necessary in 7 of the entire series of 25. A bleeding liver was found in 4 of the 25 cases, and as expected, these were all present on the right side. On analyzing the surgical approaches used in this series, it was shown that the most frequent one was thoracic. Frequently, however, adhesions make reduction of impounded viscera from above difficult, and traction from below is necessary. There are those who advocate a thoraco-abdominal approach, yet the relative frequency with which hernia through operative incisions in the diaphragm occur argue against this. Similarly, counterincisions through the diaphragm to allow intraabdominal manipulation also add the hazard of postoperative diaphragmatic hernia. In addition, one must consider that such incisions frequently denervate the diaphragm. To this extent it would, therefore, appear more logical to first approach the hernia from the abdomen, utilizing, for instance, a midline incision. This allows one to explore for intraabdominal injury and in many instances suffices for repair of the diaphragm. None of the cases reviewed here demonstrated damage to intrathoracic organs which could not have been recognized or repaired from below. This cannot be said, however, for intraabdominal trauma when using a primary thoracic approach. One case of indirectly produced diaphragmatic hernia also had a ruptured spleen and traumatic division of the distal ileum. This would have been difficult indeed to repair if it had been recognized through the left chest. A consideration of direct trauma leads one to the same point. Many institutions recommend routine abdominal exploration in cases of penetrating wounds of the abdomen. This holds true whether the abdomen has been entered anteriorly, superiorly, or posteriorly. Certainly, in some cases one is not able to reduce adequately the impounded viscera from below, and in others, exposure is not adequate for repair. In of our patients a posterior para-pericardial rent could not be exposed from the abdomen, and a posterolateral thoracotomy was necessary. This patient also had a ruptured spleen, which might have been missed by a thoracotomy alone. In postoperative and chronic diaphragmatic hernias the thoracic approach alone may well suffice. It would, however, appear that in acute cases an abdominal approach initially with prior preparation for a separate anterolateral thoracic incision would be the procedure of choice. Primary repair can usually be accomplished, as it was in this series, without the aid of pericardial grafts or prosthetic materials. Certain cases, such as long-standing hernias or those with avulsed attachments from the chest wall, may present a problem in repair. Use of prosthetic 48 THE ANNAS OF THORACIC SURGERY

14 Traumatic Diaphragmatic Hernia materials, reattachment of the diaphragm at a higher interspace, phrenicolysis, limited thoracoplasty, and construction of a ventral abdomen wall hernia have all been founded beneficial in selected cases. Fortunately, these adjuncts are seldom necessary. SUMMARY Twenty-five cases of traumatic diaphragmatic hernia have been admitted to the Vanderbilt University Hospital during the years Of these cases, the majority occurred on the left side in males following indirect trauma. The mortality rate in this series was 20% (5 patients); undoubtedly it was affected by associated injuries. Paramount to early recognition of this condition is a high index of suspicion, which when combined with a routine posteroanterior x-ray of the chest will yield the correct diagnosis in most cases. Early operation is indicated, and it is felt that a primary abdominal approach with prior preparation for a thoracic incision is the procedure of choice for acute diaphragmatic hernias. REFERENCES. Alivisotos, C. N., Bonellos, C. H., Avlamis, G. P., Sarris, M. C., and Romanos, A. N. Traumatic closed rupture of the diaphragm. Dis. Chest 46:435, Arbulu, A., Read, R. C., and Berkas, E. M. Delayed symptomatology in traumatic diaphragmatic hernia with a note on eventration. Dis. Chest 47:527, Bernatz, P., Burnside, A. F., Jr., and Clagett, 0. T. Problems of the ruptured diaphragm. J.A.M.A. 68:877, Blades, B. Ruptured diaphragm. Amer. J. Surg. 05:50, Bowditch, H. Diaphragmatic hernia. Buflalo Med. J. 9:l and 9:65, Bugden, W. F., Chu, P. T., and Delmonico, J. E. Traumatic diaphragmatic hernia. Ann. Surg. 42:85, Carlson, R. I., Diveley, W.., Gobbel, W. G., and Daniel, R. A. Dehiscence of the diaphragm associated with fractures of the pelvis or lumbar spine due to non-penetrating wounds of the chest and abdomen. J. Thorac. Surg. 36: 254, 958. Carter, N. B., and Giuseffi, J. Strangulated diaphragmatic hernia. Ann. Surg. 28:20, 948. Carter, N. B., Giuseffi, J., and Telson, B. Traumatic diaphragmatic hernia. Amer. J. Roentgen. 65:56, 95. Desforges, G., Strieden, J. W., ynch, J. P., and Madoff, I. M. Traumatic rupture of the diaphragm. J. Thorac. Surg. 39:779, 957. Gerard, F. P., and Sabety, A. M. Traumatic ruptured diaphragms: Report of a case. Dis. Chest 47:340, 965. Gibbon, J. H. Surgery of the Chest. Philadelphia: Saunders, 962. P Graevier,., and Freeark, R. J. Traumatic diaphragmatic hernia. Arch. Surg. (Chicago) 86:363, 963. Grage, T. B., Macean,. D., and Campbell, A. S. Traumatic rupture of the diaphragm: A report of 26 cases. Surgery 46:669, 959. Hedblom, C. A. Diaphragmatic hernia. J.A.M.A. 85:947, 925. Hughes, F., Kay, E. B., Meade, R. H., Jr., Hudson, T. R., and Johnson, J. Traumatic diaphragmatic hernia. J. Thorac. Surg. 7:99, 948.

15 SUTTON, CARISE, AND STEPHENSON 7. oehning, R. W., Tokaori, M., and Safar, P. Circulatory colla se from anesthesia in diaphragmatic hernia. Arch. Surg. (Chicago) 90: 09, i Nelson, J. B., Jr., Ziperman, H. H., Christenson, N. M., and Mathewson, C., Jr. Diaphragmatic injuries and post-traumatic hernia. J. Trauma 2:36, Par&, A. The Works of That Famous Chirugeon Ambroise Park. Translated out of atin and Compared with the French by Thomas Johnson. ondon, T. Cotes and R. Young, 634. ib. 0, Chap. XXX, p Schneider, C. F. Traumatic diaphragmatic hernia. Amer. J. Surg. 9:290, Solheim, K. Closed thoracic injuries. Acta Chir. Scand. 26:549, Walker, E. W. Strangulated hernia through a traumatic rupture of the diaphragm; laparotomy; recovery. Int. J. Surg. 23:257, Wren, H. B., Texada, P. J., and Krementz, E. T. Traumatic rupture of diaphragm. J. Trauma 2:7, THE ANNAS OF THORACIC SURGERY