- Email: [email protected]
Diaphragmatic hernia complicating the puerperium
DIAPHRAGMATIC S. T.
DELEE, (From
HERNIA COMPLICATING PUERPERIUM”
M.D., AKD the Services
B. I. of the
GILSON, Chicago
M.D., Maternity
THE
CHICAGO, Center)
ILL.
HERNIA through the diaphragm occurs rarely, but, due to the position of the A abnormal opening, is much more likely to be exposed to the force of increased abdominal pressure in labor than is an inguinal hernia, which is protected by the bulk of the uterus. This combination of diaphragmatic hernia and the immediate puerperium is sufficiently uncommon to merit the report of the following case: (An exhaustive survey of the literature brought to light only a single reference in the Journal of the American Medical Association. of 1937 under “Query and Minor Note, ” t.he case of a doctor’s wife whose labor and puerperium were complicated by herniation into the thorax of one-fourth of her stomach.) Our patient, a 20.year-old white gravida ii, first presented herself when three and one-half months pregnant. Her last normal menstrual period was on Aug. 25, 1939. She was considerad to be at term on June 2, 1940. The pertinent history obtained was a right inguinal herniorrhaphy at Billings Hospital in 1938, four months following a normal spontaneous delivery at Chicago Lying-in Hospital. Physical examination was essentially negative ; Wassermann reaction was negative. Her pregnancy, which was of forty-three weeks’ duration, was marked by excessive weight gain (29.5 pounds) and albuminuria. The labor came on June 27, 1940 and after thirteen and one-third hours terminated spontaneously in the birth of a g-pound female baby. A midline, second degree laceration was repaired under pudendal block anesthesia. Immadiately after delivery, the patient complained of left upper quadrant pain but was otherwise comfortable and in good condition. For the next seventeen hours she had mild lower abdominal pains, at the end of which time her pulse, temperature, respirations, and blood pressure were normal. Nothing unusual was detected by careful physical examination. When next seen, about sixteen hours later, she complained of severe left upper and lower quadrant colicky pains, of having vomited 5 or 6 times, and of obstipation. Physical examination was again negative and her pulse, temperaThe possibility of an intestinal obstruction ture, and respirations were still normal. was suggestad. The patient was closely watched. Early on the third postpartum day about fifty-some hours after delivery, with temperature 98.6” F. and pulse 100, signs developed which led to a clear-cut diagnosis. There were left-sided abdominal pains, tenderness, and slight distention. Examination of the chest revealed diminished diaphragmatic excursions and decreased breath sounds on the left. Typically intestinal borborygmus was heard high in the left axilla. The vomiting had ceased but the obstipation remained. The patient was admitted to the Chicago Memorial Hospital on July 1, 1940, with the diagnosis of intestinal obstruction on the basis of left-sided diaphragmatic hernia. She was given fluids parenterally, and her symptoms rapidly subsided. However, the next day when fluids were given orally, the pain and vomiting re-appeared. Relief was obtained from morphine and atropine, and she remained asymptomatic throughout her hospital stay. Her pulse and temperature were always normal but for the first day’s elevation of 100.4” F. Laboratory findings were negative but for occult blood in the stool on July 3. The patient left voluntarily July 10, but she agreed to return at a later date for operation.
*Presented
at a meeting
of the Chicago
Gynecological 904
Society,
December
20, 1940.
DELEE, (From
HERNIA COMPLICATING PUERPERIUM”
M.D., AKD the Services
B. I. of the
GILSON, Chicago
M.D., Maternity
THE
CHICAGO, Center)
ILL.
HERNIA through the diaphragm occurs rarely, but, due to the position of the A abnormal opening, is much more likely to be exposed to the force of increased abdominal pressure in labor than is an inguinal hernia, which is protected by the bulk of the uterus. This combination of diaphragmatic hernia and the immediate puerperium is sufficiently uncommon to merit the report of the following case: (An exhaustive survey of the literature brought to light only a single reference in the Journal of the American Medical Association. of 1937 under “Query and Minor Note, ” t.he case of a doctor’s wife whose labor and puerperium were complicated by herniation into the thorax of one-fourth of her stomach.) Our patient, a 20.year-old white gravida ii, first presented herself when three and one-half months pregnant. Her last normal menstrual period was on Aug. 25, 1939. She was considerad to be at term on June 2, 1940. The pertinent history obtained was a right inguinal herniorrhaphy at Billings Hospital in 1938, four months following a normal spontaneous delivery at Chicago Lying-in Hospital. Physical examination was essentially negative ; Wassermann reaction was negative. Her pregnancy, which was of forty-three weeks’ duration, was marked by excessive weight gain (29.5 pounds) and albuminuria. The labor came on June 27, 1940 and after thirteen and one-third hours terminated spontaneously in the birth of a g-pound female baby. A midline, second degree laceration was repaired under pudendal block anesthesia. Immadiately after delivery, the patient complained of left upper quadrant pain but was otherwise comfortable and in good condition. For the next seventeen hours she had mild lower abdominal pains, at the end of which time her pulse, temperature, respirations, and blood pressure were normal. Nothing unusual was detected by careful physical examination. When next seen, about sixteen hours later, she complained of severe left upper and lower quadrant colicky pains, of having vomited 5 or 6 times, and of obstipation. Physical examination was again negative and her pulse, temperaThe possibility of an intestinal obstruction ture, and respirations were still normal. was suggestad. The patient was closely watched. Early on the third postpartum day about fifty-some hours after delivery, with temperature 98.6” F. and pulse 100, signs developed which led to a clear-cut diagnosis. There were left-sided abdominal pains, tenderness, and slight distention. Examination of the chest revealed diminished diaphragmatic excursions and decreased breath sounds on the left. Typically intestinal borborygmus was heard high in the left axilla. The vomiting had ceased but the obstipation remained. The patient was admitted to the Chicago Memorial Hospital on July 1, 1940, with the diagnosis of intestinal obstruction on the basis of left-sided diaphragmatic hernia. She was given fluids parenterally, and her symptoms rapidly subsided. However, the next day when fluids were given orally, the pain and vomiting re-appeared. Relief was obtained from morphine and atropine, and she remained asymptomatic throughout her hospital stay. Her pulse and temperature were always normal but for the first day’s elevation of 100.4” F. Laboratory findings were negative but for occult blood in the stool on July 3. The patient left voluntarily July 10, but she agreed to return at a later date for operation.
*Presented
at a meeting
of the Chicago
Gynecological 904
Society,
December
20, 1940.