Strangulated diaphragmatic hernia in the neonatal period.

Strangulation of a diaphragmatic hernia was first described by Pare in 1575. It is a rare complication of this type of hernia; Hoffman, Levy, Sole, and Lewitan (1954) could only find 76 cases in the literature and added a case of their own. Most of the earlier instances of strangulation occurred in herniae of traumatic origin, but in recent years there has been a higher proportion in congenital herniae. The mortality rate for strangulated diaphragmatic herniae has always been very high, 88.8% before 1920 and 43.7% in later cases (Carter and Giuseffi, 1948). The mortality rate is still high because of the vagueness of symptoms, difficulties of diagnosis, and the resulting delay in operation. The youngest case previously reported was a girl, 6 weeks old, who had vomited for a week and was shocked and cyanosed on admission. The sigmoid colon had herniated in the left pleural cavity. On reduction it was found that a length of 3 in. was strangulated but viable. The diaphragmatic defect was repaired (Cooke and Corner, 1949). No case of strangulation of a diaphragmatic hernia during the neonatal period has previously been reported,though diaphragrnatic herniae, usually presenting with severe respiratory embarrassment during the first few days of life, are not uncommon. We have operated upon eight such cases during the last four years. That strangulation does not occur more often may be explained, in part, by the fact that most of the infants die as a result of respiratory embarrassment in the first few days of life unless operated upon, and there is therefore little time for strangulation to occur. Another cause for the rarity of this complication may be the relatively large size of the pleuro-peritoneal canal in these babies. This case is of interest because it is the first recorded of a strangulated diaphragmatic hernia in a newborn infant and because the diagnosis was made pre-operatively. CASE HISTORY