Hernia Through the Esophageal Opening of the Diaphragm

In view of the fact that right-sided hernia of the diaphragm is relatively infrequent, a report on the following case, observed in our Cinic, is of interest. In a series of 276 cases collected by Lacher, only I5 per cent of the total number of diaphragmatic hernias occurred on the right side. The reason seems quite obvious; the bulk of the liver, occupying the right dome of the diaphragm, prevents, in the majority of cases, the passage of the abdominal contents into the right pleural cavity. Hernias of the diaphragm may protrude through any one of the three normal apertures of the diaphragm; the foramen of Morgagni, the foramen of Bochdalek, or, the most common site, the esophageal hiatus. This opening, elliptical in shape and located slightly left of the midline, is the only one of the three openings of the diaphragm which is muscular in structure, thus lending itself to dilatation from increased abdominal pressure beneath. The opening through the diaphragm for the vena cava is to the right of the midline, tendinous in structure, and protected by the liver. There is, therefore, an anatomical basis for the preponderance of left-sided hernias. They usually enter the left chest and often force their way posteriorly; rarely they occupy the right pleural cavity. Hernias of the diaphragm may be either congenital or acquired, and may be either traumatic or non-traumatic in origin. In the congenital type, there is an imperfect muscular development, with resulting open defects through which abdominal organs herniate into the thorax. Such hernias have no sacs. Traumatic hernias, arising from injury of the diaphragm, may result from crushing injuries of the thorax or abdomen, from fractured ribs, stabs, or gunshot wounds. Eventration of the diaphragm is not a true hernia, but is rather due to an extreme atrophy of the muscular fibers. This condition is extremely rare, and is characterized by a relaxation of the diaphragm ; the thin-walled diaphragm yielding to the pressure of the