Diaphragmatocele— Diaphragmatic Hernia — Phrenic Hernia. 371 



extensive blood extravasations of that disease. An exception 

 may be made in those cases in which the hernial mass is strangu- 

 lated, as these may closely resemble spasmodic colic or hsemor- 

 rhagic congestion. 



The respiration furnishes more distinctive symptoms. The 

 breathing which may be hurried and almost panting in colic and 

 acute congestion, is changed in this lesion to a condition of ex- 

 treme oppression, the nostrils remain widely dilated in expiration 

 as well as inspiration, the angle of the mouth is retracted so as 

 to show the teeth and gums, all the facial muscles stand out, the 

 eyes are protruding and fixed, with dilated pupils, the head is 

 held extended on the neck, and the ribs are not allowed to fall in 

 freely, as after ordinary inspiration, but like the nostrils they 

 remain permanently drawn out. The efforts at inspiration are 

 violent though shallow and marked by lifting of the flanks. 

 There are usually one of two nervous catches in each expiration 

 and sometimes in inspiration as well. This is partly due to the 

 impotence of the deeply lacerated diaphragm as an organ of 

 respiration, but also to the pressure of the displaced and over- 

 distended abdominal organs on the lungs, and to the profound 

 nervous shock. The whole work has been suddenly thrown on 

 the costal muscles, and the depressed nervous system proves 

 unequal to sustaining them in the unwonted toil. 



Still clearer indications may be obtained from auscultation and 

 percussion. These are gurgling, rumbling and clucking, or a 

 coarse mucous rale which seem abnormally close to the ear, and a 

 drum-like resonance, much greater than that of emphysematous 

 lung and enormously in excess of what is given out by the sound 

 lung tissue. These may be heard at points where only pulmonary 

 murmurs naturally occur or where abdominal sounds, if heard at 

 all, are distant in health. There may also be areas of abnormal 

 flatness on percussion by reason of the protrusion of a solid 

 viscus like the liver or spleen or one with solid contents. These 

 symptoms are only clear when there is a large intrusion of 

 abdominal organs into the thorax, and they increase rapidly until 

 asphyxia supervenes. 



In cases which do not immediately threaten life the extent of the 

 phrenic laceration is usually small and the orifice may be blocked 

 by a bulky organ like the rumen, double colon, stomach or liver, 



