A 51-year-old man was seen on November 15, 1952, with a complaint of "smothering'' and "misery" in his right side of four years' duration. In 1948 the patient had had a minor fall which caused strangulation of a left inguinal hernia, necessitating a herniorrhaphy. Since the operation, he had noted shortness of breath on exertion and orthopnoea, being unable to lie flat. He had some pain along the right costal margin related to exercise and to the movement of the right arm. He complained of some right abdominal pain postprandially which was associated with borborygmi and which was relieved by belching and expelling flatus or stool.
On physical examination, there was dullness and decreased breath sounds over the right base. Bowel sounds were easily heard over the entire right chest. A recurrent left inguinal hernia and a direct right inguinal hernia were present. Laboratory examinations showed the blood count, haemoglobin, cell volume, urinalysis, serology, blood sugar and blood urea nitrogen to be negative or normal. An electrocardiogram showed nonspecific myocardial changes. Findings on roentgen examinations were as follows: Chest (figure 1): Loops of gas-filled intestines were identified above the right leaf of the diaphragm and through the shadow of the heart in the midline and to the left of the midline. Barium swallow showed extensive herniation of the small intestine and part of the colon into the thoracic cavity, where it occupied most of the right side of the thorax. The liver was displaced downward and the right kidney anteriorly. Barium enema (figure 2) showed herniation of the right colon through the foramen of Morgagni, a left inguinal hernia into which the sigmoid colon entered, and considerable diverticulosis of the sigmoid colon. A retrograde pyelogram disclosed marked displacement of the right kidney anteriorly and downward. Pulmonary function studies showed a marked restriction of all segments as given in figure 3/table 1.
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