Giant Mediastinal Hernia in the Course of Bilateral Pneumothorax

Abstract

Mediastinal hernia is a common occurrence in the course of artificial pneumothorax. Being for the most part innocuous, little thought is given it and there is wide divergence of opinion in estimating its actual frequency. Some authors, Eber among them, considered herniation of the mediastinum a constant feature in pneumothorax. This view had to be reconsidered after hypotensive pneumothorax, introduced by Ascoli, became generally used. In the majority of cases mediastinal hernia is a radiological finding only, and its presence does not influence the conduct of therapy. The following case presents some novel and interesting features, and is another example of perfect tolerance in this condition, even when herniation had attained a giant size. Case No. 4097—M. A. G., a 26-year-old, female, white cuban, was admitted to the Sanatorium in July, 1938, with ulcerative lesions of the left upper lobe and positive sputum. Left pneumothorax proved ineffective because of adhesions, necessitating intrapleural pneumonolysis. Subsequent involvement of the right lung also required its collapse by pneumothorax. Soon after institution of pneumothorax on the right side, a left mediastinal hernia was observed. This herniation became more prominent when insufflation of the left side was delayed. Inasmuch as the right side was kept between —8 and —16 inspiratory pressure, with refills of about 200 cc. of air at fifteen-day intervals, the hernia was regarded as caused by aspiration of the mediastinum into the left hemithorax. At the time we took charge of the case, finding a positive sputum with the right lung apparently clear, we were inclined to attribute the sputum findings to the more thoroughly collapsed left lung. Partial re-expansion of this lung was decided upon in order to ascertain its radiological aspect. In trying to do so, we observed an increase in the size of the hernial pouch. It ballooned out into the left hemithorax until it came in contact with the chest wall, taking the position and appearance of the left upper lobe. In order to re-collapse the left lung, air was injected into the corresponding hemithorax at the axillary level but only a further