HERNIA REDUCED "EN BLOC"

1921 Journal of the American Medical Association (JAMA)  
In a review of the literature I find that Corner and Howitt,1 in 1910, reviewed a series of 137 cases of hernia to that time reduced en bloc or en masse. In this article they state that 113 were inguinal, twenty\x=req-\ two femoral and two obdurator, but none of the umbilical or ventral variety. The mortality in the inguinal cases was 48 per cent, and in the femoral cases, 72 internai oblique muscle, the external being retracted; b, omentum; c, Poupart's ligament; d, opened hernial sac. per
more » ... ernial sac. per cent. The condition is usually a result of taxis, but may occur spontaneously. Since this publication in 1910, isolated cases have been reported from time to time by Bookman, Henningsen, Roscher, Ochsner, Harrison, Rayner and others. In all, only twelve cases could be found from 1910 to 1920. This is a remarkable difference from the quoted series of 137. However, to substantiate this great reduction is the fact that in the examination of the reports in a total of more than 12,000 herniorrhaphy cases taken from several different hospitals from 1901 to 1918, not a single case of reduction en masse is mentioned. This may mean many things, but probably points to a lessened practice of taxis in incarcerated cases. Then, too, in recent years, as a result of employers' rules, a great many more hernias are repaired while still comparatively recent and consequently small. It is the old hernia that contains the large intestine, the bladder and the cecum, and it is the elderly person that more often has a reduction en masse. This is borne out in this series of twelve cases as well as in the larger and older series. These cases showed the common symptom of slight relief after reduction and there was a bowel evacuation in two in which the hernia was of the Richter type ; but they all soon showed increasing obstructive symp¬ toms, which were diagnosed as due to adhesions, bands, etc., rather than to the true cause. In all the cases the reduction was described as occur¬ ring differently from the usual custom. In these cases 1. Corner and Howitt: Ann. Surg., 1910. reduced by the patients, it was stated that the hernia did not go back as easily as usual, and in one case reduced by the physician, it is stated that the reduc¬ tion gave the sensation of a button slipping through a button hole. To these cases I add the report of a case which shows some additional interesting features : REPORT OF CASE History.-W. S., a man, aged 20, colored, had been seized, two days before admission to the Howard Hospital, with cramplike pains in the abdomen. About three hours later vomiting began and had continued until the time of his admis¬ sion. The bowels had not moved since the attack began. The patient said he had a chill and had had fever. A physi¬ cian pronounced the case one of acute appendicitis and sent him to the hospital. Physical Examination.-The general examination had no bearing on the case. The abdomen, however, was distended, tender and tympanitic. The left inguinal region was some¬ what fuller than the right. The patient, on being questioned, stated that he had had a hernia on that side since childhood, and that it was always easily reducible when it came down. It came down at the beginning of this attack, and was very much larger than it ever had been before, and went back very slowly under manipulation three hours after the attack began. He could not state definitely which occurred first, the vomit¬ ing or the appearance of the hernia. Peristaltic sounds were increased in character and frequency. Tenderness was noted in both iliac regions, but most marked on the left. The slight fulness in the left inguinal region was a somewhat thickened, edematous spermatic cord. No hernia was demonstrable. On deep palpation above the left Poupart's ligament, an increased massive resistance was noted. Fig. 2.-The inset shows the incision necessary for the liberation of the intestine. Below is indicated the state of affairs as seen at opera¬ tion. The dotted line (g) illustrates the wound through to the internal oblique (b) ; c represents the Richter hernia, covered by the internal oblique and transversalis muscle and still in the grip of the sac neck, which has been pushed up from its old position in the internal ring; d is omenutm shown hidden above and exposed at the sac opening (/) at the internal ring. Blood count revealed 10,200 leukocytes. The temperature was 100; pulse, 110; respiration, 14. Operation and Result.-Incision was made as for. a left inguinal hernia. The cord was edematous, and the sac con¬ tained some blood-tinged fluid. Projecting into the upper limit of the sac was a tab of congested omentum. Traction on this, which was situated at the internal ring, pulled out from under the muscle an edematous congested mass of Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 05/30/2015
doi:10.1001/jama.1921.02630520037009 fatcat:r7yufeyerbeanoulywccuhnnry