Postgrad Med J: first published as 10.1136/pgmj.29.332.323 on 1 June 1953. Downloaded from June 1953 Clinical Section 323 curring in the above case is difficult to correlate. allergic response is due to an unknown allergen Before the appearance of rash on the face the and the finding of tuberculosis is just a coincident. patient gave a history of sore throat and joint pains, Whatever may have been the cause of the original and as the throat swab and the E.N.T. reports illness, this case clearly emphasizes the point were both negative it is suggested that initially which MacKenna (I95I) makes in his excellent she had subclinical tubercular infection of her review on the pathogenesis and treatment of all tonsils which, when the patient's resistance was forms of lupus erythematosus, that unless the lowered after the pelvic operation, spread to the etiology of the disease is well established no cervical glands and later by the blood stream treatment can be of lasting value and that perhaps causing miliary changes in kidneys, spleen and more than one factor is responsible for this intestinal glands as observed at necropsy. It is dreaded malady. difficult to understand why the lungs escaped this miliary invasion. Lupus erythematosus of the face Summary can be regarded as an allergic response in the A case presenting an unusual combination of collagen tissue of the face and the harmful agent, lupus erythematosus, periarteritis nodosa and as subsequent course showed, may have been a miliary tuberculosis, not hitherto recorded, is tubercular focus. This allergic response at first discussed in the light of our present knowledge of remained localized to face but as the tuberculosis the etiology of lupus erythematosus. spread the allergic response also became more I wish to express my thanks to Dr. J. S. Marr marked, causing more advanced joint changes and for referring this patient to me. later culminating into periarteritis nodosa affecting BIBLIOGRAPHY the small bowel and the clinical DUFF, G. L. (1948), Canad. Med. Ass. J., 58, 317. producing picture ORR, H. (195o). Canad. Med. Ass. J., 62, 432. of acute abdomen. The other possibility is that the MACKENNA, R. M. B. (I95I), The Medical Annual, i6x. by copyright. AUTO-REDUCTION EN MASSE OF AN INGUINAL HERNIA By ROBERT W. BAILIE, M.B., F.R.C.S.(Edin.) Lately Senior Surgical Registrar, Sefton General Hospital, Liverpool Reduction en masse of a strangulated hernia is strangulated hernia reduced en masse has been http://pmj.bmj.com/ now a very rare occurrence, but one gains the briefly summarized by Casten and Bodenheimer impression from the literature that it was more ( 941) as follows:- common during the last century, though Corner I. An inguinal or femoral hernia has been and Howitt, in a report in I908 on investigations present for several years and may have been of the records of St. Thomas's and St. Bartholo- operated on previously. mew's Hospitals, found only five cases in I,6I8 2. This hernia has become incarcerated an incidence of cent. pre- strangulated herniae, 0.3 per viously on several occasions but has always been on September 26, 2021 by guest. Protected As taxis was then very often employed in the re- reduced duction of strangulated herniae (14 per cent. of by manipulation. cases of strangulated hernia admitted to St. 3. The last reduction was accomplished with Thomas's Hospital 'escaped operation by under- more difficulty and was accompanied by pain. going reduction,' Corner and Howitt), a higher 4. The symptoms of intestinal obstruction do incidence of reduction en masse would be expected. not subside as expected or subside for only a brief Berger (1876) gave the incidence of strangula- interval. (This interval, in fact, is not necessarily tion as 2.5 per cent., and hence the incidence of very brief being, apparently, two months in one reduction en masse would be 0.0075 per cent. of of Walsham's cases.) all herniae. In a review of I2,000 cases, Eliason The continuation of symptoms of intestinal (192I) found no such case, but Nason and Mixter obstruction after the apparent reduction of a (I935), on the other hand, found three cases of this strangulated hernia is very suggestive of reduction type in a group of 73 cases of strangulated hernia. en masse and often there is absence of local signs The common course of events in a case of of the disorder though a tumour may be palpable Postgrad Med J: first published as 10.1136/pgmj.29.332.323 on 1 June 1953. Downloaded from 324 POSTGRADUATE MEDICAL JOURNAL June 1953 in the lower abdomen or above the internal in- guinal ring. Case Report The present case is described because it shows an added complication which I cannot find pre- viously reported in the literature. A male patient, aged 56 years, was admitted to Sefton General Hospital on May 9, 1950, and gave ·.b the following history: A left inguinal hernia had been present for about 20 years and was easily reducible, descended into the scrotum and, more recently, had been controlled by a truss. Three days before admission he had developed pains across the lower abdomen and tenderness in the hernial sac. He reduced the hernia easily and the pains disappeared soon afterwards. On the afternoon of the day of admission, pain ;n~. developed suddenly in the left iliac fossa which doubled him up and was followed in about 15 t.J minutes by vomiting. The pain was griping in character and further vomiting occurred. The bowels opened once after the onset of pain and the SS motion was formed. 1§ Examination revealed the patient to be in fair - general condition and not distressed. His tem- perature was 98° F., pulse rate 60 and respira- by copyright. tions 24 per minute. The abdomen was relaxed and non-tender; the left superficial inguinal ring was empty but proximal to it, in the position of Saggital section to show operation findings. The the deep inguinal ring, was a deeply placed, tender herial sac lies in the properitoneal position and swelling. Rectal examination was negative. contains strangulated bowel. The original neck A of hernia of has been invaginated into the more distal part of diagnosis strangulated pro- the sac, the constricting mechanism being now the peritoneal or interparietal type was made. inverted walls of the sac or the neck of the sac Operation was performed under pentothal, which had progressed by a form of intussusception curare and closed circuit and ether I. to lie outside and compress the entering funnel of oxygen (Dr. http://pmj.bmj.com/ Emerson). peritoneum. A left inguinal incision was used and after incis- ing the external oblique aponeurosis, the internal strangulated small bowel which was quite viable oblique muscle was retracted strongly upwards and was returned to the abdomen. The sac was and outwards to expose the sac of the hernia. This then transfixed through the neck, ligatured, ex- was found to be lying extraperitoneally, slightly cised and a Willys Andrew's modification of the above and lateral to the usual position of the deep Bassini repair carried out. inguinal ring. All attempts to find the neck of the The post-operative course was uneventful apart on September 26, 2021 by guest. Protected sac were unsuccessful as the walls of the sac ap- from some chest infection and the patient was peared to become invaginated or infolded in that discharged on the i6th post-operative day. He was region. On opening the sac near its fundus and seen at the out-patient clinic three months later dividing the wall in the general direction of the and there was no sign of recurrence of his hernia. neck, it was found that the proximal part or neck of the herial sac had apparently been invaginated Aetiology and Mechanism or intussuscepted into the more distal part of the In discussing the mechanism of reduction en sac. The constricting mechanism was formed by masse, Pearse (1931) postulates three main types, the inverted walls of the latter or the neck of the viz.: latter, which had progressed by a form of intus- Type i. The conversion of an inguino-pro- susception to lie outside and compress the entering peritoneal hernia into the properitoneal type. funnel of peritoneum. When the constricting Type 2. Change of the sac to the properitoneal mechanism was divided, the sac unfolded easily. position by its separation from its surrounding It was then found to be an indirect sac containing tissues without relief of the obstruction at its neck. Postgrad Med J: first published as 10.1136/pgmj.29.332.323 on 1 June 1953. Downloaded from June 1953 Clinical Section 325 Type 3. Removal of the strangulated bowel that the occurrence of such a secondary complica- from the inguinal to the properitoneal pouch of tion, especially in minor degree, may have been an inguino-properitoneal hernia without dis- missed in other cases as it would not be very locating the inguinal sac. obvious when viewed from the abdominal side and Types i and 3 above depend for their occurrence might be reduced by manipulation of the neck of on the presence of a preformed properitoneal sac, the sac before being recognized. and Halsted considered the important factors in In a limited review of the literature since producing this were: The presence of a badly Pearse's article (I93I), it is interesting to note that fitting truss closing the external ring but not the the mortality rate has fallen from 44.6 per cent. inguinal canal, the repeated and vigorous attempts in his cases to I5.3 per cent.