JuNB 16, 1962 MEDICAL MEMORANDA BRrr= 1671

Medical MemorandaReduction En Masse of Direct Inguinal

HerniaReduction en masse of a hernia is relatively rare. Pearse(1931) reviewed 193 cases in the literature and estimatedthe incidence as 1 in 13,000 hernias. Casten and Boden-heimer (1941) found another 15 cases and added two oftheir own. A further eight cases have appeared (Wolfe,1939; Coles, 1941 ; Cooley, 1942; Crowe, 1943;Chapple, 1950; Bailie, 1953; Millard, 1955; Murdock,1958). The condition must now be very rare as a resultof the stress on early repair of hernias and the abandon-ment of forcible taxis. Over 85% of the cases refer toinguinal hernias, and among these I have not been ableto find a single case where a direct hernia was involved.The following case is therefore of interest.

CASE REPORTAn active tool-fitter aged 64 was admitted to hospital on

October 23, 1960. He complained of periumbilical colic of18 hours' duration and of increasing severity. After thefirst few hours he repeatedly vomited stomach contents. Hisbowels had last opened the previous day. For the previous30 years he had had bilateral inguinal hernias which weresatisfactorily controlled day and night by a rat-tailed truss.Although the right hernia occasionally came down at work,reduction had always been easy. One month before admis-sion he had renewed his truss and felt the new truss to betighter than his previous one. During this month he hadnot noticed prolapse of either hernia.On examination he was a man of average build in obvious

pain during the attacks of colic. He was not shocked.Pulse 64, B.P. 150/95, temperature 980 F. (36.70 C.). Thehernias were not visible, but there were clearly palpabledeficiencies, 2 cm. in diameter, in both conjoint tendons.There was slight central distension with tenderness over thelower end of the right rectus muscle but without guarding.No mass was felt. On auscultation the bowel sounds wereexaggerated. Rectal examination was negative. A straightx-ray film showed gas and fluid levels in the small bowel.A diagnosis of small-bowel obstruction was made. Gastricsuction and an intravenous infusion were started.

Operative Findings.-Through a right paramedian incisionthe ileum was found to be distended, being obstructed by aright direct inguinal hernia which had reduced en masse intoa retropubic position. A knuckle of bruised but viablebowel was released from the constriction ring, 1 cm. indiameter, which was formed by fibrosis in the neck of theperitoneal sac.The post-operative course was uneventful, and 18 days

later bilateral herniorrhaphy through separate inguinalincisions was carried out. The right direct inguinal sac was4 cm. long and showed further fibrosis which divided it intoproximal and distal parts. The left direct inguinal herniashowed no fibrosis of its sac.

Histological Report.-The neck of the right sac showed adensely fibrous constriction band without a covering ofserosal cells.

AETIOLOGYPrevious explanations have always referred to

indirect inguinal hernias, but the principles would seemto apply to direct hernias also. Casten and Boden-heimer (1941) suggested that reduction en masse canoccur only if there is a relatively unyielding neck of thesac and a lax internal ring. In the present case the neckof the sac was constricted to 1 cm. in diameter, the

fibrosis probably being produced by recurrent traumafrom the truss, while the gap in the conjoint tendon,though only 2 cm. in diameter, was relatively lax.

Pearse (1931) concluded that a preformed spacebetween the parietal peritoneum and anterior abdominalwvall, the properitoneal sac, or diverticulum was presentin many cases, while Millard (1955) suggested that sucha sac was equally likely to be produced by forcibleattempts at reduction. There is usually a history ofdifficult reductions, the last being especially difficult,after which the symptoms of intestinal obstruction failto subside or subside only temporarily (Wolfe, 1939;Bailie, 1955). In the above case the bowel would appearto have prolapsed into its sac, then the sac, with thebowel inside, to have been pushed back into properi-toneal space by the truss, there being no history ofdifficulty in manual reduction. The properitoneal spacemay well have been preformed by similar past incidents,where the bowel had finally reduced itself completelywithout intestinal obstruction occurring. It is difficultto decide whether the bowel entered the sac just beforethe onset of the symptoms or whether there was a latentperiod; the narrowness of the constricting ringsuggests that a long symptomless latent period wasunlikely.Conclusion.-Reduction en masse is possible in direct

inguinal hernias and should be considered as a rarecause of intestinal obstruction. Early repair in directhernias which have narrow necks would seem desirable.

C. J. C. RENTON, F.R.C.S., F.R.F.P.S.,Surgical Registrar, Victoria Infirmary, Glasgow.

REFERENCESBailie, R. W. (1953). Postgrad. med. J., 29, 323.Casten, D., and Bodenheimer, M. (1941). Surgery, 9, 561.Chapple, C. F. (1950). Brit. med. J., 1, 286.Coles, J. S. (1941). J. Mi Sinai Hosp., 8, 178.Cooley, G. G (1942). Brit. J. Surg., 29, 352.Crowe, G. G. (1943). Lancet, 1, 517.Millard, A. H. (1955). Postgrad. med. J., 31, 79.Murdock, C. E., jun. (1958). Ann. Surg., 147, 531.Pearse, H. E. (1931). Surg. Gynec. Obstet., 53, 822.Wolfe, H. R. I. (1939). Brit. J. Surg., 27, 421.

The Food and Agriculture Organization has announcedthat food worth more than 12,000 has been purchasedwith money donated by the Oxford Committee for FamineRelief (United Kingdom) to combat famine in Dahomey.Mr. A. H. Boerma, head of F.A.O.'s Programme andBudgetary Service, said that 25 tons of dried fish purchasedfrom Norway would be shipped from Norway on May 29;it was due to reach Dahomey on June 20. Another 25 tonsof dried fish had been ordered from suppliers in Nigeria,and 25 tons of white beans from a U.K. firm. Theseconsignments, and the cost of transporting them to the WestAfrican republic, would be paid for from a 15,000 donationby the Oxford Committee (OXFAM). In addition, he said,the Government of Nigeria had donated, following F.A.O.'srelay of the country's request for emergency aid, some200 tons of ground-nuts. Shipment by road of this gifthad already begun. Mr. Boerma, who assumed his newpost as Executive Director of the U.N./F.A.O. World FoodProgramme on June 1, pointed out that F.A.O. was actingunder its normal responsibility for meeting requests to fightfamine and other disasters. The World Food Programme,which was approved recently but was not yet in operation,would be charged specifically with dealing with foodemergencies caused by famine and drought. The Govern-ment of Dahomey, in its request for help, said that some90,000 persons were affected by crop failure through droughtin the northern part of the country. Mr. Boerma said theUnited States of America, under its bilateral aid programme,was also rushing food supplies to the area. (F.A.O., 1 /R/Press 62/67.)