A FOLLOWUP OF HERNIA REPAIR IN MENTALLY SICK

AND MENTALLY DEFICIENT PATIENTS*

CONRAD BELL, M.D., P.A.c.s., ELVIN V. SEMRAD, M.D. ConsuIting Surgeon, MetropoIitan State HospitaI, Senior Physician, MetropoIitan State Hospital

Waltham Hospital, Waiter E. FernaId State SchooI

AND

WILLIAM CORWIN, M.D. Assistant Superintendent, MetropoIitan State Hospital

WALTHAM, MASSACHUSETTS

EPORTS of the rest&s of the opera- R tive treatment of hernia from general hospitaIs and surgica1 chnics are fre-

quently seen in the surgical journals; how- ever, the hernia problem in mentalIy sick and mentally deficient patients, although known to many surgeons, has not been summarized in the Iiterature very exten- sively, nor have the problems encountered in this group of patients been given due attention. Some writers1B2 have stressed the psychiatric compIications in surgica1 problems and the vaIue of the psychiatrist in reIation to surgery but very IittIe atten- tion has been given to the probIem from the standpoint of the actua1 handIing of psychiatric cases by the surgeon. It is our purpose in this paper to summarize our experience at the Metropolitan State Hos- pital with fifty patients suffering from hernia who were treated by surgica1 measures.

STATISTICS

The series incIuded thirty-one commit- ted psychotic patients and nineteen men- taIIy defective patients from the Waiter E. FernaId State SchooI. Psychiatric diagnoses are classified in Table I. There were forty- six males, twenty-nine from the Metro- politan State HospitaI and seventeen from the Walter E. FernaId State SchooI, and four females, two from the Metropolitan State HospitaI and two from the Walter E. Fernald State School.

Age of Patients. These varied in age from the age of sixteen to sixty-five plus. (TabIe II.) One notes that the Waiter E. FernaId State SchooI patients were a11 below the age of forty-five at the time of operation and that the majority of the Metropohtan State Hospital patients were above that age group. As the greatest percentage of recurrences occurred in the Metropohtan State HospitaI patients this one factor lends itself to some comparative analysis. In a rather Iarge series of adult norma patients reported by Longacre* in the indirect group 65 per cent of the pa- tients were under thirty-five years of age and only 26 per cent were over forty-five, while 5 I per cent of the patients with direct inguinal hernias were under thirty-live years, while 46 per cent were over thirty- five. In our group, 22 per cent of indirect inguinal hernias were under thirty-live, whiIe 78 per cent were over thirty-five. In the direct inguina1 hernias, 34 per cent were under thirty-five and 66 per cent over thirty-five.

Type of Hernia. For hernias classi- fied as to type see TabIe III. TweIve pa- tients (MetropoIitan State HospitaI, eight; Waiter E. FernaId State School, four) had bilateral inguina1 hernias. As can be noted from the table sixty-eight, or 93 per cent, of hernias were of the inguina1 type, of which thirty-two, or 47 per cent, were direct inguina1 hernias. The large propor- tion of the direct inguinal hernias occurring

* From Metropolitan State Hospital, Waltham, Massachusetts.

44

HEW SERIES VOL. LII. No. I Be11 et aI.-Hernia Repair American Journal of Surpcr,y 45

in the younger age group of the Waker E. Fernald State SchooI patients is to be noted. According to Watson” direct in- guina1 hernia is infrequent, constituting only about 5 to 7 per cent of a11 inguina1 hernias. It is stated that more recent views

TABLE I

Number of Diagnosis Cases

Schizophrenia. I 5 Akoholic psychosis. 4 Psychosis with mentat deficiency. 4

Manic-depressive psychosis. 3 Genera1 paralysis. I Traumatic psychosis. I Psychosis with cerebral arterioscIerosis I

Paranoid condition. I InvoIutionaI psychosis. I XZfentaI deficiency (W.E.F.S.S.)

Imbeciles.. I I Morons........................ 7

BorderIine. I

indicate that the percentage of direct in- guina1 hernias may be as high as 25 to 30 per cent.” A consideration of the condition of the muscles and fascia in a Iarge propor- tion of these cases wiII be made beIow. Of this group five patients, or .7 per cent, were incarcerated. The recurrent inguinal hernias were difficuIt to diagnose at times but the majority were of the direct type. Figure I iIIustrates the usua1 size and type of hernia encountered.

TABLE II

I

Age Groups

Number of Cases I

M.S.H. WEFSS

es+. 60-6~........................ ~ ~ 5$-60..........

1;: g

50-55....,.. . . . . . . . . . . . . . . ...’ 5 : 0

4$-50....... ..,...... 3 0

40-45......................... 2 4 35-40.. 4 3 30-3$......................... 2 ~ I 25-30....... 20.-25............,..........., :I :

T 5~-20 0 4

Type of Operation. These patients were a11 treated by surgica1 measures, which will

be described beIow. There were no deaths as a resuIt of the operation. One operation couId not be compIeted because of the

FIG. I. UsunI size and type of hernia.

patient’s poor condition incident to poor response to anesthesia. One patient died severa months Iater of puImonary tuber- cuIosis but did not have a recurrence of his hernia at time of death. Another patient died and, aIthough there was no recurrence shortly after the operation, a satisfactory foIIow-up was impossible.

TABLE III

1 M.S.H. 1 WEFSS

Indirect inguinal Right. Left.

Direct inguinal Right. Left.

Recurrent inguinal. Postoperative. UmbilicaI OmentaI

9 6

i II

“‘I 2

I

0

2

IO

5 7

0

Due to the fact that most of the hernias were inguina1 (a11 except five) the end re- suits will be considered only in this group. There was a tota of sixty-eight operations, two of which were not completed. Three different types of surgica1 procedure were used as foliows: (I) The regular (Bassini

46 American Journal of Surgery Be11 et al.-Hernia Repair

modified)* operation was performed on twenty-two Metropohtan State HospitaI patients and on ten Waiter E. FernaId State SchooI patients. (2) The reguIar operation plus the use of commercia1 fascia Iata strips was performed on twelve Metro- poIitan State HospitaI patients and on live Waiter E. FernaId State SchooI patients. (3) The reguIar operation pIus patient’s own fascia Iata strips was performed on seven MetropoIitan State HospitaI patients and on ten Walter E. FernaId State SchooI patients.

The Bassini operation3 was performed except that after excision of the sac the stump was transfixed to the transversaIis muscIe. In the cases in which fascia Iata was used the Bassini operation was per- formed, and the fascia Iata was used as sutures by weaving back and forth to form a sort of Iattice work to approximate the muscIes to Poupart’s Iigament.

Results of Operation. In the reguIar operative group there was no recurrence in lifteen patients or 46 per cent. These cases were r-e-examined after operation as foI- 10~s: four years, seven; three years, three; two years, three; one year, two.

In the commercia1 fascia Iata group, there was no recurrence in fourteen pa- tients, or 72 per cent. These cases were re-examined after operation as foIIows : two years, six; eighteen months, five; one year, three.

In the group in which the patients’ own fascia Iata were used in the repair, there was no recurrence in tweIve, or 64 per cent. These cases were re-examined after opera- tion as foIIows: four years, four; three and

* (a) Incision .z cm. above and paraIIe1 with the inner haIf of Poupart’s ligament, the skin being divided for a distance of about IO cm.; (b) spIitting of the fibers of the externa1 oblique, from the externalring to a point sliahtIv above the ineuina1 rina: Cc) Iiberation and op&&g of the sac, witch reduction of the contents; (d) removal of the sac Aush with the peritoneum, after transfixation and Iigation of the neck; (e) suture of the interna oblique and transversalis muscIe to the sheIving portion of the inguina1 (Poupart’s) ligament, underneath the spermatic cord which is eIevated and retracted; (f) suture of the divided aponeuroses of the externa1 oblique over the cord; (g) suture of the sub- cutaneous fascia and skin.

one-haIf years, five; three years, one; two and one-haIf years, two. In this group of cases the best resuIts were obtained in the commercia1 fascia Iata group. One has to evaIuate these figures with care in view of the fact that the cases were not foIIowed for as Iong a period of time as those in the other groups.

In summary there was no recurrence in the entire group of patients in forty-two instances, or 61.7 per cent. The greatest percentage of recurrences occurred in the Metropohtan State HospitaI cases, as can be surmised from the foIIowing figures. MetropoIitan State Hospital-no recur- rence, nineteen (67.86 per cent), Waiter E. FernaId State SchooI, fifteen (88.24 per cent), average of tota1, 73.6 per cent. Recurrence-MetropoIitan State HospitaI nine (32.14 per cent), Waiter E. Fernald State School two (I I .76 per cent), average of tota1, 24.4 per cent.

Recurrence of hernias occurred in the indirect inguinal group in live instances, in the direct inguinal group in four instances and in the recurrent inguina1 group in tweIve instances. We were unabIe to com- pIete the operation in one case (two hernias); one patient died. Of the indirect inguina1 group, one case recurred in a few days, one in a period six to tweIve months, two in a period between tweIve to eighteen months, and one in a time interva1 between eighteen to twenty-four months. In four instances the reguIar type of operation was used and in one instance the commercia1 fascia Iata operation was used.

Of the direct inguina1 group, one case recurred in fifty-six months, one in twenty- eight months, one in two months and in one case the exact time of recurrence was un- known. The types of operation used were: reguIar operation, I; commercia1 fascia Iata, I; patient’s own fascia Iata, 2.

Of the recurrent inguina1 hernia group seven cases recurred in less than three months, three in six to tweIve months, one in sixty months and in one case time of recurrence was unknown. Types of opera- tion used: reguIar operation, seven; com-

NEW SERIES VOL. LII, No. I Be11 et aI.-Hernia Repair American Journal of Surgery 47

mercial fascia lata, one; patient’s own fascia lata, four. The probIems associated with recurrence in the same patients are de- scribed more fuIIy below.

We shouId mention that the recurrences occurred in the majority of instances in patients who were operated upon at other hospitaIs the first time. Brief notes of their cases are made to summarize the nature of these cases.

CASE REPORTS

CASE I. Psychosis with menta1 deficiency, imbecile, age 44, had been suffering from a hernia for “many years” which was repaired for the first time in I933 at another hospita1. A second attempt at repair was made at this hospita1 in September, 1934, at which time it was noted that the previous repair had been of the Halstead type, with cord transplanted beneath the skin. A direct herniation was found through the fascia transversalis. The hernia was repaired on the right with patient’s own fascia Iata. On October 29, 1934, the left hernia was repaired, the usuaI operation with transpIanta- tion of the cord was used. The Ieft hernia recurred shortly after the operation and was again repaired on January 4, 1935, at which time it was noted that anatomic landmarks were markedly obscured and the patient’s own fascia Iata was used. This recurred shortly after operation and on March I, 1933, a left orchidectomy was done and the usual type of operation utiIized, since which there has been no recurrence. Patient aIso has multiple sclerosis, a hypertrophied prostate and had previousIy been operated upon for papiIIary adenocystoma of the thyroid gland.

CASE II. Genera1 paraIysis, age 58, had been operated for the first time in 1933, and on March 28, 1936, a biIatera1 recurrent indirect inguina1 hernia was noted. A fascia Iata trans- plantation operation was done. The course was compIicated by eIevated temperature and four weeks Iater the hernia recurred. On JuIy 3 I, 1936, a biIatera1 repair, reguIar operation, was again attempted, and there was recurrence on the left shortly after the operation.

CASE III. Patient, age 32, suffering from a traumatic psychosis, was operated upon Feb- ruary 16, 1935. The wounds became abscessed; the patient kept them opened with his fingers in spite of supervision. He later stated that he

did this because he did not wish to Iive and thought that if he infected his wounds this wouId hasten his death. The hernia recurred and he was re-operated upon September g, 1937; a fascia Iata repair, commercia1 type, was done and the hernia did not recur.

CASE IV. The patient age 29, imbecile, had a right inguina1 hernia present since birth, and was operated for the first time in 1930, with a recurrence in 1933 at upper end of the scar. Operation was performed here for the first time on June 6, 1936, his own fascia Iata being used in the repair, with recurrence in March, 1937. Re-operation took place on May I 8, 1937, with a commercial fascia Iata, without recurrence to date.

In evaIuating the rest& various factors warrant serious consideration, the same factors that have to be kept in mind at the time that the original repair is considered. (Table IV.) At least 26 per cent were of more than one year standing and 16 per cent of more than five years standing as far as the clinical manifestations of hernia couId be noted from the records. General gas-oxygen ether anesthesia was used in a11 cases except four, in whom spina anesthe- sia was used. On this small number there is no object in trying to relate recurrence to the type of anesthesia used. It was the opinion of Longacre in his group of cases that “the difference in the percentage of recurrence as related to the type of anes- thesia used in the operation is very small.”

TABLE IV Number of

Duration of Hernias Cases 30 years.. r 26 years. I

23 years. 2 2o years.. I $--I0 years ; 2-Tyears. 4 1-2.5 years.. 3 6months-1 year............. 8 3 months-6 months

(I postoperative). 8 Less than 3 months

(I herniation of omenturn). 26 Unknown

(I umbilical, I postoperative). I 2

Various postoperative comphcations were noted: infected wounds in nine in-

48 American Journal of Surgery Be11 et al--Hernia Repair

stances; unexpIained eIevation of tempera- ture in fourteen instances; bronchopneu- monia in four instances; unexpIained cough in two instances; postoperative ateIectasis in one; sweIIing of the testes in two in- stances; distention in one instance. Of the patients who suffered recurrences after repair onIy four had an uneventfu1 con- valescent period. Various associated find- ings were noted, the most important being the muscIe and fascia deficiency; tissue turgor and poor muscIe tone were en- countered in the majority of the abdomina1 waIIs. This was present in practicaIIy all the cases and to a very preponderant degree in seven cases. These must undoubtedIy pIay a Iarge roIe in the recurrence of hernias after operation. The associated conditions of note were eIevation of bIood pressure, hemorrhoids, varicoceIe, hypertrophied prostate, tumor of thyroid, varicosities, cardiac compIications, von ReckIinghausen disease, congenita1 syphiIis and tubercuIosis. Incarcerated hernias were found in five instances, scrota1 hernias in seven.

Chromic catgut sutures were used in a11 the operations with siIk used in the skin. AIthough no special catgut sensitivity tests were made, no such phenomenon was observed.

DISCUSSION

The above brief case histories iIIustrate in part at Ieast some of the diffIcuIt aspects of the hernia problem in mentaIIy sick and mentaIIy deficient conditions. There are aIways many factors to be considered which are present in the same cases, viz., the patient is often not onIy a medica1, neuro- logic and psychiatric probIem but has distress occasioned by a hernia. Many patients do not complain of the symptoms found in normaIs, i.e., buIging in the region without pain, but wait tiI1 the hernia has become quite Iarge or has started to pro- duce defmite distress, many times more objective than subjective. The cooperation so necessary in these cases is often Iacking in the mentaIIy iI1; they wiI1 pick at their

wounds; they wiI1 refuse to stay in bed, etc. These probIems can be minimized onIy by the constant vigiIance of the nurses and attendants who often must distribute their Iabors over many tasks. Limitation in num- bers of personne1 is a famiIiar observation.

There is one feature of interest-the rela- tiveIy greater incidence of direct inguina1 hernias in menta1 cases as compared to normaIs. There is too IittIe known of the distinctive forces Ieading to the occurrence of direct and indirect hernias to offer a satisfactory expIanation of this paradoxical situation. We have mentioned the common findings at operation of deficiencies in muscIe and fascia, both in structure and extent. It appears reasonabIe to assume that these deviations are perhaps part of a greater defect evidenced by the mental states leading to hospitaIization, on the one hand to menta1 hospitaIs and on the other to hospitaIs for the mentaIIy defective. In the Iatter instance this expIanation appears more pIausibIe since organic defect is more readiIy visibIe and the variety of somatic abnormaIities is more extensive as we11 as more common. Dietetic factors as we11 as physical exercise must aIso be considered from a theoretica point of view as causa- tive agents in producing muscIe and fascia defects. However, the average patient in state hospitals eats a we11 baIanced diet and takes part in sufficient physica stress as to diminish their importance as such causa- tive factors.

The reIation of the duration of the hernia and recurrence appear worthy of some comment. It is obvious that there is a direct ratio of age of hernia to size of hernia and consequent strains upon fascia and muscle. NevertheIess, it is our experience that this becomes important onIy insofar as the condition of the fascia and muscles varies from good or poor. Indeed it is not implau- sibIe that the common finding of poor tissues accounts for the size of the hernia even in early cases. The choice of operation is determined by the condition of the tis- sues at time of operation. We are of the opinion that reinforcing measures, such as

NEW SEKI~S VOL. LII, No. i Be11 et aI.-Hernia Repair American Journal of Surgery -19

fascia Iata, become imperative when poor groups suffering from hernias is worthy of fascia and muscIe are encountered. In serious consideration. extreme cases, orchidectomy is advisabIe to obviate the recurrence which experience SUMMARY

teaches is almost inevitable in such cases. I. A foIIow-up of hernia repair in fifty

The reIative advantages and disadvan- mentaIIy sick and mentaIIy deficient pa-

tages of commercia1 fascia Iata and auto- tients is presented.

genous fascia Iata can not be satisfactoriIy 2. Nineteen patients were more than 50 determined from the smaI1 number of cases. years of age, twenty-four patients were

In our series commercia1 fascia enjoys a between the ages of 2g and 50.

slight advantage from the point of view of 3. There was a tota of seventy-three percentage of recurrence. Additional ad- hernias, g3 per cent, or sixty-eight of which

vantage accrues from the Iack of additiona were inguinal; 47 per cent, or thirty-two

operative work required, with consequent were direct inguina1 hernias. increase in tota time of operation, as we11 4. Six patients had been previously as added nursing care and discomfort to the operated upon eIsewhere with many years patient. The Iatter, from our point of view, interva1 since the origina operation. The

becomes an important factor. We have, Iargest percentage of recurrences occurred

however, had none of the comphcations in this recurrent inguina1 group of cases.

feared by removing the patient’s own fascia 5. Sixty-one per cent of the hernias did Iata, such as rupture and herniation of not occur with a foIIow-up of one to four muscIes nor infections of the thigh opera- pIus years duration. Seventy-five per cent tions. In the case of commercia1 fascia Iata of the patients treated did not have a where postoperative infection of the herni- recurrence. orrhaphy occurred, it couId not be satis- 6. Some of the di&uIties in the manage- factoriIy determined whether this was the ment of patients of this type are pointed resuIt of the fascia Iata or the patient inter- out. fering with the normaI process of postoper- 7. The type of operation among this ative steriIity and repair. On the whoIe, we group of patients is considered. are inclined to continue the use of commer- cia1 fascia Iata because of its advantages as

BIBLIOGRAPHY

aIready discussed. We are furthermore dis- I. EBAUGH, FRANKLIN G. The psychiatrist in relation to

posed to beIieve that it is the method of surgery. Surg., Gynec. &+ Obst., 68: 372-376, 1939.

2. EBAUGH, FRANKLIN G. Psychiatric complications in

choice in the majority of herniorrhaphies surgery. Bull. A. C. S., 22: 153-158, 1937.

performed on mentaIIy iI and mentaIIy 3. BABCOCK, W. WAYNE. A Text Book of Surgery.

deficient patients suffering from hernias PhiIadelphia, 1930. W. B. Saunders.

4. LONGACRE, ALFRED B. Follow-up of hernia repair.

even where extensive tissue defect is not Sura., Gynec. @ Obst., 68: 239-246, 1939.

present. The extended use of fascia Iata 5. WATSON, L. F. Hernia. P. 181. St. Louis, 1924.

repair in non-psychotic and non-defective ivlosby.

6. N&on Loose Leaf. Surgery.