Reprinted from The International JournalopSurgery,Dec. 1897.

THE TEEATMEHT OF HEKNIA IN OLD MEN.*

By A. J. Ochsner, M.D., Chicago.Barg eon-in-thief of Augustana Hospital, etc.

It is a well-known fact that hernias in menfrequently become much more troublesome after theage of fifty or sixty. In many cases a simple trusswill suffice to retain a hernia for many years withperfect comfort to the patient until he reaches thisage, when it gradually becomes more and moretroublesome, until it seems almost or quite impossibleto retain the hernia comfortably, notwithstanding theuse of the best trusses.

This fact lias been explained by the condition ofthe tissues at this age, by the tendency many patientshave to become obese, and by the general depressionof vitality.

There is another factor of far greater importancewhich seems to have been entirely overlooked—l referto the increase in intra-abdominal pressure duringthe evacuation of the bladder andrectum, necessitatedby the obstruction due to enlargement of the prostategland, which is so common in old men.

The influence of strictures in adults and phimosisin children upon hernias has been pointed out re-peatedly, and my observations have led me to thepositive conclusion that in old men the enlargedprostate gland plays quite as important a part.

f Since Prof. Wm. White has pointed out a com-paratively simple surgical remedy for the relief of thispathological condition, it lias appeared to me that thetreatment of hernias in old men should be modified.

* Read at the meetingof the Mississippi Valley Medical Association,Oct. 6, 189".

+ Instudying the literature upon this suii ect. 1 find that Sinizin ofMoscow, claims to have performed castration for the cure of prostatichypertrophy in 188G. Priority is also claimed for Ramm, but it is cer-tainly due to the energetic work of White that the operation hasreceived proper recognition.

The procedure which I should advise in these casessimply consists' in a combination of the operation forradical cure of hernia with castration or resection ofthe vasa-deferentia.

The former operation has been advised repeatedlyfor the cure of unilateral inguinal hernia in men,because by removing the tissues of the cord from theinguinal canal, the closure of the latter is simpler andfirmer, but it has never attained any great footholdfor esthetic reasons. In old men the loss of thisorgan is not counted so high, and consequently theobjection loses in weight.

It has been shown many times that old age in itselfis not a contraindication to the operation of herni-otomy. Old patients recover quite as rapidly and asthoroughly from the operation as younger ones, andbeing able to offer benefit in two directions simultan-eously it seems as though herniotomy in old men wereparticularly indicated.

The following are, in brief, the steps of the opera-tion. An incision is made over the inguinal canal toa point about an inch from the scrotum down to thehernial sac. This is dissected out and opened. If itcontains omentum, this is drawn out as far as it willcome easily, it is ligated with a number of fine catgutligatures, being careful not to draw these too tightly;then the superfluous omentum is cut away, leavinghalf an inch projecting beyond the ligatures. Thestump of the omentum is now replaced in the ab-dominal cavity. The foot of the table is then elevated,placing the patient in the Trendelenburg position, inorder to cause the intestines to recede from thevicinity of the operation. The sac is now dissected toa point just inside of the abdominal cavity, ligatedwith fine double catgut, cut off half an inch outsidethe ligature, and the stump permitted to retractwithin the abdominal cavity. Now, the tissues ofthe cord are brought up into the wound, and the vasdeferens together with the nerves and vessels is

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ligated within the internal ring and also opposite thelower end of the wound, being careful to leave enoughvessels to prevent the testicle from sloughing. Theintervening portion is now excised. This permits thestump to withdraw within the abdominal cavity, re-maining, of course, covered with peritoneum. Theinguinal canal is now closed by suturing the conjoinedtendon to Poupart’s ligament by means of a continu-ous suture of chromicized catgut of small caliber andused double. The tissues beyond are closed by meansof deep and superficial silkworm-gut or horsehair orby buried catgut sutures. The continuous doublecatgut suture has a decided advantage over the inter-rupted or the single continuous suture, because finermaterial can be used with safety and the number ofknots is reduced to one at each end. The chromi-cized catgut is not absorbed for four weeks, mak-ing it an ideal suture material for this operation.

If the patient is suffering from double hernia, thesame operation is repeated on the opposite side; if not,the next step consists in making an incision less thanan inch in length just below the external ring on theopposite side. The cord is fished up with a strabismushook, ligated as on the other side, resected anddropped. The wound is closed with a deep suture ofhorsehair or silkworm-gut or by a buried catgutsuture. The ordinary dressing is applied The footof the patient's bed is elevated twelve to eighteeninches, so that coughing or vomiting will not forcethe intestines against the wound with sufficient forceto cause disturbance. It is, of course, necessary tochange this position in case there is any sign of pul-monary congestion.

It is kept in this position for a week or ten days.The patient is kept in bed from four to five weeks inorder to permit the wound to become strongly united,and to permit the prostate gland to reduce in size,lie is given an abundance of distilled water to drinkin order to make the urine non-irritating. In case

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cystitis exists, this is treated according to the indica-tions in each case. In case the testicle is not normal,castration may he substituted for resection of thecord.

I have been able to confirm the observation ofseveral authors, that in cases in which there is a sim-ple hypertrophy of the prostate gland, without muchchronic inflammation, the gland will reduce in sizevery rapidly, probably from one-fourth to one-halfduring the patient’s stay in the hospital, and that thepatient finds it possible to evacuate the bladder withmuch less exertion than before the operation.

The patient is advised to drink an abundance ofgood—preferably distilled—water after leaving thehospital, and to keep the bowels free in order toreduce, as much as possible, the intra-abdominal pres-sure during micturition and defecation.

If the surgeon has perfect control of the conditionsnecessary to exclude sepsis, this operation is safe, andit will relieve the patient of a great amount of suffer-ing. Every argument which has been used in favorof operation for radical cure of hernia, as well aseveryone that has been brought forward in support ofresection of the cord or castration for the relief ofconditions due to enlargement of the prostate gland,can be applied with perfect propriety in favor of thisoperation.

From the conditions present, one would expect apermanent result, but as the oldest one of my casesdates back but eight months, it is as yet too soon tospeak from experience.

I will add short histories of four cases operated byme;

Case I, No. 34884 Entered the Augustana Hospital,Jan. 9, ’97, giving the following history: He wasborn in Germany, eighty years ago. His health hasalways been excellent, barring a left inguinal hernia.

± This number corresponds with the one in my clinical records ofcases at the Augustana Hospital,

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which he first noticed about forty years ago, andwhich he attributes to heavy lifting. His hernia didnot cause much discomfort until about fifteen yearsago. Since that time it has become more and moretroublesome, and for several years it has been irreduci-ble and about as large as a man’s fist. He has alsosuffered for some time from hydrocele on the leftside as large as a small pear. For several years hehas carried both hernia and hydrocele in a bag madeof soft leather attached to a belt. It has been diffi-cult for him to evacuate his bladder, but he has neverreceived treatment for this difficulty. His prostategland is enlarged to the size of half an orange. It issmooth and hard and not very painful upon pressure.Twelve hours before entering the hospital the herniasuddenly became enlarged and strangulated. All at-tempts at reduction by means of taxis failed, and thepatient entered the hospital very much exhausted andsuffering frightfullywith the usual conditions m suchcases. One-fourth grain of morphia was administeredhypodermically, then the patient was anaesthetizedand placed on the operating table in the Trendelen-burg position. An attempt was made to reduce thehernia by means of taxis, but this failed.

After thorough disinfection an incision was madeover the inguinal canal. The hernial sac was opened.Its contents were found black throughout on accountof the tension and the violent attempts at reductionmade by the patient during the day. The sac con-tained small intestine and omentum.

Favored by the Trendelenburg position, it waspossible after some effort to reduce the intestine. Theomentum was found adherent to the sac. This wasligated, resected, and the stump returned into theperitoneal cavity. Then the tissues of the cord wereligated, resected, and the stump was permitted toretract beyond the internal ring. The sac, togetherwith the adherent omentum and the testicle, wasnow lifted out of the scrotum, the former was dis-

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seeled up to a point within the abdominal cavitywhere it was ligated with fine double catgut, resectedhalf an inch outside of this ligature, and the stumppermitted to retract beyond the internal ring. Nowthe wound was closed as described above, and theordinary dressings applied.

The patient was very stubborn, never having beensick in bed before, so he removed the dressings duringthe absence of the nurse on the second day after theoperation, got up out of bed and walked about in theroom. From this and other foolish acts a superficialinfection resulted. His pulse and temperature, how-ever, remained normal, and he was able to go homewell on February 6, a little less than a month afterthe operation.

He is still perfectly well eight months after theoperation; there is not the slightest tendency to returnof the hernia.

His urine flows perfectly free, and the prostategland has decreased very perceptibly in size on theleft side, and has become much softer than it wasbefore the operation.

Case 2, No. 3594. A retired farmer, born in Irelandseventy years ago, entered the Augustana Hospital,Feb. 22, 1897. He was strong and vigorous, but veryslight. His health had always been good, but he hadsuffered from double inguinal hernia for nearly fortyyears. Until about ten years ago an ordinary trusswas sufficient to retain the ruptures so that he coulddo farm work with perfect comfort. Since then ithas become more and more difficult to retain thehernia even with a very good truss. The openingshave increased in size, and the patient found his con-dition becoming so constantly worse that it was almostunbearable. He had suffered from constipation andhad to use a considerable amount of pressure in evacu-ating the bowels and the bladder. The prostrategland was enlarged to the size of a herds egg. It wassomewhat irregular and hard, but not painful uponpressure. The urine was normal.

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In this case I performed the operation describedabove for radical cure of hernia and resection of thevasa deferentia. The wounds were dressed withcollodion, and the scrotum supported by means of asuspensory bandage. The wounds healed by primaryunion, and the patient's recovery was normal in everyway except that on the third and fourth days he failedto pass urine. Catheterization brought only sixounces of urine on the third day and twice thatamount on the fourth During these two days thepatient see ned drowsy and sullen and I feared urse-mic poisoning, but the following day and throughoutthe period of convalescence thereafter the urine wasnormal in quantity and quality and was voided with-out any difficulty.

No remedy was given excepting an ounce of castoroil and an abundance of distilled water. The patientleft the hospital April 3, just five weeks after theoperation, perfectly well. He has remained well dur-ing the past six months.

Case 3, No. 3,835. Came to the Augustana Ho-pitalMay 34, 1897. He was born in Germany fifty-fiveyears ago. He is married and living with his wife forthirty years. He is a miller by trade and is strongand healthy, but his veins throughout the body areconsiderably dilated. He has a right inguinal herniaand a varicocele on the left side, both of which hadbecome much mox*e troublesome during the past fewyears. The hernia came on during a paroxysm ofsneezing about fifteen years ago. During the firstten years the hernia could be retained comfortably bymeans of an ordinary truss, but of late the patient hasfound it impossible to do this.

My assistant performed Bassinis’ operation for thecure of hernia on the right and resection of the en-larged veins on the left side. The wound on the rightside healed normally, but the testicle on the left sidedisintegrated, although itremained perfectly aseptic.

hive weeks after the original operation 1 laid open

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the wound on the left side, ligated the cord, and re-moved the remnants of tlie testicle and packed thewound with iodoform gauze. Healing progressednormally from this time on, so that the patient wasable to return home well three weeks later, on July24, just two months after entering the hospital. Anexamination made Sept. 24, 1897, just four monthsafter the herniotomy and not quite three months afterthe castration, showed a very marked reduction insize of the left lobe of the prostate gland, it beingfully one-fourth smaller on the left than on the rightside, which is still as large as half a egg.

For several years previous to the operation the pa-tient had found it impossible to pass urine in a freestream, and he was compelled to evacuate his bladderseveral times during the night. There is a markedimprovement regarding both of these features.

Case 4, No. 4,036, entered the Augustana HospitalAug. 3, 1897, giving the following history; He is anAmerican, sixty-five years of age, a merchant in asmall town. One of his sisters died of diabetes, butotherwise his family history is very good. Thirtyyears ago the patient acquired intermittent diabetes,from which he has noticed a slight amount of incon-venience ever since, but with good habits and a rea-sonable attention to diet he has been very comfortableand able to work. Three years ago thepatient beganto suffer from an irritable bladder. He was compelledto micturate frequently, passing only a small amountof urine each time. At this time his conditionwas diagnosed as diabetes complicated with cystitis.Internal remedies gave only temporary relief, andfive months ago the condition had become so muchworse that the patient was compelled to depend uponthe catheter entirely for emptying his bladder.

Upon entering the hospital his general conditionwas fair, although he had lost about thirty pounds inweight during the past three years. There was com-pete obstruction in the jmostatic portion of the

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urethra. The passage of the catheter gave rise toexcruciating pain at this point. It was impossiblefor him to pass more than a few drops of urine. Bypassing the catheter three times a day he obtainedmore comfort than by more frequent catheterization.The urine had a specific gravity of 1030, was acid,contained an abundance of pus, but was normalin every other respect. Fortunately the diabeteshad again subsided, so that there was no sugarpresent.

The prostate gland was enlarged to the size of halfan orange, was smooth and hard, and very tenderupon pressure. The patient also has a left inguinalhernia, which has existed for ten years, but whichhas been of so little annoyance to him that hewould not have desired an operation for its cure hadnot his prostatic disease driven him to seek relief.The hernia was easily controlled by means of a truss.As it did not increase the danger of the operation Iunited herniotomy with resection of both vasa defer-entia, as described above.

The wounds healed primarily and the patient wasable to return home September 2, Just four weeksafter his operation. He could pass some urine spon-taneously in the morning, but was still compelled touse the catheter three times a day. On September20, three weeks later, he reported being able to emptythe bladder spontaneously during the day, but thatin the evening there remained a small amount ofresidual urine which he evacuated by means of thecatheter.

It is plain that no positive conclusions can be basedupon so small a number of cases; neither- can thepermanency of the relief obtained in these cases beestablished after so short a time of observation, butthese histories seem to confirm the reasonableness ofthis method of treating hernia in old men. At thepresent time by far the greater number of the sur-geons who have written concerning the treatment of

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hypertrophied prostate glands by means of castrationor resection of the spermatic cords are strongly infavor of these operations, and those who oppose themseem to have had but little personal experience withthem.

It appears to me that the operation is sure to finda new field of usefulness in the treatment of hernia inold men.

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