Introduction and Background

il — fa (1) TUMi Tittle HNL NA COMMA HUEPSITY HEALiit SCic NCES LIBRARY — | [ALFRED M.HELLMAN IPB tr Kifevd. Nlirare nf ABDOMINAL HERNIA ITS DIAGNOSIS and TREATMENT BY W. B. De GARMO, M.D., ~ NeW yorK. Professor Special Surgery (Hernia), New York Post-Graduate Medical School and Hospital ; Fellow New York Academy of Medicine ; Member American Medical Associ- ation, New York State and County Medical Societies, Honorary Member of the Medical Society of Virginia. PHILADELPHIA & LONDON J. B. LIPPINCOTT COMPANY Copynicitr, 1907 By J. B. Liprxcorr Company Electrotyped and Printed by J. B. Lippincott Company The Washington Square Press, Philadelphia, U. S. As DEDICATION © the many practitioners of medicine and surgery who, during the past twenty years at the New York Post-Graduate Medical School and Hospital, have patiently followed the Author’s attempts to simplify the teaching of hernia, this work is dedicated. a | Digitized by the Internet Archiv in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/abdominalherniai00d PREFACE. The first appeal for aid by those afflicted with hernia, usually made to the family phy: While the surgeon has plenty of literature to guide him in his part of the work, the physician, upon whom many times the full responsibility of the case must rest, finds little Pract aid from that source in any language. It is to the physi that this book is especially addressed, and if it fails to furnish him useful suggestions regarding the diagnosis and treatment of adominal hernia, then certainly it will have fallen far short of its intent. The author's severest critic will scarcely accuse him either of writing a book too early in his prof nal career, or of compiling one from the experience of others. Many authors have been consulted, and quoted with credit, but the funda- mental part of the work is based upon personal experience, and the illustrations are largely from photographs of patients under treatment. The author realizes his liability to criticism for omitting mention of other forms of operation, popular, perhaps, in the country of their origin; but he justifies himself in the fact that they have not shown the success, that has followed the use of those here given. Furthermore he has tried to make clear the principles involved in curative measures rather than to suggest any special method. Acknowledgment of obligations to many friends is freely given, especially the following who willingly granted the use of original drawings which are a valuable addition to the text: Dr. W. S. Halsted, Baltimore; Dr. W. J. Mayo, Rochester, Minn.; Dr. William S. Bainbridge. New York: Dr. Charles N. Dowd, New York; Dr. A. E. Halstead, Chicago; Dr. and. 6 PREFACE. W. Jay Seaver, New Haven; Dr. Samuel W. Kelly, of Cleve- land, and to Professor Julius A. Becker for special dissections from which Mr. K, K. Bosse has drawn some of the anatom- ical plates, and to Dr. Alfred M. Hellman for compiling the index. Manufacturers of appliances for the relief of hernia have allowed the publishers to draw freely upon them for electro- types, with which to illustrate different forms of trusses, and the author wishes to thank in this public manner, Wm. H. Horn & Bro., The J. Ellwood Lee Co., Chesterman & Streeter, and his brother Mr. G, J. De Garmo. CHAPTER lL IL. IIL. Iv. XI. XIII. XIV. XV. XVI. XVIL XVII XIX. XX. XXII XXII. XXII. XXIV. XXV. XXVI. XXVIL. XXVIII. CONTENTS SurGicaL ANATOMY OF THE INGUINAL REGION .. .. « D Cause or INGuinAL HERNIA 2... 2 2 ee ee OF THE TESTICLE... .. . « Types AND CoNDITIONS OF INGUINAL Hasta : Tue HERNIAL Sac... - « eure eK eK Symptoms AND DIAGNOSIS OF aeiAE, HERNIA... . MECHANICAL TREATMENT OF INGUINAL HERNIA... - MECHANICAL TREATMENT OF GUINAL HERNIA IN IN- FANCY AND CHILDHOOD... . wie ee TREATMENT OF INGUINAL HERNIA BY Grsiiadrice a SuRGicaL Cure or INGuINAL HERNIA... 1 ee COMPLICATIONS IN THE SURGICAL CURE OF INcurnan HERNIA... . . eve Ke aK Stcmorp, Ca#caL AND BLADDER seit eo Re SurGicaL Cure or IncuinAL HERNIA IN THE fenaue Femorat HERNIA 2 6 ee ee ee MECHANICAL TREATHENT ¢ oF FEMORAL Weems, cee SurGicaL Cure oF Femorat HERNIA «1 2. ee ee UmpiiicaL HERNIA... . ewe ou yen MECHANICAL TREATMENT OF -UnaictcKE HiaiA ea oe SurcicaL Cure oF UmpiticAL HERNIA... 2 2. eee VENTRAL HERNIA) 2 6 5 5 ee ee Rare Forms or HERNIA... . - : ES 8 ConTRA-INDICATIONS TO THE SvrcicaL Cone oF ABDoM- INAL HERNIA... + MGR A Re a we STRANGULATED INGUINAL HEA ke ee Se aiteRlg MeEpicAL TREATMENT OF STRANGULATED Hexwta i Dae SURGICAL TREATMENT OF STRANGULATED INGUINAL HERNIA STRANGULATED FEMORAL HERNIA. . 2... ee ee STRANGULATED UmpiLicaL HERNIA... 1 1. ee eee PAGE 204 409 413 427 432 439 AMS ILLUSTRATIONS FIGURE PAGE it (Original drawing.) Showing position of superficial vessels.. 21 2. (Original drawing.) Aponeurosis of external oblique muscle and external ring. 22 3. (Original drawing.) canal . 24 4. (Coorer,) Anatomy of higuiel and femoral region. 25 5. (Original drawing.) Proximity of deep epigastric and iliac arteries to inguinal canal. . . 30 6. (Leiy.) The greater omentum . 32 7. (Gonarp from Eccues.) Partial descent of testicle. 35 8 (Goparp from Eccui Partial descent of testicle. 36 9. (Ecctgs.) Testicle in Scarpa’s triangle...... . 37 10. (Original photo.) Right testicle in canal, left at internal ring.. 38 11. (Original drawing.) Multiple cysts of cord.. 40 12. (Original photo.) Hydrocele of cord simulating irreducible hernia 13. (Macreapy.) Side view of ‘abdomen of old man 14. (Macreapy.) Early inguinal hernia. Pel (Original ‘drawinie) cA Hosni “ofcahysical’ culture tae proviives hernia Le 52 16. (Macreapy. Double oblique and direct hernia 35 17. (Ecctes.) Incomplete inguinal and direct hernie 56 18. (Original photo.) Right complete inguinal and enormous left scrotal hernie 57 19. (Original photo.) Scrotal hernia of enormous size 5 20. (Original photo.) Labial hernia in woman. 50 21. (Macreapy.) Double direct hernia..... 60 22. (Original photo.) Sigmoid hernia. 6r a (Original photo.) Right direct and left sismoid haniie,... 62 24. (Original photo.) Left interstitial hernia, right testicle in canal. 63 25, (Eccres.) Right interstitial hernia with retained testicle... 64 26. (Eccres.) Right testis in cruro-scrotal pouch with hernia 5 27. (Macreavy.) Right interstitial hernia with retained testi 66 28. (Macreapy.) Left interstitial hernia simulating femoral hernia. 67 29. (Original drawing.) Showing formation of interstitial sac.... 68 30. (Original drawing.) Three fibrous rings in acquired sac... 72 31. (Original drawing.) Two fibrous rings with strangulation in upper one veveeeensneeeee 73 32. (Ori Omentum incarcerated in ring in Con- genital sac 74 Ge CMacwaay) Herala in funicular portion of tunica vaginal 5 10 ILLUSTRATIONS. FIGuRE Pace 34 (Original drawing.) Hernia into funicular portion of tunica vaginalis with cyst below. : . (Original drawing.) Infantile sac with closed tunica vaginalis below .... “7 36. (Original drawing.) Sac of peculiar shape. 8 37- (Original drawing.) Interstitial sac 79 38. (Original drawing.) Relative thickness of tissues covering sac. 80 39. (Original photo.) Irreducible omental scrotal hernia. 40. (Original photo.) Large reducible scrotal hernia. 41. (Original drawing.) Improper method of examining for hernia a2 COriginal pliot:), Enormions irreducible lett scrotal heen 43. (Original photo.) Large scrotal hernia with true peritoneal sac 44. (Original 45. (Original photo.) 46. (Original photo.) Double congenital hernia mistaken for hydro- cele . 47. (Original photo.) Double congenital hernia retained by truss. 94 48. (Original photo.) Double congenital hernia two years after operation 95 49. (Original photo.) Typical scrotal hernia of acquired type 06 . (Original photo.) Right labial hernia ... 97 . (Original photo.) Right labial hernia, four weeks after opera- tion . (Original photo.) Sigmoid hernia . (Original photo.) Czcal hernia .. photo.) Sigmoid and Creal hernia in same patient . (Original photo.) Czcal hernia in womai |. (Eccres.) Left varicocele and femoral vari (Original photo.) Varicocele mistaken for hernia. . (Le Procre’s Mep., redrawn.) Statuette sno truss. goo B.C. 115 59. (Original drawing.) Showing shape of pelvis.. é : inal photo.) Illustration of bad truss. 61. Original photo.) Properly applied trus 2. (Original photo.) Usual manner of applying German truss. 63. (Original drawing.) Position in which a truss spring should be applied . (Girigine! photo) De Garina Hood uss applied. ‘ "(Original photo.) De Garmo-Hood truss applied, back view Group of variously shaped pads (thirteen figures). A standard of sizes for truss pads (four figures). . (Macreapy.) Measuring for inguinal truss... (Original drawing.) Methods of taking diagram with lead tape 154 . (Original drawii Method of taking diagram, second position 155 . (Original draw’ Pelvic diagrams contrasting shape....... 156 ILLUSTRATIO (Original drawing.) Pelvic diagrams contrasting shape Shaping truss springs (seven figures)... : ; (Horw.) Hard-rubber cross-body truss applied. 75. (Original photo.) Large labial hernia . (Original photo.) Labial hernia retained by cross . (Horn.) Hard-rubber Hood truss applied... 78. (Original photo.) Recurrent hernia in woman 79. (Original photo.) hernia “ 80. (Original photo.) Large double hernia . 81. (Original photo.) Large double hernia retained by Hood truss. 167 82, (Horn.) Combination of radical-cure truss with ordinary dou- ble truss ——— . 83. (Macreapy.) English “ Rat-tail” truss, applied. 84. (Ecctes.) English double truss, applied. 85. (Horw.) Hard-rubber French truss, applied 86. (Original photo.) Double retained testes and hernia; truss BEDIED) con guoienpenaecccres 87. (Original photo.) Double retained testes and hernia 88 (Macreavy.) Truss for reducible interstitial hernia. 80. (Original photo.) Large irreducible scrotal hernia...... 90. (Macreapy.) Hinged-cup truss for irreducible hernia. inal photo.) Enormous irreducible left scrotal hernia nal drawing.) Method of supporting large inreducible hernia 93. (Original drawing.) applied ee . 94. (Original drawing.) Hood's truss applied to girl six months old 192 95. (Original photo.) Cross-body hard-rubber trus: 96. (Eccues.) Hank of worsted truss 97. (Original photo.) Cross-body hard-rubber truss strap 98. (Original photo.) De Garmo-Hood truss on girl. o9. (Original photo.) De Garmo-Hood truss on boy. 100, (Original photo.) German scrotal hernia truss on boy ror. (Seaver.) Gymnastic exercise no. 1.... to2. (Seaver.) Gymnastic exerci 103. (SEAvER.) Gymnastic exerci tog. (Seaver.) Gymnastic exerci old boy with eross-body truss with perineal 105. Gymnastic exercise no. 106. Gymnastic exercise no. 107. Gymnastic exercise no. 108. Gymnastic exercise no. 109. (Original drawing.) Sac separated from cord and anatomy of inguinal region 110, (Original drawing.) Curved blunt needle 12 ILLUSTRATIONS. FIGURE PAGE 111. (Original drawing.) Internal oblique stitched to Poupart’s ligament 112, (Original drawing.) Aponeurosis closed by continuous suture. 225 113. (Hatstep.) Relative position of sac, cord and vas deferens... 229 114. (Hatstep.) Cremaster fastened under internal oblique........ 230 113. Internal oblique fastened to Poupart’s ligament... 231 116, (Harsrev.) Overlapping of aponeurosis (first step). = 232 117. (Hatstep.) Overlapping of aponcurosis (second step) + 233 118. (Hazstep.) Sectional view of fascial layers............ + 234 119. (Weutsteix, redrawn.) Transplanting of cord (first step).... 235 120. (Wuuisterx, redrawn.) Transplanting of cord (second step). . 236 rat. (Hastep.) Halsted’s method of utilizing split sheath of rectus 237 122, (Original drawing.) Right retained testicle in boy of 10 years. 240 123. (Original photo.) Right retained testicle in boy of 9 years... 24r 124. (Original photo.) Double retained testes in boy of 13 years.. 241 125, (Original drawing.) Delayed testicle surrounded by sac..... 242 126. 127. 128. 120. 130. 131. 132. 133- 134. 133. 136. 137. 138. 139. 140 . (Original photo.) Omentum and sac . (Original photo.) Scrotal hernia to within two inches of knee... 268 . (Original photo.) Side view of preceding case... (Original photo.) Double retained testes two years after opera- tion 243 (Original photo.) Retained left testicle and interstitial hernia. 244 (Original photo.) Sac of interstitial hernia before opening... 245 (Original photo.) Sac with testicle inside . 246 (Original drawing.) Retained testicle, sac opened. . 247 (Original drawing.) Purse-string suture in sac. (Original drawing.) Sac tied by purse-string suture......... 248 (Original drawing.) Lifting muscles to place testicle beneath them (Original photo.) Interstitial hernia and retained testicle: (Original photo.) Interstitial hernia three weeks after opera- tion (Original photo.) Double hernia in child of 7 years supposed to be a girl 252 (Original photo.) Same as preceding, with hernia reduced.... 253 (Original photo.) Same as preceding: 255 (Original drawing.) Appendix adherent to anterior wall of SAC Leese (Original sac . (Original drawing.) Appendix incarcerated in fibrous ring... 260 2. (Original photo.) Sac and omentum removed together . (Original photo.) Omentum spread out for ligating. . (Original photo.) Omentum irreducible from shape. (Original photo.) Omentum, hypertrophied ILLUSTRATIONS, 13 ricuRE 149. (Original photo.) Prece 150. (Original photo.) Large scrotal he 151. (Original photo.) Preced 152. (Original photo.) Preceding case five years later with hernia on opposite side 53, (Original phot.) Enormous serotal hernia in man’ of 70 y 154. (Original photo.) Irreducible scrotal hernia, intestine only... 155. (Original drawing.) Peculiar mesentery found in preceding ¢ seven weeks after operation. containing bladder. . weeks after operation 156. (Original drawing.) Hernial sac containing free ecccum and loops o£ intestine 157. (Original drawing.) Hernial sac in front of cecum. 158. (Original drawing.) Form of purse-string suture for sigmoid . (Original drawing.) bladder 161. (Original drawing.) arately : 162, (Original drawing.) Closure of canal in female by single suture 2 163. (Original drawing.) Anatomy of femoral region. 164. (Original drawing.) Transverse section of femoral region 165. (Redrawn from Gray.) Showing relative position of femoral hernia and large vess jor 166. (Original photo.) Double femoral hernia in man of 50 302 167. (Original photo.) Reducible femoral hernia of enormous 303 168. (Original photo.) Irreducible femoral hernia. 303 169. (Original photo.) Double femoral hernia in woman, 306 170. (Original drawing.) Cystic femoral sac 307 171. (Original photo.) Femoral hernia of pecttiar shape, in woman, 308 172. (Eccues.) Left varicose saphena vein 173. (Original photo.) Femoral and labial vai of 35 years ee : 174. (Original photo.) Lipoma simulating femoral hernia. 175. (Original photo.) Femoral hernia in woman, cross-bod: applied 176. (Original drawing frou photo.) Cro: for femoral hernia (Redrawn.) German femoral truss applic 78. (Redrawn from Macrrapy.) English femoral truss applied. . (Original drawing from photo.) Adjustable truss applied to femoral hernia . si “ see: (Original drawing from plete.) Dé Garnio: femoral: cris ap- plied ERAN truss -body hard-rubber truss 14 ILLUSTRATIONS. FIGURE PAGE 181, (Original photo.) Inguinal and femoral hernia in woman, truss applied + 329 (Original drawing.) Location of incision for femoral hernia... 334 . (Original drawing.) Showing femoral protrusion under Pou- part's ligament .. . 335 184; (Original drawing.) ‘Femotal Operation: sae drawh dow. . 336 183, (Original drawing.) Femoral hernia operation, sutures in place 337 186. (Original drawing.) Femoral hernia operation sutures tied.. 338 187. (Original drawing.) Femoral hernia operation; blunt needle.. 330 188. (Original photo.) Double reducible femoral hernia, woman of 60 years 189. (Original photo.) Same case, side view 190. (Original photo.) Same case six weeks after operation tot. (Original photo.) Femoral hernia of unustal type.. 192. (Original photo.) Umbilical hernia in child of 3 years 193. (Original photo.) Enormous irreducible umbilical hernia. 104. (Original photo.) Same case, side view... 5. (Original photo.) Enormous umbilical hernia; . (Original photo.) Reducible umbilical hernia in 200-pound APFOMAN (9 heb aE RETA ENTS SET AEGIS Poe deen ceemonseee 197. (Original photo.) Irreducible umbilical hernia in woman 198. (Original photo.) Irreducible umbilical hernia in man . (Barsrivce.) Multiple hernie ..... . (Bamnseper.) Same case showing § hernic in median line . (Dr. S. W. Ketty.) Plate and plaster for umbilical hernia (Dr. S. W. Ketty.) Plate and plaster applied.....0........05 . (Original photo.) Truss applied for umbilical hernia, child of 3. years 3 204. (HorN.) Outlines of umbilical plates. (Continued.),Size of umbilical plates. (Ecctzs.) An English umbilical truss... . . (Horn.) Diagram for abdominal belt measure... 7. (Ecctes.) English rim-plate concave umbilical tru: . (Original drawing.) Vertical overlapping of abdominal wall.. 376 . (Mayo.) Transver elliptical incision ... . (Mayo.) Transverse overlapping sutures in place. 379 (Mayo.) Transverse overlapping, complete ... 212, (Original photo.) Post-operative ventral hernia. (Original photo.) Deposit of fat simulating ventral hernia.... . (Original photo.) Ventral hernia following gun-shot wound (Original photo.) Same, front view. ‘ . (Original photo.) Bilateral post-operative ventral hernia. . (Original photo.) Ventral hernia after appendix operation. 8. (Macreapy.) Spontaneous double lumbar hernia . (Macreapy.) Truss for right lumbar hernia . (Down.) Congenital lumbar hernia 339 30 34t 342 347 348 349 350 ricune Pace: 221. (Dowp,) Anatomy of congenital lambar_ hernii you . (Down.) Operation for lumbar hernia sutures placed........ 403 (Dowp.) Operation for lumbar hernia sutures tied. ...... 404 . (Original photo.) Exstrophy of bladder and vaginal hernia... 4oo (Original photo.) Same case with appliance . 407 (Hory.) Appliance for perineal hernia 4o8 Chassirication or Trusses by Groves, Grovr oF: Springless trusses (seven figur French, German and English trusses (eight figures)