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HEALTH SCIENCES STANDARD
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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 j Member American Medical Associ-
ation, New York State and County Medical Societies, Honorary
Member of the Medical Society of Virginia.
PHILADELPHIA a^ LONDON
J. B. LIPPINCOTT COMPANY
K U
Copyright, 1907
By J. B. LippiNcoTT Company
Electrotyped a7id Printed by J. B. Lippincott Company
The Washingiofi Square Press, Philadelphia, U. S. A.
DEDICATION
TO 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.
Digitized by tine Internet Archive
in 2010 with funding from
Open Knowledge Commons
http://www.archive.org/details/abdominalherniaiOOdega
PREFACE.
The first appeal for aid by those afflicted with hernia, is
usually made to the family physician.
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 practical
aid from that source in any language. It is t(j the physician
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 professional 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.
Acknowdedgment of obligations to many friends is freely
given, especially the following who wdllingly 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.
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. Ell wood Lee Co., Chesterman & Streeter,
and his brother Mr. G. J. De Garmo.
CONTENTS
CHAPTER PAGE
I. Surgical Anatomy of the Inguinal Region 17
II. Descent of the Testicle 34
III. Cause of Inguinal Hernia 44
IV. Types and Conditions of Inguinal Hernia 54
V. The Hernial Sac 71
VI. Symptoms and Diagnosis of Inguinal Hernia .... 82
VII. Mechanical Treatment of Inguinal Hernia .... 114
VIII. Truss Fitting 152
IX. Mechanical Treatment of Inguinal Hernia in In-
fancy and Childhood 189
X. Treatment of Inguinal Hernia by Gymnastics . . . 204
XL Surgical Cure of Inguinal Hernia 214
XII. Complications in the Surgical Cure of Inguinal
Hernia , . 239
XIII. Sigmoid, C^cal and Bladder Hernia 277
XIV. Surgical Cure of Inguinal Hernia in the Female . 292
XV. Femoral Hernia 297
XVI. Mechanical Treatment of Femoral Hernia 317
XVII. Surgical Cure of Femoral Hernia 331
XVIII. Umbilical Hernia 344
XIX. Mechanical Treatment of Umbilical Hernia ... 355
XX. Surgical Cure of Umbilical Hernia 372
XXI. Ventral Hernia . 383
XXII. Rare Forms of Hernia 39S
XXIII. Contra-Indications to the Surgical Cure of Abdom-
inal Hernia 409
XXIV. Strangulated Inguinal Hernia 413
XXV. Medical Treatment of Strangulated Hernia .... 427
XXVI. Surgical Treatment of Strangulated Inguinal Hernia 432
XXVII. Strangulated Femoral Hernia 439
XXVIII. Strangulated Umbilical Hernia 443
ILLUSTRATIONS
FIGURR PAGE
4-
5-
6.
7-
8.
9-
10.
II.
12.
13-
14.
IS-
16.
17-
18.
19.
20.
21.
22.
22-
24.
25-
26.
27.
28.
29.
30.
31-
32.
33-
Original drawing.) Showing position of superficial vessels.. 21
Original drawing.) Aponeurosis of external oblique muscle and
external ring 22
Original drawing.) Aponeurosis opened to show deep part of
canal 24
Cooper.) Anatomy of inguinal and femoral region 25
Original drawing.) Proximity of deep epigastric and iliac
arteries to inguinal canal 30
Leidy.) The greater omentum 32
GoDARD from Eccles.) Partial descent of testicle 35
GoDARD from Eccles.) Partial descent of testicle 2>^
Eccles.) Testicle in Scarpa's triangle 27
Original photo.) Right testicle in canal, left at internal ring. . 38
Original drawing.) Multiple cysts of cord 40
Original photo.) Hydrocele of cord simulating irreducible
hernia 41
Macready.) Side view of abdomen of old man 46
Macready.) Early inguinal hernia 48
Original drawing.) A form of physical culture that produces
hernia 52
Macready.) Double oblique and direct hernise 55
Eccles.) Incomplete inguinal and direct hernise 56
Original photo.) Right complete inguinal and enormous left
scrotal hernias 57
Original photo.) Scrotal hernia of enormous size 58
Original photo.) Labial hernia in woman 59
Macready.) Double direct hernia 60
Original photo.) Sigmoid hernia 61
Original photo.) Right direct and left sigmoid hernije 62
Original photo.) Left interstitial hernia, right testicle in canal. 63
Eccles.) Right interstitial hernia with retained testicle 64
Eccles.) Right testis in cruro-scrotal pouch with hernia 65
Macready.) Right interstitial hernia with retained testis.... 66
Macready.) Left interstitial hernia simulating femoral hernia. 67
Original drawing.) Showing formation of interstitial sac... 68
Original drawing.) Three fibrous rings in acquired sac 72
Original drawing.) Two fibrous rings with strangulation in
upper one 72
Original drawing.) Omentum incarcerated in ring in Con-
genital sac 74
Macready.) Hernia in funicular portion of tunica vaginalis.. 75
9
10
ILLUSTRATIONS.
FIGURE PAGE
34. (Original drawing.) Hernia into funicular portion of tunica
vaginalis with cyst below "^6
35. (Original drawing.) Infantile sac with closed tunica vaginalis
below "jy
36. (Original drawing.) Sac of peculiar shape 78
2,7. (Original drawing.) Interstitial sac 79
38. (Original drawing.) Relative thickness of tissues covering sac. 80
39. (Original photo.) Irreducible omental scrotal hernia 83
40. (Original photo.) Large reducible scrotal hernia 84
41. (Original drawing.) Improper method of examining for
hernia 87
42. (Original photo.) Enormous irreducible left scrotal hernia.... 89
43. (Original photo.) Large scrotal hernia with true peritoneal
sac 90
44. (Original photo.) Typical congenital hernia in adult 92
45. (Original photo.) Double congenital hernia in boy 93
46. (Original photo.) Double congenital hernia mistaken for h}-dro-
cele 93
47. (Original photo.) Double congenital hernia retained by truss. 94
48. (Original photo.) Double congenital hernia two years after
operation 95
49. (Original photo.) Tj-pical scrotal hernia of acquired type 96
50. (Original photo.) Right labial hernia 97
51. (Original photo.) Right labial hernia, four weeks after opera-
tion 98
52. (Original photo.) Sigmoid hernia 99
53. (Original photo.) Caecal hernia lOO
54. (Original photo.) Sigmoid and Caecal hernia in same patient. . loi
55. (Original photo.) Csecal hernia in woman loi
56. (EccLES.) Left varicocele and femoral varix 103
57. (Original photo.) Varicocele mistaken for hernia 105
58. (Le Progre's Med., redrawn.) Statuette showing truss. 900 B. C. 115
59. (Original drawing.) Showing shape of pelvis 122
60. (Original photo.) Illustration of bad truss-fitting 127
61. Original photo.) Properly applied truss 128
62. (Original photo.) Usual manner of applying German truss.... 129
63. (Original drawing.) Position in which a truss spring should
be applied 130
64. (Original photo.) De Garmo-Hood truss applied 140
65. (Original photo.) De Garmo-Hood truss applied, back view. . 141
66. Group of variously shaped pads (thirteen figures) 149
(yj. A standard of sizes for truss pads (four figures) 150
68. (Macready.) Measuring for inguinal truss I53
69. (Original drawing.) Methods of taking diagram with lead tape 154
70. (Original drawing.) Method of taking diagram, second position 155
71. (Original drawing.) Pelvic diagrams contrasting shape 156
ILLUSTRATIONS. 1 1
72. (Original drawing.) Pelvic diagrams contrasting shape 157
73. Shaping truss springs (seven figures) 159-160
74. (Horn.) Hard-rubber cross-body truss applied 161
75. (Original photo.) Large labial hernia 162
y6. (Original photo.) Labial hernia retained by cross-l)ody truss.. 163
77. (Horn.) Hard-rubber Hood truss applied 164
78. (Original photo.) Recurrent hernia in woman 164
79. (Original photo.) De Garmo-Hood truss applied to recurrent
hernia 165
80. (Original photo.) Large double hernia 166
81. (Original photo.) Large double hernia retained l)y Hood truss. 167
82. (Horn.) Combination of radical-cure truss with ordinary dou-
ble truss 168
83. (Macready.) English " Rat-tail " truss, applied 170
84. (EccLES.) English double truss, applied 171
85. (Horn.) Hard-rubber French truss, applied 172
86. (Original photo.) Double retained testes and hernia; truss
applied 1 78
87. (Original photo.) Double retained testes and hernia 179
88. (Macready.) Truss for reducible interstitial hernia 181
89. (Original photo.) Large irreducible scrotal hernia 184
90. (Macready.) Hinged-cup truss for irreducible hernia 185
91. (Original photo.) Enormous irreducible left scrotal hernia.... i85
92. (Original drawing.) Method of supporting large inreducible
hernia 187
93. (Original drawing.) Five-weeks-old boy with cross-body truss
applied 191
94. (Original drawing.) Hood's truss applied to girl six months old 192
95. (Original photo.) Cross-body hard-rubber truss 193
96. (EccLES.) Hank of worsted truss 194
97. (Original photo.) Cross-body hard-rubber truss with perineal
strap 195
98. (Original photo.) De Garmo-Hood truss on girl 196
99. (Original photo.) De Garmo-Hood truss on boy 197
100. (Original photo.) German scrotal hernia truss on boy 198
lOi. (Seaver.) Gymnastic exercise no. i 205
102. (Seaver.) Gymnastic exercise no. 2 206
103. (Seaver.) Gymnastic exercise no. 3 206
104. (Seaver.) Gymnastic exercise no. 4 207
105. (Seaver.) Gymnastic exercise no. 5 208
106. (Seaver.) Gymnastic exercise no. 6 208
107. (Seaver.) Gymnastic exercise no. 7 209
108. (Seaver.) Gymnastic exercise no. 8 210
109. (Original drawing.) Sac separated from cord and anatomy of
inguinal region 221
no. (Original drawing.) Curved blunt needle 223
12
ILLUSTRATIONS.
FIGU
III.
112.
113-
114.
115-
116.
117.
118.
119.
120.
121.
122.
123.
124.
125-
126.
127.
128.
129.
130.
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132.
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138.
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140.
141.
142.
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144.
145-
146.
147-
148.
RE PAGE
(Original drawing.) Internal oblique stitched to Poupart's
ligament 224
Original drawing.) Aponeurosis closed by continuous suture. 225
Halsted.) Relative position of sac, cord and vas deferens... 229
Halsted.) Cremaster fastened under internal oblique 230
Halsted.) Internal oblique fastened to Poupart's ligament... 231
Halsted.) Overlapping of aponeurosis (first step) 232
Halsted.) Overlapping of aponeurosis (second step) 233
Halsted.) Sectional view of fascial layers 234
WullsteiNj redrawn.) Transplanting of cord (first step).... 235
Wullstein, redrawn.) Transplanting of cord (second step).. 236
Halsted.) Halsted's method of utilizing split sheath of
rectus 237
Origina
Origina
Origina
Origina
Origina
tion
Origina
Origina
Origina
Origina
Origina
Origina
Origina
them
Origina
Origina
tion
Origina
be a
Origina
Origina
Origina
sac .
Origina
sac .
Origina
Origina
Origina
Origina
Origina
Origina
Origina
Origina
drawing.) Right retained testicle in boy of 10 years. 240
photo.) Right retained testicle in boy of 9 years.... 241
photo.) Double retained testes in boy of 13 years. . 241
drawing.) Delayed testicle surrounded by sac 242
photo.) Double retained testes two years after opera-
243
photo.) Retained left testicle and interstitial hernia. 244
photo.) Sac of interstitial hernia before opening... 245
photo.) Sac with testicle inside 246
drawing.)
drawing.)
drawing.)
drawing.)
Retained testicle, sac opened 247
Purse-string suture in sac 247
Sac tied by purse-string suture 248
Lifting muscles to place testicle beneath
249
photo.) Interstitial hernia and retained testicle 250
photo.) Interstitial hernia three weeks after opera-
251
photo.) Double hernia in child of 7 years supposed to
jirl 252
photo.) Same as preceding, with hernia reduced.... 253
photo.) Same as preceding 255
drawing.) Appendix adherent to anterior wall of
257
drawing.) Appendix adherent to posterior wall of
259
drawing.) Appendix incarcerated in fibrous ring.... 260
photo,
photo,
photo,
photo,
photo,
photo,
photo.
Sac and omentum removed together 262
Omentum spread out for ligating 263
Omentum irreducible from shape 264
Omentum, hypertrophied 265
Omentum and sac 266
Scrotal hernia to within two inches of knee. . 268
Side view of preceding case 269
ILLUSTRATIONS. l.'J
FIGURE PAGE
149. (Original photo.) Preceding cape seven weeks after operation. 270
150. (Original photo. j Large scrotal hernia containing bladder.... 2~\
Original photo.) Preceding case six weeks after operation.. 272
Original photo.) Preceding case five years later with hernia
on opposite side 273
Original photo.) Enormous scrotal hernia in man of 70 years 274
Original photo.) Irreducible scrotal hernia, intestine only.... 275
Original drawing.) Peculiar mesentery found in preceding
case 276
Original drawing.) Hernial sac containing free caecum and
loops of intestine 278
Original drawing.) Hernial sac in front of cjecum 279
Original drawing.) Form of purse-string suture for sigmoid
sac 281
Original drawing.) Lifting internal oblique to bury stump of
sac 282
Original drawing.) Protrusion consisting of hernial sac and
bladder 287
Original drawing.) Hernial sac and bladder protruding sep-
arately 289
Original drawing.) Closure of canal in female by single suture 294
Original drawing.) Anatomy of femoral region 298
Original drawing.) Transverse section of femoral region.... 299
Redrawn from Gray.) Showing relative position of femoral
hernia and large vessels 301
Original photo.) Double femoral hernia in man of 50 years. . 302
Original photo.) Reducible femoral hernia of enormous size. 303
Original photo.) Irreducible femoral hernia 305
Original photo.) Double femoral hernia in woman 306
Original drawing.) Cystic femoral sac 307
Original photo.) Femoral hernia of peculiar shape, in woman. 308
EccLES.) Left varicose saphena vein 312
Original photo.) Femoral and labial varix in pregnant woman
of 35 years 313
Original photo.) Lipoma simulating femoral hernia 315
Original photo.) Femoral hernia in woman, cross-body truss
applied 2^2
Original drawing from photo.) Cross-body hard-rubber truss
for femoral hernia 323
Redrawn.) German femoral truss applied 325
Redrawn from M.a.cready.) English femoral truss applied... 326
Original drawing from photo.) Adjustable truss applied to
femoral hernia 327
180. (Original drawing from photo.) De Garmo femoral truss ap-
plied 328
U ILLUSTRATIONS.
FIGURE PAGE
i8i. (Original photo.) Inguinal and femoral hernia in woman., truss
applied 329
182.
183.
184.
185.
186.
187.
188.
189.
190.
191.
192.
193-
194.
195-
196.
197.
198.
199.
200.
201.
202.
203.
204.
205.
206.
207.
208.
209.
210.
211.
212.
213.
214.
215-
216.
217.
218.
219.
220.
Original drawing.) Location of incision for femoral hernia... 334
Original drawing.) Showing femoral protrusion under Pou-
part's ligament 335
Original drawing.) Femoral operation; sac drawn down.... 336
Original drawing.) Femoral hernia operation, sutures in place 337
Original drawing.) Femoral hernia operation sutures tied.. 338
Original drawing.) Femoral hernia operation; blunt needle.. 339
Original photo.) Double reducible femoral hernia, woman of
60 j-ears 339
Original photo.) Same case, side view 340
Original photo.) Same case six weeks after operation 341
Original photo.) Femoral hernia of unusual type 342
Original photo.) Umbilical hernia in child of 3 years 347
Original photo.) Enormous irreducible umbilical hernia 348
Original photo.) Same case, side view 349
Original photo.) Enormous umbilical hernia; man of 45 years 350
Original photo.) Reducible umbilical hernia in 200-pound
woman 350
Original photo.) Irreducible umbilical hernia in woman 351
Original photo.) Irreducible umbilical hernia in man 351
Bainbridge.) Multiple hernije 352
Bainbridge.) Same case showing 5 hernise in median line.... 353
Dr. S. W. Kelly.) Plate and plaster for umbilical hernia.... 356
Dr. S. W. Kelly.) Plate and plaster applied 357
Original photo.) Truss applied for umbilical hernia, child of
3 years 359
Horn.) Outlines of umbilical plates 366
Continued.), Size of umbilical plates 367
EccLES.) An English umbilical truss 368
Horn.) Diagram for abdominal belt measure 369
EccLES.) English rim-plate concave umbilical truss 370
Original drawing.) Vertical overlapping of abdominal wall. . 376
Mayo.) Transverse elliptical incision 37S
Mayo.) Transverse overlapping sutures in place 379
M.\YO.) Transverse overlapping, complete 380
Original photo.) Post-operative ventral hernia 387
Original photo.) Deposit of fat simulating ventral hernia.... 388
Original photo.) Ventral hernia following gun-shot wound. . 389
Original photo.) Same, front view 390
Original photo.) Bilateral post-operative ventral hernia 391
Original photo.) Ventral hernia after appendix operation.... 393
Macready.) Spontaneous double lumbar hernia 399
Macready.) Truss for right lumbar hernia 400
DowD. ) Congenital lumbar hernia 401
ILLUSTRATIONS. 1.5
FIGURE PAGE
221. (DovvD.) Anatomy of congenital lumbar hernia 402
222. (DovvD.) Operation for lumbar hernia sutures placed 40,3
223. (DowD. ) Operation for lumbar hernia sutures tied 404
224. (Original photo.) Exstrophy of bladder and vaginal hernia.. 406
225. (Original photo.) Same case with appliance 407
226. (Horn.) Appliance for perineal hernia 408
Classification of Trusses by Groups.
Group of:
Springless trusses (seven figures) 119-120
French, German and English trusses (eight figures) 125-126
Cross-body type of trusses (eight figures) 131-132
Chase type of trusses (eight figures) 133-134
Hood type of trusses (Twelve figures) ,. . . 137-13Q
Unclassified trusses (four figures) 143-144
Double trusses (ten figures) 145-146
Trusses for femoral hernia (sixteen figures) 318-321
Infant umbilical trusses (nine figures) 358
Adult umbilical trusses (eighteen figures) 361-365
Trusses for ventral hernia (six figures 394-395
Diagrams (original drawing) showing formation of femoral hernia,
extra-peritoneal fat and lipoma 300
ABDOMINAL HERNIA
ITS
DIAGNOSIS AND TREATMENT.
CHAPTER I.
INTRODUCTION.
Definition. — Hernia is the protrusion from a cavity, of
any of its natural contents ; as hernia of the brain from the
cranial cavity, or hernia of the lung from the cavity of the
chest. Abdominal hernia is, therefore, the protrusion through
the retaining wall of any of the enclosed viscera. This gen-
erally occurs at some point in the muscular wall that is weak-
ened by the transmission of nerves and blood vessels, at points
congenitally defective, or through muscular parts that have
been previously lacerated or incised.
The word " Rupture^' so commonly used to denote a con-
dition of hernia, will be, as far as possible, avoided in this
work, as it leads to an erroneous impression of what actually
occurs. In the early ages this term was applied under
the supposition that there was actual rupture of the peri-
toneum. It is now well known that there is rarely laceration
of tissue. Hernia results, in almost every instance, from the
gradual stretching of tissue and escape of the abdominal con-
tents, either into a preformed (congenital) sac, or by the
formation of a sac (acquired) from the peritoneal lining of
the abdomen.
Abdominal herni?e derive their names from the part of
the abdominal wall through which they pass. The terms
mgumal, femoral, or umbilical, denote at once their place of
2 17
18 ABDOMINAL HERNIA.
escape, the exception to this being ventral hernia, which may-
occur at any point in the anterior abdominal wah other than in
the regions named. As ventral hernia occurs at points in the
muscular wall so strong as ordinarily to resist hernial protru-
sion, it follows that when it does occur, it is either due to some
congenital defect or is the result of some injury, such as a
stab wound or a cutting operation. Extreme distension of the
abdomen may also result in such separation of its aponeurotic
fibres as to allow of protrusion.
A little more than 73 per cent, of all hernias are of the
inguinal type. Next in frequency is femoral hernia, with 18
per cent., and third, umbilical hernia with about 8^ per cent.
This leaves. about i per cent, for all of the rarer forms.
The individual may have a single hernia or multiple
hernise. It is not uncommon to find inguinal and umbilical, or
inguinal and femoral hernise in the same subject.
The type, or form, of hernia is notably influenced by sex,
as shown by the following comparison :
Male: Inguinal, 96.33 per cent.; femoral, 2.53 per cent.;
umbilical, 1,14 per cent.
Female: Inguinal, 50 per cent.; femoral, 33.15 per cent.;
umbilical, 15.9 per cent.
That age has a decided influence on the occurrence of
hernia is shown by the exhaustive studies of Paul Berger. His
tables show 19.6 cases to 1,000 individuals in the first year of
life, and drops to 4.2 per 1,000 in the second year; then there
is a gradual decline up to the twentieth year when only 0.88 is
found. From this time on to the seventy-fifth year the in-
crease of proportion is constant, reaching at this age its highest
point, 24.20 per 1,000 individuals.
Hernia consists of the sac and its contents; the sac being
formed from peritoneum, the lining membrane of the ab-
dominal cavity. It may be formed at the time of the first pro-
trusion and is then termed an acquired sac. As will be demon-
strated later, a congenital sac may have existed long before the
protrusion of the hernia, by the persistence of a pouch of
INTRODUCTION. 19
peritoneum {Tunica Vaginalis) which normally should have
been obliterated at, or shortly after, birth.
The sac consists of its body, or the expanded portion,
which contains the bulk of the protrusion ; the neck, which is
the constricted part running through the muscular wall ; and its
mouth, the aperture of communication with the peritpneal
cavity.
The acquired sac on first protruding, may be free from
adhesions, and reducible, but readily becomes attached to sur-
rounding tissues and from that time is irreducible. It then fur-
nishes a permanent, moist, serous lining to the canal through
which it protrudes.
Hernia of the bladder, of the caecum and sigmoid flexure,