THE BaRITSH ] T CURE OF HRI[JL9,10 58MDCLJOURNAL] THE R~AD~ICALTUEO ENA [JULY 9, 1904. but in cases where this layer is thin I have found the modi- In other cases it is quite certain that hundreds of thousands fication easy of performance, and giving a perfect result. of persons pass through their lives with comfort and safety The loops should be applied at distances of one-ttlird of an inch with the assistance of a well-fitting truss, but I most certainly from each other, and should so pierce the fascia as to bring would not refuse to perform the radical cure for a person who together a corresponding width of fascia on both sides. was anxious to be relieved of his truss, and who, from a senti- Removal is easy; one thread of each loop is divided close to mental point of view, objected to the mechanical support. the skin beside the gauze pad; pulling on the other end Now before you could honestly take upon yourself the re- quickly releases it, and it is drawn out. When once all the sponsibility of advising and operating on a patient for the loops are free, the secondary thread is easily withdrawn, cure of hernia, you must satisfy yourself and your patient in whether slightly kinked or not. Care must be taken in all some cases as to the following facts, and you must be pre- eases to carry the suturing for at least half an inch at each pared with more or less exact knowledge on the subject. extremitybeyond the line of fascial division, so as to produce i. And first of all. Can you assure him that the operation a fold in the yet undivided tissue. is a safe operation so far as his life is concerned, as well as By the use of one or other of these plans it will be evident his testicle. that we possess means by which the all-important tendinous 2. Secondly, does the term "radical cure" mean radical cure expansion known as the deep fascia may be reunited safely in the sense of permanency of cure ? Is the operation a real and permanently, and that the latter methods also enable us cure or only a temporary palliative ? when organic union is firm to remove all foreign material 3. Should very young people be operated upon, and if not, from the interior of the wound. at what age should the operation be performed? Something more might be said as to the different behaviour 4. Should a truss be worn after the operation, and if so, for of the tissues in different parts of the abdominal wall; espe- how long, and if not, should any support or precaution be cially as to the difficulty experienced in the reunion of peri- taken to prevent return ? toneum near the epigastrium as compared with the ease of 5. You must satisfy yourself as to the best material for this manoeuvre below the umbilicus, and certain modifications suture, and lastly, but assuredly not least, the best form of which thereby become necessary, but this paper is already too oppration to perform. long, and they must be left for future statement. You see from the list of questions that you must either When a large hernia has to be closed, and the fascial edges answer to the patient or yourself that the proeedure is not are widely separated, the method adopted by both Dr. quite so simple as the public believe, and Inot quite so lightly Macnaughton-Jones and Mr. Rutherford Morison of placing to be undertaken as some would teach. stay sutures so as to embrace the whole rectus muscle, and so obtain a firmer and more comprehensive grip of the tendon Safety of the Operation. on either side, is an admirable one, but does not, in my I think we may most certainly answer this question in the opinion, dispense with the necessity for obtaining a broad affirmative and say " the operation is perfectly safe, provided union of the actual opposing portions of this tendon such as it is done by a skilled, competent operator with experience." is produced by the Noble method. It is an accessory of very Out of 104 cases in one practice there were only 2 deaths, great use, but not the primary requisite. Dr. Macnaughton- both from zymotic diseases, and in America Dr. Coley lost I Jones uses strong silver wire; Mr. Rutherford Morison strong case out of i6o operations from pneumonia. These are just a chromicized gut. After all, these are measures for the cure, few examples illustrating the freedom from trouble after this not for the prevention of post-operative hernia. operation. Is the Testis in any Danqer from the Operation 2 It most certainly is in the hands of the unskilled surgeon who endeavours to pull and drag and rend the layers of bllintralT XDrma"ttzratia fascia covering the hernial sac, instead of cutting straight ON down to the sac and gently peeling it from its nearest CURE covering. THE RADICAL OF HERNIA. Atrophy of the testis and inflammation with abscess and Given at the Post graduate College and Polyclinic, London. sloughing have followed this operation in careless hands. By MAYO COLLIER, M.S.Lond., F.R.C.S.ENG., Senior Surgeon, North-West London Hospital. Blow Far does the Operation bring about a Complete or Radica and Permanent Cure ? V4ENTLEMEN,-I have brought for inspection to-day two cases Please always safeguard your own reputation and that of sur- both quite simple of diagnosis, but about which there are gery in general by telling your patients that many of the best many points to discuss and much to say. and most promising cases lapse, that the hernia returns and requires a second operation or a truss. Tell your patient that RADICAL CURE OF HERNIA. only in some cases does the patient never require further The patient, as you see, is apparently a strong, healthy assistance or treatment, but also tell your patient that " an fellow, who comes to the hospital with the most absolute operation will most certainly improve matters, and that after belief and faith that I can perform some simple operation on an operation a patient is better off than he was before, and what he says is a rupture in the left groin, so that he will that most certainly it gives immunity to a certain number for never have to wear a truss again, and never be troubled with a certain time." a return of his complaint. In short, he wants me to perform As a matter of fact, it is fair to say that in 25 per cent. of the radical cure in the belief that the radical cure will do all the cases operated on the hernia returns and requires a for him that he thinks. second operation or the assistance of a truss before eight This is the general belief among the lay public on the sub- years. ject of the operations for the relief of rupture. I need hardly tell you that this view is incorrect; and the approximate What is the Earliest Age at wvhich an Operation should be truth on th" subject of the radical cure for hernia I shall Undertaken ? endeavour to put before you to-day. It is a matter of common knowledge that quite a number of Now, the first question you must be prepared to answer is male children below I year have inguinal hernia, and that this, Why an operation at all? Why not a comfortable and quite a large percentage of these get well with the use of well-fitting truss? This question must be answered from properly-fitting trusses. On these grounds a truss should several points of view, and first, there are seven classes of in most cases be recommended in preference to an operation cass where a truss cannot be relied upon and an operation is up to, we will say, the 4th year, and in some cases longer. Of most certainly indicated, namely: course, complicated cases where there are no contraindica- I. Cases of irreducible hernia. tions should be submitted to operation as early as 2 years. 2. Cases of strangulated hernia. 3. Cases where the hernia is not controlled by a truss. The Use of a Truss After Operation. 4. Cases of hernia with ectopia testis. This recommendation will depend not only on the state of 5. Cases where rupture unfits for the public service. the patient before operation, but on his condition and duties 6. Hernias in incompetent and ignorant people. after the operation. Speaking generally, favourable cases 7. Very large hernias hampering the movements of the with small sacs, sound tissues, and well-formed abdominal patients, and threatening personal comfort seriously. walls, if allowed to rest for at least two or three months after In all these cases it would be your duty to prefer and ad- operation, will not require a truss. Per contra, large sacs, vise an operation rather than outside mechanical supports. weak ab(dominal walls, pendulous abdomens with much fat THE BRITISH JULY 9, I1904.] THE RADICAL CURE OF HERNIA. IMEDIICAL JOURNAL 59 =T are better supported with a broad, flat truss. The same With your permission, I will just remind you of a few applies to all patients who after operation will have to per. salient points in the anatomy of this region. And first of all form heavy and arduous work, or who suffer from chronic this rupture is situated in the inguinal canal. Now what is bronchitis, asthma, or chronic engorgement of the portal the inguinal canal? It is an oblique passage in the layers of system.