Douglas Bryan, Haydn Brown
1909 The Lancet  
of course be restored by sutures which, far from improving C the result, are merely a source of weakness and trouble. As the sac can be completely removed without laying open the canal at all in all but a few complicated cases such as some irreducible hernias and cases of retained testes it is far better to avoid this procedure. By Kocher's method, which I invariably practise, it is perfectly easy first to free the whole sac and afterwards to drag it upwards and outwards until the whole of the
more » ... ax peritoneum naturally present in the neighbourhood of the internal ring is rendered taut and smooth on its abdominal surface. In this position it is maintained when the sac is invaginated and pushed through the abdominal wall close to the anterior iliac spine in the manner familiar to all who have t looked at the excellent figures in Kocher's °° Operative Surgery." Anyone who has once seen the ease and quickt ness with which this manoeuvre can be accomplished and the perfect removal of the sac which it achieves I cannot t imagine returning to the tedious and misdirected operations which depend for their result on suturing the inguinal canal. In speaking of perfect removal of the sac, I refer, of course, to the neck or upper portion and not the fundus. The neck of the sac is much longer than inexperienced operators suppose. If it is separated from the cord (not merely the vas but all the constituents) upwards to the full extent the actual junction of the neck with the general peritoneum is marked, as Kocher has pointed out, by a thick pad of sub-peritoneal fat which forms an outlying spur of the prevesical fat. Indeed, to obtain full isolation of the sac it is often necessary to expose and detach the bladder both in inguinal and femoral hernias. Unless this fatty pad is reached and identified a pouch of peritoneum, or at least a pit will probably be left and recurrence is certain. This I believe to be the only cause of failure-viz., imperfect dealing with the sac, and for the benefit of house surgeons and many others to whom I have demonstrated the source of fallacy I have summed up the whole duty of the herniotomist in a few words : the sac, the whole sac, and nothing but the sac. I venture to commend this little aphorism and the facts which it embodies to surgeons generally. The operation for radical cure of hernia has become, next perhaps to the operation for adenoids, the commonest operation in surgery. It is performed in every hospital, large and small, in the kingdom, and the numbers run into prodigious totals. If there were less confusion of thought and more simplicity of practice among those who instruct the rising generation of students and practitioners we should hear less of operations which require four to six weeks in bed afterwards, or the "precautionary " use of a truss, or of refusing to operate on people over 40 because of the danger and uncertainty of radical operation. We should be able to agree that the operation is one of the simplest and safest in surgery, that it can be performed at any age, and that the expectation of permanent cure and relief from the nuisance of a truss can be reasonably and confidently put at 95 per cent. if no higher. I believe that the congenital theory of hernia explains and harmonises the anatomical and clinical facts which without it are full of confusion. Its general adoption will necessarily involve greater simplicity and uniformity in the operation of radical cure and will finally banish many of the complicated, misdirected, and imperfect operations which still cumber surgical text-books. are in receipt of your letter of the 19th instant with regard to the photos of the Lister Institute. We are very sorry if we have indirectly caused annoyance to your client who kindly gave us the opportunity of taking the photos of the Institute. We have not seen the pamphlet to which you refer for it was not published by us, but we understand that the photos used therein are photos which we supplied to a firm who asked for them. We stated at the time the permission was granted to us that we required the photos for publication in the Scientific American. Please accept our sincere apology for the annoyance we have caused your client by supplying the photos to the firm in question. We undertake not to use or supply the said photographs to any journal or person without, ii3 every case, previously obtaining the consent of the Lister Institute. Yours faithfully, WORLD'S GRAPHIC PRESS, LIMITED, Sgn.
doi:10.1016/s0140-6736(01)25821-8 fatcat:slklfinuu5hkldh4vxf3y32sam