By performing the operation as indi cated, the constriction caused by the ex ternal ring disappears with the slitting up of the aponeurosis of the external oblique.
[If the teal cause of the constriction were due to the neck of the sac, it would still be impossible to reduce the hernia. In every one of my seven cases (in children) the aponeurosis was widely opened, and this alone was sufficient to render reduction of the hernia easy, which would have been impossible had the constriction been due to the neck of the sac. This view, as I have stated, is directly contrary to the teachings of most writers. Tariel states that, out of 81 cases of strangulated hernia in children which he collected, the neck of the sac was regarded as the cause of the constriction in 58 cases. WILLIAlt B. COLEY.] The bowel should be treated with the utmost gentleness, and a warm towel should be frequently applied until it is reduced. If the serous coat is still smooth and glistening, it may be safely reduced; purple or mahogany color—provided it has not lost its elasticity—is not a con tra-indication for replacing it in the abdominal cavity. In cases of doubt as to the propriety of returning the bowel, it is well to apply a hot towel for a few minutes, the constriction having been re lieved. If the circulation materially im proves, it can be returned with safety.
If the peritoneal coat is granular and devoid of lustre and remains cold after the division of the constriction, it would be the better plan not to return the intes tine, but to allow it to remain in place, protecting it by a sterile dressing. Exam ination a few hours later will determine whether it has sufficient vitality to per mit of its being, returned with safety into the abdominal cavity.
If the bowel is gangrenous, and there is no doubt that it is unsafe to return it, two methods of procedure may be adopted: Primary resection may be per formed, or the gangrenous knuckle may be left in place. If left in place, there is no need of sutures, as the adhesions will be sufficient to prevent it from slipping hack into the abdomen. The gut may be simply opened and the wound fully protected with antiseptic dressing, the gangrenous knuckle may be removed, and the cut ends of the gut fastened to the skin by means of sutures.
[It is very difficult to lay down any absolute rule as to which mode of pro cedure should be adopted. While col lected statistics somewhat favor the operation of primary resection, it is prob able that the cases treated by artificial anus were the more desperate. WILLIAM B. COLEY.] In the choice of procedures much must be left to the judgment of the operator himself. If he is a surgeon possessing the requisite technical skill, and the pa tient's condition does not contra-indicate a prolonged operation, it is probable that primary resection will give the better result. This is especially true if the amount of intestine is small.
One hundred and sixty-eight cases of gangrenous intestine in strangulated her nia collected in whicheither resection of or the gut the ablishment of an arti ficial anus was adopted. From these it would appear that the results of the former course (a mortality of 47.1 per cent.) are far more favorable than those of the latter (76.6 per cent.). Mikulicz (Schmidt's .Tahrbficher, May, '92).
Two hundred and eighty-nine resec tions for gangrenous hernia: compared with two hundred and eighty-seven cases in which an artificial anus was estab lished. The mortality in the former group is per cent.; in the latter, 74 per cent., or 25 per cent. greater. In analyzing the causes of death, the advantage is, in each instance, in favor of primary resection. Diffuse peritonitis and profound collapse regarded as almost the only contra-indications to resection. Zeidler (Centralb. f. Chin, Jan. 21, '93).
Case of rapid gangrene of a hernial sac. The patient, aged 48, had a re ducible hernia for nine months, and had worn a truss. After a full meal he sneezed and suffered agony, having rupt ured the bowel into the sac. An oper ation performed four hours later showed the sac to be perfectly black. The bowel was simply congested, and a tear inch long was found in it. The gangrene was strictly limited to the sac. There was no strangulation of the sac or contents. Robert Jones (limit. Med. Jour., Feb. 1, '90).