The treatment of a doubtful or gan grenous loop of bowel in a hernial sac can hardly be considered as ordained by universal custom. Resection of the loop and suture of the ends is, from all points of the most satisfactory in those cases where it can he legitimately clone; but there are not a few patients in whom such a course would be wholly unjusti fiable. In these the alternative courses are: 1. Opening of the bowel (a) with, (b) without, the division of the constric tion at or near the neck. There are several recorded examples of persisting obstruction when the bowel has been merely opened. The division of the con striction adds no risk worth considering, and should be adopted. 2. The removal of the gangrenous loop and the stitching it of the open ends to the skin, or the in troduction into the distended end of a Paul tube. 3. Helferich's operation. The raffling down of healthy bowel be yond the loop (above and below it), and the union of these by a Murphy button. The gangrenous or doubtful loop is cov ered with an antiseptic dressing, and re section performed when the patient has rallied. But in all eases the surgeon must recognize that, if possible, with reasonable prospects, resection and su ture should be performed. B. G. A. Moy nihan (Practitioner, Nov., 1900).
Resection of the diseased portion of the bowel recommended vith Schleich's infiltration method of anaesthesia. The dangers of shock and collapse after the operation are thus obviated besides that of inhalation pneumonia. The Murphy button is used after carefully emptying the intestines. W. Petersen (Deutsche med. Woch., Mar. 7, 1901).
In patients suffering from prolonged strangulation and who are much pros trated, or when the amount of intestine is very large, it is much safer to leave the gut in place to be dealt with at a subse quent operation. If the operator has had little experience in intestinal sur gery, there is no room for debate as to which is the safer procedure. In many cases of femoral hernia the artificial anus has been known to close spontaneously.
[In 382 cases treated from 1822-1858, FrikholTer found the mortality to be 19.4 per cent. in cases strangulated 1 day or less; 49 per cent. in cases strangu lated 2 days. Habs Iieichel, in 129 cases operated upon under aseptic conditions, found a mortality of 12.5 per cent. in cases that had been strangulated 1 day; 26.1 per cent. in those that had been strangulated for 2 days. B. COLEY.] The mortality following operation in strangulated hernia in the leading Eng lish hospitals is given as upward of 40 per cent. In 940 cases treated at St. Thomas's, Guy's, and St. Bartholomew's it was 43 per cent. At the London Hos pital it was nearly 50 per cent. Even in recent years the mortality in the four largest hospitals in London is not less than 40 per cent. This high mortality
is not ascribed to the operation, but to the time allowed to elapse between strangulation and operation. In cases operated upon during the first twelve ( hours the mortality is trifling. Bowlby (Lancet, May 20, '93).
Accounts of one hundred cases of strangulated hernia in infants under 1 year, all of which were subjected to operation. I here were twenty deaths. Death after operation in these cases is almost invariably due to delay. Charles N. Dowd (Archives of Pediatrics, Apr., '98).
In May, 1899, during an operation for the radical cure of a large inguinal hernia in a young man, the vas deferens was accidentally cut completely across. After sewing up the hernial ring and before closing the wound, the cut ends of the vas deferens were united in the same manner as a ureter is at times repaired after similar injury. This was clone by making a split in the lower portion of the tube for a short distance and draw ing the upper portion into the lower split end by means of two sutures and needles attached to the upper end. After the upper portion was drawn into the lower a few sutures were used to close the split and hold the parts together. Within a few weeks the patient has been seen, and it was found that there has been no special change in the testicle of that side; it certainly had not undergone though rare, cannot be cured by trusses.
I believe it is seldom necessary to op erate upon children under 4 years of age, and the practice of some surgeons of operating upon infants ender 1 year is open to serious question.
hernia in children should, with very rare exception, never be oper ated upon, for the reason that they are almost invariably cured either sponta neously or by means of mechanical sup port.
Study of 232 published cases of strangulated hernia in infants. The rel ative rarity of this condition in infants is attributed to the feeble resistance of the tissue forming the canal. Appendicu Lir forms of hernia are common in in fants. The symptoms of strangulated enterocele differ slightly from those of hernial appendicitis. In the latter the arrest of fa.cal matter and gas is not absolute. and the ease may result in scrotal suppuration. The prognosis of hernial appendicitis is less favorable than that of strangulated enterocele.
able that the cases treated by artificial anus were the more desperate. WrwAlf Ti. COLEY.} In the choice of procedures much must be left to the judgment of the operator himself. If lie 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.