One hundred and sixty-eight cases of gangrenous intestine in strangulated her nia collected either resection of the gut or 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.). Mikuliez (Schmidt's .Ta brldicher. May. '92).
The result of operation in strangulated hernia depends on the general condition. If a healthy appendix is found in the sac of a strangulated hernia, it should, in the author's opinion, be removed if the general condition is sufficiently good. Plstor (Revue de Chin, June, 1002).
-1. In a general way, the younger the patient the better the chances of radical cure.
2. Operation is indicated in all young adults, inasmuch as there is little pros pect of cure by a truss after the age of maturity. The operation in skilled hands is attended with almost no risk and the chances of a cure without the further need of a truss are excellent.
3. All cases of irreducible omentum in patients that are fit subjects for an ab domical operation.
4. All eases of femoral hernia if no contra-indication is present.
In the treatment of inguinal hernia in children the following are the cases in which an operation may be advised: 1. Where a child is being properly fed, but in whom a hernia after a fair trial is not retained by a suitable truss, so that there is little or no chance of a spontaneous cure. 2. Where part of the contents of the sac are irreducible. 3. Where a truss has been worn for at least three years, but with no apparent cure of the protrusion. 4. Where a child has reached the age of at least three years, but has never worn a truss. 5, Where a herniotomy has to be performed for strangulation. Eccles (Brit. Med. Jour., May 13, '00).
Very large irreducible hernia in stout persons should not, as a rule, be operated upon. The risks are large and there is little prospect of permanent cure.
Radical Operation for Inguinal Her nia.
At present the weight of evidence is strongly in favor of the superiority of Bassini's method in operations for in guinal hernia. This method, first per formed by its author in 1884, was intro duced to the profession in 1890. Bas sini published 251 cases with but 1 death and 7 relapses. It is performed in the following manner: The canal being laid open to the internal ring, the sac is sepa rated, drawn down, ligated, and resected. The closed peritoneum is then returned, the spermatic cord is pushed aside, and the posterior margin of Poupart's liga ment is exposed. The border of the rectos and the edges of the internal oblique, the transversalis, and the trans versalis fascia are then sutured to Pou part's ligament under the cord. The latter is then placed upon the layer of the abdominal wall thus formed, and the border of the external is sutured to Pou part's ligament over the cord, avoiding compression of the latter. A new canal is then formed for the cord. The wound is then closed.
Halsted's method, while it closely re sembles that of Bassini, differs in the direction of more complicated technique. The published results, though excellent, are inferior to those of Bassini.
[Halsted, instead of trying to repair the old canal and the internal abdominal ring, makes a new canal and a new ring. The latter should fit the cord as snugly as possible, and the cord should be as small as possible. The skin incision ex tends from a point about five centi metres above and external to the inter nal abdominal ring to the spine of the pubes. The subcutaneous tissues are divided so as to expose clearly the apo neurosis of the external oblique muscle and the external abdominal ring. The aponeurosis of the external oblique mus cle, the internal oblique and transversa lis muscles, and the transversalis fascia, are cut through from the external ab dominal ring to a point about two centi metres above and external to the inter nal abdominal ring. The vas deferens and the blood-vessels of the cord are isolated. All but one or two of the veins of the cord are excised. The sac is carefully isolated and opened and its contents replaced. A piece of gauze is usually employed to replace and retain the intestines. With the division of the abdominal muscles and the transversalis fascia the so-called neck of the sae van ishes. There is no longer a constriction of the sae. The sae having been com pletely isolated and its contents re placed, the peritoneal cavity is closed by a few fine silk mattress-sutures, some times by a. continuous suture. The sac is cut away close to the sutures. The cord in its reduced form is raised on a hook out of the wound to facilitate the introduction of the six or eight deep mattress-sutures which pass through the aponeurosis of the external oblique, and through the internal oblique and trans versalis muscles and transversalis fascia on the one side, and through the trans versalis fascia and Poupart's ligament and fibres of the aponeurosis of the ex ternal oblique muscle on the other. The two outermost of these deep mattress sutures pass through muscular tissues and the same tissues on both sides of the wound. They are the most impor tant stitches, for the transplanted cord passes out between them. If placed too close together the circulation of the cord might be imperiled, and if too far apart the hernia might recur. The precise point out to which the cord i; trans planted depends upon the condition of the muscles at the internal abdominal ring. If in this situation they are thick and firm, and present broad, raw sur faces, the cord may be brought out here. Put if the muscles are attenuated at this point, and present thin. cut edges, the cord is transplanted farther out. The skin-wound is brought together by buried skin-sutures of very fine silk. He uses an uninterrupted buried skin-suture without knots, which is withdrawn after two or three weeks. The transplanted cord lies on the aponeurosis of the ex ternal oblique muscle and is covered by skin only.] The Bassini and Halsted methods have given such satisfactory results, with so :small a mortality, that the writer be lieves that simple reducible hernia should be included among the indi cations for operation. J. B. Deaver (Amer. Jour. of the Med. Sciences, June, '95).