ABDOMEN GANGRENOUS HERNIAE.
Primary Resection of Gangrenous Herniae. Primary resection as opposed to artificial anus in gangrenous hernia is the plea of the author, sup ported by the utterances of Kocher twenty years ago, and again affirmed by experiences of Mikulicz ten years later. Statistics of v. Bramman show that artificial anus performed in sixty-eight gangrenous hernia gave a mortality of 45.6 per cent ; author's twenty-five gangrenous hernia with resection method showed but 4o per cent. mortality. All the operations were performed under Schleich's infiltration anaesthesia, and only division of constrict ing ring and dissection of the sac were painful at times because of the inaccessibility of these parts to proper infiltration. Excep tional ether was employed. The fate of the operation centres about the anatomical find of the proximal loop, as more marked changes are found in it than in the distal loop, as it is more affected by faulty taxis, and also the seat of postoperative lesions. For all of these reasons extensive resection of it is indicated up to that level where the mesenteric vessels vascularizing it are intact and the bowel therefore healthy. To gain the requisite oversight of the area of disease, and to insure a proper technique, extensive incision is to be practised (herniolaparotomy). All this is feasible under infiltration anaesthesia. At this stage the septic contents are allowed to flow from the proximal loop and lateral anastomosis practised. Indications for this operation hold good even in the presence of advanced age if the general condi tion be good. A beginning peritonitis with serosanguinolent or cloudy exudation is no contraindication. If the proximal loop is extensively involved, the extent of resection is only enlarged. The magnitude of the resection and the time necessitated for its performance are materially offset by the great gain accruing from the infiltration anaesthesia. This is evidenced in the con dition of the patient at the end of the operation (one and one-half hours), as opposed to the collapsed state after general anaesthe sia. If any doubt exists concerning the replaced bowel or peri toneum, the wound is filled with a Mikulicz tampon, and the radi cal operation abandoned.
After-Treatment. Resort is had to enema until the bowel, by escape of flatus, proves its patency. Within the first days milk and fluids in small quantities were administered.
Complications.—Bronchopneumonia and pneumonia as causes of death are conspicuously absent. Deaths were principally traceable to faulty technique or conservatism in the extent of resection.—Beitriige zur klinischen Chirurgie, Band xxviii, Heft 3.