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THE UNIVERSITY OF PENNSYLVANIA PRESS, 
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London Balliere. Tindall A Co». to King William Street. Strand. 
OCTOBER, 1892. 
The Treatment of Gangrenous Hernia. 
By J. Ransohoff, M. D., F. R. C.S., 
Cincinnati. THE TREATMENT OF GANGRENOUS HERNIA. 
By J. RANSOHOFF, M. D., F. R. C. S., 
OF CINCINNATI. 
PROFESSOR OF ANATOMY AND CLINICAL SURGERY IN THE MEDICAL COLLEGE 
OF OHIO; SURGEON TO THE CINCINNATI, AND GOOD SAMARITAN HOSPITALS. 
NOTHING more clearly demonstrates the evolution of 
surgical thought and practice than a comparison of the 
questions deemed of prime importance in relation to strangu- 
lated hernia at the extremes of two decades. 
Prior to 1870, the question to be answered in every case was, 
“ Is the sac to be opened, or not.” At present, a condition 
is hardly to be conceived in which the operator would refrain 
from opening the peritoneal tunic, thoroughly inspecting the 
hernial contents and wherever feasible supplementing the relief 
with the radical operation. 
Taxis which then played so prominent a role in all cases 
has been accorded a more and more subordinate position as its 
dangers, ever increasing with the age of the strangulation, were 
more fully appreciated, and in proportion as surgery sought the 
light for its manipulations in large and open wounds. Then, the 
teaching of the German and English schools regarding gangre- 
nous hernia prevailed. The oft-encountered sloughing gut was 
incised and permitted to drain as an abscess. Now the really 
vital lesson of kelotomy, that in its early performance lies its 
safety, has been widely learned. Therefore gangrenous hernias 
are becoming relatively less frequent. Of 27 cases which have 
come under my observation, only 4 were gangrenous. Three 
times have I seen gangrene of the intestines; once of the 
mesentery alone. In one of the former, the strangulation had 
existed less than 24 hours. Of 170 kelotomies for strangulation 
in Hagedorn’s clinic (1) gangrene, real or suspected, was 
encountered but 25 times. In Gottingen Konig (2) had 49 2 
J. RANSOHOFF. 
strangulations in 5 years, gangrene being present in 8. Of 61 
cases occurring over a period of 12 years in Czerny’s clinic (3) 
15 were gangrenous. Of 94 cases operated on in the Mass. 
General Hospital (4) 7 were gangrenous and 2 doubtful. 
F. A. Southern (5), of the Manchester Royal Infirmary, 
reports 85 cases of hernia and among them 9 of gangrene. 
Thus of 486 cases occurring within about twenty years only 68 
or about 14 per cent, were gangrenous or doubtful cases. 
Clearly, therefore, the experience with this condition of any one 
man, unless possessed of an unusual clinical material, must 
be limited. It is therefore by cumulative evidence that the proper 
management of this most fatal complication of hernia must be 
evolved. In this belief I venture on the report of the following 
cases: 
Case 1. Walter P., set. 29, farmer, Carlisle, Ky. Rupture of 
several years’ standing. Truss worn, but irregularly. While at work 
strangulation appeared on the 1st of August, 1889. Continued work 
for some time and attempted reduction. After 48 hours Dr. Tilton 
was summoned but taxis failed. The necessity for an immediate 
operation was urged but it was declined. I saw the patient on the 
night of the fifth day. Abdominal distension marked. Obstipation; 
vomiting frequent but not feculent. Pain severe about umbilicus. Great 
restlessness. Temp. 102°; pulse 100, and full. Scrotal hernia size of 
foetal head; hard and without impulse on coughing. Skin red and 
cedematous. Operation by lamp-light. In the hernial sac was fully a half 
pint of foul-smelling bloody serum. Omental mass as large as a fist; 
of dark-brown color, putrid and friable; no adhesions to sac. (The 
latter was a dusky blue in color). There was no intestine in the hernia. 
After carefully cleansing the sac and its contents and covering the 
protruded omentum in gauze, the constriction at the internal ring was 
divided. The omentum was easily drawn into the wound, after 
severing some slight adhesions. It was ligated and returned to the 
abdominal cavity. Thorough intra-abdominal drainage through the 
wound was provided for. Death 24 hours post-operationem from 
peritonitis. An autopsy was not made. 
Case 2. Mrs. M. set. 69. Hernia of 15 (?) years’standing. Has 
frequently had symptoms of fecal impaction. After a supposed attack 
of this kind had lasted three days, Dr. J. Marcus was summoned. I 
saw the patient in the evening of the fourth. There had been fecal 
vomiting for two days. Aside from a decided dyspnoea from which Figure i. 
Dr. Ransohoff’s Case of Strangulated Femoral Hernia TREATMENT OF GANGRENOUS HERNIA. 
3 
the patient suffered at all times, the general condition was not good. 
There was no elevation of temperature. Pulse irregular. 
The appended illustration displays the woman’s femoral hernia. 
Large and lobulated it covered the entire upper and lower part of the 
thigh. Transverse measurement 11 inches ; longitudinal 7 inches. 
The greater portion of the hernia was soft. In its depths there was an 
indefinitely outlined mass which was painful on pressure. Believing 
the case to be one of impaction within the sac and recognizing the 
gravity of an operation under the conditions present, the patient was 
anaesthetized with a view to operation if taxis moderately used did 
not overcome the difficulty. That I did not operate at once was a 
fatal error. With very little force gurgling was elicited and the mass 
before mentioned seemed to have subsided. After coming out from 
the narcosis, the patient’s condition was found to be unrelieved. 
When I saw her next day, she was moribund. Exit lethal sixteen 
hours post operationem. 
Autopsy.—On opening the sac it was found to be multilocular; 
the many diverticula evidently resulting from the lesser resistance of 
the meshes between the denser fibres of the cribriform fascia. The 
coils of intestine were for the most part as freely movable as in the 
abdomen. In one of the saccules an obstruction was found. It was 
produced by a band as large as a quill. It sprang by a broad base from 
the free border of a coil of intestine and was attached to the under 
surface of the mesentery of the same coil. In the loop thus formed a 
second coil had become entangled. 
Above and below the constriction-furrow the bowel was normal. 
In the constriction groove itself a localized gangrene or rather pres- 
sure necrosis had led to a perforation. The aperture is about one- 
sixth of an inch in diameter; and on the free border of the intestine. 
There is no fecal extravasation. 
The band springs from the ileum about 14 inches from the ileo- 
ccecal valve. It presents a central cavity which tapers off towards its 
mesenteric attachment. The character and position of the band make 
it certain that it is a Meckel’s diverticulum. Though often producing 
acute intestinal obstruction in the belly cavity, I have not been able 
to find the record of a case where it had given rise to obstruction in a 
hernia. In this regard the case presented is unique. 
Case 3. Miss D. set. 30. Seen with Dr. Jenkins, Newport. 
No previous history of rupture. While lifting a mattress felt some- 
thing give way in the groin, four days before operation. Was seen 4 
J. RANSOHOFF. 
by Dr. Jenkins on third day, when taxis was attempted. Then vomit- 
ing became severe and abdominal pain intolerable. An operation was 
permitted, hernia large as a walnut. No impulse on coughing, not 
very tender. Absolute obstruction since inception. Abdomen not 
distended. General condition very good. On opening the sac several 
ounces of bloody serum escaped. There presented itself a knuckle of 
small intestine apparently of the ileum about four inches long of bluish 
color and moderate distension. The serous covering was glistening. 
In the centre of the coil opposite to its mesenteric attachment, there 
was a black gangrenous patch large as a silver quarter and circular in 
outline. 
After carefully cleansing the sac wall and intestine, the constric- 
tion at Gimbernat’s ligament was divided and then brought into the 
wound. Although the constriction-furrow was unusually deep there 
was no evidence of present or probable necrosis. The afferent bowel 
was considerably larger than the efferent coil, but presented a healthy 
appearance. Indeed, during the few moments that the hernial con- 
tents were being studied with a view to definite action the circulation 
returned to all of the gut save the gangrenous patch alluded to. It 
was finally determined to return the entire intestine to the abdominal 
cavity, retaining by two catgut sutures passed through mesentery and 
wound margins, the gangrenous surface in absolute relation to the 
floor of the wound. The latter was lightly packed with gauze, and a 
sterilized dressing applied over all. The vomiting continued for 
several hours. Ten hours after the operation the patient had several 
large and watery evacuations. On the fifth day perforation of the 
intestine ensued and during two weeks the large portion of the intes- 
tinal contents discharged through the fistula. Without other treat- 
ment than compression the aperture gradually contracted, and in a 
little over a month had entirely closed. The process of sloughing 
was unattended by either local or general reaction. The patient has 
since remained well. 
Case 4. Mrs. K. seen with Dr. Harfif. Patient, aet. fifty-six. 
was for many years the subject of an irreducible inguinal-labial hernia 
of the right side. Has repeatedly suffered from incarceration. Once 
reduction was accomplished under anaesthesia. While at work on 
Friday morning, she experienced a sudden and excruciating pain in 
the hernial protrusion and suffered immediately from nausea and 
vomiting. Saw the patient twelve hours after first symptoms 
supervened. The hernial protrusion, large as a cocoanut, was soft 
and resonant throughout. Impulse on coughing plainly perceptible TREATMENT OF GANGRENOUS HERNIA. 
5 
in many parts of the mass. From the base of the hernia projecting 
towards its surface a coil of intestine could easily be outlined and 
palpated. It was dense, hard and resisting; like a link of tightly- 
packed sausage in shape and to the touch. Diagnosis, strangulation 
by band; gangrene probable, notwithstanding the excellent general 
condition of the patient. It was nearly midnight when I first saw 
the patient, and necessary assistance was not at hand. The operation 
was therefore deferred until morning. During the intervening ten 
hours very extensive effusion into the sac had taken place. The con- 
stricted coil could no longer be clearly outlined. 
Incision ten inches long in axis of tumor. On opening the sac 
some half dozen pouches connecting with it were exposed and in 
them were coils of bowel and adherent omentum. The sac presented 
the usual appearance of an old reducible hernia. In one of the com- 
partments near the greatly enlarged ring a loop of the bowel had 
become fixed by a band. The sac, separated from the general cavity, 
when opened, discharged six or eight ounces of a foul, bloody serum. 
Within it was a coil of gangrenous bowel. Completely sequestering 
with gauze the infected area, the constricting band was divided and 
the sloughing gut brought into the wound for inspection. Along the 
line of constriction a deep groove had been formed but there was no 
necrosis. The coil itself was of a dark chocolate color and lusterless. 
Under its surface, which presented few abrasions, were many hemor- 
rhagic extravasations, chiefly near the free border. Perforation had 
not taken place. Above and below the constriction groove the intes- 
tine seemed normal. The patient’s general condition warranting the 
procedure, primary resection was determined on. Having thoroughly 
protected the wound, and brought the intestine well down, a gauze 
cravat was lightly drawn through the mesentery an inch above and 
below the constriction groove. Excision followed, the mesentery 
being divided a short distance from the gut and parallel to it. 
Hemorrhage from the mesentery was free, but no ligatures were 
required. As the mesenteric wound was brought together by a con- 
tinuous silk suture beginning at its centre and including its entire 
thickness, the bleeding points were included within it. When com- 
pleted the mesenteric suture line measured about four inches. As 
this suture progressed the intestinal ends naturally approached each 
other. No clamp was used ; the fingers of an assistant answered 
admirably. The ends were of uniform diameter. For suturing, fine 
silk and an ordinary cambric needle were used. The suture employed 
was the continuous Lembert. Particular care was taken at the mesen- 
teric attachment. When completed the suture appeared weak at two 6 
J. RANSOHOFF. 
points. These were fortified by additional sutures. The sutured 
bowel was returned to its sac, the wound thoroughly irrigated and 
closed except for gauze drainage at its most dependent portion. 
Time of operation, fifty minutes. Length of gut removed, fourteen 
inches. Union primary, and recovery uninterrupted. Nineteen 
months have passed since the operation ; the patient continues well. 
The first case presented is of interest in that the omentum 
is rarely involved in the sloughing process of a gangrenous 
hernia. B. Schmidt (6) questions altogether the existence of 
primary strangulation of the omentum. Of Hagedorn’s 170 
cases (7), gangrenous omentum was only once the sole occupant 
of the sac. 
I have found reports of two other cases—one from Heidel- 
berg (8) ; the other of W. H. Bennett (9) of St. George’s Hos- 
pital. The safety of the omentum from gangrene is readily 
found in the ease with which it forms adhesions to the sac wall 
through which it then receives its nutrition. The case first reported 
appears to me to put a quietus on the theory long advocated and 
recently again promoted by Banks, namely, that the constriction 
ring should not be divided in most cases of gangrenous hernia 
on the ground that it is a bar to the development of general 
peritonitis. By the constriction the septic products of the 
hernia may be isolated for a time. But peritonitis developes 
from within. In the case presented there was no communication 
between the sac and the general belly cavity, but just within 
the neck was the large gut fixed ,by the adherent omentum, and 
its wall rendered paretic through traction was unable to resist the 
passage through it of the organisms which fatally infected the 
peritoneum. Fortunately there can be but one opinion as to the 
management of gangrenous omentum. Excision after ligation 
in healthy tissue, and return to the peritoneal cavity will gener- 
ally end in recovery unless peritonitis already exists. The three 
cases quoted all recovered, although in each the radical opera- 
tion followed that for strangulation. The wisdom of this proce- 
dure in all cases might be seriously questioned. In severe cases 
where peritonitis already exists or is threatened, the last step 
might advisedly be refrained from and thorough drainage secured. 
At all events, capillary drainage through gauze can never be 
harmful. It may be relied upon to forestall the development of TREATMENT OF GANGRENOUS HERNIA. 
7 
a peritonitis, and where the process already established is yet 
local, avert a fatal issue. 
When gangrene involves the intestine, the solution of the 
problem is far less easy. Since Ramdohr first successfully re- 
sected the gut for hernia in 1727, the possible success of primary 
excision has been conceded. 
Of recoveries there have been many. But the measure, 
however ideal, has never gained firm footing among surgical 
procedures. This in face of the fact that the results from the 
alternative measure, that of the formation of an artificial anus, 
have been most deplorable. Recently Poulsen reports 29 cases, 
(10) with but 4 recoveries. Of 35 cases as treated at St. Bar- 
tholomew’s, 4 were saved (Brit. Med. J., June, ’91, i. p. 701). 
Certain it is that all cases should not be treated alike and that 
every case ought to be considered with reference, first to the con- 
dition of the intestine and its environments, and second the 
probable ability of the patient to bear the shock of a prolonged 
operation. 
In three of the cases presented many of the changes except 
those of the afferent portion of the bowel were found. For a 
strangulation affects the gut either along the line of constriction, 
at some or all points of the coil involved or in the course of the 
intestine for a varying distance above the point of constriction. 
Where the constricting band binds the gut, a well marked groove 
is made by direct pressure. The constriction, tight enough to 
occlude the calibre of the bowel, may not interfere with its vas- 
cular supply. If gangrene results it will be from pressure at the 
bottom of the groove and limited in extent. Except for the 
usually small ulcer in the constriction groove, the gut above and 
below may be normal in appearance. In the fruitless efforts of 
nature to protect the general peritoneum, adhesions are quickly 
formed between bowel and neck of sac. In the attempt to sever 
these the fragile wall of the bowel tears along the line of con- 
striction. Doubtless many cases of this kind occur, the fecal 
outpour taking place at the time of the operation. To avoid 
this it might be wise to follow the practice of Mikulicz (11), who 
in every case of suspected gangrene opens the ring from within 
the belly cavity, thus making a laparo-kelotomy which permits 
as he thinks thorough isolation by gauze of the infected area. 8 
J., RANSOHOFF. 
The difficulty appears in the fact that pressure gangrene limited 
to the furrow and made by the constricting band is not always 
easily recognized. Fortunately the tissues about it, whether torn 
by manipulation or not, are in a fair condition for partial excision 
and lateral suture, by which the patient may be saved the perils 
and annoyance of an artificial anus. Krumm reports such a case 
successfully treated, and Barette three of pressure gangrene suc- 
cessfully managed in the same manner. The deleterious effects 
of strangulation are not equally visited on all parts of the coil. 
In some cases, as in the fourth presented, the entire knuckle is 
of dull chocolate or grayish color, with or without subserous 
hemorrhages. It is soft, friable, gangrenous throughout. In 
others, as in the second, the force of the strangulation although 
influencing the circulation of the whole, appears to affect most 
seriously the central part of the knuckle and at a point removed 
farthest from the mesentery. It is clear that if in such a case 
excision were to be done it could only be. beyond the limits of 
constriction. The cyanotic gut about the really gangrenous 
centre would ill support a suture. Let alone, it will recover. 
The handling incident to suture might easily prevent it. 
Furthermore in cases of this nature the gangrene is often more 
extensive than is apparent. Beginning generally in the mucosa, 
the serous tissue is the last, and therefore least affected. The 
fixation of the gangrenous area in the bottom of the wound, 
relying on nature to make the anus preternahiralis appears to 
me sound judgment. The data on which this view is based 
differ from those which militate against the formation of a fecal 
fistula when the gut is gangrenous in its entirety. 
First and foremost, the calibre of the gut remains patent, and 
death from inanition is rendered impossible. Again, artificial 
anus which results will probably be small and close in a few 
weeks or months without operative interference. Where the 
gangrenous area is surrounded by healthy tissue and sufficiently 
small it may be excised and closed as would be a gunshot wound, 
or it may be united, as suggested by Lindner (12), and closed by 
sutures holding the contiguous parts together in horizontal fold. 
Of the former practice and lateral suture Barette (13) reports 24 
cases with 21 recoveries. Sachs (14) reports a case similarly 
treated with success. When gangrene involves the entire Figure 2. 
(See Page 2.) TREATMENT OF GANGRENOUS HERNIA. 
9 
knuckle strangulated the appearances are sufficiently character- 
istic. Chocolate or dark slate colored, denuded in patches of its 
peritoneum and in a collapsed condition, it fails to react to 
mechanical or chemical irritation. The odor is fetid before per- 
foration has taken place. Where the strangulation has been very 
acute, as in the last case reported, the changes in and about the 
hernia sac need not be very marked. After the escape of a vary- 
ing amount of turbid bloody fluid from the sac, the latter appears 
of a bright or dusky-red minus the glistening appearance of the 
normal serosa. When it is of older date, one after another of 
the hernial coverings are involved in the inflammation. They 
are welded together, in turn to break down. A fecal abscess is 
the result. In the recent strangulation no difficulty is encoun- 
tered in bringing the intestine into the wound after division of 
the ring. In that of four or five days, adhesions make this the 
most delicate part of the operation. It is here that the lesions 
most difficult to deal with are found, and which, with or without 
operation, are the most frequent death-causing factors. 
The most serious and far-reaching changes in gangrenous 
hernia are often found in the afferent portion. They may be said 
to involve its calibre, its nutrition, its contents and the peritoneum 
singly or together. Although long recognized, the dangers in- 
herent in this part of the intestine have recently been strongly 
brought forward by Beneke. Above the constriction there is 
always some dilatation with more or less paresis and congestion of 
the intestinal wall. It may be darker in color and oedematous from 
venous stasis. Possibly from the same cause its mucous lining 
secretes abnormally and as a result at times enormous accumu- 
lations of fluid are found: according to Mikulicz from one to 
three quarts. This forms an excellent culture medium for bac- 
teria and in the process of putrescence toxines are formed, the 
absorption of which doubtless accounts for many deaths under 
the mask of acute sepsis from strangulated hernia before peri- 
tonitis has developed. The disintegration of this fluid gives rise 
to a fecal odor irrespective of the site of the constriction, and it 
is this fluid forced into the stomach and thence regurgitated that 
is so often mistaken for fecal vomit. (Mikulicz.) Furthermore 
the wall of a paretic and congested gut has no power to resist 
the pathogenic organisms which it encloses. Far above the 10 
J. RANSOHOFF. 
constriction hemorrhagic infiltrations, diphtheritic-like deposits 
on, or ulceration of, the mucous membrane, may ensue. This is 
far more liable to such necrotic changes than the outer tunics 
and there is no way of knowing how far the process has ex- 
tended. In one of Kocher’s (15) cases the gangrene extended 
four inches and in one of Taendler’s (16) six inches above the 
suture line. In a case not submitted to operation the diphther- 
itic deposits were found six feet above the constriction. 
When death follows hernia, the symptoms of peritonitis are 
rarely absent. In the majority of cases, even of gangrene, there 
is no perforation within the abdomen, and the course of the peri- 
toneal infection must have been through the macroscopically in- 
tact gut. That it may occur where the gut does not enter into 
the hernia has already been seen (case 1). It has long been 
known through Nepveu’s (17) investigations that the fluid tran- 
sudate in a hernial sac is rich in pathogenic organisms before 
gangrene has developed. Benneke (18) has recently shown that 
the bacteria readily pass through the wall of the paretic bowel 
and produce diffuse peritoneal infection. On microscopic sec- 
tions he was enabled to trace their progress through the intestinal 
wall. From these metastatic infection in remote organs may 
ensue. The process is like that seen in other morbid conditions 
of the intestine; notably in typhoid fever and appendicitis, where 
peritonitis develops without actual perforation. 
Equally important with the local, is the general condition of 
the subject of a strangulated hernia in determining the plan of 
procedure. When delay has brought the patient to the verge of 
collapse, when even the shock from prolonged anaesthesia can- 
not be ventured, that must be done which most readily gives re- 
lief to the strangulation. It may be the opening of a fecal ab- 
scess, the division of the stricture, or the rapid fixation of the 
gut in the wound. Whatever the procedure adopted in the con- 
dition indicated, the result will probably be the same—death 
within a few hours or days. 
In most cases, however, the condition is less deplorable and 
evidently tolerant of a somewhat prolonged operation. It is in this 
class that choice must be made between the establishment of an 
artificial anus and resection of the bowel with immediate suture 
of the divided ends. TREATMENT OF GANGRENOUS HERNIA. 
11 
Unfortunately authorities are not to be relied on, for they 
are divided. In England, Baker, MacCormac, Banks, and 
Treves decidedly oppose the greater operation of resection. In 
this country the same opinions have been held unless they have 
been recently influenced by the reports of successful cases of ex- 
cision by McCosh (19), Richardson (20), Dawbarn (21), and 
others. In Germany, Kocher’s and Czerny’s first successes were 
followed by many failures which frustrated the natural desire of 
surgeons to make primary excision the normal procedure in 
gangrenous hernia. Finally Reichel’s (22) critical review of the 
statistics in 1883 made it appear that the preferable primary oper- 
ation was enterostomy to be followed by a second operation for 
the closure of the preternatural opening. From the very first 
Kocher has remained steadfast to the ideal operation, and in 
Mickulicz he has recently found a most able supporter. 
The advantages and disadvantages of the two procedures 
are almost apparent. If primary resection is successful the pa- 
tient is well in from four to six weeks. If an artificial anus is 
successfully established a second operation of a very serious 
nature must follow. The artificial orifice is as large as the bowel 
and the mucous membrane is prone to prolapse. Such an open- 
ing never closes spontaneously. 
While in a considerable number of cases the enterotome of 
Dupuytren might be successfully applied with the low mortality 
of five per cent. (Korte) (23), it will fail in many cases and be ab- 
solutely inapplicable in others. Again, according to Dupuytren 
it should not be used for two or three months after the primary 
operation. It is during this interval that the very greatest dan- 
ger from artificial anus is encountered, that from progressive 
inanition. Recently Poulsen (24) has used it twelve and even 
nine days after the first operation. 
It has not yet been established how much of the intestinal 
canal is essential to the maintenance of nutrition, but where the 
fistula is above the milk-part of the ileum rapid emaciation and 
death follow before any secondary procedure for closing it can 
be practiced. McCosh does not overrate the argument of statis- 
tics in the statement that the death-rate of all cases in which an 
artificial anus is made, including the operations for its relief, 
is fifty per cent. The danger from secondary resection and 12 
J. RANSOHOFF. 
enterorrhaphy is very considerable. Haenel mentions forty- 
three cases with sixteen deaths and two failures. 
To be successful the artificial anus must be established in 
healthy bowel, else the dangers inherent in the afferent portion 
will not be removed nor will a free outflow from the intestine be 
secured. The only advantages therefore which can be claimed 
for this method are the rapidity with which it can be performed 
and the slight technical skill required in its performance. A fur- 
ther advantage is supposed to exist in the lesser danger connected 
with this as compared with the major procedure of immediate 
resection. 
There is hardly a subject in surgery concerning which statis- 
tics are so much at variance as are those relating to gangrenous her- 
nia. According to Korte of 111 cases treated by enterostomy eleven 
ended fatally. Herman (quoted by Haenel) mentions 83 cases 
with 7 deaths. On the other hand Weil (25) reports 15 cases 
with 13 deaths. Benno Schmidt places the mortality at 85.5 per 
cent, for the formation of an artificial anus as against 71.1 per 
cent, for primary resection. 
F. A. Southern, surgeon to the Manchester Royal Infirmary, 
recently reports eighty-five cases of herniotomy with nine cases 
of gangrene. All of the latter died. In six an artificial anus 
was made; in three primary excision. 
If statistics are of any value in solving the relative merits of 
enterostomy and primary excision, it is evident that the reports 
of scattered cases are far less weighty than such from a few and 
skilled operators and from hospital records where nothing is 
concealed. Such a tabulation has recently been made by Mick- 
ulicz (26) from seven large clinics of Germany and Switzerland. 
Of one hundred and sixty-eight cases of gangrenous hernia one 
hundred and nine died. Of ninety-four in which an artificial 
anus was made seventy-two died; mortality, seventy-six per cent. 
Of sixty-eight primary excisions thirty-two or forty-seven one- 
tenth per cent. died. Of six intermediary resections five died. 
It would appear from this that the mortality of primary excision 
is very much less than that of the lesser operation. But this can 
be accounted for by the certainty that the latter was often used 
as a last measure in conditions approaching collapse and there- 
fore precluding the major operation. TREATMENT OF GANGRENOUS HERNIA. 
13 
The advantages of primary resection are patent. Its advan- 
tages are, in the time required for its performance and in the 
danger of peritonitis from imperfect technique. In a measure 
both can be overcome. The first of these is probably grossly 
ejcaggerated. With separation of the mesentery as indicated in 
the fourth case and its closure by suture to be followed by the 
continuous Lembert suture or by lateral anastamosis, not more 
than half an hour at most should be required for the enteror- 
raphy. Complicated clamps, a separate row of stitches for mucous 
and serous tunics, interrupted sutures unnecessarily waste 
time. Where the continuous suture is used and appears weak 
at points a few supplementary stitches can easily be taken. 
Suturing the mesentery brings the intestinal ends naturally 
together and gives assurance that the most treacherous part of 
the suture, that near the mesentery, can be properly applied. 
The second danger is from injudicious selection of the lines for 
suture. As elsewhere in gangrenous processes the danger lies 
rather in removing too little than too much. If Kocher excised 
five and Koeberle six feet of intestine, a few inches more or less 
cannot be important. In acute cases where the calibre of the 
gut has not been long occluded and koproostasis is little if at all 
developed, an inch or two on each side of the constriction groove 
will probably bring the suture line in healthy tissue. Where the 
mesentery has not been included in the strangulation, the same 
favorable conditions may be expected. Where however much 
dilatation of the afferent gut exists, its thorough evacuation 
should precede the enterorraphy. After hernia, as after laparo- 
tomy for obstruction, it is fatal to return a distended gut to the 
abdomen. The second danger, that of septic infection of the 
peritoneum, can in a large measure be reduced by thorough 
irrigation of the sac before suturing; by careful handling of the 
gangrenous gut without the wound meanwhile protecting the 
peritoneum by gauze packing. Finally, the sutured intestine 
should be left just within the abdominal cavity and a radical cure 
should not be attempted. Mickulicz, whose success surpasses 
that of any other operator—21 cases with 14 recoveries—insists 
on the open treatment of these cases. Should fecal extravasa- 
tion ensue from defective suture or other cause, it would naturally 
turn towards the wound whereby the danger of general peritonitis J. RANSOHOFF. 
14 
would be largely averted. For from two to five days after the 
operation the sutured intestine remains where it is placed within 
the abdomen, and after that length of time the development of 
peritonitis is not probable. To hasten the process of wound 
repair, deep and superficial sutures might be drawn through the 
wound margins and kept over the gauze packing, to be tightened 
without anaesthesia after the danger line has been passed. 
Between the extreme measures considered, others looking 
towards a compromise have recently been brought forward by a 
number of surgeons. Among these are the intermediary excis- 
ion and suture of Riedel (27). The artificial anus is established 
in the usual way. After twenty-four or forty-eight hours the 
edges of the intestine are vivified and united by suture. In 
1882 Bouilly (28) suggested excision and suture, the latter being 
purposely made imperfect at one point to guide the fecal extrava- 
sation. To avert the danger from imperfect suture, Hahn (29) 
follows the kelotomy with a median laparotomy. Through this 
wound he brings the divided ends of the bowel, thoroughly pro- 
tecting the abdomen against infection by packing them in gauze. 
When the suture is completed the closed knuckle is kept in the 
wound and gauze splints until union is assured. The com- 
petency of the suture is certain after 24 hours, when the bowel 
is returned to the abdomen and the external wound closed. It 
is difficult to understand why the same procedure could not be 
carried out in the inguinal herniotomy wound. Nevertheless 
Hahn has had two successes with it, and in a third, reported by 
Kutschera (30), the result was equally satisfactory. 
To overcome the danger from death from inanition Helferich 
(31) has recently combined enterostomy with an intestinal anas- 
tomosis above the constriction furrows. By this method two 
courses are open to the intestinal circulation and the closure of 
the artificial anus is greatly facilitated. The operation was done 
in two cases, one of which was successful, the fecal fistula closing 
spontaneously. 
There is yet another class of .cases in which the condition of 
the bowel is such that whereas gangrene is not yet present, it 
might through subsequent necrosis cause death if returned to 
the abdomen. Such a knuckle is a menace. Who has not seen 
it ? Especially if operating by light both artificial and bad. TREATMENT OF GANGRENOUS HERNIA. 
15 
Bowel that is not at all doubtful in appearance will at times repay 
the trust placed in it by a perforation. Among 96 deaths after 
herniotomy, it was in 26 cases the result of returning intestine 
to the abdomen which subsequently perforated. In Hagedorn’s 
clinic three deaths out of 15 resulted in the same way. To 
return doubtful intestine is unnecessarily jeopardizing life. To 
treat such intestine as radically as bowel already gangrenous is 
an extreme measure, not to be advocated. Fortunately the intes- 
tine can be retained in the wound for a number of days in gauze 
packing or by sutures. When its viability has been established 
it is an easy matter to return it to the abdomen. Graefe (32) 
recently reported a successful case in which the intestine was so 
retained for five days before replacing it. Should the dread of 
adhesions be feared, the intestine might be retained just within 
the abdomen by fixation sutures or by gauze. In the event of 
gangrene the fecal extravasation would course toward the exter- 
nal wound. 
When in 1880 Czerny reported his first case of primary excis- 
ion for gangrene, he believed that the operation would not displace 
the older operation of enterostomy. Although the last four years 
have brought forward success after success from primary resec- 
tion, the dictum of Czerny still holds good. Each operation 
has its proper field. The boundary lines are becoming more 
clearly defined. Nevertheless it must always remain for the 
judgment and tact of the surgeon as individual cases arise to 
determine the proper procedure to be adopted. In operative 
surgery, as elsewhere, the ideal should be sought. This would 
make primary excision the normal procedure in gangrenous 
hernia, and only cogent reasons should cause the operator to 
refrain from striving for the ideal. 
1. Zeitsch. f. Chir., Band 32, p. 356. 
2. Konig, Spec. Chir., Band 2, p. 351. 
3. Beit. z. Klin. Chir., Band 7, p. 4. 
4. Richardson, Trans. Anier. Surg. Soc., vol. 7, p. 205. 
5. F. A. Southam, Lond. Lancet, 1891, 2, p. 1217. 
6. Twelfth Congress of German Surgeons. 
7. Loc. cit., case No. 182. 
8. Krumm, Beitr. z. Klin. Chir., Band 7, p. 8. 
9. W. H. Bennet, Lancet, 1891, 2, p. 1377. 
REFERENCES. 16 
J. RANSOHOFF. 
10. Poulsen, Berl. Klin. Wochenschr., Nov. 16, 1892. 
11. Mikulicz, Berl. Klin. Wochenschr., Nov. 10, 1892. 
12. Lindner, Berl. Klin. Wochenschr., 1891, p. 277. 
13. Barette, These de Paris, 1883, “ De l’lntervention chirurg. dans les 
Hernies.” 
14. Sachs, Deutsch. Zeit. f. Chir., Band 32, p. 93. 
15. Kocher, Centralbl. f. Klin. Chir., 1880, p. 466. 
16. Madelung, Archiv. f. Klin. Chir., Band 27, p. 287. 
17. Nepveu, Gaz. Med. de Paris, s. iv. 4, p. 75. 
18. Virchows Archiv., Band 120, p. 7. 
19. McCosh, N. Y. Med. J., vol. 49 p. 281. 
20. Loc. cit. 
21. N. Y. Med. Record, vol. 89, p. 428. 
22. Paul Reichel “Die Circulaire Darmnaht,” Zeitsch. f. Chir., Band 19, 
p. 230. 
23. Korte, Berl. Klin. Wochenschr., 1883, p. 797. 
24. Poulsen, Loc. cit. 
25. Prag. Med. Wochenschr., 1887, p. 81. 
26. Berl. Klin. Wochenschr., 1890, No. 10. 
27. Deutsch. Med. Wochenschr., 1883, No. 45. 
28. Revue de Chirurgie, 1882, p. 362. 
29. Berl. Klin. Wochenschr., 1888, No. 26. 
30. Wien Med. Presse, 1888, p. 1911. 
31. Archiv. f. Klin. Chirurg., Band 41, p. 337. 
32. D. Zeitschr. f. Chirurg., Band 34, p. 82.