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condition. If this can not be found, then the case is not an appropriate one for this operation. It is hardly excusable to have gangrene resulting be- cause of separation of the mesentery. TesasJ has shown that, if the mesentery is separated, even for the shortest distance, close to its intestinal attachment, gangrene of that portion of the gut is sure to follow unless it be at once re- sected. When the separation takes place at a certain dis- tance — say, two to three centimetres — from its line of at- tachment, it may be of considerable length without endan- gering the vitality of the gut. To escape in part from some of the dangers of both operations, Riedel * recommends that the gangrenous por- tion be fastened away from the wound well down on the thigh, and that it be left in this situation until the next day, a free incision having been made to allow the intestinal contents to escape. At the end of this time the bowel will have recovered its contractility, the distension will have been relieved, and it will be easy to determine at what point the blood-supply is abundant. Another advantage is that the operation of suturing can generally be carried out without the use of an ansjesthetic. If a longer time, as is generally recommended, is allowed to elapse before the secondary operation be attempted, anajsthetization becomes a neces- sity. This plan strikes me as one that would be most ap- propriate in certain Clomipramine 50mg doubtful cases. * " Correspondenzbl. f. schweiz. Aerzte," vol. xvi. f " Bull, de la soc. de chir.," Paris. Clomipramine 10 Mg X " Arch. f. klin. Chir.," Bd. xxxiii, p. 303. * " Deut. med. Wochenschr.," 1883, p. 656. The final decision must rest, however, on the death-rate of the different operations. If either method is attended by a smaller mortality than the other, then this is the one to adopt. All statistics agree that the operation of enterorrha- phy, performed for closure of an artificial anus, is less dan- gerous than the operation of immediate Clomipramine 25mg resection and suture done for gangrenous intestine. For the former operation the mortality in both Makin's table * of thirty-nine cases and in Reichel's f thirty-seven cases is computed as being Clomipramine Tablets about Buy Clomipramine Online 38 per cent. For the latter operation Makin calculates a death- rate of 52 per cent, in fifty-five cases, and the figures of Reichel in fifty-six cases and of Madelung J in forty-four cases are practically the same. I have been able to collect accounts of one hundred and fifteen cases where the opera- tion of resection and suture has been at once carried out in the treatment of intestine found gangrenous from strangu- lation in hernite. Out of these cases fifty-seven died and fifty-seven recovered (one was doubtful). This gives a mor- tality of 50 per cent. This result differs but little from the 52 per cent, which other writers have computed from a smaller number of Buy Clomipramine cases. I have been careful to exclude all cases where Clomipramine 50 Mg the suturing was not done at once, and no case is Clomipramine Hydrochloride Tablets mentioned unless a cylinder consisting of the entire cir- cumference of the gut bad been resected. The death-rate of the operation of resection for cure of artificial anus is 38 per cent. I find that writers often compare these two rates in their endeavors to decide which is the preferable operation. This is Clomipramine Anafranil unjust. In such a calculation they Clomipramine Hydrochloride for- get to reckon the deaths due to the operation of kelotomy and formation of the anus, and the dangers to which a pa- tient is exposed before the anus can be closed. If we would judge Clomipramine 20mg fairly from statistics, we must add together these three mortalities, and compare the sura-total with our 50 per cent. It is difficult, however, to ascertain how many pa- tients succumb to the original operation, or as the result of the establishment of an artificial anus before it can be closed. Cases fatal from either of these causes are apt not to be reported. Schmidt,* in an analysis of three hundred and eight cases where kelotomy was done for strangulated hernia, and where the gut was simply returned, found that 2'7*4 per cent. died. If, then, for the sake of calculation, we were to place the death-rate of the primary operation at 20 per Clomipramine Buy cent., it would not, I Clomipramine For Ocd think, be excessive. Of the number who die before the anus can be closed, certainly 5 per cent, would be moderate. The sum of these mortalities is 63 per cent., which we Anafranil Clomipramine have computed as the death-rate resulting from operations for gangrenous hcrnise where a temporary artificial anus has been established. Of course, to some extent this reasoning is theoretical, and, in order to strengthen it, I collected reports of one hundred and twenty cases which had been treated in this manner. Sixty-two of the patients died from the effects of operation or as the re- sult of the anus, and fifty-eight recovered, giving a mortality of about 52 per cent. Korte || reports thirty such cases which have come under his observation, sixteen patients having Clomipramine Ocd died and fourteen recovered. I think, however, that * Loc. cit. f Loc. dt. * "Deut. med. Wochenschr.," 1883, p. 246. I " Bei-l. klin. Wochenschr.," 1883, No. 57. \ Loc. cit. 286

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