POST-OPERATIVE HiEMATEMESIS, WITH NOTES OF ELEVEN CASES. By Robert Purves, M.B., F.R.C.S.Ed., Tutor in Clinical Surgery University of Edinburgh, and Assistant-Surgeon Deaconess Hospital. Attention was at first directed to the occurrence of post-operative hrematemesis by von Eiselsberg, who recorded eight cases at the German Surgical Congress of 1899. Of thirty-seven cases since recorded, I have obtained some particulars in twenty-nine. Twenty-four followed abdominal operations?including, (eight cases), gall-bladder (three cases), appendicitis (six cases); also after ovariotomy, tuberculous , intestinal obstruction, exploration for stab of abdomen, and exploratory incision in the iliac fossa. Of the five other cases, two followed excision of the rectum; one, suprapubic lithotomy; and one, removal of cancer of the palate. Htematemesis has also followed infection of the urinary tract. The following eleven cases have been collected from the wards of the Eoyal Infirmary, and for permission to report them I am indebted to the courtesy of Professors Annan- dale and Chiene and Dr. MacGillivray. Case 1. Mrs. 3v., ait. 53 (Prof. A.), had an umbilical hernia for twe \e years, which gave rise to periodic attacks of pain, , and ; no vomiting at present. Previous history was negative.? Operation, September 9, 1901.?The sac contained a large loop of small intestine and a considerable mass of adherent omentum. During the operation the bowel -\vas perforated; little or no escape of contents occurred, and the opening was at once sutured; part of the omentum was removed. There was no chloroform sickness. The first hsemate- mesis occurred thirty hours after operation, when she suddenly vomited a large quantity of coffee-ground fluid. This was accompanied by intense pain in the hypogastrium. Thirty-six hours after the operation, liaemate- niesis was repeated and continued at short intervals until death, which occurred three hours later. Before death she became delirious, and. had severe . Pulse was very fast, and her respirations were thoracic. There was no sectio, but the probability of sepsis was considerable. 238 ROBERT PURYES.

Case 2.?Fred. C., set. 67 (Prof. A.), had suffered from symptoms of stone in the bladder for three months. The urine was healthy. Has never had any gastric trouble.?Operation, October 18, 1900.?Uric acid stone crushed and removed. There was no chloroform sickness. Three hours after the operation he vomited a small quantity of coffee-ground fluid. No pain and no severe retching. During the next day there Avas some pain over the epigastrium, relieved by fomentation; was better on the following day. No pus in the urine, and no pain. Sixty hours after the operation he became collapsed, and vomited 10 oz. of black fluid. Pulse was intermittent and there was some tympanites. He rallied under strychnine, strophanthus, and washing out of the stomach with hot water, but collapsed again, and died without vomiting five hours later. It was not certain that sepsis was present, but his general condition and the tympanites made it very probable. Case 3.?Mrs. L., a3t. 38 (Prof. A.), had for nine months suffered from periodic attacks of pain in the right side, with slight ; of late more frequent and severe. The day before operation she had a severe attack, vomited and became jaundiced. Has never had any gastric trouble. Diagnosis was gall stones; and on October 27, 1900, the gall bladder and ducts were explored, but with negative result. A hard swelling was found occupying the head of the pancreas. It was believed to be malignant, and the abdomen was closed. (The pylorus was examined by invaginating the stomach wall.) There was no CI1C1;! sickness, and progress was uneventful until the ninth day, then deep- seated colicky pain commenced in the right hypochondrium. In the ?evening she fainted and collapsed, cold sweat and ice-cold hands and feet. Wound appeared healthy. The following day she vomited bilious fluid continuously, which toward evening became grumous and dark ,(ten days after operation). The hsematemesis continued off and on for the next twelve hours, then ceased, and she improved. Seven days later she again collapsed, vomited between one and two pints of black fluid, and died in half an hour. The sectio revealed an abscess which whole of the no replaced the pancreas, malignant disease ; the biliary passages and peritoneum were healthy. Stomach and showed no ?change. The omentum shows areas of fat necrosis. Case 4.?Peter C., a3t. 50 (Prof. A.), had suffered from renal for eleven years. Has twice passed a stone. Symptoms referred chiefly to the right side, but at times to the left. Urine non-purulent. X-ray showed three stones in right kidney. No history of gastric trouble.? Operation, February 20, 1901.?Lumbar incision. Kidney a mere shell full of stones. Stones removed and wound drained. No chloroform sickness, but was very restless. First hsematemesis occurred eighteen hours after operation; without warning he vomited three pints of black grumous fluid. Hsematemesis continued in small mouthfuls all day. Treatment by ice, ergot, and stimulants was unavailing, and he died thirty-six hours after the operation. Sectio showed some pus in the of the Tuberculous and nodules in " pockets right kidney. peritonitis spleen and liver ; no necrosis on section. Stomach and duodenum showed aiothing. Case 5.?Hugh C., set. 43 (Mr. MacG.), had a right reducible in- POST-OPERATIVE HSEMATEMESIS. 239

June 14, 1901. Bile in gall bladder clear, but lining membrane velvety and hyperaemic. A small piece of omentum was removed. Fistula estab- lished. There was no CIIC13 sickness. The first hsematemesis occurred thirty-six hours after operation, 2 oz. of grumous fluid being suddenly vomited. Twelve hours later, again vomited a small quantity of dark fluid, and continued bringing up mouthfuls of similar fluid at intervals half an hour. Rectal of feeding and lavage of the stomach gave tem- with porary relief. A repetition very hot water gave relief "for eight hours, but seventy hours after operation the hsematemesis returned, and continued at intervals, unchecked by treatment, until her death on the seventh day. There Avas no sectio, but the slight elevation of tempera- ture, quick pulse, and general condition appeared to justify the con- clusion that a general infection had taken place from the infected gall bladder. Case 9.?Airs. D., jet. 27 (Mr. MacG.).?Had her ovaries removed twelve months ago for persistent uterine haemorrhage. The bleeding was cured, but she acquired a ventral hernia. Xo history of gastric trouble.?Operation on June 25, 1901, at which omentum was found adherent to the scar ; part was removed. CHC13 sickness was severe, and was succeeded by hsematemesis six hours after the operation. During a she period of one and a half hours twice vomited black grumous fluid, 3 oz. in all. Vomiting ceased until midnight. During the following twelve hours she vomited bilious fluid (free from blood) three or four times. Case 10.?Woman, set. 40 (Prof. A.).?A case of uterine fibroids, was for which abdominal hysterectomy performed. There were many was removed. adhesions ; no omentum Abdomen was closed. CHC13 was all more severe in the sickness slight day, evening; patient very weak, and little or no efl'ort was made in vomiting. Became a passive regurgitation, which continued off and on until it was succeeded twenty- four hours after operation by the first hsematemesis. Small quantities of black fluid were brought up at intervals. The amount and frequency increased, and she died forty-eight hours after the operation. Tempera- ture was subnormal, pulse quick, pain was absent, also tympanites, but she was preternaturally acute, and restless up to the hour of her death. Case 11.?Man, set. 27 (Prof. A.).?Two uric acid calculi were removed from the right kidney. CIIC13 sickness, slight at flrst, and occurring at long intervals, increased in frequency on the following day. During the next twenty-four hours vomiting continued, more violent and in greater quantity. Forty hours after operation, black fluid con- taining blood replaced the bilious vomit, and continued till death, fifty- two hours after operation, and twelve hours after onset of hsematemesis. Temperature was subnormal, pulse rapid, very restless, perspiring, and he complained latterly of abdominal pain. Reference to the cases reported here and elsewhere render it at once apparent that the advent of hamiatemesis after operation is a serious complication. The mortality is high, eight of the eleven cases having ended fatally, a death-rate of 72*5 per cent.; and of twenty-nine cases, already recorded, 69 per cent. died. Age apparently is of no moment, the cases reported here occurring in POST-OPERATIVE H^MATEMESIS. 241

of individuals whose ages varied from 24 to G7. The incidence hiematemesis is, moreover, not associated with any particular form of operation. In the majority of instances it has followed opera- tions in relation to the abdomen. But, 011 the other hand, I have been informed of two cases in which it followed amputation through the thigh, and the removal of a neuroma in an amputation stump; and, as a rule, there is no history of previous gastric symptoms or vomiting of blood. The mode of onset of the hccmatemesis.?Chloroform sickness a few may 01* may not precede the hiematemesis, and in only cases can be held responsible for initiating the bleeding. In those cases in which vomiting after the anaesthetic is present, it appears more usual for the hiematemesis to gradually supervene, the more or less frequent bilious vomiting continuing for a variable period until the appearance of blood. The bilious vomiting in many cases becomes less violent before the onset of hiematemesis, and sometimes becomes a mere passive regurgitation, the lluid welling the up into the mouth at frequent intervals, and overflowing, patient making little or no effort to eject it. This same character of the vomiting is a feature of the later stages, when blood is sub- stituted for bilious fluid. In the absence of chloroform sickness, The one finds that the first hiematemesis is often quite sudden. a time before- patient may or may not have felt faint for short hand, and, generally speaking, the degree of preliminary collapse is proportionate to the amount of the hiematemesis, but it may in the happen that only a small portion of the blood contained stomach is vomited. In the majority of cases hiematemesis sets in within forty-eight hours of the operation, though it may be not delayed for some days. I11 two cases reported here, it did occur until the seventh and tenth days. or The duration of hccmatemesis.?There may be only one 011 which two occasions, within a period of two or three hours, con- blood is vomited, which is favourable; or the vomiting may hours. tinue at frequent intervals for a period of fifteen to twenty as a rule a fatal 1 his is the state of affairs in many cases, and has termination within twenty-four hours of the onset of hiematemesis. of some A return of black may occur after an interval vomiting and days, and in some instances the vomiting has continued off 011 for several days. The nature of the hccmatemesis.?The vomitus is generally small some cases, in quantity, to be measured in ounces; though in especially in those where the initial vomiting is a hiematemesis, quantities of one to three pints of black fluid may be brought up. It consists, as a rule, of blackish brown fluid, with a varying or the amount of bile, and of blood, like coffee-grounds digested be sediment of hare-soup. Occasionally clots of blood may is asso- vomited, or even pure blood which has not clotted. This of vessels, as ciated with an ulcer perforating a vessel, or rupture 17 "ED. MKD. 5C1?NEW SER.?VOL. XI. III. 242 ROBERT PURVES.

in hepatic cirrhosis. In such cases the hsematemesis is copious' from the commencement. The total amount of blood lost in any case is not so great as one might easily be led to suppose, for it is mixed with more or less mucus, bile, and fluid present in the stomach; and an ounce or less of blood, when partially digested, will stain several ounces of stomach contents. The general condition of the patient.?The feature of these cases that is most striking is the state of collapse and asthenia into which the patients often so rapidly enter. The condition is often a perfectly obvious toxcemia, from a recognisable septic infection of the operation wound. But in many cases, and chiefly in those of the greatest gravity, one is at a loss to account with certainty for the cause of the depression and rapidly advancing inanition. The temperature is rarely high, and often subnormal. The pulse is almost invariably rapid and irregular. Pallor, faint- ness, and coldness of the extremities are frequently prominent signs, and unduly so, if one considers the amount of blood that has been lost. In some, restlessness and mental acuteness, marked by an anxious and alert, though momentary, interest in trifling- matters, is very prominent; such an appearance as, in the absence of tympanites or definite signs of peritonitis, makes one feel that one has to do with a general infection, whose course has been too rapid to permit of the appearance of those signs which enable one to make a diagnosis clinically of an infective process. Etiology.?Many theories have been advanced to endeavour to explain the occurrence of post-operative hamiateniesis, but so far no particular one has served to elucidate all cases. First, The administration of an amesthetic has been suggested, but it is evident that if it had any relation to hsematemesis the complication would arise more frequently, and would occur within a comparatively short time after amesthesia; whereas, although in cases the the majority of luematemesis appears within forty-eight hours, in many cases several days elapse. Moreover, cases have been recorded in which hfematemesis followed operations under cocaine. Secondly, Laparotomy has been associated with the occurrence of luematemesis. It is difficult to conceive that the fact of opening the peritoneum has an immediate bearing 011 the condi- tion, for it has followed operations 011 the palate (von Eiselsberg), 011 the bladder (Broca), in both of which no peritonitis or suppura- tion was found post-mortem; after lithotomy and litholapaxy cases two, and four in which the peritoneum was intact, and in three urinary cases referred to in a discussion by Guyon. Also, I have ascertained that it has followed amputation through the thigh, and the removal of a neuroma from an amputation stump. Still, it is not to be overlooked that, in the great majority of cases,, the peritoneum has been opened either in some form of abdominal affection or in the course of hernia operation. POST-OPERATIVE HiEMATEMESIS. 243

Thirdly, The vomiting after general anaesthesia cannot be regarded as more than a predisposing cause, as it is frequently absent and in many cases is slight. In some cases it may, 110 doubt, bring about ecchymosis of the gastric mucous membrane and the ultimate formation of minute digestive ulcers, or may cause an ulcer to perforate into a vessel. Fourthly, Similarly, fasting before operation can only be looked upon as a possible predisposing factor. Fifthly, Injury to the stomach or duodenum by surgical handling has been suggested as a possible cause of the formation of ulcers, and has been referred to by both von Eiselsberg and Schmidt. The appearance of such ulcers has been noted by Wagner, Korte, and Kronlein, but the injury has as a rule been more violent than can occur in ordinary circumstances. Injury may result in a definite tear of a part of the wall, or only a detachment of the mucous membrane from the deeper layers of the stomach. Whether the latter can be followed by an ulcer is a disputed point. Kronlein holds that the detached mucous membrane may be digested and result in peptic ulcer, while Relm will not admit its possibility. Billroth has shown ulceration of mucous mem- brane over an embolus to occur more readily in the presence of acid gastric juice than in alkaline intestinal fluid. It seems probable, therefore, that ulceration can also occur after detach- ment of mucous membrane from the stomach wall. This explanation of hrematemesis could, however, only apply to the few cases in which the stomach was invaginated to examine the pylorus, or otherwise handled, and moreover only in those particular cases in which some days have elapsed before the onset of hsematemesis, for Kronlein has shown that a delay of several days exists between the receipt of injury and the appear- ance of severe symptoms. In Schmidt's case this explanation of the hemorrhage is quite possible. More severe bruising of the stomach wall, as by the application of clamps, has been shown to result in ulcers, von Eiselsberg refers to three cases in which, after pylorectomy, ulcers appeared "in the stomach unconnected with the line of suture which had healed. " Sixthly, Thrombosis of the omental vessels after injury or ligature, followed by embolism in the wall of the stomach and formation of ulcers," is an explanation advanced by von Eisels- and in six and berg, out of his eight cases omentum was ligatured removed during the operation. In the seventh case the mesentery of the bowel concerned in an artificial anus was injured by the patient twisting and pushing back the protrusion himself. He bases his explanation on the investigations of von Recklinghausen, who has shown that it is possible for particles of tumour or pus to be brought from one part of the venous circulation to another directly, without passing through the lungs. This depends on the presence of a retrograde movement of the circulation in the veins, 244 EOBERT PURVES.

which can occur in tricuspid incompetence, and perhaps also in the course of violent coughing or vomiting. Other observers have recorded cases which prove that this may occur. This explanation can only hold good if, 011 examination of the liver and lungs, no deposits are found; otherwise the emboli must have followed the ordinary route. I11 reference to the stomach, in particular, von Eiselsberg considers that, after ligature of the omental branch of the epiploic artery, the vessel becomes thrombosed and the thrombus extends back to the origin of the vessel. The vessels lie at right angles to one another, and he conceives that a portion of the thrombus projecting into the epiploic may be swept off into the passing stream and carried 011 into some of the branches going to stomach wall, there to form a thrombus, and ultimately a digestive ulcer. He considers that this is the most prominent etiological factor in the production of post-operative hcematemesis. Friedreich has investigated the subject experimentally, and has found that ligature of vessels in the omentum results in most cases in points of necrosis in the liver. If the ligatured area approached the course of the epiploic artery, then he observed hemorrhages or small ulcers in the stomach wall, their position corresponding to the distribution of the vessel; he showed specimens illustrating the changes in the stomach and liver, and stated that the vessels concerned in the ligature showed desquamation of epithelium. He considers that these changes were entirely the result of the omental ligature. He points out that the ligature of the vessels, apart from the mesh of the omentum, is sufficient to produce necrosis in the liver and stomach, and further indicates that vein and artery will invariably be ligatured together, and that the thrombus in the vein, which need not necessarily extend to the epiploic vein, is disintegrated by the inflow from the artery into the thrombosed mass. Thus is produced a simple hepatic embolism, and there is no need for retrograde movement in the veins. The artery under these same conditions may become thrombosed back to its origin, and in the manner indicated by von Eiselsberg produce embolism in the minute gastric branches of the epiploic artery. Friedreich suggests that embolism does not occur in all cases of ligature of omentum, because?(1) the blood in different cases will vary in quality; (2) the size of the omental thrombus will vary; and (0) the mechanical movement of the thrombus, as by vomiting, is more probable in some cases than in others. He also thinks that it is less common in women than in men, 011 account of the longer omentum of the former. His own three cases and three-fourths of von Eiselsberg's cases were men. The theory of retrograde embolism is supported by experiments performed by Arnold and von Eiselsberg. The results obtained by Rodman and myself have been negative; no change, naked-eye or microscopic, being found in either the liver or the stomach. POST-OPERATIVE HJ5MATEMESIS. 245

Of the cases recorded here, this theory alone can be applied to four. In these the haemorrhage began in from three to thirty-six hours after the operation. If one considers that several days elapse before the appearance of ulcers after injury (Kronlein), I think one is justified in concluding that three or six hours is too short a time to permit of the formation of an ulcer after embolism. It is probable that, if the thrombus were infected, the necrosis would be more rapid, but in two of the three cases in which von Eiselsberg considers the thrombus to have been infected, the haemorrhage occurred later than in other presumably non-infected cases. Seventhly, Sepsis is believed to be the cause by Rodman. That sepsis can produce congestion and small haemorrhages in mucous membrane has been recognised. Billroth has observed duodenal ulcer after operation, which caused death from haemorrhage, and which he believed was referable to the septicaemia present. Dieulafoy records six cases of hrematemesis during appendicitis, four of which proved fatal. He found in the gastric mucous membrane minute ulcers, which lie attributed to the toxaemia producing haemorrhagic necrosis of the mucous membrane. Similar cases have been recorded by other observers. Lucas Champonniere has remarked on the occurrence of haematemesis in the course uf sepsis, especially when associated with abdominal malignant disease. Guyon has observed haematemesis in three cases where a septic infection of the urinary tract existed. Sepsis is held respon- sible for the duodenal ulcer following burns (Billroth). Although von Eiselsberg considers embolism to be the most prominent factor, lie states that probably the emboli in different cases vary in virulence, and considers that in five of his cases some degree of of infection^ the embolus existed; in one a "slightly virulent embolus," and in four "infected thrombi." But, 011 the other there are 110 hand, cases recorded where it appears certain that septic infection was present. In this series of eleven cases, in only ?ue was there 110 indication of sepsis. In all the others a source of infection was certain 01* probable. Mayo Robson considers that can none of the suggested causes referred to satisfactorily explain the occurrence of haematemesis, and thinks that it depends 011? Eighth, A nervous reflex influence. This is 110 more easy to than prove the other suggestions, but if it were a true solution of the it I question, is, think, admissible to suppose that sepsis would, in many cases, determine the onset of the reflex, or prolong the duration of its action, and thus render the condition more serious. In favour of this theory, and against sepsis, Robson points out in that many of the cases tympanites and other signs of septi- caemia are absent. In relation to the causation of gastric ulcers, there is, in the British Medical Journal of January 18, a note of interesting experi- ments by Dr. Van. Ijzeren, a Dutch physician, who has, by 246 ROBERT PURVES. division of the pneumogastric nerve below the diaphragm, in rabbits, produced, in eleven out of twelve cases, gastric ulcers corresponding to those found in man, the ulcers forming two to three weeks after division of the nerves. He attributes the production of the ulcers to necrosis of mucous membrane, follow- ing on obliteration of vessels by muscular spasm. Beflex nerve influence to produce hsematemesis will, in all probability, act on vessels; and, considering the fact that Van Ijzeren found ulcers took two weeks to form after nerve section, it is difficult to see how the relatively slight stimulus to reflex action produced by opera- tions, which in many cases have not concerned the abdomen at all, could in a few hours bring about a change in normal mucous membrane sufficient to result in bcemorrhage. Ninth, The pressure of gauze packing on the bile ducts and portal vein is referred to by Kehr as a possible cause, but he has seen htematemesis in cases where no packing was introduced. He has seen it in several cases after operations on the liver and gall bladder, and also after a Bassini's operation for hernia, and remarks on the absence of peritonitis in such cases. Finally, It is, I think, clear that all cases of post-operative h;ematemesis are not due to any one cause. In a certain number of cases it can be attributed, without doubt, to gastric ulcer or rupture of a vessel, where atheroma or cirrhosis of the liver is present, and in such cases it is no doubt precipitated by chloroform sickness. Injury, and a non-infected embolus from ligatured omentum, may similarly account for some cases. But, I believe, in those cases in which such an explanation is not possible, and they are the majority, that the origin is of an infective nature. In many cases the association with sepsis is clear, but in others, where the absence of conclusive signs of septic infection exist, where there is no sign of gastric ulcer, cirrhosis, or atheroma, where no ligature of omentum has been performed?in these cases I regard the condition as one in which a transient infection has occurred, the only obvious evidence of which is the luematemesis, In some cases, at first inexplicable, the appearance of a suppurat- ive parotitis, or a small abscess after several days, indicate the relation of the hrematemesis to an infective process. Ordinary cases of gastric ulcer can lose a very large quantity of blood, without death ensuing, and the relatively small amount lost in post-operative hsematemesis could not possibly, unaided, bring about a fatal result. A superadded toxtemia alone can account for it. This view is confirmed by Engelhardt and Neck, who, after a long series of experiments on the relation of ligature of the omentum and its relation to hrematemesis, come to the conclusion that one must, in case of ulcers or erosions in the stomach, first exclude bacterial infection of the stomach, by careful microscopic examination, before considering hypothetically other possibilities. POST-OPERATIVE H^EMATEMESIS. 247

Referring to the method of infection of the stomach, after omental ligature, they conclude that it occurs either directly from the omentum, by passing back along the thrombosed veins, or through the systemic circulation. Prognosis.?Is always grave. The conclusions I have come to are these? 1. Tlie more marked the septic reaction is in a case?as shown by discharge from the wound and temperature?the better is the chance of recovery. 2. Subdued or masked infection, with subnormal temperature and rapid pulse, a rapidly increasing vital depression, the vomit- ing tending to become regurgitant?all these render prognosis graver. 3. If bilious vomiting appears after one or two hsematemeses, the prognosis is favourable. The only three cases in which this sign appeared, recovered. Treatment.?The line of treatment to be adopted is one similar to that used in cases of septicaemia. The stomach should be washed out at once with 2 per cent, soda solution, at a temperature of 110? to 120? F., until the fluid returns clear; to be followed by a washing out with a 1 to 1000 solution of nitrate of silver. Where collapse is marked, infusion of normal saline into a vein should be done as well, and both procedures should be repeated if there is any return of haematemesis or collapse. Strychnine hypo- dermically is of value. All cases should be fed per rectum, and no nourishment should be given by the mouth. Tripier recom- mends high hot-water enemata, the free use of calomel and ice to the epigastrium. Delder employed ice-cold saline solution for lavage of the stomach, followed by 1 in 1000 nitrate of silver solution, as advocated by Kehr, which, in conjunction with saline infusion into the veins, brought about the recovery of his case. In a case at present under treatment in Prof. Annandale's wards, lavage with hot saline, followed by the introduction of 1-5 minims of a 10 per cent, cocaine solution, has yielded ex- cellent results. Supiarenal extract or adrenalin has not been tried in these rases, so far as I know; the disadvantage of this agent appears to lie m the transient nature of its action, and the tendency for a reaction 'when its haemostatic effect has passed off.

REFERENCES. J? Pendred.?Brit. Med. Journ., London, November 17, NELM Med. and Journ., O- inna WlNSL0W-?Boston Surg. September 21, 1900. Hughes Bennett.?Brit. Med. Journ., London, March 23, 1900. Ma^o Robson anb Moynihan.?"Surgery of the Stomach, London, 1901. Mayo Robson.?Ibid., Brit. Med. Journ., London, March 10, 1900. Yon Eisei.sberg.?-Arch. f. Tdin. Cliiv., Berlin, 1899, Bd. lix. Heft 4. Friedreich.? Verliandl. d. deidscli. Gesellsch. f. Cliir., 248 E. PERCY PATON.

Berlin, April 20, 1900. Adolf Deiiler.?Deutsche Ztsclir. f. Clnr., Leipzig, 1900, l>d. Ivii. S. 10. Lauenstein.?Ibid., 1900, Ed. lvii. S. 9. Schmidt.?Ibid., 1900, Bd. lv. S. 28. Reichard.?Centralbl. f. Cliir., Leipzig, 1900, No. 5. Kehr.?"Gall Stone Disease," London, 1901. Dieulafoy.?Bull. Acad, de vied., Paris, Fevrier 12, 1901. Lucas Champonniere.?Ibid., Fevrier 19 et 26, 1901. Guyon.? Ibid. Tripier.?Semaine med., Paris, 1898, tome xviii. p. 241. Broca.?Bidl. et mem. Soc. de Cliir. de Paris, Juillet, 1900, tome xxvi. Mansell Moullin. Lancet, London, October 20, 1900. Rodman.?Trans. Am. Surg. June, 1900. Engeliiardt und Neck.?Deutsche Ztsclir. f. Cliir., Leipzig, 1901, Bd. lviii. No. 17.