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, hernia (eight cases), gall-bladder (three cases), appendicitis (six cases); also after ovariotomy, tuberculous peritonitis, 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, vomiting, and constipation ; 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 abdominal pain. 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 jaundice; 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 liver showed no ?change. The omentum shows areas of fat necrosis. Case 4.?Peter C., a3t. 50 (Prof. A.), had suffered from renal colic 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 <nrinal hernia for some years. No record of previous history.?Operation, November 17, 1896.?Radical cure of hernia. Omentum probably not removed. Wound became septic. CHC13 sickness was not noted. The first liaematemesis occurred seven days after operation, when, in the course of the afternoon, he vomited clots of dark blood, in all three times. He subsequently vomited bilious fluid. Was slightly collapsed for some hours after the haematemesis. There was no return of hsematemesis, and recovery was complete. Case G.?James M'N., ret. 32 (Mr. MacG.), had a right inguinal hernia for twelve years, irreducible of late years. Has never had gastric trouble.?Operation, May 3, 1901.?Sac contained caecum and appendix ; there were many adhesions. The appendix was removed, but no omentum. Chloroform sickness commenced immediately after opera- tion. The first hsematemesis occurred three hours later, gradually replacing the bilious vomit. Continued for half an hour in small quantities. Six hours later, he twice vomited a few ounces of grumous fluid. During the next two days was sick at intervals, but the vomit was free from blood. Temperature rose gradually to 101?, and on the fifth day profuse sero-sanguineous discharge took place from the wound. On the sixth day the temperature fell, but he coughed Tip mucus streaked with blood. No physical signs were found in the lungs, and the haemoptysis did not recur. Discharge from the wound ceased, but the temperature rose again, and on the fourteenth day the wound became red and tender. A considerable quantity of dark blood clot Avas evacuated, but no pus. Blood oozed freely for some days, then gradually ceased. The temperature fell, but on the thirty-second day rose again, due to the presence of a deep-seated abscess at the upper part of the wound. This was evacuated. His subsequent progress was satisfactory. Case 7.?David T.s ret. 62 (Prof. C.), had symptoms of vesical calculus for three years, latterly some cystitis, never any blood. Urine was purulent. No history of gastric trouble. Suprapubic lithotomy was performed on January 27, 1893, and the bladder drained. He struggled violently during anaesthesia, and CHCl.j sickness commenced early. It continued all day and night at intervals, and less frequently on the following day; was checked by bromide and hot coffee. During the next night he twice vomited bilious fluid. The first lirematemesis took place next morning, forty-six hours after operation, a large quantity of clotted blood. In half an hour, again vomited a small quantity of clots. Rectal feeding was adopted and ergot given, but five hours later he vomited grumous fluid, and died fifty-four hours after operation. It was concluded that an atheromatous vessel had ruptured. The sectio showed extensive atheroma. The stomach and upper part of small intestine contained dark blood. There were two old ulcers on the lesser curvature of the stomach. An arterial branch close to an ulcer had a clot in it discoloured by the stomach contents, but no perforation into the vessel could be established. There was calculous pyelitis of the right kidney. Case 8.?Mrs. K., set. 56 (Prof. A.), had gall-stone colic of five years' duration, and three years ago passed a stone. Attacks have been increasing in frequency, and she now has cholecystitis. No history of gastric trouble. Stones removed from gall bladder and cystic duct on 240 ROBERT PURYES. 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.