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PAPERS READ AT THE ANNUAL MEETING HELD IN COUNCIL BLUFFS, SEPTEMBER 6, 7, 1906.

THE CAUSE AND POSSIBLE PREVENTION OF GASTRIC AND INTESTINAL HEMORRHAGES FOLLOWING OPERATIONS FOR APPENDICITIS, HERNIA AND ALL OTHER OPERATIVE PROCEDURES INVOLVING THE BLOOD SUPPLY OF THE OMENTUM AND VISCERA.*

J. E. Summers, Jr., M. D., Omaha, Neb.

ANY surgeons of great experience have escaped having observed cases of the types indicated by the title just read, thus little has been written in this country about such hemorrhages. The best paper written in English, treating of this subject of which I have knowledge, is that by our fellow member, Dr. Donald Macrae, Jr.; the paper read in Denver, December, 1903, before the Western Surgical and Gynecological Association, and embraces, besides Dr. Macrae's own keen thoughts, the conclusions of most writers in English, as well as some Continental authors.

* President's Address, Medical Society of the Missouri Valley, Council Bluffs, Ia., September 6, 1906.

A most exhaustive and important paper by L. Sauvé, entitled "Des Hemorrhagies Intestinales, Consécutives a L'Opération des Hernies en Général" (Intestinal Hemorrhages Consecutive to Operations for Hernia in General) published in the Revue de Chirurgie, February, March and April, 1905, furnishes a fine historical sketch of the subject as well as an advanced study, and I have liberally used these articles in the preparation of my paper. Likewise Drs. Viktor Lieblein and Heinrich Hilgenreiner have written in Deutsche Chirurgie, 1905, exhaustively on "Die Geschwüre und Die Erworbenen Fisteln Des Magen-Darmkanals" (Ulcers and Acquired Fistulae of the Gastro-Intestinal Tract). In this book will be found the most complete study and bibliography yet published on all subjects which directly or indirectly may be brought within its title.

The papers of Macrae, Sauvé and Lieblein, Hilgenreiner are cf such great importance. I have not hesitated in availing myself of the work of these gentlemen, though in some respects disagreeing with them when their opinions are not borne out by my own experience.

Before discussing the etiology of these gastro-intestinal hemorrhages, I will briefly narrate my personal experiences:

CASE I. One evening some ten years ago, I saw in consultation a feeble elderly gentleman suffering with an incarcerated left inguinal hernia. The history showed that there had been many similar attacks in which reduction had been quite easy, and in this instance light taxis failing, and the symptoms of pressure being mild it was decided to apply an ice-bag. During the night the hernial protrusion returned into the abdomen. The next day there were several, not serious, bloody bowel movements. Such occurrences have been noted, especially in the days when "taxis" was the chief effort in the reduction of hernia and before early safe operation became the possible treatment.

CASE II.-I operated upon a man 60 years old for the radical cure of a long standing right inguinal hernia. The operation was not difficult, but there were numerous adhesions, both of bowel and omentum to each other and to the sac. Convalescence was ideal until the eighth day, when without warning terrible gastric hemorrhages killed the man at the end of a few hours. Post mortem examination by Dr. Lavender showed the stomach mucosa deeply stained with blood, and there were many small punctate erosions.

CASE III. I operated upon a woman 50 years of age for a large strangulated umbilical hernia. The patient lived on the Kansas border of my state, and it was twenty-four hours after the occurrence of the strangulation before I was able to reach her home and operate. There were large masses of dark colcred omentum and one loop of small bowel in the sac, the bowel was in fair condition. Most of the bad looking omental masses were removed and the operation completed as a radical cure. The patient was returned to bed in good condition, and I had no suspicion of any but a favorable result. Within two hours the patient was seized with copious hemorrhages from the stomach and died from loss of blood. No post mortem.

CASE IV. A young married woman 25 years old, six months pregnant, developed an acute right sided pyonephrosis. I drained the right

kidney through a vertical incision in the loin.

One week later the infec

tion appeared in the left kidney. I drained this kidney in the same manner as on the other side. In making the exposure of the left kidney it was noted without opening the peritoneum, that the descending colon hugged the kidney and left loin, i.e., that its mesocolon was unusually short, and in the technic of exposing and draining the kidney, the mesocolon was necessarily manipulated more than is customary. Twenty-four hours after the second operation abortion took place. On the fourth day following operation terrible hemorrhages from the bowel occurred, killing the patient.

Post mortem by Dr. Ludington. Starting opposite the kidney and descending down practically the whole length of the descending colon, the mucous membrane was dyed with blood. There were no macroscopical ulcerations; the blood had oozed through the mucous membrane and caused death by hemorrhage.

CASE V. I did a resection of the transverse colon for carcinoma in a man 38 years old. With the exception of the pathology indicated the abdominal organs appeared healthy. A few hours after the operation blood appeared in the vomitus-the vomiting had been induced by the ether anesthesia. I was fearful of serious, if not fatal, consequences, but the hemorrhage soon ceased and the recovery was further uneventful.

These five cases (reported in synopsis) at the times of their occurrence, have given me much anxiety and self-communion. Many causes for the occurrence of gastric or intestinal hemorrhage following the kinds of operations indicated in the title, have been written of, some of which are easily understood, per ex. diseases of the liver or circulatory apparatus or tumors. Any pre-existing lesion causing congestion or damming back of the portal circulation may readily after moderately gentle manipulation of either the stomach or intestinal walls lead to moderate or severe hemorrhages into these viscera. Ischemia or cholemia are known to tends towards hemorrhage, likewise sepsis and personal idiosyncrasies. Undoubtedly all of these and other conditions have lead to serious, if not fatal, gastro-intestinal hemorrhage. "A hematemesis from a venous cirrhosis is not compatible with a normal individual; one of the principal troubles of all hepatic dyscrasias is a tendency to hemorrhages; and cirrhotics bleed from their stomachic and esopbogical veins exactly in the same manner as they have epistaxis" (Sauvé).

When such conditions could be reasonably excluded I have no conception of hemorrhages of this kind following operations outside the abdomen, although they have happened, in my opinion other explanations of their occurrence are understandable.

The practical points to consider are: 1st. What are the causes of these hemorrhages? 2d. How are they avoided? 3d. When they do occur what is the most hopeful treatment? In the study of reported cases of post-operative gastric and intestinal hemorrhages one is immediately struck by the fact that there are two types: those in which the hemorrhage occurs a few hours after the operation, and those in which the hemorrhage does not follow until about the end of the fourth day to later periods. Although many writers, among them Rodman in America, have

attributed these post-operative hemorrhages to sepsis, I am firmly convinced that trauma is at the bottom of all cases in which no pre-existing circulatory congested condition existed; and when these hemorrhages have followed extra-abdominal operations unintentional trauma was applied in some way to the abdominal viscera by position or pressure on the abdominal walls.

To date it has never been positively proven, experimentally, clinically or by post mortem whether in these post-operative gastric or intestinal hemorrhages the source of the hemorrhage was venous or arterial. In this connection it may be profitable to review briefly some of the experimental and clinical facts from which deductions have been made. The study of these intestinal hemorrhages was at first confined to their relation to strangulated hernia. The tightness and the duration of the constriction, the amount of force applied by taxis, and the length of the intestinal loop constricted determined in a degree the volume of the intestinal hemorrhage. Schnitzler basing his conclusions upon the experimental work of Litten in the application of ligatures to mesenteric vessels in the study of the production of infarctions, wrote in 1894 the first scientific article on the symptoms, cause and prognosis of these immediate or early enterorrhagias, and the condition has been designated "Schnitzler's Disease.

As Schnitzler had written of early hemorrhages, Ullman wrote of late hemorrhages, their production from four to seventeen days after operation, declaring the cause to be a thrombosis of the mesenteric arteries; he showed that hemorrhage might occur in non-strangulated cases. These late hemorrhages were designated as the "Type Ullmann." The next article of note was by Kukula of Prague who insisted that a venous thrombosis was the causes of the hemorrhages, insisting upon the complexity of their causes (Sauvé) "Schnitzler, Ullmann, and Kukula are the three great names connected with the subject of hernial enterorrhagia, and those who have written later are chiefly paraphrasers."

A resumé of the ideas of Schnitzler, Ullmann and Kukula may be worth while in the understanding of both early and late intestinal and gas. tric hemorrhages following abdominal operations (Sauvé), As a result of Litten's experiments, above referred to, published in Virchow's Archives 1875, it was shown that enterorrhagia did not follow if the ligature was removed and the blood current in the mesenteric arterioles and the capillary arteries and veins re-established before they were destroyed, otherwise it did.

Litten in writing of his experiments says, "Apply a ligature on a branch of the mesenteric artery. At the moment of ligation naturally all pulsation ceases in the artery and the intestine becomes anemic. The ligature must remain two and one-half hours before the destruction of the intestinal vessels of a dog is produced. If then one removes the ligature, immediately the blood is precipitated from the aorta into the territory of the mesenteric artery, and in an instant a powerful pulsation is established, and is followed by a great hemcrrhage into the mesentery and under the peritoneal covering along the vessels. Hemorrhages into the intestine likewise occur.

"After a short time the extravasation can follow if the ligature has not remained too long and if peritonitis does not develop. The hemor