- Email: [email protected]
Gallstone obstruction of bowel
GALLSTONE OBSTRUCTION OF BOWEL A. A. SKEMP,
M.D. AND F. LA
CROSSE,
T
HE etiology of bowe1 obstruction is frequentIy obscure and frequently regardIess how thorough and painstaking the investigation, one is surprised when the uItimate cause is uncovered either at operation or at postmortem examination. A case recentIy under observation had certain features of rather unusuaI interest and seemed worth whiIe recording. A femaIe patient, aged seventy-two years, entered the hospitaI compIaining of nausea, persistantIy increasing vomiting and epigastric pain of three days duration. She was perfec,tIy we11 prior to onset of these symptoms. Two years previousIy she had a simiIar attack which Iasted for two weeks. She had had no gaII-bIadder coIic, jaundice or vomiting of bIood. In the past, there have been attacks of diarrhea which Iasted onIy a day. She has had food dyscrasia. RecentIy there has been some sweIIing of the ankIes and shortness of breath. On physica examination patient was found to be obese and seemed quite duI1 mentaIIy. Temperature, puIse and respiration were normaI. The heart and Iungs were normaI. The abdomen was very much distended with marked tenderness in the right Iower quadrant. There was ankIe edema. BIood pressure was 172/70, the urine was scanty and showed a trace of albumin and some white bIood ceIIs. Two white bIood counts showed Ieucocytosis of 15,000 and 12,000. Non-protein nitrogen 97 mgm. per IOO C.C. of bIood. Patient refused surgery. Hot turpentine stupes were appIied, milk of moIasses enema given and the Wangensteen method of siphonage was used to contro1 the vomiting and reduce the distention. The second day after admission the patient was comatose, the distention increased and she died the fourth day after admission. The postmortem findings are reported from the records of Dr. E. Thurston, resident pathoIogist. Body is that of a we11 nourished eIderIy white femaIe. Livor mortis is present in the 166
G. TRAVNICEK,
M.D.
WISCONSIN
dependent parts. There is a huge distention of the abdomen. There is a moderate pitting edema of the ankIes. Abdominal Cavity: Upon opening the abdomen the greatIy distended Ioops of smaI1 intestine force their way into the incision. These Ioops are markedIy engorged, and from the serosa1 surface smaI1 quantities of fibrin may be scraped. There is no free IIuid or gas present. Tboracic Cavity and Organs: Both Iungs are bound down on a11 surfaces by oId adhesions. There is no free ffuid in either pIeura1 cavity. On section, the Iungs are crepitant, with a few areas of ataIectasis. There is no free ffuid in the pericardia1 cavity, and no changes are noted in the endocardium except for a sIight degree of thickening of the aortic cusp of the mitra1 vaIve. Myocardium is firm. There is a sIight degree of fatty infiItration into the right heart muscIe. There is a sIight degree of arterio scIerosis of the coronaries and aorta. Abdominal Organs: The previousIy described degree of distention is found to end abruptIy about 20 cm. proxima1 to the iIeocoIic vaIve in the iIeum. Distant to this point the iIeum is apparentIy of a norma appearance. A firm mass Iying within the Iumen of the iIeum at this point is found to be the cause of the distention. Stomach: No changes are noted in the stomach except for a sIight degree of congestion. The mucosa of the duodenum is hyperemic and shows many petechia1 hemorrhages. Gall bladder is found adherent in the first part of the duodenum. Upon opening the duodenum a fistuIa is found between the fundus of the gaI1 bIadder and the Iumen of the duodenum. This opening is approximateIy one centimeter in diameter. Upon opening the gaI1 bIadder, severa smaI1 stones are found in the contracted sac. The ampuIIa of Vater is found to be patuIous and shows the signs of the previous passage of gaIlstones by the tears in the waIIs. The common biIe duct is opened and no changes noted in the hepatic ducts. The cystic duct is found and dissected, it ending at its junction with gaI1 bIadder.
bIindIy
New SERIESVOL. XxX11, No. I
Skemp
& Travnicek-Obstruction
Jejunum and Ileum: The mucosa of the opened jejunum and iIeum everywhere is markedIy engorged and shows in many places smaII spherica uIcers. Dissecting down to the point of obstruction the cause is found to be a gallstone, measuring 4 cm. in Iength and 2 cm. in breadth. At the point of impaction, the mucosa is markedIy uIcerated. No changes are noted in the coIon. Kidneys are somewhat Iarger than usua1, the capsuIes of each stripping easiIy but the surfaces are fineIy scarred and severa smaI1 cysts are noted. On section there seemed to be a thinning of the cortex. There is granuIar appearance and irreguIarity of the coIumns of gIomeruli. There is an increase in the peripeIvic fat. No changes ard noted in the ureters or bIadder. Ovaries are atrophic; the uterus is small and hard. Provisional Anatomic Diagnosis: I. Old choIecystitis and choIeIithiasis. 2. ChoIecystoduodenaI fistula. 3. Acute intestina1 obstruction due to gaIIstones. 4. Toxemia. 3. Chronic parenchymatous nephritis. We have reviewed a series of cases recentIy reported in various journaIs and have noted the features of interest which are prominent in the symptomatoIogy and treatment of the cases. It is obvious that the mortahty rate is extremeIy high as the diagnosis is practicaIIy never made accurateIy, aIthough obstruction of the bowe1 is generaIIy suspected. One very outstanding feature in recounting the case protocoIs has been that very frequently there has been no history of either gaIIbIadder colic or galI-bladder dyspepsia, and very frequentIy Iikewise “scout pIates” of the abdomen have faiIed to revea1 gaIIstones. In our own case the history of gaIIbIadder disturbance was inadequate for diagnosis, the opening between the gaI1 bIadder and the duodenum was scarceIy more than one centimeter in diameter. The common duct was smaI1 and constricted but this huge gaIIstone couId find an unphysiologic exit from its habitat in the gaI1 bIadder and stiI1 obstruct the bowe1
American
~~~~~~~or surgery
I 67
and cause death. This occurred in a portion of the bowe1 where distensibiIity is great and where there is no sphincteric action to be responsibIe for the obstruction. Reference has been made to the passage of Iarge gaIIstones through the common duct causing obstruction of the small boweI. StiII we could find no exampIe of this type of stone migration. The stones generaIIy recorded have been of more or Iess uniform size of 3 to 4 cm. The mortaIity, although unusuaIIy high, seems to depend in a measure on severa factors. The first and foremost is the faiIure of diagnosis. The symptomatology is not fuIminating enough to persuade the patient to consult the doctor earIy and the doctor has frequentIy procrastinated because of the unusua1 features which generaIIy present themseIves at the time of the first examination. FrequentIy the obstruction at first is onIy partia1 and this is often misIeading. The second factor in the high mortaIity rate is the roIe pIayed by the various degenerative diseases we found in these seniIe patients. Perforations and peritonitis have Iikewise been the cause of death. In our patient the initia1 examination was made three days after the onset of the symptoms, and aIthough obstruction of the bowe1 was diagnosed, the patient refused surgery. Preoperative diagnosis did not consider gaIIstone obstruction but rather a large bowe1 maIignancy. There seems no reason why a reasonabIy Iow mortaIity cannot be obtained in the operative management of these cases if it is feIt that the obstruction of the bowe1 means surgery and that this shouId be instituted as soon as possibIe after the onset of symptoms. The comatose condition of our patient and the high nonprotein-nitrogen content of the bIood, made us fee1 that uremia was deveIoping, but it shouId not be forgotten that the bowel obstruction is featured by bIood chemistry of that type and shouId not be considered too seriousIy in the appraisa1 of the operabihty of the case.
168
American Journal of Surgery
Skemp
In conch&on, obstruction gaItstone shouId not be forgotten in obese individuah with a mild evoIution of obstructive symptoms even though there is no past history of gahstone cohc or of gaII-bladder dyspepsia. X-rays wiII not make the diagnosis which wiI1 always be tentative unti1 the visua1 examination at the operative tabIe or postmortem examination. REFERENCES GARDINER, H. IntestinaI obstruction due to gallstones. The Lancer, (Aug. 12) 1933. JOHNS, JOSEPH. Intestinal obstruction due to impacted gaIIstones. Jour. of Micb. St. Med. Sot., (March) 1933. MARSHAL, V. F., HEITMEYER, P. L. and SWANTON, M. E. IntestinaI obstruction due to gallstones. Wise. Med. Jour., (Jan.) 1931. ANGLE, LEWIS W. Acute intestina1 obstruction caused by impacted gaIlstones. Am. J. Surg., (Sept.) 1932. VAN RAVENSWAAY, ALEX. Acute intestina1 obstruction by Iarge gaIlstone. Am. J. Surg., (April) 1932.
REFERENCES 7. WIDENMANN, A. Ueber partieIIen Riesenwuchs. Beitr. 2. @in. Cbir., 8: 625-638, r8gr-1892. und Hemihyper8. STIER, E. Uber Hemiatrophie trophie nebst einigen Bemerkungen iiber ihre Iaterale LokaIisation. Deutscbe Ztscbr. j. Nervenbeilk., 44: 21-64, 1912. g. WIELAND, E. Zur PathoIogie der dystrophischen Form des angeborenen partieIIen Riesenwuches. Jab&. j. Kinderb., 65: 519584, 1907. IO. COHNHEIM, J. F. Lectures on General PathoIogy, 1889-1890. I I. WAGNER, P., Zur Casuistik des angeborenen und erworbenen Riesenwuches. Deutscbe Ztscbr. j. Cbir., 26: 281-306, 1887. 12. HAGEN, F. B. Ueber Knockenund GeIenkanomaIieen, insbesondere bei partieIIem Riesenwuchs und bei muItipIen cartigaginfren Exostosen., Arch. j. klin. Cbir., 41: 420-466, 1891. 13. KITAIGORODSKAJA, 0. D. Angeborene Hypertrophie im WindesaIter. Jabrb. .f. Kinderb., 125:
38-89. rgzg
APRIL,1936
& Travnicek-Obstruction
14. BROCA and MASSONAUD. J. Pbysiol. BrownSequard, 1859. 15. CAUBET, H., and MERCAD$, S. Hypertrophie CongenitaIe des OrteiIs. Rev. de cbir., 29: 86-104, 493-509, 613-627, 1904. 16. SPREITZER, 0. H. CongenitaI partia1 gigantism; gigantism of feet. Ztscbr. j. ortbop. Cbir., 58: 423-431, 1933. 17. MCFARLAND, B. L. Hemihypertrophy. Brit. M. J., I: 345-346, (Mar. 3) x928.
ALDRICH. J. F. and BARNES, BENJAMIN S. Obstruction of the smaI1 intestines due to gaIlstones. Jour. lowa St. Med. Sot., (Feb.) 1933. VIDGOFF, JACK. Acute intestina1 obstruction due to gaIIstones. Am. J. Surg., (March) 1933. JUNKIN, H. D. Obstruction due to gaIIstones. Am. J. Surg., (March) 1933. ROSENTHAL, EUGENE. IntestinaI obstruction caused by impacted gallstones. The Lancet, (JuIy) 1934. MCWHORTER, GOLDER L. Acute obstruction of the smaI1 intestine due to a gaIIstone. Arch. Surg., (Nov.) 1929. COOK, P. H. and WATKINS, ROYAL P. Recurring intestina obstruction by gaIIstones. New England Jour. Med., (Sept. 8) 1929. HENNESY, M. C. Intestinal obstruction due to a gaIIstone. Jour. Iowa St. Med. Sot., (Nov.) 1934. CURRY, J. G. GaIIstone intestinal obstruction. Jour. Micb. Med. Sot., (Jan.) 1931. DIACK, SAMUEL L. and FAGAN, EDWIN P. Intestinal obstruction due to gallstones. Surgical Clinics of North America. (Dec.) 1934 (Pacific Coast). CABOT, RICHARD, C. An abdomina1 emergency with vomiting and epigastric pain in a woman of 77. New England Jour. Med., (March 2) 1933. JACKSON, J. A. and EWELL, G. H. Acute intestinal obstruction due to a Iarge gaIIstone. Wise. Med. Jour., (Nov.) 1930.
OF DR. THOMAS* 18. LISSER, HANS. CongenitaI total hemihypertrophy, J. A. M. A., 82: 1046, (Mar. 29) 1924. rg. WAKEFIELD, E. G. Unilateral, congenita1 hypertrophy, invoIving right side of a femaIe aged six. Ann. Int. Med., I: 292-296, (Nov.) 1927. 20. PIRES DE LIMA, J. A. Macrodactyly of toes; case. Ann. d’anat. path., 4: 219-221, (Feb.) 1927. 2 I. CURRI, D. MegaIosyndactyIia of foot; case. Cbir. d. org. di movimento, 18: 243-248, (Sept.) 1933. 22. L,~PEz, R. VARA. CongenitaI megaIodactyIia; case. Progresos de la clin., 42: 96-99, (Feb.) 1934. 23. DOMBROVSKY, A. I. MegaIosyndactyIia; case. Miincben. med. Wcbnscbr., 75: 1503, (Aug. 31) 1928. 24. YMAZ, J. I. MacrodactyIy; pathogenesis and surgica1 therapy; case. Hosp. argent., 3: IIOO1103, (June 15) 1933. 25. WESTERGAARD,0. H. MegaIodactyIia of right foot, Med. rev., 51: 62-67, (Jan.-Feb.) 1934. 26. TATAFIORE, E. CongenitaI macrodactyly; case. Pediatria, 42: 405-412, (April) 1934. 27. ALOI, V. Case of giant toe. Rijorma med., 43: 79, (Jan. 24) 1927. 28. BUJWID, 0. Rare monstrosity of foot (macrodactyIy); case. Polska gas. lek., 6: 960, (Nov. 20) 1927. 29. YOKOTA, K. SyndactyIia combined with macrodactyIy in patient with fibrolipoma of right foot. Taiwan Igakkai Zassbi (Abstr. Sect.), 33: 5, (Feb.)
* Continued from p. I I 2.
1934.
M.D. AND F. LA
CROSSE,
T
HE etiology of bowe1 obstruction is frequentIy obscure and frequently regardIess how thorough and painstaking the investigation, one is surprised when the uItimate cause is uncovered either at operation or at postmortem examination. A case recentIy under observation had certain features of rather unusuaI interest and seemed worth whiIe recording. A femaIe patient, aged seventy-two years, entered the hospitaI compIaining of nausea, persistantIy increasing vomiting and epigastric pain of three days duration. She was perfec,tIy we11 prior to onset of these symptoms. Two years previousIy she had a simiIar attack which Iasted for two weeks. She had had no gaII-bIadder coIic, jaundice or vomiting of bIood. In the past, there have been attacks of diarrhea which Iasted onIy a day. She has had food dyscrasia. RecentIy there has been some sweIIing of the ankIes and shortness of breath. On physica examination patient was found to be obese and seemed quite duI1 mentaIIy. Temperature, puIse and respiration were normaI. The heart and Iungs were normaI. The abdomen was very much distended with marked tenderness in the right Iower quadrant. There was ankIe edema. BIood pressure was 172/70, the urine was scanty and showed a trace of albumin and some white bIood ceIIs. Two white bIood counts showed Ieucocytosis of 15,000 and 12,000. Non-protein nitrogen 97 mgm. per IOO C.C. of bIood. Patient refused surgery. Hot turpentine stupes were appIied, milk of moIasses enema given and the Wangensteen method of siphonage was used to contro1 the vomiting and reduce the distention. The second day after admission the patient was comatose, the distention increased and she died the fourth day after admission. The postmortem findings are reported from the records of Dr. E. Thurston, resident pathoIogist. Body is that of a we11 nourished eIderIy white femaIe. Livor mortis is present in the 166
G. TRAVNICEK,
M.D.
WISCONSIN
dependent parts. There is a huge distention of the abdomen. There is a moderate pitting edema of the ankIes. Abdominal Cavity: Upon opening the abdomen the greatIy distended Ioops of smaI1 intestine force their way into the incision. These Ioops are markedIy engorged, and from the serosa1 surface smaI1 quantities of fibrin may be scraped. There is no free IIuid or gas present. Tboracic Cavity and Organs: Both Iungs are bound down on a11 surfaces by oId adhesions. There is no free ffuid in either pIeura1 cavity. On section, the Iungs are crepitant, with a few areas of ataIectasis. There is no free ffuid in the pericardia1 cavity, and no changes are noted in the endocardium except for a sIight degree of thickening of the aortic cusp of the mitra1 vaIve. Myocardium is firm. There is a sIight degree of fatty infiItration into the right heart muscIe. There is a sIight degree of arterio scIerosis of the coronaries and aorta. Abdominal Organs: The previousIy described degree of distention is found to end abruptIy about 20 cm. proxima1 to the iIeocoIic vaIve in the iIeum. Distant to this point the iIeum is apparentIy of a norma appearance. A firm mass Iying within the Iumen of the iIeum at this point is found to be the cause of the distention. Stomach: No changes are noted in the stomach except for a sIight degree of congestion. The mucosa of the duodenum is hyperemic and shows many petechia1 hemorrhages. Gall bladder is found adherent in the first part of the duodenum. Upon opening the duodenum a fistuIa is found between the fundus of the gaI1 bIadder and the Iumen of the duodenum. This opening is approximateIy one centimeter in diameter. Upon opening the gaI1 bIadder, severa smaI1 stones are found in the contracted sac. The ampuIIa of Vater is found to be patuIous and shows the signs of the previous passage of gaIlstones by the tears in the waIIs. The common biIe duct is opened and no changes noted in the hepatic ducts. The cystic duct is found and dissected, it ending at its junction with gaI1 bIadder.
bIindIy
New SERIESVOL. XxX11, No. I
Skemp
& Travnicek-Obstruction
Jejunum and Ileum: The mucosa of the opened jejunum and iIeum everywhere is markedIy engorged and shows in many places smaII spherica uIcers. Dissecting down to the point of obstruction the cause is found to be a gallstone, measuring 4 cm. in Iength and 2 cm. in breadth. At the point of impaction, the mucosa is markedIy uIcerated. No changes are noted in the coIon. Kidneys are somewhat Iarger than usua1, the capsuIes of each stripping easiIy but the surfaces are fineIy scarred and severa smaI1 cysts are noted. On section there seemed to be a thinning of the cortex. There is granuIar appearance and irreguIarity of the coIumns of gIomeruli. There is an increase in the peripeIvic fat. No changes ard noted in the ureters or bIadder. Ovaries are atrophic; the uterus is small and hard. Provisional Anatomic Diagnosis: I. Old choIecystitis and choIeIithiasis. 2. ChoIecystoduodenaI fistula. 3. Acute intestina1 obstruction due to gaIIstones. 4. Toxemia. 3. Chronic parenchymatous nephritis. We have reviewed a series of cases recentIy reported in various journaIs and have noted the features of interest which are prominent in the symptomatoIogy and treatment of the cases. It is obvious that the mortahty rate is extremeIy high as the diagnosis is practicaIIy never made accurateIy, aIthough obstruction of the bowe1 is generaIIy suspected. One very outstanding feature in recounting the case protocoIs has been that very frequently there has been no history of either gaIIbIadder colic or galI-bladder dyspepsia, and very frequentIy Iikewise “scout pIates” of the abdomen have faiIed to revea1 gaIIstones. In our own case the history of gaIIbIadder disturbance was inadequate for diagnosis, the opening between the gaI1 bIadder and the duodenum was scarceIy more than one centimeter in diameter. The common duct was smaI1 and constricted but this huge gaIIstone couId find an unphysiologic exit from its habitat in the gaI1 bIadder and stiI1 obstruct the bowe1
American
~~~~~~~or surgery
I 67
and cause death. This occurred in a portion of the bowe1 where distensibiIity is great and where there is no sphincteric action to be responsibIe for the obstruction. Reference has been made to the passage of Iarge gaIIstones through the common duct causing obstruction of the small boweI. StiII we could find no exampIe of this type of stone migration. The stones generaIIy recorded have been of more or Iess uniform size of 3 to 4 cm. The mortaIity, although unusuaIIy high, seems to depend in a measure on severa factors. The first and foremost is the faiIure of diagnosis. The symptomatology is not fuIminating enough to persuade the patient to consult the doctor earIy and the doctor has frequentIy procrastinated because of the unusua1 features which generaIIy present themseIves at the time of the first examination. FrequentIy the obstruction at first is onIy partia1 and this is often misIeading. The second factor in the high mortaIity rate is the roIe pIayed by the various degenerative diseases we found in these seniIe patients. Perforations and peritonitis have Iikewise been the cause of death. In our patient the initia1 examination was made three days after the onset of the symptoms, and aIthough obstruction of the bowe1 was diagnosed, the patient refused surgery. Preoperative diagnosis did not consider gaIIstone obstruction but rather a large bowe1 maIignancy. There seems no reason why a reasonabIy Iow mortaIity cannot be obtained in the operative management of these cases if it is feIt that the obstruction of the bowe1 means surgery and that this shouId be instituted as soon as possibIe after the onset of symptoms. The comatose condition of our patient and the high nonprotein-nitrogen content of the bIood, made us fee1 that uremia was deveIoping, but it shouId not be forgotten that the bowel obstruction is featured by bIood chemistry of that type and shouId not be considered too seriousIy in the appraisa1 of the operabihty of the case.
168
American Journal of Surgery
Skemp
In conch&on, obstruction gaItstone shouId not be forgotten in obese individuah with a mild evoIution of obstructive symptoms even though there is no past history of gahstone cohc or of gaII-bladder dyspepsia. X-rays wiII not make the diagnosis which wiI1 always be tentative unti1 the visua1 examination at the operative tabIe or postmortem examination. REFERENCES GARDINER, H. IntestinaI obstruction due to gallstones. The Lancer, (Aug. 12) 1933. JOHNS, JOSEPH. Intestinal obstruction due to impacted gaIIstones. Jour. of Micb. St. Med. Sot., (March) 1933. MARSHAL, V. F., HEITMEYER, P. L. and SWANTON, M. E. IntestinaI obstruction due to gallstones. Wise. Med. Jour., (Jan.) 1931. ANGLE, LEWIS W. Acute intestina1 obstruction caused by impacted gaIlstones. Am. J. Surg., (Sept.) 1932. VAN RAVENSWAAY, ALEX. Acute intestina1 obstruction by Iarge gaIlstone. Am. J. Surg., (April) 1932.
REFERENCES 7. WIDENMANN, A. Ueber partieIIen Riesenwuchs. Beitr. 2. @in. Cbir., 8: 625-638, r8gr-1892. und Hemihyper8. STIER, E. Uber Hemiatrophie trophie nebst einigen Bemerkungen iiber ihre Iaterale LokaIisation. Deutscbe Ztscbr. j. Nervenbeilk., 44: 21-64, 1912. g. WIELAND, E. Zur PathoIogie der dystrophischen Form des angeborenen partieIIen Riesenwuches. Jab&. j. Kinderb., 65: 519584, 1907. IO. COHNHEIM, J. F. Lectures on General PathoIogy, 1889-1890. I I. WAGNER, P., Zur Casuistik des angeborenen und erworbenen Riesenwuches. Deutscbe Ztscbr. j. Cbir., 26: 281-306, 1887. 12. HAGEN, F. B. Ueber Knockenund GeIenkanomaIieen, insbesondere bei partieIIem Riesenwuchs und bei muItipIen cartigaginfren Exostosen., Arch. j. klin. Cbir., 41: 420-466, 1891. 13. KITAIGORODSKAJA, 0. D. Angeborene Hypertrophie im WindesaIter. Jabrb. .f. Kinderb., 125:
38-89. rgzg
APRIL,1936
& Travnicek-Obstruction
14. BROCA and MASSONAUD. J. Pbysiol. BrownSequard, 1859. 15. CAUBET, H., and MERCAD$, S. Hypertrophie CongenitaIe des OrteiIs. Rev. de cbir., 29: 86-104, 493-509, 613-627, 1904. 16. SPREITZER, 0. H. CongenitaI partia1 gigantism; gigantism of feet. Ztscbr. j. ortbop. Cbir., 58: 423-431, 1933. 17. MCFARLAND, B. L. Hemihypertrophy. Brit. M. J., I: 345-346, (Mar. 3) x928.
ALDRICH. J. F. and BARNES, BENJAMIN S. Obstruction of the smaI1 intestines due to gaIlstones. Jour. lowa St. Med. Sot., (Feb.) 1933. VIDGOFF, JACK. Acute intestina1 obstruction due to gaIIstones. Am. J. Surg., (March) 1933. JUNKIN, H. D. Obstruction due to gaIIstones. Am. J. Surg., (March) 1933. ROSENTHAL, EUGENE. IntestinaI obstruction caused by impacted gallstones. The Lancet, (JuIy) 1934. MCWHORTER, GOLDER L. Acute obstruction of the smaI1 intestine due to a gaIIstone. Arch. Surg., (Nov.) 1929. COOK, P. H. and WATKINS, ROYAL P. Recurring intestina obstruction by gaIIstones. New England Jour. Med., (Sept. 8) 1929. HENNESY, M. C. Intestinal obstruction due to a gaIIstone. Jour. Iowa St. Med. Sot., (Nov.) 1934. CURRY, J. G. GaIIstone intestinal obstruction. Jour. Micb. Med. Sot., (Jan.) 1931. DIACK, SAMUEL L. and FAGAN, EDWIN P. Intestinal obstruction due to gallstones. Surgical Clinics of North America. (Dec.) 1934 (Pacific Coast). CABOT, RICHARD, C. An abdomina1 emergency with vomiting and epigastric pain in a woman of 77. New England Jour. Med., (March 2) 1933. JACKSON, J. A. and EWELL, G. H. Acute intestinal obstruction due to a Iarge gaIIstone. Wise. Med. Jour., (Nov.) 1930.
OF DR. THOMAS* 18. LISSER, HANS. CongenitaI total hemihypertrophy, J. A. M. A., 82: 1046, (Mar. 29) 1924. rg. WAKEFIELD, E. G. Unilateral, congenita1 hypertrophy, invoIving right side of a femaIe aged six. Ann. Int. Med., I: 292-296, (Nov.) 1927. 20. PIRES DE LIMA, J. A. Macrodactyly of toes; case. Ann. d’anat. path., 4: 219-221, (Feb.) 1927. 2 I. CURRI, D. MegaIosyndactyIia of foot; case. Cbir. d. org. di movimento, 18: 243-248, (Sept.) 1933. 22. L,~PEz, R. VARA. CongenitaI megaIodactyIia; case. Progresos de la clin., 42: 96-99, (Feb.) 1934. 23. DOMBROVSKY, A. I. MegaIosyndactyIia; case. Miincben. med. Wcbnscbr., 75: 1503, (Aug. 31) 1928. 24. YMAZ, J. I. MacrodactyIy; pathogenesis and surgica1 therapy; case. Hosp. argent., 3: IIOO1103, (June 15) 1933. 25. WESTERGAARD,0. H. MegaIodactyIia of right foot, Med. rev., 51: 62-67, (Jan.-Feb.) 1934. 26. TATAFIORE, E. CongenitaI macrodactyly; case. Pediatria, 42: 405-412, (April) 1934. 27. ALOI, V. Case of giant toe. Rijorma med., 43: 79, (Jan. 24) 1927. 28. BUJWID, 0. Rare monstrosity of foot (macrodactyIy); case. Polska gas. lek., 6: 960, (Nov. 20) 1927. 29. YOKOTA, K. SyndactyIia combined with macrodactyIy in patient with fibrolipoma of right foot. Taiwan Igakkai Zassbi (Abstr. Sect.), 33: 5, (Feb.)
* Continued from p. I I 2.
1934.