VOLUME LXXXXVIII NUMBER 6.

ANNUAL SUBSCRIPTION THREE DOLLARS.

It has been my fortune to have seen three cases of typhoid perforation during the past winter. Two cases occurred under my observation on the East Medical Service of the Cincinnati Hospital (Dr. Joseph Eichberg), and the other case I report conjointly with Dr. J. R. King, of Hyde Park.

The cases are interesting not only from the results, but more so from the standpoint of diagnosis. We should be on the alert for such occurrences as hemorrhage and perforration in all our typhoids, and still even in the third week of typhoid we have all had experiences in this disease which make us hesitate before pronouncing a definite opinion on the symptoms. I call special attention to the symptoms in these cases which allowed us to make the diagnosis of typhoid perforation.

CASE I.

Frank T., aged twenty-six, admitted to hospital March 16, 1907.

Patient claimed he had never been sick in his life, except three attacks of stomach trouble in past eighteen months, which attacks consisted of pains only, without further disturbance. Onset began eight days previously with headache, general malaise, weakness, anorexia, abdominal pain, constipation, fever and some cough. Temperature 103.2°, pulse 92, respiration 24. Expression a trifle dull, eyes heavy. Breath sounds are sharpened, few inconstant high-pitched râles over big tubes. Heart, first sound a little prolonged. Pulse regular, fair volume and tension, arteries normal.

Abdominal wall tensely held, note tympanitic, pain and tenderness in right iliac fossa, and along left costal edge. Liver normal in size. Spleen extends from eighth to eleventh ribs in left posterior axillary line, ninth rib and one-half inch inside mid-axillary line to ninth rib and mid-scapular line. Stomach reaches one-half inch below navel. Tongue furred over centre and tip with a heavy grayish fur; edges free and red. Appetite poor. Bowels open, stools greenish, thin, yellow and offensive. Urine clear, amber, slightly acid, 1022; no albumin, no sugar. Widal positive in forty-five minutes, 1 to 40 dilution. Whites, 4,600.

muscular abdominal pain, without other bad symptoms, relieved by ice-bag.

March 21. Again complaining of central abdominal pain to-night, no distension noted. Liver dullness normal, three stools since noon. Hope's mixture, 3 ss, two hourly, rectal tube and ice bag. Passed a good night

March 22. Fairly severe chill at 9.20 A. M., lasting twenty minutes. After chill temperature 101.2°, pulse 124, and then complains of more severe abdominal pain, localized more about navel than ever before. Abdominal wall tense, right rectus more rigid than left, local point of tenderness on right iliac fossa. Coils of intestine can be made out through abdominal walls. Vomited greenish mucus and water, about 3ii. Stool at 9:10 showed one amall blood clot, facies getting more and more pinched. White count, 11 A. M., 5,000. Pulse getting weaker hourly, all food and medicine withheld since 9 A. M. Transferred to surgical department, and abdomen opened at 2 P. M. Ether anesthesia. Abdominal cavity found full of feces. Intestines about ileo-cecal valve coated with broad thick patches of lymph. Typhoid ulcers seen in ileum, several causing marked thinning of the wall of the intestine, the appendix was found inflamed with a perforating ulcer about the middle of its length. Region about the appendix bound down by adhesions. Appendix was removed and one particularly thinned spot over ulcer in ileum was sewed up. Strychnine, grs. 1-30. Patient left table in almost as good shape as before the operation.

March 23. Death 6:30 A. M.

Necropsy.-Typhoid fever, general peritonitis. Well-developed, emaciated adult male, showing recent laparotomy. Intestines matted together with pus and lymph in pockets between coils, Intestines distended with gas and fluid stool. Pelvis contained some purulent fluid. On opening the bowel, deep typhoidal ulcerations found, most marked and numerous near the ileo-cecal valve. Ileum showed deep ulcers for several feet from valve. In cecum itself there was a cluster of deep ulcers near origin of appendix. The appendix itself had been removed; stump was in good condition. Here and there throughout ileum were submucous hemorrhages. Spleen was markedly hypertrophied. Other organs nothing abnormal found.

CASE II.

years.

dull type and located in the frontal frontal region. This continued about four weeks. Cough, at first mild, now severe, has increased steadily; at times would throw up yellow mucus. No pain in side or shortness of breath. At times would vomit mucus tinged with bile. Bowels were loose. No abdominal pain. Appetite is poor. At times has had fever. Has taken no medicine and has had no medical attention until admittance into hospital. Temperature 98.8°, pulse 96, respiration 28. Patient shows evidences of the recent use of alcohol. Hair is disheveled, face flushed, speech thick, breath alcoholic. Expression at present rather dull and heavy, eyes congested, pupils medium, react slowly but fully to light; lips fair color, are parched. Respiration free, easy and regular. Breath-sounds everywhere a little roughened, with slightly prolonged expiration. Over the large tubes moist rales are heard. At the bases there are some inconstant subcrepitant râles. Fremitus and resonance normal. Dry, short, hacking cough at intervals, no expectoration. Heart normal. Pulse regular, fair tension, and of good volume.

Abdominal walls well muscled and large, slightly curved outline. Note tympanitic. No tenderness anywhere on pressure. Liver dullness from fifth interspace to costal border in right nipple line. Splenic dullness slightly enlarged. Stomach seems fairly full of food and drink. Lips dry and cracked. Tongue moist and generally covered with a grayish fur, tremulous. Coarse tremor of hands and tongue present. Ordered absolute rest in bed, milk diet, blue mass, grs. v, oil, 3 ss, 6 a. M.

February 1. Rested well all night, no medication except blue mass and oil. White count, 2,600. Widal postive, twenty minutes, 1 to 40 dilution. This morning complains of abdominal pain. Temperature 100°, pulse 120, respiration 36, short and forcible, thoracic type. Liver dullness from lower

border fourth rib to one inch above costal border in right nipple line. Abdomen swollen, tympanitic, generally tender, especially so at McBurney's point. Pulse rapid and hard. No movement of bowels.

At 11 A. M. temperature 104.4°, pulse 140, respiration 44. Excruciating pain and tenderness over McBurney's point, and in entire right iliac region. Liver dullness gone except from fourth to fifth ribs. Referred to surgical service.

At 1 P. M. Widal very positive, twenty minutes, one to forty dilution. White count, 2,600. Transferred to East surgical service for operation for typhoid perforation.

At 4 P. M. Operation, ether anesthesia. Incision made over ileo-cecal valve. Pus oozed out of abdomen as soon as it was opened. Intestinal coils showed a severe general peritonitis. In exploring for the perforation pockets of pus were opened up in every direction. Perforation was located in the

ileum near cecal valve. It was about three-sixteenths of an inch in diameter, and feces were passing through it. This perforation was closed. No other perforations were found, although there were other typhoid ulcers which had almost perforated. This region was drained with iodoform gauze packed about the most suspicious looking ulcers. Two other abdominal incisions were made, in median line and on left side. A large drainage-tube was put in each, and abdominal cavity was thoroughly washed out with salt solution. Patient received two pints of salt solution intravenously during the operation, and was in as good condition after the operation as before.

After-treatment: Fowler's position, continuous rectal irrigation with salt solution. Strychnia (onethirtieth of a grain, three hourly); morphia, onefourth of a grain hypodermically, p. r. n. In spite

of all treatment, patient grew continuously worse and died eight hours after operation.

CASE III.

Miss L., aged fifty-three, seen by me in consultation with Dr. J. R. King, of Hyde Park. Family history good. Has never been seriously ill since childhood. Patient was seen by me January 18, 1907, at which time she had been under the care of Dr. King for a period of two weeks for typhoid fever. According to the history as given by Dr. King, the patient was up and about until January 5, although she had complained of not feeling well for one week before consulting her physician. Until two days previous to my visit the course of the disease, which was manifestly a true typhoid, was rather mild, her temperature at no time going above 103° F., with good pulse and a very satisfactory general condition. Bowels had moved regularly. Heart, lungs and kidneys in good condition. On January 16 patient had a hemorrhage from the bowels; hemorrhage repeated itself on February 17; the amount of blood lost on these two days amounted to one pint and a half.

Early in the afternoon of January 17, 1907, Dr. King was called to the patient because of pain in the lower portion of the abdomen. There was at this time slight tenderness over the lower portion of the abdomen and a moderate amount of disturbance. Dr. King reports the general condition of the patient as good, with no marked change in the pulse and temperature. Pulse 108, temperature 103°, respiration not accelerated and facial expression good. During the night the abdominal pain became aggravated and the abdominal distension more marked.

Patient was seen by me with Dr. King at 9 A. M. Facial expression that of suffering and anxiety. Features somewhat pinched and color ashy gray. Respiration about 30 per minute; pulse of fair volume, regular and of moderate tension; rate, 124 per minute. Heart-sounds free and rhythm good. Abdomen very much distended. Liver dullness decreased and marked tenderness, more particularly over lower part of abdomen. Percussion tones full and tympanitic. We had no doubt of a typhoid perforation and accordingly advised immediate operation.

On account of the extreme gravity of the case we did not think it advisable to remove patient to a hospital. Dr. C. L. Bonifield was called upon, and within two hours from the time of my first seeing her an abdominal section was done. Patient was given ether and a large and free incision was made in the median line. The intestines were distended and covered with lymph. Fecal matter was found in the abdomen and a perforated typhoid ulcer was found in the ileum within six inches of ileo-cecal valve. This ulcer was simply inverted and the peritoneal edges stitched together. The cavity was flushed with a warm salt solution; the peritoneal cavity was then thoroughly drained with three large cigarette drains, one introduced into the pelvis and the other in the region of the flanks. Patient was put in the upright sitting posture and strychnia and digitalis administered hypodermatically.

In the evening the temperature was 990 and pulse 120. General condition satisfactory. On the following morning the drainage from the abdomen was found to have been very abundant, the dressings being thoroughly saturated.

During the next ten days the pulse continued to improve from day to-day, the temperature at no time going above 100.5° F. Hot water in small doses was administered at frequent intervals for three or four days after the operation. Drainage continued satisfactory. Liquid bowel movements were obtained daily. Albumen water and malted milk were given

three days after the operation. Patient felt more comfortable each day, and the improvement in the general condition was marked. After the third day the morning temperature was usually normal and the pulse bteween 90 and 98 per minute, with good volume and tension. One week after the operation the patient was obtaining water, beef tea, orangealbumen water and certified milk. Part of the packing in the abdominal wound was removed at this time. The stools at this time partly formed and cotained small quantities of mucus. Considerable flatus was expelled.

On January 29 packing was removed and abdominal wounds flushed with salt solution. Smaller amount of packing reinserted daily. From this time until February 11, 1907, dressings were changed morning and evening. Bowels moved well.

On February 11, 1907, the discharges from the abdominal wound were found to contain fecal matter, and this could be traced down on the left side from the region of the descending colon. The abdominal wound was flushed with a lysol solution.

On February 13 the amount of fecal matter coming from the abdominal incision was very abundant. This continued so for one week, and then gradually diminished, allowing an approximation of the abdominal incision. In spite of this complication, the condition of the patient remained satisfactory, with daily improvement of pulse and strength. No further complications occurred, and the patient is at this time able to leave her bed and walk about the apartment.

I may be permitted to offer a few remarks in regard to these cases.

It will be noticed in the report of Case I that we had to deal with a patient who gave the history of two or three attacks of abdominal pain long before the onset of his typhoid fever. There was a complaint of abdominal pain and some tenderness during the whole time of his stay in the hospital.

It will be noticed as a point of some interest that at the time of the operation there was no abdominal distension. In fact, the abdomen was flat and the walls retracted. The Widal test was positive, and at the time of making the diagnosis of typhoid perforation the leucocyte count was not increased. The general condition of the patient, as far as strength, pulse and temperature were concerned, did not change remarkably until the onset of chill. In this case the perforating ulcer was found to be in the appendix. Microscopic examination revealed a typical typhoid ulcer. The old adhesions may have modified the symptoms from the start, but it is equally certain from the conditions found at the time of operation that the peritonitis must have existed for twenty-four or fortyeight hours. The interesting features are the slow onset of symptoms, absence of leucocytosis and absence of abdominal distension.

In Case II the patient actually came into the hospital under the influence of alcohol in the third week of typhoid. The condition

was promptly recognized and surgical measures adopted.

In Case III, which resulted in recovery, I think we may attribute the good result to early recognition and the common sense of the patient and relatives in allowing an immediate operation. In the next place, I believe that thorough and complete drainage, as established by the operator, Dr. Bonifield, insured the prompt recovery.

DISCUSSION.

DR. C. L. BONIFIELD: The subject of typhoid perforation is usually interesting, because of the difficulty of recognizing it at a time when operative treatment offers a good chance of cure. Osler is quoted as having said that he could not recall having seen a case get well without operation, and certainly the probability of a patient recovering without an operation is so remote as to be negligible. As near as could be ascertained from available statistics, about 25 per cent. of the cases of operation recover; therefore, every case in which a diagnosis is made before a case is moribund should be given the benefit of surgical attention.

This case, the first one I operated on, occurred at the Good Samaritan Hospital several years ago. Dr. E. W. Mitchell saw the case with me and confirmed the diagnosis of perforation before the operation. This case did not recover, but I do not think her death should be charged to the perforation or lack of success of the operative treatment, because her general condition had been so bad for several days preceding that we had little hopes of her recovery.

A few words as to the technique of the operation may not be out of place here. In the first case I made the ordinary appendix incision, because it is well known that the perforation is usually in that immediate neighborhood. I found the perforation with the greatest ease, and repaired it without difficulty through this incision, but with our present methods of drainage general peritoneal infection I think this incision does not answer so well as the medium one.

The per

In the case reported to-night by Dr. Greiwe I Imade a free incision in the median line. I found the perforation in the lower part of the ileum without difficulty, because when I seized this coil of intestine the fecal matter poured out in a stream. foration was really a double one-that is, two holes in one ulcer. The peritoneum was closed with two rows of sutures, one of fine silk, the other of chromic catgut. The peritoneal cavity was flushed with hot saline solution, and three large drainage-tubes cut spirally and filled with gauze were introduced, one into each pouch of the kidney and one into the Douglas' cul-de-sac. The omentum was pulled down over the intestines and a large pad of gauze placed between it and the abdominal incision, and the latter was loosely approximated with a few through-andthrough silkworm sutures. The patient was placed straight up in bed.

The two most important points, I think, from my general knowledge of abdominal surgery and my reading of successful operations for perforation, are early operation and rapid work. If an experienced practitioner strongly suspects perforation, an operation should be made at once. It is better to operate on several cases where no perforation exists than to let one die with perforation for want of operative treatment. Dr. Eichberg shakes his head, but I believe experience will prove that those cases in

which the abdominal symptoms simulate perforation will be improved by drainage. The next point in importance to operation as soon as possible after perforation is rapid work. Under no circumstances should a surgeon operate leisurely in a peritoneal cavity, for under the most favorable conditions the mortality and the morbidity of intra-peritoneal operations increase with the length of time the abdomen is open, and the weaker the patient and the more desperate his condition, the more important does the time element become. One should not stop to make a careful toilet of the peritoneum, but should content himself with removing the fecal matter that has been poured out and establishing the freest possible drainage.

DR. JOSEPH EICHBERG: I would like to ask what Dr. Bonifield considers the cause of the pus?

DR. BONIFIELD: The gauze drain pressed against

the colon.

DR. EICHBERG: All of us wish to congratulate Dr. Bonifield on this successful case. To my knowledge, it is the first case of operation for typhoid perforation that has recovered in Cincinnati. In the Cincinnati Hospital the cases that have come to operation have uniformly ended in death. One case of abdominal perforation, followed by profound stupor, and in which the Widal test was positive, was operated on in five hours after entrance into the hospital, but died. It was a case of walking typhoid, brought in from the street in a state of collapse. In other cases which had been under observation for some time, the occurrence of perforation could be accurately determined. One was placed on the operation-table within three hours, but died.

Dr. Bonifield called attention to the prompt acceptance and limited time of operation. Where patients have died some deaths must be charged to unnecessary delay during the operation in the effort to make things perfectly secure.

In Dr. Greiwe's case attention was called to the white blood count. The leucocyte count was less than normal. An inability to develop a certain excess of leucocytes is evidence of such profound toxemia that it prevents the patient from rallying. Too much attention cannot be given to leucocyte count.

A drop in the temperature is always an alarming symptom. A drop in the temperature frequently heralds perforation. Surgeons have usually no chance of interfering before collapse. Some advise waiting until time has been given for a certain amount of reaction. Dr. Bonifield is right in saying that time should not be lost-regardless of temperature.

In the report of the first case from the Cincinnati Hospital there was no distension. Regarded as one of the cardinal symptoms of perforation, it is often wanting in the early history. The same is true of obliteration of the liver dullness. A considerable interval may elapse before the liver dullness is effaced. Its absence by no means excludes perforation. Neither does the absence of distension exclude the possibility of perforation. Pain may be present when there is no indication of perforation. One always considers prostration, both mental and physical, when estimating the liability to perforation. Dr. Bonifield has said that distension means peritonitis. If so, then the medical man certainly sees many cases of peritonitis which subside spontaneously. We are not justified in saying that every case of distension is one of peritonitis, nor that peritonitis, even if fully developed, always indicates perforation. The surgeon probably has the opportunity of seeing only the worst cases. There are many cases of distension of high degree without either perforation or peritonitis.

It is an old axiom that things which are equal to the same thing are equal to each other. There are

some cases which counterfeit typhoid perforation so perfectly that we cannot be convinced they are anything else, and yet they get well; so that we must assume the possibility, however remote, of recovery from typhoid perforation without operation. A case

of typhoid perforation may be no worse than one of perforated appendix-it may recover from the perforation and from the typhoid. I have seen three such cases, undoubtedly of typhoid perforation, in my practice; they all recovered without operation.

An element of utmost importance is the rapidity with which inflammatory products and pus accumulate in the peritoneum after perforation of a hollow viscus. Of this, the best evidence is furnished in cases of gunshot perforation. During my service as pathologist a number of cases bearing on this point were studied in the Cincinnati Hospital. It was during an election, at a time of a great deal of political feeling in Cincinnati. Men from civil life were sworn in as deputies and armed with weapons, of which they did not know the use. Thirteen cases of gunshot wounds were brought into the City Hospital and thirteen post-mortems were held within a few days. In one case the bullet had nicked the vena cava and caused constant seepage. One patient did seven hours after the receipt of the injury; the peritoneum was everywhere covered with lymph and pus had accumulated in the dependent portions of the cavity.

The formation of pus gives no definite idea of the time at which the perforation takes place. A sharp, sudden pain is a pretty definite landmark, owing to the profound physical and mental prostration from the preceding toxemia, but in many cases there may be neither pain nor tenderness. The facies is important as a guide, and change of expression deserves to be ranked as one of the most striking indications. But the symptoms are variable. In many cases suspicion will justify an operation, though too much should not be expected from surgical intervention under conditions so unfavorable.

DR. W. D. HAINES: The important points in dealing with typhoid perforation are early recognition of the condition, dispatch in operating and the establishment of thorough drainage. The last point, that of drainage, is most important in the after-management of perforation cases. If the peritoneal cavity is extensively soiled with fecal matter, it should be irrigated, but dry mopping will serve better if there is but a small amount of fecal matter present, as it may be done quickly and does not entail possibilities of flushing, in scattering infection throughout the peritoneal cavity. Trimming the margin of the perforation preparatory to suture is a useless waste of valuable time. The perforation should be closed by one ог two layers of serous sutures and the patient placed in bed as soon as possible.

It has been said that no case of typhoid perforation recovers without operation. I know of a case where the patient recovered and lived two years after the accident. He came to operation for the relief of a fecal fistula which followed the perforation.

As Dr. Bonifield has well said, it is far better to open an abdomen occasionally where perforation does not exist than to permit one patient to die of this accident without the benefit of operation.

DR. E. W. MITCHELL: A recent writer has said that when an operative case of typhoid perforation recovers, as much credit is due to the physician who makes the early diagnosis and demands prompt intervention as to the surgeon who makes the operation. We have certainly reached the time when the physician should be on the outlook for perforation, and should call the surgeon immediately upon the development of symptoms, for it is upon the early operation

that success very largely depends. As statistics show that fully one-fourth of the cases promptly operated recover, while recovery without operation is so rare as to be a medical curiosity, there should be no hesitancy in giving the patient his one chance out of four for recovery. I believe that we shall in the future see a still further reduction in the mortality after operation, when physicians have become more alert in making the early diagnosis and the surgeons have had greater experience in the technique of the operation. Nevertheless, the mortality must always be high, since, however prompt and skillful the surgery, many must die from the toxemia of the disease, from hemorrhage or from some of the complications. In many cases there is no difficulty in the diagnosis. When we find shock, pain, tenderness and muscular rigidity all present the diagnosis is evident; obliteration of liver dullness when present adds to the certainty, but it is often absent, and sometimes one of the late rather than early signs. In many cases the

diagnosis is one of the most difficult problems we have to meet. I have no doubt all of us who have had the opportunity to follow any considerable number of cases of typhoid to the post-mortem table have seen perforations in cases in which it had not been suspected. Pain is perhaps the most constant and characteristic of all the signs, and yet typhoid patients often bave the pain who do not develop perforation. Shock is not always evident. Next to pain I should place muscular rigidity as a characteristic sign. There may not be the characteristic drop and rebound of temperature. The anxious facies, the rapid, thready pulse, the disturbed respiration, the swollen belly are the symptoms of the peritonit's, symptoms which come too late to give a patient the best chance, and our aim should be to make our diagnosis before the development of a peritonitis. In the doubtful cases one must weigh and compare the symptoms, be guided by the preponderance of evidence, and in case of doubt I should agree with those who have said operate.

Multilocular cysts of the ovary are not uncommonly met with in dealing surgically with the pelvic organs, and when found are usually removed so as to give no further trouble.

The time was when relief for a tumor of any kind in the pelvis was not easily had, but now the surprising thing about the cases of large size is that they are allowed to grow to such enormous size without seeking relief.

This case is not reported so much on account of its size as from the fact that there were several things that were more or less interesting connected with it,

viz. :

1. The extensive adhesions to the peritoneum and absence of visceral involvement.

2. The jutting out from the left hypochondriac space of two prominences which had the shape on palpation and gave one the impression of a displaced kidney or spleen, but later proved to be two locuments of the tumor.

3. Acute dilatation of the stomach sixty hours following the operation. History of case as follows:

Miss L., white, deaf mute, aged forty-four. Occupation, house-keeper.

Family history good; four sisters, all healthy. Physical examination showed presence of fluid, large mass in left side; length of uterus normal. Palpation showed a fluctuating tumor extending well into the abdomen and pelvis. The different locuments could not be moved from side to side or up or down, showing that it was firmly attached.

The general appearance of the patient was, excepting for the enormous size of the abdomen and slight emaciation, good; bowels and kidneys were normal.

Patient was operated upon March 27, 1907. She was prepared in usual way. Median incision extending from above umbilicus to pubes. The cyst wall was found adherent to the parietal peritoneum over nearly tl e whole abdomen. The cyst wall was punctured by the cannula and about five gallons of a dirty looking fluid drawn off. This fluid was withdrawn slowly and from one cyst, as the remaining cysts were too small and numerous to be tapped by a cannula of any size.

As the primary Cavity was being emptied of its con