Stated Meeting, October 28, 1896.

The President, DR. J. C. WILSON, in the chair.

DR. JOSEPH PRICE read a paper upon SURGERY FOR TYPHOID PERFORATIONS. [See page 577].

DISCUSSION.

DR. GEO. E. SHOEMAKER said that the time has come when the courage which it takes to operate in cases of typhoid perforation is to be rewarded. Granted that the diagnosis has been carefully made, it seems that the surgeon should not hesitate to intervene in this way with the object of saving an almost hopelessly lost life. Too great emphasis, however, cannot be placed upon the importance in this connection of rapid and deft surgery. The man who is unskilled in the best technic adapted to work of this kind should certainly not attempt this character of operation. The parts will not bear handling. No touch upon a peritoneal surface must be made unless it has a definite object to accomplish, and after this is accomplished the parts must not be meddled with. With rapid surgery and the knowledge obtained from dealing with septic peritonitis, which leads us to use gauze drainage in addition to glass drainage, the surgeon will certainly obtain some reward for efforts in this direction.

DR. F. WOODBURY said that Dr. Price is to be congratulated on his results, especially in view of the circumstance that these cases were brought from their own homes to the hospital in the third week of typhoid fever and with perforation and peritonitis, in what is generally regarded as a very serious condition, and one indeed in a state of collapse. Dr. Woodbury noticed years ago in hospital experience a long series of cases in which the patients with typhoid fever, who were removed to the hospital in the second or third week of the disease, were very likely to die. They did badly, and the disturbance and change of surroundings, and the nervous excitement attending the change at the height of the disease, were sufficient to seriously disturb the prognosis. Dr. Woodbury asked if, in a series of cases of the character under consideration, suffering from this grave complication of typhoid, the prognosis would not be somewhat improved by doing the operation at the patient's own home instead of transporting him or her to a hospital? And, in the second place, as to the indication for operation. May it be assumed in all cases of typhoid fever in which there is

an appearance of local peritonitis, that a perforation has occurred and that celiotomy is indicated? A third question is: Can we obtain from the character of the discharges any guiding principle, or any assistance in making up our opinion as to the necessity for this operation?

For instance: in a case in which during the third week of typhoid fever the patient has committed some excess in diet, has eaten some hard substance, or taken some orange-juice and swallowed a seed, and perforation has resulted; knowing this fact, it would seein that the indication for operation would be imperative. Also, when the discharges from the bowel are very fetid and may be assumed to be highly toxic in character, their presence in the peritoneal cavity would be a powerful argument in favor of operating.

On the contrary, if, in the treatment of the disease, the bowel-contents have been kept in as nearly an aseptic condition as possible by the administration of some such agent as Bnaphthol, or naphthalin or guaiacol, so that the discharges are kept almost odorless, and when there is otherwise doubt as to the necessity of operation, would this fact throw the balance in favor of delay or not?

DR. W. E. HUGHES said that, as a physician, he was perhaps a little more ready to recommend operation than a surgeon might be, but it is unquestionable (certainly from his experience) that a pronounced perforation in the course of typhoid fever means infallibly death, unless prevented by operative interference. He does not look on perforations in the course of typhoid fever as very largely mechanical, but thinks that there is usually preceding them a certain amount of local peritonitis. That is, the process has been virulent enough to infect a small area of peritoneum about the ulcer. Perforation in the course of typhoid fever, then, can be resolved into possibly two classes: one, in which the process is an exceedingly virulent one, and, after a preliminary very trifling peritonitis there is a large perforation, free escape of contents of the intestines into the abdominal cavity and necessarily widespread peritonitis. Cases of this kind die within a few hours or a day at most after perforation. There has usually been a well-marked history of typhoid fever, and there can be little mistake in diagnosis. In the other class of cases perforation has been more prolonged, or at least there have been primary adhesions preceding perforation, and here there may easily arise a very serious error. From past experience, Dr. Hughes would be inclined to recommend for operation not a case of simple peritonitis,

but a case in which this peritonitis had become pronounced enough to be recognized as ushering in perforation, because then he would fear acute peritonitis, or after perforation had Occurred that there would soon be peritonitis. The diagnosis of perforation in typhoid fever is exceedingly difficult in the walking cases in which no clear history of typhoid fever can be obtained, but in which there is unquestionably a local peritoneal condition, which would indicate operation, and whether the case be one of typhoid fever or of appendicitis.

Dr. Hughes related the history of a child some seven years of age, seen in consultation, who presented a history of rather indefinite belly-pain, with some little irregularity of the bowels for ten days or so before the acute onset. The attending physician maintained that there had been no elevation of temperature whatever until three days previously to the visit. Then there was a rapid rise in temperature, with extreme distention of the belly, vomiting, and a great deal of pain. The child became wildly delirious, and appeared extremely ill.

When the child was first seen there was a grave suspicion of typhoid fever, but nothing to base a positive diagnosis upon. There was

a little rigidity in the right iliac fossa, and a peculiar doughy feel of peritonitis, and operation was advised. The surgeon consulted refused to operate because the case looked so much like one of typhoid fever and minimized the local symptoms. On the following morning the belly had become soft, the temperature had fallen, and typhoid spots were visible. Two or three days later sudden collapse occurred, with death. Post-mortem examination showed a localized abscess following on perforation and then giving way of adhesions. The case was one of typhoid fever complicated with peritonitis.

In another case, admitted to the Presbyterian Hospital during the second week of unquestioned typhoid fever, suddenly the temperature rose, the pulse fell below normal, and there was a condition of collapse, with pain in the right iliac fossa, distended belly, appreciable rigidity in the region of the appendix, followed by vomiting, which became stercoraceous, and death finally ensuing. Post-mortem examination showed that there had been a localized abscess induced by peritonitis, with rupture of the abscess and general septic peritonitis. Nine days had elapsed between the origin of the abscess and death. It would probably have been easy to have saved that patient's life by means of an operation. Thus in the class of cases in which there is a slow oncoming of the perforation operation is unquestionably absolutely necessary, and will save a large percentage of lives, the more so as these cases are rather common in typhoid fever.

Dr. Hughes scarcely believed it possible to stop intestinal hemorrhage by any operative interference, or, if it be possible, it is surely not possible to tell in which cases operative

one.

interference should be instituted. In his experience, hemorrhage in typhoid fever is a bleeding from a number of ulcers much more frequently than it is of bleeding from any In the last two cases, dead from hemorrhage, in which he made post-mortem examinations, the bleeding had taken place from the colon, and not from the ileum. Such cases as these are not operable cases. When there has been a sudden single profuse hemorrhage, the site of bleeding is likely to be ileum, while when there has been a series of small hemorrhages culminating finally in one large fatal one, it is more likely that the site of the bleeding is the colon.

DR. MORDECAI PRICE said that as a general thing he believed that when actual violence has been done to the bowel, the ulceration is of the character of simple impinging upon the peritoneum, and, as has been said, a patch has been applied, and if the leakage takes place it is confined to a small area of the peritoneum, and there is ample warning of the danger to the patient. In these cases we have almost assurance that surgery will be a saving of life.

In the other cases in which from some violence or straining, or from some foreign body that comes in contact with the ulcer and produces perforation, general peritonitis and death are likely to result in a very few hours, and unless the lesion is one that has been anticipated, the results of the operation, to be sure, are very doubtful, but surgery should be attempted in these cases.

Dr. Price contended that the danger of transporting cases to the hospital was not so great as that of failing to do so early enough. It would naturally be better to do operations at home if the patients were favorably situated. But the surroundings are often our masters. For instance, many cases to be operated upon come from hovels and without a clean towel or a clean basin in the house. In many cases it is necessary to supply not only the surgery, but also clean bed-linen and bed-clothing. For poverty-stricken patients requiring operation the hospital is unquestionably the best place. The surroundings are better, the nurses are better, the food is better, and the whole morale of the case is better.

DR. J. B. ROBERTS said that no modern surgeon, educated in current methods, would hesitate to operate upon a case of perforation in typhoid fever. Of course there are surgeons who, perhaps, have not come quite to the modern standard in practice who might refuse, because they have not become quite convinced of the value of antisepsis and asepsis. The indications seem clear that in any sort of a perforation in the belly the abdomen ought to be opened and the perforation sewed up. The operation will, of course, very often prove fatal. It does not make any difference about statistics in these cases any more than it would in intraperitoneal rupture of the blad

der. It is the surgeon's duty to do what he can as promptly as possible, and not to be deterred by statistics in surgery or any line of treatment. It is better in the majority of surgical cases to remove the patient to a hospital or some place where proper surroundings can be secured.

DR. G. G. DAVIS said that the question of operation has been settled practically by the physicians themselves, when they state that recovery is virtually impossible without it. The late Dr. William Hunt used to boast that he was the only known case in Philadelphia of recovery from perforation in typhoid fever, without an operation—a fact that would go to show how seldom such a recovery is. The mortality from operations undertaken for typhoid perforation will be very high, at all events, from the earlier ones. The patient who has a perforation is usually in a somewhat advanced stage of the disease, with a weak heart, and is likely to be extremely debilitated. The operation is one that not only requires skill, but exceptional skill. Everyone, perhaps, may not possess the required skill, and certainly the mortality that has heretofore existed does not compare with the results related by Dr. Price.

There is probably nobody in Philadelphia who does more operative work in abdominal affections than does Dr. Joseph Price, and for him to be able to report only three cases of operations after perforations shows that there must occur a large number of perforations in patients who are permitted to die without being given the chance of operation. For that reason the responsibility of operation is one that devolves largely upon the physician. Dr. Price has raised the question of the effect of the anesthetic on the patient. in some cases ether does bring up the pulse, at least for a time, it cannnot be maintained that patients do not suffer shock from operations. Almost all operations that are accompanied by anesthesia are productive of greater or less shock, and the truth probably is that prolonged anesthesia does diminish the probability of recovery.

While

DR. ALFRED STENGEL agreed with the statement that intestinal perforations are of different sorts. In his experience they have very frequently been minute, or accompanied by a localized peritonitis, and rather gradual in their pathologic development, if not in their clinical manifestations.

While anyone who understands the conditions presented will not for a moment doubt the advisability of modern surgery in dealing with intestinal perforation, it must be realized that the operation in itself is one of the extremest difficulty. Very frequently the most successful, the most deft, the most experienced surgeon in this very particular line of surgery will fail to find the lesion or all of the lesion. In some cases there are several perforations, some of which may be found with the greatest difficulty post mortem, and this difficulty will arise in even greater measure to the operating

surgeon. Complete resection of the bowel would, of course, obviate the necessity of looking for separate perforations in cases in which a limited part of the bowel is involved; but if trimming and stitching, and not resection are practised, it will be necessary to find each separate perforation. In some cases these are so covered by lymph and without marked extravasation of intestinal contents that some perforations are liable to escape notice. In Dr. Stengel's experience in postmortem work, the intestinal lesions in cases of large hemorrhage, cases of rapidly fatal hemorrhage, have almost without exception been in the colon near its junction with the ileum, In or in the ileum just above the valve. these cases there are very large ulcers as a rule, and in a very considerable proportion this is the only seat of disease, ulcers being absent or very few in the ileum or lower part of the colon. It would be excessively difficult to manage such a case; and there may be some doubt that operation is indicated in these cases. Intestinal perforation in the course of typhoid fever is not a condition for medical treatment. There have been cases of recovery even with the formation of fistulæ, but these cases are so exceptional that they have practically no weight whatever in the discussion. When intestinal perforation has occurred the case may be considered out of the physician's hands. The question then is whether the surgeon wishes to undertake the operation. The physician's only responsibility in these cases lies in his calling in a surgeon; if the surgeon refuses the operation, the responsibility is upon him.

DR. G. G. DAVIS related the case of a man who was brought into the hospital some two or three years ago, a foreigner, unable to speak English, totally delirious, with hurried, rapid, breathing, very weak pulse and a temperature of about 104°. The abdomen was very much distended and there was dulness in the right iliac fossa. There was absolutely no history to be had. The patient was evidently extremely sick and apparently at the point of death. It was thought that possibly there might be some trouble with the appendix. Operation revealed a distended cecum, while the appendix was found to be somewhat inflamed, but evidently not enough so to account for the general condition. Further investigation showed the small intestine adjacent to the cecum to be agglutinated in a plastic purulent peritonitis. At this point the patient exhibited symptoms of collapse, so that some of the adhesions were broken up, the surrounding area packed with gauze and drained and most of the wound left open. The patient died, and post-mortem examination revealed two perforating typhoid fever ulcers in the neighborhood of the ileo-cecal valve. The case serves to illustrate the difficulties attending operations of this kind. To have persisted in a search for the perforations and to have closed them would have caused death promptly upon the operating table.

DR. J. C. WILSON said that the great majority of cases of perforating ulcer of the bowel in enteric fever perish promptly from general peritonitis and collapse. The exceptions to this rule are extremely rare. In some few cases of perforation immediate general infection of the peritoneum is prevented by adhesions of the wall of the gut to adjacent viscera. Local peritonitis and abscess-formation, with its attendant dangers to life, result. There are also cases, but their number is few, in which all the signs of peritonitis develop and recovery takes place without subsequent trouble of any kind. It was a case of this sort, seen seven or eight years ago, that led to the communication referred to by Dr. Price. The patient was a girl about nine years of age who, about the twentieth day of the attack, suddenly developed symptoms of peritonitis. Dr. Keen was asked at once to see the patient with the view of operating. The necessary preparations were made, but after some hours, slight improvement having taken place, the operation was deferred until the following day. It was then found that the pain and tympanites had diminished and considerable improvement in the general condition had occurred. The patient made a good recovery without operation. She was treated by opium in full doses. Dr. J. Ewing Mears has suggested that the surgeon has three procedures at his command in the cases of intestinal perforation during enteric fever. First, he may find the lesion, trim out the involved portion of the gut and stitch the perforation; second, he can resect the compromised portion of the gut; and third, in default of being able to satisfactorily carry out either of these plans he may simply make an artificial anus, treat the peritoneum according to the indications in individual cases and wait. Of course these procedures are desperate, but the case is desperate and in ninety-nine out of every hundred accidents of this kind without surgery death is certain. The condition should be approached just as would be a fulminant case of appendicitis. The lesions are in the great majority of instances massed in the neighborhood of the ileo-cecal valve. Perforations rarely occur more than eighteen or twenty inches above that point in the bowel.

These

In some instances abdominal tenderness, excessive tympanites, tremor and hemorrhage from the bowels precede perforation. symptoms must always be looked upon as danger-signals. Under such circumstances the possibility that prompt surgical intervention may become necessary is to be considered and it is a good practice for the physician in charge of the case to at once divide the responsibility with a surgeon, who can see the patient at intervals in consultation. The greater number of perforations, however, develop suddenly. When the symptoms of perforation show themselves the case practically passes out of the hands of the physician into those of the surgeon. The condition is so desperate that the surgeon often hesitates to

perform an operation attended with so little hope of success. Speaking from the standpoint of the physician, Dr. Wilson contended that under such circumstances the physician is justified no longer in merely requesting, but he should at once demand that the surgeon shall lend his aid in the effort to avert impending death.

DR. JOSEPH PRICE expressed regret that there is not a specialist in intestinal surgery in the world specially equipped and always prepared for emergencies. With the aid of such an operator more cases could no doubt be saved. Thus, in a case of typhoid under observation for two weeks, and running a uniform course, the physician, if a keen clinician, anticipating perforation, will suggest the association of a surgeon as soon as symptoms pointing to that condition arise. If there be not time to associate a surgeon the physician should use a pocket-knife, pulling out the gut and sticking a darning-needle in; then cleansing and draining with gauze. The result will be better than with no operation; but whatever the method used, it must be rapid and simple. It will never do to waterlog patients with ether. In none of the cases recorded did the operation last longer than one hour.

Dr. Price related that he had a great many times opened the abdomen for general suppuration in which he did not even seek the fistula, employing only irrigation and the open treatment. A large proportion of the patients recovered, although many were in collapse. Secondary operations in other cases have given evidence of the fact that ulceration had existed in the primary operation.

Dr. Price referred to a case of multiple perforation seen years ago, in which the patient's condition was so desperate on the table that the ether was withdrawn. The state of the bowel for some 12 inches was bad, but the defect was repaired as well as it could be, as the condition would not justify such extensive resection, and the ileum at a healthy point 20 inches from the ileo-cecal valve was connected with the colon. The woman recovered, and is in good health yet.

Referring to the transportation of these patients, Dr. Price said that his results have always been best in private practice. In a series of over two hundred abdominal sections in alleys and courts, with the nurse sleeping on an ironing-board or three chairs (until he could afford to have a cot taken around), with a cesspool four feet off, and everything calculated to be detrimental, only one case was lost, but such work required an enormous expenditure of vital force. Besides, nurses do not, as a rule, care to go into alleys or courts and do that sort of work, no matter how well they are paid. In a long series of cases the patient's home is to be preferred, if provided with the bare necessities of life, a couple of basins, a tea-kettle and water; but on account of the great amount of time consumed in making visits at long distances, it is more convenient to have one's patients concentrated in one place.

Dr. Price insisted that operation in cases of typhoid perforation to be successful must be prompt; delay is fatal. Allusion was made to the case of a boy who had fallen from a hatchway and developed abscesses in three or more mesenteric glands. It was not thought that the fall was more than a coincidence, not a cause, that the boy was ill, that the typhoid suppuration in the mesenteric glands had been overlooked. Recovery followed section and open treatment. Dr. Price added that he had only recorded those cases that he was satisfied were typhoid. He had also operated on some of stercoral fistula that he is satisfied were typhoid perforations.

DR. J. T. RUGH read a paper entitled PROFOUND TOXIC EFFECTS FROM DRINKING LARGE AMOUNTS OF STRONG COffee.

[See page 549.]

DISCUSSION.

DR. J. B. ROBERTS related a similar case seen ten years ago in a man under treatment for pneumonia. He was convalescing nicely, when suddenly he became very excitable. Dr. Roberts was sent for at night and found the man evidently intoxicated with something, but could not find out with what. The patient had not been taking any alcoholic stimulant of any account. Subsequently, on further inquiry, it was learned that some enterprising druggist had sent the man a sample bottle of bromo-caffein and that he had taken large amounts of it. The diagnosis was then clear. The symptoms had been distinctly those of caffein-poisoning.

DR. J. MADISON TAYLOR said that cases of peculiar susceptibility to drugs often have to do with a variety of causes, among them alterations in conditions of personality. He referred to a case of bromism in which the man became quite maniacal. The mania was of the sudden and violent order and it had been taken into consideration by those who first saw him that he was taking occasionally, for a very simple cause, bromids, which he increased on his own responsibility, with the result of inducing the profound effects referred to.

DR. M. PRICE said that he has observed many cases of nervous excitability, inability to sleep and indigestion and other symptoms attributable to improper food in which investigation showed that coffee was the only substance to which responsibility could be attached; and on avoidance of the stimulant the symptoms disappeared.

DR. JOHN B. ROBERTS read a paper on THE PERFECT SURGICAL NEEDLE; WITH REMARKS ON COMMON DEFECTS IN NEEDLES.

[See page 583.]

DISCUSSION.

DR. JOSEPH PRICE Contended that the resistance encountered in passing needles does not take place at the point mentioned by Dr.

Roberts. Erichsen, in his Military Surgery, attributes death to tight sutures and suturetracts. Charles Hunter called attention to the fact that a suture should always fill up the needle-track. With the needle proposed it does not. This needle offers great resistance in its huge belly, between the point and shank of the needle, more so than any needle in use. This will cause more difficulty in penetrating tissues than any other needle in the group presented, more suture-tract abscesses, more liability to clot along the track of the needle, more suppuration, pain and sepsis. In Dr. Price's opinion surgical needles should be fine, straight and sharp, with a perfect point, and without belly and cutting edge. Keith's is the ideal needle, which can be placed nearly everywhere. Tetanus and sepsis have a number of times followed the use of the Baker Brown or Peaslee handled needles-that old bayonet-needle, with a handle, commonly used for perineal work.

DR. G. G. DAVIS said that for certain deeplying tissues the Hagedorn needle is pre-eminently suitable and not bad elsewhere. The glover's needle is an absolutely useless needle. While workers in leather may know what they want, it is not good enough for surgeons, because, as sold, it is not polished. It is too much to expect nurses to sharpen three-cornered needles or needles of any kind. Instrument-makers themselves not infrequently fail to furnish well-sharpened needles.

DR. GEO. E. SHOEMAKER said that it is not uncommon to see a man with a towel, trying to push a needle through the skin and uttering imprecations. This is due largely to the oxidization of the needle in boiling. For some time it has been Dr. Shoemaker's practice to sterilize needles by holding the eye in an alcohol flame before the operation; then, throwing them into alcohol until needed. Treated in this way, needles need not be boiled. They always keep bright and pass through the tissues readily; and their use is unattended with complications.

It has been found that neuromata after amputation almost always appear in scar tissue, and are especially fixed against the sawn end of the bone. Senn endeavors to obviate this by amputating the nerve high up in the tissue, and then cutting a V-shaped wedge out of the distal end, uniting the two flaps with sutures so that none of the interior of the nerve-trunk is exposed-all nerve tissue is covered in by the endothelial sheath.-The Medical Age.

The regular meeting of the medical section of The Buffalo Academy of Medicine, was held November 10, with this program: "Case of Chronic Diarrhea Successfully Treated by Lavage," Dr. S. A. Dunham." Importance of Early Attention to Hypertrophy of the Naso-Pharyngeal Lymphoid Tissue," Dr. F. W. Hinkel."Reflex Effects in the Pharynx and Mouth of Intra Nasal Disease," Dr. Horace Clark.