OPERATION IN THE PREPERFORATIVE STAGE OF TYPHOID.
DR. ROBERT G. LE CONTE detailed the history of a colored man, aged twenty-three years, who was admitted to the Pennsyl vania Hospital, December 23, 1896. He had been well and at work until three days previous to admission, when he began to have pain in the pit of his stomach, with constipation of his bowels and loss of appetite. The pain soon shifted to the right iliac region and became very severe and constant. He had chilly sen sations with fever, but no vomiting, headache, epistaxis, or pain in the back, and none of the prodromic symptoms of typhoid fever. On admission, temperature was F.; pulse, 88; respiration, 20. Tongue heavily coated all over, not tremulous. Specific ulcer on the left arch of the palate. Heart, lungs, and urine negative. The abdomen was distended and tympanitic ; the right abdominal muscles much more rigid than the left ; ex quisite tenderness over the iliac fossa, with a small, easily pal pable tumor which was dull on percussion. No enlargement of the spleen was demonstrable.
With the above symptoms and a history of sudden onset, a diagnosis of appendicitis was made, and immediate operation ad vised. The patient was etherized, and the abdomen opened over the tumor to the outer side of the semilunar line. Serous fluid with flakes of lymph immediately escaped. The last six or eight inches of the ileum were sharply bent on itself and glued together with recent adhesions. These adhesions were broken up, and this portion of the ileum with the cxcum and part of the ascend ing colon were delivered through the wound. This portion of the bowel was highly inflamed, deeply congested, and covered with lymph. On washing away the lymph, some six or seven spots were seen, about the size and shape of a small olive, purple in color, with bluish-black necrotic centres. These necrotic areas were on the cmcum and ascending colon as well as on the ileum, and were on the portion of the bowel opposite to the mesenteric attachment. They were unquestionably necrotic Peyer's patches that had ulcerated through to the peritoneum. The appendix was normal except for its peritoneal coat, which had become infected from the neighboring inflammation. It was evident at a glance that if the bowel was returned in such a condition perforation would speedily take place and peritonitis and death follow.
Three methods of procedure presented themselves : (I) In vaginating the necrotic areas with sutures. This was not at tempted for fear the sutures would not hold in such a diseased state of the intestine, and if they did hold, that stricture of the gut would result. (2) A resection of the damaged area, some eight inches of the ileum, the cmcum, and part of the ascending colon. This was rejected, owing to the patient's condition not warranting such a radical procedure. (3) Packing off with gauze this area of the intestine from the general abdominal cavity. This was done, and at the same time the appendix was amputated, on account of its damaged peritoneal coat and the fear that it might cause further trouble. Two sutures were placed in the upper angle of the wound, while the ends of the gauze packing filled up the rest of the incision. The temperature following operation was normal, but it speedily rose to F. The pulse, however, was of good character, and at no time exceeded 120. Thirty-six hours later very offensive pus and fecal material were discharged from the wound. Ten days later the faces began to lessen in amount, and within four weeks of the opera tion the fistula had entirely closed. In the mean time the patient developed a typical typhoid condition. His tongue became tremu lous ; the edges cleaned off, sordes developed, mental hebetude appeared, emaciation was rapid, the bowels were loose, and tym pany persisted. The blood was twice subjected to the Widal test, and responded both times. The temperature for twenty days varied from roe to when it gradually dropped to normal, and then became slightly subnormal. From this time on the con valescence was uneventful, and he rapidly gained the weight he had lost. He was discharged from the hospital in good health fifty days after admission.
Dr. Le Conte called attention to the early date at which per foration may occur in typhoid fever, and also to the fact that in anomalous cases of enteric fever the diagnosis from appendi citis cannot always be made.
DR. G. G. DAVIS remarked that the case was so close to one of perforation as to be practically one of perforation. It furnished data as to how long a patient may be in recovering, provided packing is resorted to and a fmcal fistula ensues. There is no doubt that in some of these cases there is not time to perform an ideal operation, in other words, to close the perforation ; the chances of the patient's recovery will be enhanced by treating the case as did Dr. Le Conte,—isolating the infected area and draining rather than invaginating and suturing. He believed it to be a fact that typhoid-fever patients stand operation very much better than is usually supposed or than one might expect. If surgeons resort to operation as readily as some advise, attempt ing the diagnosis of the preperforative stage, no doubt they will operate occasionally and not find a perforation. He had done so in one case. He reported three cases in the University Medical Magazine a few months ago, and in one of them there was no perforation found ; yet that patient improved very markedly. There was some evidence of peritonitis, and the operation ap peared to benefit the patient very markedly. Therefore, even if one does not find a perforation, the operation will probably be of benefit to the patient.