■KC\%' Vo (Columbia IttitirrBttg Co'^. tu tt|0 (Eity of Nm fork iMnmtt iCtbrarg ^ ^ K c Digitized by tine Internet Archive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/surgicalcomplicaOOkeen THE SURGICAL COMPLICATIONS AND SEQUELS OF TYPHOID FEVER BY WILLIAM W. KEEN, M.D., LL.D. PROFESSOR OF THE PRINCIPLES OF SURGERY AND OP CLINICAL SURGERY, JEFFERSON MEDI- CAL COLLEGE, PHILADELPHIA ; VICE-PRESIDENT OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA ; MEMBRE CORKESPONDANT ETRANGER DE LA SOCIETE DE CHIRURGIE DE PARIS; MEMIiRE hONORARIE DE LA SOCIETE BELGE DE CHIRURGIE. BASED UPON TABLES OF ITOU CASES COMPILED BY THE AUTHOR AND BY THOMPSON S. WESrCOTT, M.D. INSTKUCrOK IN DISEASES OF CHILDREN, UNIVERSITY OF PENNSYLVANIA; VISITING PHYSICIAN TO THE METHODIST EPISCOPAL HOSPITAL, PHILADELPHIA. A CHAPTER ON THE OCULAR COMPLICA- TIONS OF TYPHOID FEVER BY GEORGE E. DE SCHWEINITZ, A.M., M.D. PROFESSOR OF OPHTHALMOLOGY, JEFFERSON MEDICAL COLLEGE; PROFESSOR OF DISEASES OF THE EYE. PHILADELPHIA POLYCLINIC; OPHTHALMIC SURGEON TO THE PHILADELPHIA AND ORTHOPEDIC HOSPITALS. AND AS AN APPENDIX THE TONER LECTURE, No. V. PHILADELPHIA W. B. SAUNDERS 925 WALNUT STREET 1898 Copyright, 1898, ky W. B. Saunders. U-iu'^ooy OL-oI^c^ \ TABLE OF CONTENTS. CHAPTER I. Introduction, lo CHAPTER n. Pathology of the Surgical Complications and Sequels OF Typhoid Fever, 17 CHAPTER III. Typhoid Gangrene, 52 CHAPTER IV. Typhoid Affections of the Joints, 91 CHAPTER V. Typhoid Affections of the Bones, 109 CHAPTER VI. Typhoid Abscesses, i47 CHAPTER VII. Typhoid Hematomata, 166 CHAPTER VIII. Cerebral Complicaiions of Typhoid Fever, 169 CHAPTER IX. OiiTis Media in Typhoid Fever, 181 CHAPTER X. Typhoid Parotitis, 183 CHAPTER XL Typhoid Affections of the Thyroid Gland, 186 7 e TABLE OF CONTENTS. CHAPTER XII. p^cE Typhoid Affections of the Larynx, i88 CHAPTER XIII. Typhoid Affections of the Pleura, Lungs, and Heart, 199 CHAPTER XIV. Typhoid Affections of the Esophagus and the Stomach, 202 CHAPTER XV. Intestinal Perforation in Typhoid Fever, 212 CHAPTER XVI. Typhoid Affections of the Liver and the Gall- bladder, ■ 244 CHAPTER XVII. Typhoid Affections of the Spleen, 274 CHAPTER XVIII. Typhoid Affections of the Sexual Organs, 2 78 I. Male, . .278 II. Female, ..282 CHAPTER XIX. Specific Mixed Infections in Typhoid Fever, .... 289 Erysipelas, ... 289 Tetanus, 294 Anthrax, 294 Malignant Edema, 295 CHAPTER XX. Ocular Complications of Typhoid Fever, 296 CHAPTER XXI. Conclusions, 314 Appendix: the Toner Lecture, "... 333 Index, 383 LIST OF ILLUSTRATIONS. PAGE Plate I. Typhoid Bacilli in the Liver (Fraenkel and Simmonds), opposite 62 Plate II. Suppurative Typhoid Leptomeningitis (Ohl- macher), opposite 172 Plate III. Necrosis of the Cricoid Cartilage (Fussell), opposite 194 Plates IV and V. Perforating Typhoid Ulcers of the Intestine (Museum of the Pennsylvania Hospital), opposite 216 Fig. I. "Shirt-stud Abscess" of Bone (Cornil and Pean), 135 Fig. 2. Parotidean Sweating (Osier), 185 Fig. 3. Typhoid Ulcers of the Stomach (Fenwick), . .207 Fig. 4. Typhoid Leukemic Spleen, 276 TONER LECTURE. Fig. I. Typhoid Necrosis of the Skull, 344 Fig. 2. Typhoid Ulcer of Larynx, 349 Fig. 3. Perichondritis Laryngea after Typhoid, . . . 350 Fig. 4. Perichondritis Laryngea AFTER Typhoid, . . .351 Fig. 5. Perichondritis Laryngea AFTER Typhoid, . . . 352 ERRATA. Page 40, line 3, for once read one. Page 74, line 8, for anus read arms ; line 9, for 20 cases read ^/; line 13, for 75/ read 7^7 / line 14, dele and anus. Page 183, line 7, for j6^ read jj^. SURGICAL COMPLICATIONS AND SEaCELS TYPHOID FEVER. CHAPTER I. INTRODUCTION. The present monograph had its origin in two lectures. On February 17, 1876, I dehvered the fifth Toner Lecture " On the Surgical Complications and Sequels of the Continued Fevers," which was published by the Smithsonian Institution in March, 1877. On June 9, 1896, I delivered the Shattuck Lecture, before the Massachusetts Medical Society. In casting about for a subject for the latter lecture, it occurred to me that it would be just twenty years since my Toner Lecture, and that the literature accumulated on the subject during that period would well warrant a sequel, a sort of " Vingt ans apres^ Accordingly, I asked Dr. Thompson S. Westcott to undertake the tabulation of the cases re- corded since 1876. They amount to over 900 cases. Not only did he tabulate the cases, but also ac- curately analyzed their results. That he has done his task with completeness and accuracy is evident in every chapter. It was evident that a single lecture 1 1 12 SURGERY OF TYPHOID FEVER. would not suffice for the discussion of so extensive a mass of material, and hence I restricted the Shat- tuck Lecture to " Gangrene as a Complication and Sequel of the Continued Fevers, Especially of Typhoid." (Trans. Mass, Med. Soc, 1896, and Boston Med. and Surg. Jour., July 2 and 9, 1896.) This Lecture I have made Chapter III in the present book, though much altered to fit it for its new place. I determined, therefore, at my earliest leisure, to take up the various other complications and sequels of typhoid, and so make as complete a monograph as possible. I was the more disposed to do so be- cause, though individual complications or sequels had been considered by various authors, no one since my previous attempt had treated the subject as a whole. I was also the more desirous of doing so because of the fact that the bacillus of typhoid had been discovered by Eberth in 1880, and hence our views of the pathology of these surgical lesions had under- gone a great and necessary change. Yet even now almost every chapter shows how deficient we are in precise knowledge of the exact nature of these lesions. Every case hereafter reported should be completed, if possible, by a bacteriological examina- tion. Negative evidence is as Important as positive. How large a role the complications and sequels of typhoid play is well shown by the statement of Holscher (Munch, med. Wochen., 1891, No. iv) that of the 2000 fatal cases there tabulated, only 24 per cent, died as a result of the typhoid infection per se, and 76 per cent, from the various medical and surgical complications and sequels. INTRODUCTION. 1 3 The Toner Lecture and the present book together cover 1 700 cases, and practically include nearly all the cases recorded in the last fifty years. The table ends with the literature of 1895, except a few important cases which have been reported after the table was completed and analyzed. The cases of Perforation of the Intestine (Chap. XV) and those of Perforation of the Gall-bladder (Chap. XVI) have been brought down to January, 1898. In the analysis of results (as to age, sex, location, etc.), unless otherwise stated the figures combine the results of the two series of cases of 1876 and 1896. Single cases not seldom reappear in several chapters, since a case of gangrene might also suffer from a periostitis and a parotitis, and require to be considered under each heading. Such multiple le- sions are quite characteristic of typhoid. The diagnosis in a moderate number of cases is somewhat doubtful, but I have not felt at liberty to change it. The number of errors from this source, as well as those arising from the indefiniteness and meagerness of some of the histories, is not so great as to impair the substantial accuracy of the analyti- cal results, especially for clinical purposes. In the present book I have considered not only the six complications and sequels treated in the Toner Lecture, but I have added a formal chapter on the Pathology of the Surgical Affections of Typhoid, and also twelve chapters on other surgical affections of particular organs and regions. The surgical treatment of intestinal perforation did not exist in 1876. One of the principal additional chap- ters, from the practical standpoint, is upon this sub- 14 SURGERY OF TYPHOID FEVER. ject. As this is so vitally important I have included a table of all the cases thus far reported. In con- nection with this chapter I wish to call especial atten- tion to the "conclusion" No. lo, formulated on page 318, that the essential mortality is not the mortality of the whole series (80.7 per cent.), but the mortality of those cases operated upon within the first twenty-four hours (69.4 per cent.), and that this will be further reduced when prompt surgical interference is the rule. In the chapter on Typhoid Affections of the Gall-bladder I have called attention to the propriety of immediate operation in peritonitis arising from similar perforations of the gall-bladder — a surgical chapter just opening. Four such cases have been operated upon with three recoveries. I have slightly changed the title of the present work both to distinguish it from my Toner Lecture and because nearly all of the cases in the second series are the surgical results of typhoid fever alone. In the first series of 785 cases (excluding 352 of parotitis following typhus), 252 cases fol- lowed typhoid, 119 followed typhus, and 62 fol- lowed other continued fevers. In the second series, 887 followed typhoid, only 23 cases followed typhus, while 4 followed other continued fevers. No better or more cheering evidence of the improved sanitation of the civilized world could be given than this palp- able diminution inthe ravages of typhus fever. At the same time it is to be noted that these figures are to some extent deceptive. The unfortunate habit, especially of the Germans, of designating typhoid fever as " typhus abdominalis," and (from the far greater frequency of typhoid) the not infrec^ent use INTR OD UCTION. I 5 of the word " typhus " alone, without the qualifying adjective, when typhoid was really the disease, makes the number of cases of typhus somewhat larger than it really is. Happily in the second series this is much less frequent. If a true typhus bacillus should be discovered, how will our German friends discrimi- nate between the two ? What endless confusion will arise ! — a confusion so easily avoided if the adjective "typhoid," or "enteric," were now used to designate the so-called " typhus abdominalis." The original tables on which my Toner Lecture was based unfortunately were not preserved. Hence in some of the analyses the later table alone has been available for points not covered by the earlier lecture. Where this is the case it is so stated. At first I had intended to publish also the tables and the bibliography in full, but this would have so in- creased the bulk and the cost of the book that I re- luctantly relinquished the idea. Instead of this I have given copious references. The ophthalmic lesions after typhoid are such a special class that I have asked my friend, Prof. George E. de Schweinitz, to write that chapter. The thoroughness and completeness of this chapter, like all his work, is very noteworthy. Both to him and to Dr. Westcott I desire to express my earnest thanks. I should also mention Profs. William H. Welch, William Osier, W. M. L. Coplin, and D. Braden Kyle, to whom I am indebted for valuable suggestions and assistance. I also wish to acknow- ledge the courtesy of a number of gentlemen who have sent me notes of unpublished cases. In order to make the work as complete as pos- 1 6 SURGERY OF TYPHOID FEVER. sible I have added, in a Postscript (page 321), a number of cases of importance which have appeared as the book has been passing through the press. They concern Chapters II, VIII, XVI, and XVII. I would be wanting both in courtesy as well as in gratitude did I not take this opportunity to express my obligation to the gentlemen in charge of the library of the Surgeon General's Office, U. S. A., for placing at my disposal both twenty years ago and now the treasures of that unrivalled collection. Without that, the Index Catalogue and the Index Medicus, it would have beeui practically impossible to make the work even approximately complete. The enlightened and liberal management of that library has made the whole world debtors to America, and it should receive even a far more generous support from the Government than it has had. My Toner Lecture was the first publication in which were gathered together the many surgical results of typhoid fever. Before its publication only sino-le surp-ical lesions had been considered or sporadic cases had been published. Unfortunately, not having appeared in any of the medical journals, it never became well known to the profession. I have, therefore, with the kind permission of the Smithsonian Institution, republished it in the Ap- pendix. CHAPTER II. PATHOLOGY OF THE SURGICAL COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. The province of the physician and that of the sur- geon are, in general, sufficiently sharply defined and differentiated, yet they have many points of contact. While some diseases belong exclusively to the prov- ince of the one and some to that of the other, other diseases may fall with equal propriety under the care of either practitioner. Still another class of cases, however, beginning in the domain of medicine may terminate in that of surgery, and we may lack their complete history from the very fact of this division of their care and interest. Among the diseases classed as strictly medical, none deserve the appellation more definitely than the continued fevers, and especially typhoid fever. Yet the present work shows that these fevers are not infrequently the cause of the gravest and least expected surgical troubles, mention of which is gen- erally omitted, even in our best text-books on medi- cine, still more rarely noticed in works on surgery, and, where noticed, it is only with the greatest brevity. The surgical results of scarlet fever and the other exanthemata have lone been recognized and de- scribed. But up to 1876, when I published my Toner Lecture, surgical troubles after typhoid 17 1 8 SURGERY OF TYPHOID FEVER. and other continued fevers were deemed rather among the curiosities of Hterature, than looked upon as somewhat rare, but yet well-ascertained surgical post- febrile lesions, which should be expected from time to time and, therefore, watched for and, if pos- sible, prevented. Since 1880, when Eberth discov- ered the bacillus of typhoid fever, our views of the pathology not only of the fever itself, but also of its complications and sequels, recent and remote, have undergone an entire revolution and we now under- stand much that was formerly inexplicable. I shall only consider the pathology of typhoid sufficiently for us to see its bearing from the surgical side ; more than that would be out of place. The pathology of typhus fever is so much less clear and certain, and the number of cases after typhus so much smaller, especially at the present time, that I shall entirely omit its special consideration. In order to gain a clear idea of the pathology of typhoid and post-typhoid lesions, I will consider : 1 . The viability of the typhoid bacilli both in and out of the body ; and, therefore, the possibility of their causing late as well as early sequels of the fever. 2. Their wide diffusion in the various organs of the human body, and, therefore, the possibility, if not the probability, that all the various surgical results may be caused by them. 3. Mixed infections of the typhoid bacilli with other bacteria, 4. The pyogenic faculty of the typhoid bacilli. 5. Typhoid infection of different organs without typical typhoid lesions in the intestine. PATHOLOGY. 19 I. The Viability of the Typhoid Bacilli [a] Outside the Human Body. — In favorable condi- tions — e. g. in a bacte-riological laboratory — the typhoid germs may live indefinitely: but in unfavor- able conditions, also, their viability is remarkable. Thus Losener ' found that the bacilhis only disap- peared from the body ninety-six clays after burial. In feces they may live even for months.^ Remlinger and Schneider Miave found them in the feces of five out often patients who had never had typhoid -fever. Schiller'* impregnated threads with the bacillus, and found them still active in periods of from one to two years. Uffelmann ^ found them still living and active after eighty-two days in dry sterile sand. {b) Their Viability Inside the Human Body.^ — I will not mention instances, of which there are a large number, in which the typhoid bacilli have been found in abscesses, etc., within three or four weeks after the fever, but only those cases in which they have been found months and even years after- ward. By far the longest time after the fever, when the 1 Arbeit, kaiserlich. Gesundheitsamte, 1895. 2 Ziegler, Allgem. Pathol., 1895, i, 597. 3 Ann. de I'lnstitut Pasteur, 1897, xi, 55. * Arbeit, kaiserlich. Gesundheitsamte, v, 312. 5 Centralbl. f. Bakteriol., 1894, Nos. 5 and 6. ^ Schniizler, Centralbl. f. Bakteriol. und Parasitenk., 1894, 270, in a case of old osteomyelitis, found the staphylococcus pyogenes aureus after ihirty- five years, and Krause, Fortschritte d. Med., ii, Nos. 7 and 8, found the same organism after thiity years. Both these, however, may have resulted from a continuous or a late re-infeciion. I merely mention them as instances of the extreme viability of these organisms also in the human body. 20 SURGERY OF TYPHOID FEVER. typhoid,bacillus has been found, and in pure culture, is diat of von Dung-ern.' Fourteen years and a half after the fever the bacillus was found in an abscess about the gall-bladder. A resume of the case is given in Chapter XVI. Buschke ^ reports the case of a woman of sixty- six who fell ill of typhoid in October, 1886. Before Christmas, when she left her bed, she complained of swelling, pain, and tenderness in the fifth and sixth ribs and cartilao^es on the rio^ht side. The pain and tenderness subsided, but the swelling did not disappear. In December, 1893, without any evidence of a re-infection, the pain returned, but again subsided only to recur for a third time. On her admission to the hospital February 19, 1894, below and to the inside of the right breast was a swellincr the size of a hen's eesf. soft and fluctuating^ in parts. In the axilla was an enlarged gland. On February 26th the swelling was incised, the pus evacuated, and the granulation tissue curetted. A pure culture of the typhoid bacillus was found in the pus. Hence over seven years after the fever the bacilli had retained their vitality and their virulence, as was shown not only by the abscess in the patient, but by experiment. Bouillon cultures of these bacilli were injected into rabbits. These rabbits, it is true, remained well, but from the places where the injections were made new cultures were taken, with every antiseptic precaution, and these injected in other rabbits proved fatal, and from their dead 1 Miinch. med. Wochen., 1897, No. 26, p. 699. 2 Lebensdauer d. Typhusbacillen in ostitischen Herden, Fortschritte d. Med., 1894, 573. PATHOLUCY. 21 bodies the typhoid bacillus was obtained, thus com- pleting the circle of proof. Bruni ' records the case of a woman of thirty-six who, in 1889, during" convalescence, developed an osteoperiostitis of the right femur with tenderness over the left tibia. Six years later an osteomyelitis developed in the latter bone. The tibia was tre- phined, and from the pus in the medullary cavity typhoid bacilli were obtained and their virulence es- tablished by inoculation. The next longest case on record is that of Sultan.^ For six years after the fever the patient had had a fistulous openingleadingdown to the clavicle. Though an infection with the ordinary pyogenic or other extraneous bacteria would seem to be inevitable in a case of open suppuration extending over so long a period, the discharge showed a pure culture of the typhoid bacillus. Chantemesse^ has described a case with abscesses in the right tibia, left femur, left ulna, and a left finger in which a pure culture of the typhoid bacillus was found after four years. In addition to these extraordinary cases, the fol- lowing authors have found the bacilli, usually in pure culture, after long periods. Parsons * reports a pure culture in the case of a sinus open and discharging for three months ; Pean and Cornil,^ in a tibial peri- ostids and abscess after eight months ; Chantemesse,^ in a similar case, after six and a half months, and in 1 Ann. de 1' Institut Pasteur, 1896, x, 220. 2 Deutsch. med. Wochen., 1894, 675. 3 Bull, et Mem. Soc. Med. des Hop., 1893, x, 779. * Johns Hopkins Hosp. Reports, v, 417. * Bull. Acad. Med., Paris, 1891, 3d series, xxv, 599. ^ Bull, et Mem. Soc. Med. des Hop., 1893, x, 779, 22 SURGERY OF TYPHOID FEVER. another after eleven months ; Chantemesse and Widal/ in an abscess after fifteen months; Orloff,^ in a case of periostitis after eight months ; Klemm,^ in an osteomyeHtis after a year ; Chantemesse and Widal/ after eighteen months ; Werth,^ in an ova- rian cyst after eight months ; Berg,^ in a case of chondritis of the costal cartilages after three years ; Lockwood/ in a tibial abscess after fifteen months ; Hintze,^ in a " cold " periosteal abscess after ten months ; Fraenkel,^ in a pleural effusion after five months, and in an abdominal abscess'" after four and a half months. Of course, in many cases the typhoid bacilli have not been found. Thus, Schede " was unable to find them in ten cases of abscess of bone. All were due to the pyogenic bacteria. But such cases, however numerous they might be, could not change the facts above cited in which there is positive and cumulative proof of the long-continued vitality and virulence of the typhoid bacilli in various tissues, but especially in the bones. That they may be, and not only may be but certainly are, responsible for the mischief in the midst of which they were found, even though it be long after the fever, is a most reasonable conclu- sion. This is rendered still more certain by the experimental proof of the pyogenic power of the typhoid bacilli shortly to be given (p. 40). 1 Traite de Med., July, 1S91, i. 2 Deutsch. med.Wochen., 1890, p. 1806. 3 Arch. klin. Chir., 1893, xlvi, 862. * Sem. Med., 1893, 542. * Deutsch. med. Wochen., 1893, No. 21. 6 Centralbl. f. Chir., 1896, 153. 7 Lancet, 1895, i, 531. » Centralbl. f. Bakteriol., Oct. 10, 1893, 445. 9 Buschke, loc. cit., 581. 10 Deutsch. med. Wochen., 1894, p. 152. 11 Miinch. med. Wochen., 1888, No. 11. PATHOLOGY. 23 II. The Wide Diffusion of the Typhoid Bacilli in Various Organs and Tissues of the Body. — Scarcely a single tissue or organ of the body escapes invasion by the typhoid bacilH. Not only the normal tissues are invaded, but, as is seen by the preceding section and in many later chapters, they are found in the pus of abscesses in every region of the body and in empyema, in the effusion of teno-synovitis, in the non-purulent fluid of orchitis, etc. Among the various tissues and organs in which the bacilH have been found are the following: I. The Blood. — The bacilH of typhoid are not com- monly found in the blood. When present, they are most numerous in the first twelve days of the dis- ease. From then until the end of the third week they diminish rapidly, and during the fifth and sixth weeks are only found exceptionally (Park). It is probable that they reach the blood by the lymphatics, since they are found in abundance in the thoracic duct.' That they must be distributed to other parts of the body {vide infra) by the blood (though so rarely actually found there) is made probable also by the fact that not rarely they are found in multiple organs of the body which could only be reached through the circula- tion. This is strikingly shown in the remarkably well- studied cases of Flexner,^ in which he found them in the mesenteric glands, the spleen, the liver, the bile, the kidneys, die lungs, the marrow of the bone, and in the blood of the heart. In the kidneys there were a large number of abscesses resembling miliary tuber- ^ Dehu, Le role du bacille d'Eberth dans les complications de la fievre typhoide, Th^se de Paris, 1893. p. 59. 2 Jour, of Pathol, and Bacteriol., 1894, iii, 202. 24 SURGERY OF TYPHOID FEVER. cle, which, however, were proved to be real abscesses containing the bacillus of typhoid in pure culture. Vincent ' also gives details of six cases in which they were found in the blood, the spleen, the liver, the mesenteric glands, the brain, the spinal cord, the cerebrospinal fluid, the kidneys, and the lungs. Neuhauss,^Riitimeyer,3 Achalme,'* Kuhnan,^ Ander- son,^ Guarnieri,^ and Block ^ have also found them in the blood, and in some instances proved their activity by injection into animals. Kanthack and Tickell ^ and Ohlmacher'° have found them in the blood in mixed infection with the streptococcus. That they must exist in the blood and be diffused by it is also proved by several cases in which the fever, having caused the patient to abort, the bacillus of Eberth has been found in the placenta and the fetus (p. 32). In these cases no other route for the infection is possible. Chantemesse and Widal " also found the bacilli in large quantities in the fetus and the amniotic fluid of the cobaye. 2. In the endocardium and endocardial vegetations. 3. In the walls of the arteries and the veins, pro- ducing arteritis and peri-arteritis, phlebitis and peri- phlebitis. 1 Ann. de I'lnstitut Pasteur, 1893, vii, 141. 2 Berlin, klin. Wochen., 1886, Nos. 6 and 24. 3 Centralbl. f. klin. Med., 1887, No. 9. * Comptes Rendus Soc. de Biol., June 21, 1890. ^ Berlin, klin. Wochen., June 23,1896. « Med. News, Aug. 8, 1896, 155. "^ Revist. Gen. Clin. Med., 1892, 234. * Johns Hopkins Hosp. Rep., June, 1897. 9 Edinb. Med. Jour., July, 1897, 22. 10 Cleveland Med. Gaz., May, 1897. 11 Gaz. Hebdom., March 4, 1887, 146. PATHOLOGS: 25 4. In thrombi in the heart arteries and veins. These three are considered more fully in Chap- ter III, on Gangrene, since they bear especially upon that process. 5. In the muscles they have been found by Gas- ser,' Raymond/' Rosin and Hirschel/ Jahradnicky.-* 6. In the Connective Tissues. — There are only three cases in our table in which a bacteriological exami- nation has been made. In Vincent's case ^ the typhoid bacilli were found in the cardiac vegetations and the blood in the heart, in the spleen, kidney, brain, bone-marrow, etc., but no observations were made as to the muscular hematoma. In Lockwood's,^ the pus of an abscess over the tibia contained only the bacilli of Eberth fifteen months after the fever. Raymond,^ in 1890, after a careful examination by Strauss, reported that the bacillus of Eberth was found in pure culture. Among other such muscular cases are those of Swiczinki^ and Tinctine.^ 7. Skin. — Most of the infections of the skin are probably pyogenic, but Rheiner '° has found the typhoid bacillus in the skin in cases of post-typhoid erysipelas. See also Valentini " and Raymond '^ for other tacts. Sittmann '^ records a curious case of a suppurating lipoma of the skin of the knee in which the typhoid bacillus was found in pure culture. 1 Pein, L' Action pyogenique dii bacille typhique, p. 88. ^ Ibid., p. 58. ^ Deutsch. med. Wochen., 1892, No. 22. * Centralbl. f. Chir., 1896, 336. ■^ Merc. Med., Feb. 17, 1892, p. 73. ^ Lancet, 1895, i, 531. ^ Pein, These de Paris, 1891, p. 58. "* Chronica Lekarska, 1894, No. 8. 3 Arch, de Med. Exp. et d'Anat. Pathol., 1894, vi, I. 10 Arch. f. Path. Anat., 1885, c, 185. 11 Berlin, klin. Wochen., 1889, No. 17. 12 Gaz. Med. de Paris, 1891, No. 9. 13 Deutsch. Archiv f. klin. Med., liii, 1894, 352. 26 SURGERY OF TYPHOID FEVER. 8. Synovial sheaths of tendons at ankle. Grancher' reports the only case I have found, 9. Joints. — In Chapter IV I have given the results of all the bacteriological examinations I have myself made or found recorded. They are all negative so far as finding the typhoid bacillus, except that they were once recorded as present soon after experi- mental inoculation into the joints. 10. Bones. — Very many observers, as indicated in Chapter V, have found the bacilli in the marrow of the bones, where they have remained for a greater or less time without producing disease. Usually these cases have been observed either at post-mortem examinations or in experimental researches. In other cases the bacilli have been found In periostitis, abscess, osteomyelitis, etc. I do not pretend to give a complete list, but among them may be named : Ebermeier, Deutsch. Arch. f. klin, Med., 1889, xliv, 140. Flexner, Jour, of Pathol, and Bacteriol., Nov., 1894, iii, 202. Orloff, Wratsch, 1889, No. 49, and 1890, Nos. 4, 5, and 6. Valentini, Berlin, klin. Wochen., 1889, No. 17, 368. Achalme, Comptes Rendus Soc. de Biol., June 21, 1890, 387. Chantemesse and Widal, Arch, de Physiol., 1887. Chantemesse, Bull, et Mem. Soc. Med. des Hop., 1890, vii, 655 ; 1893, X, 779. Bauer, Centralbl. f. Chir., 1895, 788. Colzi, Lo Sperimentale, Ixv, 1890, 623. Melchior, Jahresbericht Fortschritte Pathol. Mik- roorgan., Band viii. 1 Bull. Med., 1S92, vi, 1271. PATHOLOGY. 27 Dupraz, Arch. Med. et Anat. Pathol., Jan. i, 1892, 76. Busclike, Fortschritte d. Med., 1894, 573- Sultan, Deutsch. med. Wochen., 1894, 675. Parsons, Johns Hopkins Hospital Rep., v, 417. Gilbert and Girode, Comptes Rendus Soc. de Biol., July II, 1890, and May 2, 1891. Klemm, Arch. f. klin. Chir., 1893, xlvi, 862 ; xlviii, 792. Pean and Cornil, Bull. Acad, de Med., 1891, 3d series, xxv, 599. Quincke, Berlin, klin. Wochen., 1894. No. 15. Hintze, Centralbl. f. Bakteriol., 1893, 445. Helferich, Berlin, klin. Wochen., 1890, 979. Vincent, Merc. Med., Feb. 17, 1892, ']■}). Berg, Centralbl. f. Chir., 1896, 153. Rosin and Hirschel, Deutsch. med. Wochen., 1892, 493- Welch, N. Y. Med. Record, 1893, i, 631. Barbacci, Lo Sperimentale, 1891, 356. Mouisset, Lyon Med., 1891, 326. II. In the brain and spinal cord (meningitis, ab- scess, etc.): Ohlmacher, Jour, of Amer. Med. Assoc, Aug. 28, 1897, xxix, 419. Kamen, Internat. klin. Rundschau, 1890, Nos. 3 and 4. Neumann and Schaeffer, Virchow's Archiv, 1887, cix, 480. Honl, Centralbl. f. Bakteriol. und Parasitenk., xiv, Adenot, Lyon Med., 1889, l^^os. 34 and 36, and Arch, de Med. Exp. et d'Anat. Pathol., 1889, No. 5. Hintze, Centralbl. f. Bakteriol., Oct. 10, 1893, 445. Mensi and Carbone, Riforma Med., 1893, No, 2. Silva, Riforma Med., 1891. 28 SURGERY OF TYPHOID FEVER. Vincent, Merc. Med., Feb. 17, 1892, p. ']Ty. Tinctine, Arch, de Med. Exp. et d'Anat. Pathol., 1894, vi, I. Fernet, Bull. Soc. des Hop., 1891, No. 23, 361. Daddl, Lo Sperimentale, 1894, No. 17, 325. Balp, Revist. Gen. Ital. Clin. Med., 1890, No. 17, 406. Chantemesse and Widal, Gaz. Hebdom., 1887, 146. Curschman, Verhandl. Kongress f. inner. Medizin, 1886, 469. Kiihnan, Berlin, klin. Wochen., 1896, June 23d. 12. In the thyroid gland : Colzi, Revist. Gen. Clin. Med., 1891, No. 10, and Lo Sperimentale, 1891, No. 2. Honl, Centralbl. f. Bakteriol. und Parasitenk., xiv, 767. Jeansalme, Arch. Gen., 1893. Spirig, Correspondenzbl. schweiz. Aerzte, Feb. i5» 1891. Dupraz, Arch, de Med. Exp. et d'Anat. Pathol., Jan. I, 1892, p. 76. Kummer and Tavel, Rev. de Chir., June, 1891, and Aetiol. d. Strumitis, Basel, 1892. 13. In the orbit : Panas, Cinquieme Congres de Chir., March 30, 1891. 14. In the parotid gland : Lehmann, Centralbl. f. klin. Med., Aug., 1891, 649. Janowski, Centralbl. f. Bakteriol. und Parasitenk., 1895. xvii, 785. 15. In otitis media : Destree, Jour. Med. Brux., xcii, Aug. 15th. Vincent, Ann. de I'lnstitut Pasteur, Paris. 1893. PATHOLOGY. 29 16. In the heart=muscle : Chantemesse and Widal, Gaz. Hebdom., 1887, 146. I 7. In the lungs : . Plexner, Jour. Path, and Bacterlol., Nov\, 1894, iii, 206. [8. In the pleura (empyema, etc.) : Charrin, Soc. Med. des Hop., March 17, 1891. Infection of the pleuritic fluid with the typhoid bacil- lus, but no intestinal lesions of typhoid. Fernet, Bull. Soc. Med. Hop., 1891, May 21, 236. Loriga and Pensuti, Riforma Med., 1890, 1232. Valentini, Berlin, klin. VVochen., 1889, 368. Spirig, Mittheil. aus klin. und med. Instit. d. Schweiz, Basel, 1893-94, 11^- Kelsch, Merc. Med., March 2, 1892, p. 97. Weintraud, Berlin, klin. Wochen., 1893, xxx, 345. Rendu and de Gennes, La France Med., 1885, ii, 1821. Belfanti, Revist. Gen. Ital. de Clin. Med., 1890, No. 20. Foa and Bordoni-Uffreduzzi, Riforma Med., 1887, No. I. Burci, Arch. Ital. clin. Med., 1893, xxxii, i. Arustamoff, Centralbl. f. Bakteriol. und Parasitenk., vi, 1889. 19. In the peritoneum : Fraenkel, Sem. Med., April 27, 1887. Lehmann, Centralbl. f, klin. Med., Aug., 1891, 649. Raymond, Sem, Med., 1891. Fraenkel, Deutsch. med. Wochen., 1894, 152. 20. In the liver : Guarnieri, Revist. Gen, Clin, Med., 1892, 234. Chantemesse and Widal, Gaz. Hebdom., 1887, 146. Chantemesse, Bull, et Mem, Soc, Med. des Hop., 1893, X, 779. 30 SURGERY OF TYPHOID FEVER. Cygnaiis, Ziegler's Beitrage, etc., 1890, vii. Flexner, Jour. Path, and Bacteriol., Nov., 1894, iii, 202. Lannois, Rev. de Med., 1895, No. 11, 909. Vincent, Merc. Med., Feb. 17, 1892, jt,. Rosin and Hirschel, Deutsch. med. Wochen., 1892, 493- Gaffky, Mitth. kaiser. Gesundheitsamte, ii, 1884. Fraenkel and Simmonds, Die setiolog. Bedeut. d. Typhusbacillen, Leipzig, 1886. 21. In the gall=bladder and bile : Von Dungern, Miinch. med. Wochen., 1 897, No. 26. Osier, see Chapter XVI. Chantemesse, Traite de Med., i, 764. Mason, Boston Med. and Surg. Jour., May 13, 1897, and Trans. Assoc. Amer. Phys., 1897. Gilbert and Girode, Sem. Med., 1890, No. 58, and Mem. Soc. Biol., 1893, 956. Chiari, Prag. med. Wochen., 1893, ^^- 22, 261. Dupre, Les Infections Biliaires, These de Paris, 1891. Fournier, These de Paris, 1896. Salzmann, Wiirttemb. med. CorrespondenzbL, 1870, p. 84. Flexner, Jour. Pathol, and Bacteriol., Nov., 1894, iii, 202. Welch, Johns Hopkins Hosp. Bull., Aug., 1891, No. 15, 121. Blackstein, Johns Hopkins Hosp. Bull., No. 14, p. 96. Alexieef, Amer. Jour. Med. Sci., Oct., 1897, 466. 22. In the spleen : Flexner, Jour. Pathol, and Bacteriol., Nov., 1894, iii, 202. Ohlmacher, Jour. Amer. Med. Assoc, August 28, 1897, xxix, 419. PATHOLOGY. 31 Kanthack and Tickell, Kdinb. Med, Jour., July, 1897, 22. Vincent, Merc. Med., Feb. 17, 1892, ^^. Roux and Vinay, Lyon Med., June 10, 1888. Neuhauss, Berl. klin. Wochen., 1886. Chantemesse and Widal, Gaz. Hebdom., 1887, 146. Ebermeier, Deutsch. Arch. f. klin. Med., 1889, xliv, 140. Laveran, Bull. .Soc. Med. des Hop., 3d series, vol. viii, p. 90. Haushalter, Merc. Med., Sept. 20, 1893, 453. Klihnan, Berl. klin. Wochen., June 23, 1896. Guarnieri, Revist. Gen. Clin. Med., 1892, 234. 23. In the mesenteric glands : Flexner, Jour. Pathol, and Bacteriol., Nov., 1894, iii, 202. Ohlmacher, Jour. Amer, Med. Assoc, August 28, 1897, xxix, 419. Lehmann, Centralbl. f. klin. Med., August, 1891, 649. Fraenkel, Sem. Med., 1887, ^12)- Vincent, Merc. Med., Feb. 17, 1892, ']'x^. Gilbert and Girode, Comptes Rendus Soc, Biol., May 2, 1 89 1, Kiihnan, Berl, klin. Wochen., June 23, 1896. 24. In the kidney : Flexner, Jour. Pathol, and Bacteriol., Nov., 1894, iii, 202. Faulhaber, Beitr, path, Anat. und allg. Path., x, Koujojeff, Centralbl. f. Bacteriol. und Parasitenk., 1889. Vincent, Merc. Med., Feb. 17, 1892, 73. Von Wiinscheim, Prag. med, Wochen., xliv, 1894. Seitz, Centralbl, f, Bakteriol., ii, 1887. Neumann, Berlin, klin. Wochen,, 1890. 32 SURGERY OF TYPHOID FEVER. 25. In the urine : Bouchard, Rev. de Med., 1 881, 671. Kanthack and Tickell, Edinb. Med. Jour., July, 1897, 22. Wissokowitsch, Zeitschr. f. Hyg., vol. i, p. i. Seitz, Bakteriol. Studien z. Typhusaetiologie, 1886. Hueppe, Fortschritte d. Med., 1886, 447. Koujojeff, Centralbl. f. Bakteriol. u. Parasitenk., 1889, vi, 24. Neumann, Berlin, klin. Wochen., 1888, No. 7, 1890, No. 6. Faulhaber, Ziegler's Beitr. path. Anat. u. allg. Pathol., X, i8qi. Karlinski, Prag. med. Wochen., 1890, xv, 437. 26. In the ovary : Werth, Deutsch. med. Wochen., 1893, No. 21. Sadeck, Miinch. med. Wochen., 1896, No. 21. 27. In the testicle and epididymis : Girode, Arch. Gen., 1892, i, clxix, 43. Tavel, Correspondenzbl. schweiz. Aerzte, 1887, 590- Gasser, Arch, de Med. et de Pharm. Milit., 1895, No. 3, 228. Menetrier in Pein, These de Paris, 1890, p. 18. Belfanti, Revist. Gen. Ital. Clin. Med., 1890, No. 20. 28. In the placenta and fetus : Widal and Chantemesse, Gaz. Hebdom., March 4, 1887, 146. Hildebrand, P'ortschritte d. Med., 1889, vii, 889. Eberth, Fortschritte d. Med., 1889. vii, No. 5. Ernst, Beitr. path, Anat. u. allg. Path., 1890, viii, p. I, Etienne, Gaz. Hebdom., 1896, No. 16. Janizewski, Miinch. med. Wochen., 1893. PATHOLOGY. 33 Prascanni, Jahresb. Fortsch. Path. Microorcranism., 1892. Neuhauss, Berl. klin. Wochen., 1886. Reher, Arch. Exp. Pathol, et Pharmacol., xx, 420. Giglio, Centralbl. f. Gynekol., 1890, No. 46.' Griffith'' reports an interestinir case of a child born at full term while the mother was still ill of typhoid fever. The attack was light, the rose spots appeared on November 13th, and the child was born on the 1 8th. When the child was seven weeks old it responded to Widal's test. He concludes that the child had had an attack of the fever in 7iteT-o. A still more remarkable case is reported by Etienne.2 He examined a five months fetus born of a mother aged eighteen, on the twenty-ninth day of typhoid. "The child's spleen and intestines, as well as other organs, showed no evidence of the dis- ease, and the placenta was healthy. Blood from the right side of the heart and from the spleen, liver, and placenta was carefully examined and cultures made. The typhoid bacillus was found in abun- dance. The fetus had really died of typical acute blood-poisoning from a large dose of the bacillus before the occurrence of any local change." III. Mixed Infection of the Typhoid Bacillus and the Pyogenic and Other Bacteria. — Very rarely specific infections, such as those of tetanus, erysipelas, anthrax, and malignant edema, occur in 1 In this bibliography I have been materially assisted by Flexner's paper, Ziegler's allgemein. Pathol., Dmochowski and Janowski's, and Rosin and Hirschel's papers. 2 Med. News, May 15, 1897. 3 Brit. Med. Jour., Epitome 1896, ii, 35, from the Gaz. Hebdom., 1896, No. 16. 3 34 SURGERY OF TYPHOID FEVER. cases of typhoid fever. These mixed infections are considered in Chapter XIX. In this section I shall only review the relation of the typhoid and the pyogenic bacteria. The subject can not be sharply separated from that of the next section — cases of suppuration caused by the typhoid bacillus in pure culture — but will well lead up to it. Many authors, especially those who made the earlier bacteriological examinations, disbelieved ab- solutely — and very naturally — in the pyogenic prop- erties of the typhoid bacillus. They ascribed all suppurative lesions during or following the fever to an infection by the pyogenic bacteria alone or to a superadded or secondary infection by the pyo- genic bacteria in addition to that by the typhoid bacillus. Many surgical affections during and after typhoid are undoubtedly almost constantly purely pyogenic. For example, otitis media almost always results, so far as we know, from pyogenic bacteria ; parotitis in the great majority, and the same is true of abscesses, etc. In many cases even of disease of the bones this is equally the fact— ^. g., Schede ' in ten cases of abscess of bones found only the pyogenic bacteria, and Dunin ^ found the same bacteria in eiofht cases of lesions of bones. Nay, more than this, the pyogenic infection may, though very rarely, result in distinct pyemia or sep- ticemia in which the typhoid bacilli play no part whatever. Thus one case reported by Wagner ^ com- 1 Miinch. med. Wochen., 1888, No. 11. 2 Deutsch. Arch. f. klin. Med., 1886, xxxix, 369. « British Med. Jour., 1S91, i, 18. PATHOLOGY. 35 menced with a crural [)lilebitis relatively early in the disease (the ninth day), death occurring from pyemia on the eighteenth day. In another, reported by Spillman,' gangrene of the lips occurred, probably due to carious teeth, and tlie patient died from staphy- lococcus septicemia, the aureus being found in the spleen, kidneys, and liver. It had probably obtained entrance from the mouth and set up a secondary systemic infection during convalescence as the earlier infection was disappearing. Rendu ^ reports another case with purulent arthritis of the right hip-joint, abscesses of the right thigh, and osteomyelitis, puru- lent pleuro-pneumonia, and nephritis. Julliard ^ re- ports a case of septicemia following a typhoid hemorrhage in the neck. That mixed infection should occur in typhoid fever is not at all remarkable, since the intestinal ulcers and, in a large minority of the cases also, the ulcera- tion of the mucous membrane of the mouth, and the bedsores which are so frequent in typhoid, afford favorable ports of entry.'^ Mixed infections, by co-existing pyogenic and typhoid bacteria, as would be expected, are not un- commonly met with. Thus Lehmann^ reports a fatal case of encapsulated peritoneal abscess and sup- purative parotitis, and in the parotid was found a mixed culture of the Eberth bacillus and the staphy- lococcus. 1 Merc. Med., 1895, No. 13, 145. 2 Witzel, Gelenk- u. Knochenkrankh. ^ Guyot, Etude sur 1' Hematocele periuterine, etc., dans la Fievre Typhoide, These de Paris, 1879. * See Introduction for a fuller discussion of these points. 5 Centralbl. f klin. Med., 1891, 649. 36 SURGERY OF TYPHOID FEVER. Spirig ' records a case of suppuration in the thy- roid with a mixed culture of the typhoid bacillus and the staphylococcus albus, and Parsons'' records a case of osteomyelitis and necrosis of the left radius in which the citreus and the typhoid bacillus co-existed, while the aureus alone caused a suppurative periosti- tis of the right tibia. Rendu ^ found, in the pus of a typhoid empyema, both the pyogenic and the typhoid bacteria. In a few cases a mixed infection occurs in which the typhoid bacillus exists in one place and a pyo- genic organism in another. Thus Laveran ■* records a case of abscesses on the dorsum of the right hand, right arm, and left forearm in which the staphylococ- cus only was found in these abscesses with great numbers of the typhoid bacilli in the spleen. Flex- ner^ reports a case of very wide diffusion of the typhoid bacilli in other organs, but in the parotid gland only the streptococcus was found. It has been suofSfestecl that those cases in which suppuration occurred and the typhoid bacillus alone was found, were due to a primary mixed infection from the pyogenic bacteria and the typhoid bacilli, but that the former had perished after producing the suppuration, leaving the typhoid bacillus alone in the pus. But in some cases, as Kamen ^ has pointed out, the interval that elapsed was too short (less than 1 Correspondenzbl. schweiz. Aerzte, Feb. 15, 1891. 2 Johns Hopkins Hosp. Reports, vol. v. 3 La France Med., 1885, ii, 1821. * Bull. See. Med. des Hop., 3d series, vol. viii, p. 90. * Jour. Pathol, and Bacteriol., 1894, iii, 202. ^ Internat. klin. Rundschau, 1890, Nos. 3 and 4. PATHOLOGY. 37 two weeks) for us to suppose that the pyogenic bacteria could have died out ; and the result of ex- periments upon animals and the now very numerous cases in which the typhoid bacillus alone has been found in man preclude the probability of this as- sumption. The results noted in the various chapters follow- ing, show that it is specifically stated that " pure cultures " of the typhoid bacilli were found in 63 out of 82 cases of suppuration of various kinds. In making the resumes, undoubtedly the word "pure" was sometimes accidentally omitted by us, so that the truth is probably under, rather than over, stated. The extreme disproportion in the figures as they stand, however, is a most convincing proof of the unquestionable pyogenic property of the typhoid bacillus. Experiments upon animals have pointed positively also in the same direction. Both of these points are more fully considered in the next section of this chapter. This, however, is a favorable opportunity to consider the results of laboratory researches to determine the behavior of the pyogenic bacteria in mixed cultures, especially the staphylococcus and the streptococcus. Vincent,' in mixed cultures of the bacillus of Eberth and the staphylococcus or the streptococcus, has observed the greatest difference in the influence of these two pyogenic organisms on the bacillus of typhoid. The staphylococcus is remarkably inimical to the growth of the bacillus of typhoid, so that the latter will disappear from a mixed culture, while, on 1 Ann. de I'lnstitut Pasteur, 1893, vii, 141. 38 SURGERY OF TYPHOID FEVER. the contrary, when mixed with the streptococcus, the typhoid bacilkis grows vigorously. In his ex- perimental researches he found that doses of the streptococcus or of the bacillus of typhoid, neither of which was fatal if injected singly, if injected together would produce the most violent reaction and death. In 41 cases of typhoid in which various suppurative processes occurred, in 32 the complica- tion was due to the aureus or albus. All of these recovered in spite of extensive suppuration and multiple periostitis. On the other hand, of eight cases in which the streptococcus either alone or associated with the bacillus of Eberth was found, five died, showing a striking difference in the fatality especially of the mixed infection by these two pyo- genic organisms. Valliard ' says that if two animals are infected, the first with a feeble dose of the streptococcus and the second with a similar dose of the typhoid bacil- lus, both will be ill for a few days and then recover, but that if a third animal is infected with the same dose of the two bacilli together death follows with stupor, diarrhea, and fever. Dr. Kyle informs me that he has observed the same fatality after mixed infection with the streptococcus and other bacteria. OrlofT^ also has shown that six weeks after an injection of mixed cultures of the typhoid bacillus with the albus and the aureus, the latter was not destroyed but that in one-third of the cases the albus had disappeared. 1 Quoted by Grancher, Bull. Med., 1892, vi, 1273. 2 Centralbl. f. Chir., 1890, p. 387. PATHOLOGY. 39 The acknowledged difficulty of distinguishing be- tween the colon bacillus and that of typhoid is also alleged as a reason for doubting the pyogenic faculty of the latter and toascribe the suppuration to the colon bacillus. But first the number of cases of suppura- tion which the typhoid bacillus has been found in pure culture (p. 2il^ 's such as to make it very improbable that they could all be due to the colon bacillus in so distant and so many organs and tissue^ ; and, secondly, the very exact and careful differentiation of the two bacilli by their various stains and different reactions which, in view of this very objection, have been made by Flexner, Dmochowski and Janowski, Haushalter, Ouervain, Bruni, Ohlmacher, and others, would overthrow the objection. The following remarks by Flexner show that this differentiation is now not only possible but certain : "The weight of opinion among bacteriologists at this time is that the colon group of organisms can be sharply differentiated from the typhoid bacillus. However, it no longer suffices for distinguishing them to observe the colony growth upon agar-agar, gelatin plates, or the growth upon potato ; neither does the possession of mobility and stainable flagella serve to distinguish the typhoid from the colon bacil- lus. On the other hand, the power of acid and indol production, the property of setting up fermen- tative changes in sugar, with the liberation of gas and the coagulating influence upon milk, possessed by the colon group of organisms, separate it from the typhoid organism, which produces alkali, does not yield indol in cultures, is not capable of ferment- 40 ' SURGERY OF TYPHOID FEVER. ing- sugar, and has no coagulating effect upon milk."^ In at least once case of superficial necrosis of the femur, Klemm ^ has found both the colon and the typhoid bacilli co-existing. While, therefore, it is possible that the pyogenic bacteria may have been the cause of the suppuration in many of the cases and may have died out in others, it is undoubtedly true that the typhoid bacilli have very frequently a pyogenic faculty. Why in some conditions the typhoid bacillus should be pyogenic and in others not, we can only at present speculate. No reason can be alleged. But we are precisely in the same position as to the pyogenic function of other bacilli, — for example, the colon bacillus, which we certainly know to be a possible if not indeed a frequent cause of sup- puration in certain conditions, — e.g., appendicitis, — whereas ordinarily it is an entirely harmless intes- tinal organism. IV. The Pyogenic Faculty of the Typhoid Bacilli. — The proof of this lies first in observed cases in man in which the typhoid bacilli have been found in pure culture, and, secondly, in experiments upon animals. The first to observe this pyogenic property of the typhoid bacilli were Rendu, ^ Fraen- kel,^ and Tavel.^ 1 Flexner, Jour. Pathology and Bacteriology, 1S95-96, vol. ii, p. 20. On the same page, in a foot-note, he mentions the various recent methods of distinguishing between the two bacilli. 2 Arch. f. klin. Chir. , xlviii, 692. ^ La France Med., 1885, ii. * Sechste Kongress Inn. Med., 1887. 5 Correspondenzbl. schweiz. Aerzte, 1887. PATHOLOGY. 4 1 [a) In Man. — The objections have been consid- ered in die preceding section. As already stated, there are at least (}■}) cases in which the typhoid bacillus alone existed in various suppurative disorders, and 19 more in wliich the ty- phoid bacillus was found, but no mention is made — at least in the table — as to whether other organisms were sought and found. It is, however, reasonable to conclude that any careful bacteriologist would not limit his search to the typhoid bacillus alone, and that had other oroanisms been found, it would have been so stated. Nearly all of the 82 cases taken together, therefore, were probably cases in which the typhoid bacillus existed in pure culture in sup- purative lesions. That they were also the direct cause of the sup- puration both the number of the cases and the other confirmatory evidence seem to prove. Certainly the burden of proof lies upon the opponents of this reasonable view. Not only the number of these cases, but their wide distribution, is worthy of note. The typhoid bacilli have been found in pure culture in sup- purative lesions in the ribs, clavicle, radius, ulna, femur, tibia, and the bones of the fing-ers and the toes ; in the blood, heart-muscle, the endocardium, and the arteries and the veins of the legs ; in the muscles of the neck, shoulder, abdominal wall, and legs ; in the peritoneal cavity, the spleen, the liver, the bile, the kidney, the urine, and the mesenteric glands ; in the brain ; in the parotid gland ; in the thyroid gland ; in the lungs and the pleura ; in the ovary; in the testicle. 42 SURGERY OF TYPHOID FEVER. (^) In Animals — There is now a large number of experiments in which the injection of the typhoid bacil- lus in pure culture, obtained from human subjects, has produced suppuration in animals. No other known cause existed for the suppuration, and the inference that the typhoid bacillus was the cause is unavoidable. The present work is scarcely the place in which to discuss this subject in detail, but those interested in the subject may consult the following authors who have furnished such proof of the pyogenic faculty of the typhoid bacilli. The somewhat extensive list — and it could have been much enlarged — shows that this property of the bacillus of Eberth has received experimental support from very many careful ob- servers : Sirotinin, Zeitschr. f Hyg., i, 1886. Beumer and Peiper, Zeitschr. f Hyg., i, 1886, and ii, 1887. Colzi, Lo Sperimentale, 1890, Ixv, 623. Buschke, Fortschritte d. Med., 1894, xii, 613. Gaffky, Mitth. kaiserl. Gesundheitsamte, Berlin, ii, 1884. Fraenkel and Simmonds, Aetiolog. Bedeut. d. Ty- phusbacillen, Leipzig, 1886. Seitz, Centralbl. f. Bakteriol., ii, 1887. Melchoir, Dehu, /oc. cit., p. 187. Achalme, Soc. Biol., June 11, 1890. Orloff, Pein, loc. cit., p. 79. Gilbert and Girode, Bull. Soc. Biol., July 1 1, 1890, and May 2, 1891. Michon, Des Supp. dans la Fievre Typhoide, These de Paris, 1 890. Gasser, Pein, loc. cit., p. 88, Dmochowski and Janowski, Ziegler's Beitrage, xvii, 1895. PATHOLOGY. 43 Typhoid Infection of Different Organs Without Typical Typhoid Lesions in the In- testine. — A number of cases of typhoid infection ini various parts of the body, — very largely surgical, — without any typhoid lesions in the intestine, have been reported. Those which I have met with are as follows : 1. In the Spleen. — Du Cazal' reports the case ol a man, age twenty-one, who had pneumonia and pleu- risy, enlarged spleen with great tympany, bleeding from the nose, and headache, but no typhoid spots. He was admitted to the hospital March 2, 1893, and died on the 13th, about the twenty-third day of the disease. Typhoid bacilli in pure culture were found in the spleen, and their identity was confirmed by experiments upon animals. The intestines were entirely free from any typhoid lesion. He refers also to cases by Vincent, Valliard, Chantemesse, Rendu, Fernet, and Kelsch. 2. In the Spleen, Blood, and Urine. — Cheadle^ re- ports a very carefully examined case of typhoid fever without ulceration of the intestine in which both the "Widal serum-test durino- life and the bacterio- lop-ical examination made after the death of the patient rendered the diagnosis absolutely certain." A boy, aged three, was admitted to the hospital No- vember 8, 1896, with a history of diarrhea, vomit- ing, and debility. A brother and a sister of the patient had been in the same hospital suffering from typhoid fever. Rose-colored spots appeared, the abdomen was swollen and tympanitic, and the 1 Bull, et Mem. Soc. Med. des Hop., 1893, p. 243. 2 Lancet, 1897, ii, 254. 44 SURGERY OF TYPHOID FEVER. liver was enlarged but the spleen was not. Ten days after his admission, and probably about the twentieth day of the disease, epistaxis and vomiting occurred. By the twenty-sixth day he was coma- tose, and died December ist, about the thirty-third day of the disease. " On the twenty-first day of the disease, November 19th, on applying the serum-test Mr. MacCallan found that there were loss of motility of most of the bacilli and marked clump formation. The typhoid bacillus was separated from the urine on the twenty- sixth day of the disease by Parietti's method. On the thirty-second day he suspended in five c.c. of water part of a two-day-old stock culture of the bacillus, and to this were added two drops of blood from the patient. The fluid, previously cloudy, be- came clear after some hours, the bacilli having formed clumps and settled to the bottom of the tube as a flocculent, uneven mass. " At the post-mortem examination no ulceration of the intestine was visible, and Peyer's patches and the colon appeared to be normal. * * * * ^\\^ spleen was normal in size and appearance, was opened aseptically, and cultures on agar, gela- tin, and potato were made. The culture-tubes after incubation showed typical colonies of the typhoid bacillus. Mr. MacCallan examined micro- scopically for typhoid bacilli 30 or 40 sections of the spleen, but was unable to recognize any. This was not surprising, as Gaffky says that it is sometimes necessary to examine 200 stained microscopical sec- tions of the spleen in case of typhoid fever before groups of the bacilli can be recognized. The mes- PATHOLOGY. 45 enteric Mands and liver were enlarged. Before the heart was opened, blood was collected from the right auricle in Pasteur pipettes, and the serum-test was carried out with a culture of bacilli which had been separated from the patient's urine. Loss of motility in most of the bacilli and clump formation were observed." 3. In the Spleen. — Hodenpyl, in a paper soon to be published in the British Medical Journal,' reports the case of a man, age thirty-one, who had all the ordin- ary symptoms of a "typical typhoid fever, including the rash, of a severe type." He died on the seven- teenth day of the disease. The necropsy showed " no enlargement of the mesenteric lymph-nodes. * * * * The mucous membrane of the small in- testine was pale. There was neither swelling nor ulceration of the lymphatic structures. Careful ex- amination of Peyer's patches by transmitted light failed to reveal the slightest lesion. The appendix was normal. The colon was dilated and thickly studded with ulcers." The bacteriological examina- tion was made by Dr. E. H. Wilson, bacteriologist to the Brooklyn Board of Health, and later by Drs. Hiss and Dyar, assistants in bacteriology in the labora- tory of the College of Physicians and Surgeons, who, working independently of each other, identified the cultures from the spleen as those of the bacillus of typhoid. 4. In the Spleen. — Beatty ^ reports the case of a man, age thirty-four, who died on the sixth day of illness. Death was preceded by jaundice, hematuria, 1 Brit. Med. Jour., 1897, ii, or 1898, i. 2 Brit. Med. Jour., 1897, i, 14S. 46 SURGERY OF TYPHOID FEVER. and coma. Post-mortem, the spleen and mesenteric glands were enlarged, but the intestines were healthy. From the spleen typhoid bacilli were grown. He also reports a second case, supposed to be similar to this, but in which no bacteriological ex- amination was made. 5. In the Spleen. — Banti ' reports the case of a woman, age thirty-one, who died on the twenty-sixth day of a typical and apparently uncomplicated attack of typhoid fever. The autopsy showed no lesion of the intestine, but the stained section of the spleen demonstrated bacteria, which Banti reearded as typhoid bacilli. 6. In the Spleen. — Karlinski ^ reports three cases, occurring in a wide-spread epidemic of typhoid fever, which presented, during life, the symptoms of this disease. They were affected in much the same way as other fatal cases, which last showed at autopsy the characteristic lesions of the small intestine in typhoid fever. The autopsies of these three fatal cases failed to show any involvement of the lymphatic structures, nor was there swellino- or ulceration of either laree or small intestines. The mesenteric lymph-nodes and spleen were swollen in each case. In one case the spleen was five ' times its normal size. Culti- vations from the spleen revealed the presence of the typhoid bacillus in each case. 7. In the Brain, — Balp ^ reports a case in which the patient entered the hospital, having had a fall which caused unconsciousness and fracture of the humerus. 1 Riforma Med., 1S87, 1448. 2 Wien. med. Wochen., 1891, 470. 3 Revist. Gen. Ital. Clin. Med., 1890, 406. PATHOLOGY. 47 Suppurative meningitis, both spinal and cerebral, was found at the post-mortem. There was a tear of the nasal mucous membrane communicating with the meninges. In the pus from the meninges was found the bacillus of Eberth. 8. In the Brain. — Neumann and Schaeffer' report the case of a woman who died in the hospital uncon- scious and without history. No lesions of typhoid were found in the intestine, but from the meninges were obtained pure cultures of the typhoid bacillus. 9. In the Brain. — Adenot^ reports a case in which there was absolutely no lesion found in the kidneys, spleen, mesenteric glands, or intestines, and yet the patient died on the tenth day, five days after the onset of meningitis, and in the fluid infiltratino- the brain — for there was no pus — the bacillus of Eberth was found in pure culture. 10. In Pleuritic Pus. — Charrin^ reports the case of a man who died of a purulent pleurisy. The bacteri- ological examination of the fluid showed the presence of the typhoid bacillus, but none of the intestinal lesions of typhoid were found. 11. In a Suppurative Goiter. — Kummer and Taveh report a case in which there was suppuration in an old goiter, due to the typhoid bacillus. The thyroid disease began on the second day. No typhoid bacilli were found in the stools, and no other evi- dences of typhoid infection were present. The bacteriological examination by Tavel was made, it is true, by older methods, but was most careful and ^ Virchow's Arch., 1887, cix, 477. 2 Lyon Med., 1889, Nos. 34 and 36. 3 Soc. Med. des Hop., March 17, 1S91. * Rev. de Chir., 1891, 507. 48 SURGERY OF TYPHOID FEVER. exhaustive. The patient made an excellent re- covery. 12. In the Qan=bladder. — Osier ' records a case of acute cholecystitis under the care of Halsted and Gushing. A woman, age twenty-six, who had never had any illness resembling typhoid fever, on March I, 1897, after an enormous meal, was seized with vomiting, fever, and pain in the region of the gall- bladder, with indistinct tumefaction. On March 1 6th Halsted operated, finding a large gall-bladder distended with a brownish-tinted material and 15 large stones. She recovered. Gushing made cul- tures showing the presence of the typhoid bacillus, and the patient's blood gave the characteristic indol reaction to this and to another culture of typhoid bacilli. 13. In the Liver, Spleen, and Blood. — Guarnieri^ re- ports a case of angiocholitis, produced by the typhoid bacillus, without the characteristic lesions of typhoid in the intestine. The bacillus was culti- vated from the liver and spleen, and from the blood of the patient twelve days before death. The following additional references to cases show- ing the presence of typhoid bacilli in various organs, but without typhoid lesions in the intestine, have been kindly furnished me by Dr. Flexner : 14. In the Intestine. — Widal ^ gives the following references : In a case of Pick's "^ the sero-diag-nosis o ^ Trans. Assoc. Amer. Pliys., 1S97, xii, 396. 2 Baumgarten's Jaliresbericht, 1892, vol. viii, 234, from Revist. Gen. di Clin. Med., 1892, p. 234. 3 Etude sur le Serodiagnostic, etc. Ann. de ITnstitut Pasteur, May, 1897, p. 426. * Wien. klin. Wochen., 1897, No. 4, 82. PATHOLOGY. 49 had been positive during life. At the autopsy the lesions of typhoid fever were not found in the intes- tine or in the spleen, but the typhoid bacillus was cultivated from the intestine. 15. In the Spleen, Lungs, and Pleural Effusion. — \\\ the case of Chambon and Menard,' the disease pre- sented during- life the symptoms of typhoid fever and acute tuberculosis. The sero-diagnosis was positive three times. The autopsy showed granules (tubercles?) in the lungs, meninges, kidneys, liver, spleen, and intestines, but no typhoid lesions in the intestines. Cultures from the spleen, lungs, and pleural effusion gave a bacillus which was identified as the bacillus typhosus. Flexner ^ and Hodenpyl accept the case of Du Cazal as proved from the bacteriological point of view, but reject other cases as not differentiating the colon and the typhoid bacilli with sufficient accuracy by the methods employed. I do not feel myself competent to decide such a technical point, but will only call attention to two facts : First, the cases of Cheadle and Hodenpyl seem to have been most carefully studied by the later methods, and that of Kummer and Tavel with equal care by older methods, and would seem to be fairly conclusive. Moreover, if the single case of Du Cazal is accepted, Xh^ principle is admitted ; and if admitted in one case, — rare, it is true, but accepted as certain, — then there is no reason why it may not be true in other cases. Secondly, while in this or that case the conclusion 1 Soc. Med. des Hop., 1897, No. 2. 2 Jour. Path, and Bacteriol., 1895, 210. 50 SURGERY OF TYPHOID FEVER. mieht be erroneous, it Is hard to believe that over a dozen observers — careful men, trained to their work — would all be wrong. Even if they did work with imperfect methods, their conclusions, when supported by the three or four acknowledged to have been in- vestigated by accurate and modern methods, it seems to me, must be accepted as in general correct. Possibly the explanation of those cases of infection in which the typhoid bacilli have attacked not the in- testine but other organs may be found in the investi- gations of Remlinofer and Schneider.' These authors found the typhoid bacillus in earth, in drinking water, and in the intestinal canal in healthy persons. The bacteria obtained resembled those from true typhoid stools in form, culture, and biological tests, but they were less virulent and the cultures were not affected by the serum-test. They believe that Eberth's bacil- lus is, to a certain degree, ubiquitous, that it occurs in drinking water, in the soil, and in the digestive tract of healthy persons as well as in those suffering from typhoid ; that it can remain in the bowel of healthy persons innocuous until an accidental weak- ening of the intestine or the appearance of other bacteria gives it the power to manifest its action. Pancini,^ after investigating six cases (abscess of the liver from dysentery, suppurating echinococcus cysts, etc.), in all of which a bacillus in all respects resembling the typhoid bacillus was found, but with- out any typhoid fever or typhoid intestinal lesions, says that one of three conclusions is inevitable : (i) That typhoid bacilli are so frequently found in 1 Ann. de I'lnstitut Pasteur, vol. xi, p. i. 2 Riforma Med., 1893, 95, in Centralbl. f. Bakteriol., 1893, xiv, 497. PATHOLOGY. 51 the human intestine as to be regarded as normal ; (2) that the colon bacilli can not be distinguished from the typhoid bacilli ; or (3) that the typhoid bacilli must be only varieties of the colon bacilli. Which of these conclusions is correct I do not feel myself competent to judge, and most pro])ably it is as yet an unsolved problem. Frangulea/ in a paper at the recent Moscow Con- gress, accepts the last very frankly. Hiss, in an important recent paper,^ has pointed out the means of differentiating the two with ap- proximate certainty. Flexner^ has done the same. ^ Verein's Beilage z. Deutsch. med. Wochen., Sept. 16, 1897, 187. 2 Jour, of Exp. Med., ii, 677. 3 Jour. Path, and Bacteriol., 1895. CHAPTER III. TYPHOID GANGRENE/ English and American authors in the past have not given the attention to gangrene after typhoid which its importance deserves. Thus Reynolds and Bartholow make no allusion to it ; Wilson only "al- ludes to granorrene of the lunor ^nd the mouth, two of its rarer sequels ; Flint mentions it, but had never seen a case ; while Murchison in his classical work, and Hutchinson in an excellent chapter on typhoid in Pepper's System of Medicine give it only a brief notice. Nor have the surgeons done it any better justice. Neither Gross, Agnew, Ashhurst, nor Holmes ^ mention it. Barwell ^ refers to it briefly. It is not mentioned in Dennis' or Park's System of Surgery and not alluded to in Treves' System. We owe our chief knowledge of the subject to French authors, and to a few recent German and Americans publications. Larrey,'* Hildebrand,^ Ali- bert,^ and Fabre ^ mention sporadic cases of gan- grene, but attention was first seriously called to its occurrence in typhoid fever in 1857 by Bourgeois^ 1 This chapter is based partly on my Toner Lecture, but is chiefly an ex- pansion of the Shattuck Lecture (see preface). Some paragraphs in that lecture which were merely incidental are omitted, and others have been transferred to the introduction. . 2 System of Surgery. * International Encyclopedia of Surgery. * Mem. et Campagnes, iii, 72. ^ Typhus Contagieux, 1806. 6 These de Paris, 1838. "^ Gaz. Med. de Paris, 185 1, 539. s Bull. Soc. Med. des Hop., Paris, 1857, iii, 311. 52 TYPHOID GANGRENE. 53 and BoLirguet.' The next papers of any importance were by Gigon in icS6i and 1863.^ The former es- tablished the fact of gangrene from arterial obstruc- tion by autopsy, though he regarded the gangrene as a coincidence rather than a consequence of the fever. In 1863, Patry^ confirmed these earlier ob- servations. The cases reported by these authors were included in the summary published in the Toner Lecture (1876) already alluded to. Since my own contribution, some of the more important papers are those of Spillman/ Gaston David,5 Barie,^ Deschamps,^ Haushalter,^ Flexner,^ and Quervain,'° besides a very large number of in- dividual cases, which have been reported by various authors. Under gangrene I exclude from consideration the familiar and frequent bedsores, which, though actu- ally often partaking of this character, are scarcely in the same category as the cases I shall consider. One would suppose a prioiH that gangrene would only follow severe attacks, but so large a number of cases of gangrene have been reported after rela- tively mild attacks, that we must concede the possi- 1 Gaz. Hebdom., 1857, 646. 2 L'Union Med. 3 Arch. Gen., 1863, i, 129, 549. * Gangrene des Organes Genitaux de la Femme, Arch. Gen., 1881, 7th series, vi, 150. 5 La Gangrene Typhoide, These de Paris, 1883. ^ L'Arterite aigue consec. a la Fievre Typhoide, Rev. de Med., 1884, iv, No. I. '' L'Arterite aigue dans la Cours de la Fievre Typhoide, These de Paris, 1886. 8 Merc. Med., September 20, 1893, 453. * Johns Hopkins Hosp. Rep., Nov., 1894, 120 ; and Jour. Path, and Bac- terioL, Nov., 1894, iii, 202. 1" Centralbl. f. inner. Med., August 17, 1895, 793. 54 SURGERY OF TYPHOID FEVER. bility of gangrene in mild cases as well, as severe ones. Hence the watchfulness of the physician should never relax by reason of the fact that the case is running a mild course, and that gangrene is an infrequent result of typhoid. While gangrene is an important complication or sequel of typhoid, it is fortunately rare, so that most practitioners, and even some men of vast experience in large hospitals, have never seen a case — for ex- ample, Flint and Murchison. Holscher,' in 2000 fatal cases of typhoid, does not report a single case, though he records 59 cases of thrombosis of the femoral vein, and Bettke,^ in 1420 cases, found only four cases of gangrene, all limited to the toes. In my former lecture I tabulated 43 cases from typhoid and 56 from typhus. ^ Since 1876, Dr. Westcott has found 90 cases of actual gangrene, of which 72 fol- lowed typhoid, in addition to which he has tabulated 21 cases of arterial and 48 of venous thrombosis not followed by gangrene. In its infrequency, therefore, it is in marked contrast to the bone lesions, of which he has found 168 cases, all after typhoid, to which, from my former lecture, are to be added t^^ after typhoid and four after typhus, or a total in typhoid alone of 205 cases of bone lesions to 133 of gan- ofrene. Date of Onset. — While gangrene is generally a late complication during the course of the fever, or an early sequel during convalescence, it is never a very 1 Miinch. med. Wochen., 1891, xxxviii, 43. 2 Inaug.-Diss. , Basel, 1870. 3 Thirty-four of these after typhus were reported by Estlander (Langen- beck's Archiv, 1870, p. 453) in a frightful epidemic following a financial crisis and a series of bad harvests in 1862—67, in Finland. TYPHOID GANGRENE. 55 late sequel, as is the case in the bone lesions. The latter often do not occur until several weeks, some- times months and occasionally even years, after the attack of fever. This is doubtless due to the fact that the bacilli of typhoid find a favorable nidus in the bones, especially in the marrow, and have been re- peatedly demonstrated by stain and culture after six, twelve, or eighteen months, and even after so extra- ordinary long a period as six' or seven years. ^ In addition to this, the slowness of all pathological pro- cesses in the hard osseous tissues, as contrasted with their rapidity in the soft parts, would naturally lead us to expect that gangrene would occur far earlier than lesions in the osseous tissues, yet ab- scess of the brain may occur two or three months after the fever (see Chapter VIII), The earliest time at which gangrene occurred, I find, is on the fourteenth day,^ and the latest in the seventh week."* By far the commonest time for this dangerous complication to appear is the second and third weeks, during which 39.2 per cent, of all the cases occurred. The causes for the appearance of gangrene in the second or third weeks, or late rather than early in the disease, are probably twofold. First, during the earlier stages of the disease the general vitality of the patient and the resistance of the tissues are such that they can combat successfully the evil tendencies of the fever; but, secondly and chiefly, just as for 1 Sultan, Deutsch. med. Wochen., 1894, 675. 2 Buschke, Fortschritte d. Med., 1894, 573. ^ Donald, Lancet, 1892, i, 417. * Forgues, Rec. de Med. Mil., 1S80, 3d series, xxxvi, 386. 56 SURGERY OF TYPHOID FEVER. the production of the intestinal lesions, so for the gangrene, a certain length of time is required for the diffusion of the bacilli and their toxic products, and for their resulting evil effects. Both causes unite in working together and to the same end. By the second or the third week the bacilli and their toxic products have become diffused through the system; excessive feebleness has followed the small amount of food taken and the exhaustion from the continued high temperature; the heart' has become weakened, which favors the formation of thrombi, not only in the heart but also in the vessels, either as a result of arteritis or of autochthonous thrombosis ; emboli frequently result ; and with the sluggish cir- culation, the general enfeeblement both of mind and body, and the frequently obstructed vessels, the advent of gangrene at this period of the fever should occasion no surprise. Indeed, the surprise is rather that it is so rare. Let us now consider the pathology, symptoma- tology, and treatment. Pathology. — Various writers have been the par- tizans of one or another single cause for the occur- rence of gangrene during and after typhoid fever. This seems to me an error, for, as I hope to show, there are a number of causes, of which one will exist in one case and another in another case, sometimes singly, sometimes in combination. ^ We do not appreciate how much a continued higli temperature alone exhausts a patient. Were tlie body composed of water alone, to raise the temperature of a person weighing 150 pounds from 98.5° to 103.5°, — i. e. five degrees (to say nothing of the expenditure of force needful to keep it there), — - requires an expenditure of force equal to raising 285 tons one foot (150X5 X772 foot pounds). A girl of loo pounds weight, simply lying still in bed, suffering from such a fever, does daily the work of two or three men. TYI'HOID GANGRENE. 57 In my loner Lecture 1 was disposed to regard the causes of gangrene as chiefly three : first, the altered blood ; secondly, the weakened heart ; and, thirdly, the mechanical difficulties in carrying on the circulation, especially in distant parts ; and that all of these caused the gangrene by the production of thrombi, either macroscopic or microscopic. Since that lecture was delivered, however, the bacillus of typhoid has been discovered, and has been proved by a number of careful examinations to play an im- portant, and in some cases at least a direct, role in the production of gangrene. It is greatly to be re- gretted that only very few cases have been studied wnth the scientific precision which they deserve. By calling renewed attention to the subject, however, I hope to stimulate others, especially in this country, to make thorouoh bacterioloeical examinations in the future. Every chapter in this monograph shows how deficient our knowledge is for want of such in- vestigations. All the more are such careful exam- inations necessary, since the opportunities to make them are so rare, and when they do occur It is only too seldom that it is in the hands of men with the opportunity, the capability, and the disposition for makinor such examinations. In two cases in my tables ergot had been freely given in consequence of hemorrhage.' Were these the only cases of gangrene, one might suppose that this had had a determining influence, but as gan- grene followed in 88 other cases, in none of which 1 Finlayson, Amer. Jour. Med. Sci., March, 1891, and Sarda, Rev. Gen. de Clin, et de Therap., 1892, vi, 401. 58 SURGERY OF TYPHOID FEVER. had this drug been administered, its exhibition must be considered as merely incidental. As a foundation for our study of the pathology of typhoid gangrene, let me recall a few of the facts which have been demonstrated bacteriologically. First, not a few cases of typhoid fever suffer from a mixed infection. This is much more apt to lead, however, to other disorders than Pfanofrene. For example, as I shall show hereafter, there have been a number of cases of tetanus, erysipelas, anthrax, and malignant edema, due, of course, to a mixed infection of the typhoid and these specific bacteria (Chapter XIX). In addition to this, the large number of cases of suppurative disorders in various organs, bones, spleen, muscles, etc., presume the presence of the ordinary pyogenic bacteria, and their presence has been proved by stain and culture. In two cases in my tables pyemia or septicemia, a rare condition, is noted,' in both of which the pyemia followed a phlebitis without gangrene. Turnino- now to the cases in which bacteriological examinations have shown pure cultures of the bacil- lus of Eberth, we must note, as bearing upon the occurrence of gangrene, that they may be found : {a) In the blood ; {U) in the endocardium ; {c) in the walls of the arteries; {d^ in the walls of the veins; [e] in the thrombi ; and (_/) in the perivascular tissues. {a) Typhoid Bacilli in the Blood — This has already been fully considered in Chapter II, page 23, and need not be repeated. 1 Wagner, Brit. Med. Jour., 1891,!, 18; and Spillman, Merc. Med., 1895, No. 13, 145. TYPHOID GANGRENE. 59 [b) In the Endocardium.' — Viti '' not only found the bacillus of Eberth in the granulations of endocar- ditis, but by the injections of the bacillus alone into rabbits he was able to produce endocarditis with vegetations. Vincent 2 records another case occurring- in a soldier who was undoubtedly free from a preceding endocarditis, but died from typhoid, and in the vegetations on the mitral valve pure cultures of the bacillus of Eberth were found. Girode "* made a similar observation. Gilbert and Lion ^ were also able to produce such endocardial vegetations experi- mentally by injections of pure culture of the typhoid germs. Besides the actual discovery of the bacillus of Eberth in the endocardial vegetations, it is not un- common to find ante-mortem clots in the cavities of the heart. Forgues,^ Beaumanoir,^ Fritz, ^ and Val- lette (quoted by Ferrand^) have all recorded such post-mortem findings. These clots are formed prob- ably during the period of cardiac weakness, especially in the second and third weeks," and, as the heart begins to regain its force and lose its frequency, are washed into the circulation as emboli. In the viscera their presence is shown by multiple infarcts ; in the legs, by the occurrence of gangrene. 1 Cf. Flexner, Jour. Path, and Bacteriol. , 1894, iii, 202, for several cases. ''■ Atti della R. Accademia del Fisiocritici di Siena, 4th series, vol. ii, fasc. 5, 6, 1890. 3 Merc. Med., Feb. 17, 1892,73. 4 Comptes Rendus Soc. Biol., 1889, 622. ^ Comptes Rendus, 1889. « Rec. de Mem. de Med. Mil., 1880, 3d series, xxxvi, 386. "^ Prog. Med., 1891, ix, 364. ^ Charite Annalen, vi, 169. ^ Contrib. a 1' Etude de la gangrene des membres pendant la cours de la Fievre Typrioide, These de Paris, 1890. 10 Drewitt, Lancet, 1890, ii, 1023. 6o SURGERY OF TYPHOID FEVER. [c] In the Walls of the Arteries. — Rattone ' reports four cases in which, in sections of the arterial tunics, he was able to obtain pure cultures of the bacillus of typhoid. [d') In the Walls of the Veins, — Haushalter^ found the bacillus in sections through the veins ; and both he and Vaques found the pyogenic microbes in the walls of the veins in cases of typhoid phlegmasia. Arteritis, endarteritis and peri-arteritis, phlebitis and periphlebitis, have been described by a number of authors, especially Ferrand, Deschamps,^ Met- tler,4 Barie,^ Quervain,^ and Haushalter.^ With the exception of the last two, the descriptions are pa- thological, but without bacteriological confirmation. Ferrand^ quotes numerous cases of endarteritis of the iliac, femoral, and popliteal arteries, followed by thrombosis and gangrene. Barie describes two forms of arteritis ; first, an obliteratino- form, and, secondly, a parietal form. In the first there is pro- found alteration of the middle coat, the muscular fiber cells being infiltrated with embryonic cells, with sclerosis of the external coat and vegetations in the lumen. Sometimes, indeed, the three coats are in- distinguishable. In others the lining membrane is covered with small elevations consisting of masses of round and fusiform cells. There is a loss of elasticity in the vascular walls, which become fri- able and easily distended. The loss of smoothness ^ Delia Arterite Tifosa in Dehu, loc. cit. 2 Merc. Med., Sept. 20, 1893, 453. ^ These de Paris, 1886. 4 Phila. Med. Times, Feb. 19, 1887, 339, and N. Y. Med. Jour., March 9, 1895, 289. 5 Rev. de Med., 1884, iv, 7. s Centralbl. f. inner. Med., Aug. 17, 1895, 793. ■^ Merc. Med., Sept. 20, 1893, 453. » These de Paris, 1890. TYPHOID GANGRENE. 6 1 of the intinia, the irregularities of its surface, and the diminished caHber from the swelHng are readily con- ceived causes for the formation of thrombi, resulting frequently in gangrene. The thrombi, at first red, but later decolorized, become adherent to the wall, and finally the artery becomes a solid cord. Distal secondary thrombosis is slow. The lumen of the vessel and of its branches is gradually obliterated, and the gangrene, therefore, is correspondingly slow, and not sudden as in embolism ; but from the orig- inal thrombi secondary emboli may form, and so hasten the gangrene by sudden obliteration of the anastomotic circulation. As a ride, therefore, in arterial thrombosis the gan- grene is dry, but occasionally during the course of the dry gangrene from arterial obstruction, the vein also becomes obstructed, and part or all of the limb may fall into sudden ruin from moist gangrene. The parietal arteritis, according to Barie, is not attended with thrombosis, and is usually followed by recovery. That arteritis should occur in typhoid is rendered also probable by its appearance in other allied spe- cific diseases, such as small-pox, diphtheria, tubercu- losis, syphilis, rheumatism, etc. How the bacilli reach the walls of an artery or vein is a question. Ordinarily they are not found in the blood ; and yet the fact that they may be widely distributed throughout the body, and that the only reasonable mode of such an extensive diffusion is by the blood, the cases of Flexner, Vincent, and others amply prove [cf. Chapter II). Haushalter believes that during their maximum they may reach 62 SURGERY OF TYPHOID FEVER. the vessels by the vasa vasorum,' which, it must be remembered, especially in the veins, reach the middle, and often the internal coat. He is inclined, however, to believe that the process is as follows : that an infection of the pelvic or crural ganglia occurs, fol- lowed by an infection of the perivenous cellular tissue by retrograde lymphatic circulation. In these cases he supposes that a periphlebitis exists, fol- lowed by a secondary endophlebitis precipitating a thrombus by the ferment furnished by the bacilli. This, I confess, seems to me much less likely than the former view. ie) In the Thrombi. — Both Rattone and Haushalter found the bacillus of typhoid in thrombi. The latter calls attention to the fact that he was not able to stain them in the thrombus, due, he thinks, to the fibrin, which, being decolorized with great difficulty, probably obscured the bacilli ; but he was able to demonstrate their presence by cultures. He found the endothelium of the veins destroyed. On the surface of the clot next the vein wall a layer of leu- cocytes was intimately united both to the clot and to the wall of the vein. The typhoid bacillus existed only in the thrombosed portion of the vessels ; and he is of the opinion that either the bacilli or their products caused the destruction of the endothelium and the resulting clot, and that, in all probability, in the products of the bacilli was found the ferment necessary to produce the coagulation. Plate I, from Fraenkel and Simmonds,^ shows 1 For a number of cases in which bacteria were found in the vasa vasorum, see Lockwood, Traumatic Infection, London, 1S96. 2 Die setiologische Bedeutung des Typhusbacillen, Leipzig, 1886. PLATE I. i- Fig. I. — Section of liver of a patient dead of typhoid fever. Bacilli were found also in the spleen. «, A vessel and its branches completely obstructed by typhoid bacilli; below it and to the left a close small-cell infiltration which almost entirely obscures the vessel, b, A so- called lymphoma. Fig. 2. — Enlargement oi Fig. I, a, showing the individual bacilli. Fig. 3. — The liver of a rabbit dead after an injection of pure culture of typhoid bacilli in the ear-veins. Bacilli were found also in the spleen and the mesenteric glands, a, A vessel entirely obstructed by typhoid bacilli. The section shows at various points diffused small-cell infiltration. Fig. 4. — Enlargement of Fig. 3, a, showing the individual bacilli. (Fraenkel and Sim- monds, "Die etiologische Bedeutung des Typhusbacillen," Leipzig, L. Voss, 1886. Repro- duced by the kind permission of the authors and publisher.) TYPHOID GANGRENE. 63 excellently the actually observed thrombosis of the vessels of the liver by the bacilli of typhoid. (y) In the Perivascular Tissue. — Quervain found the bacillus in pure culture in the pus surrounding the popliteal artery and vein. That the bacillus should cause suppuration around a vessel and be found in pure culture ought not now to astonish us. The pyogenic power of the typhoid bacillus is fully considered in the introduction. Having now determined the bacteriological facts, let us see how they may be applied pathologically in explaining the causation of gangrene. The cause of gangrene may be stated in practi- cally a single phrase — obstruction to the circulation.'' The three factors I have already quoted from my first lecture — the altered blood, the weakened heart, and the mechanical difficulties of the circulation in distant parts, especially the last two — still hold good, but there must be added to them the important role of the typhoid bacillus in assisting, and often, it may be, in directly precipitating, the coagulation of the blood, which is the cause of the obstruction. Four different varieties of obstruction, therefore, may exist and sometimes co-exist : First, arterial emboli of cardiac origin ; secondly, autochthonous thrombi in the arteries; thirdly, autochthonous thrombi in the veins ; and, fourthly, — probably, though I believe there have been no cases absolutely demonstrated pathologically, — thrombi in the small peripheral ves- sels. In Chapter VIII, on the cerebral complica- tions of typhoid, I have reproduced the illustrations of Ohlmacher showing obliterative endarteritis in 1 Cf. Oliver, Lancet, 1896, i, 1778. 64 SURGERY OF TYPHOID FEVER. suppurative typhoid meningitis. These observations, toeether with the demonstration of actual thrombi caused by the typhoid bacilH themselves in the vessels as shown by Fraenkel and Simmonds (Plate I), throw an important light, it may be, on this cause of gangrene. I . Arterial Embolism of Cardiac Origin. — This has been observed not only at postmortems, but clini- cally. Thus, Hayem ' observed the alteration of the heart two days before gangrene of both legs com- menced, the first symptoms being acute pain in the legs with a sensation of cold. The pulsation disap- peared first in the dorsalis pedis, then in the pop- liteal, then in the femoral. Amputation showed that, though the arterial walls appeared to be healthy, the femoral artery was partly obstructed by a clot. The obstruction being only partial allowed a feeble circulation to go on. The popliteal and all its branches below the inferior articular were entirely free from any clot. The patient died, and the necropsy showed endocarditis and clots in the heart ; the aorta was obstructed by a clot extending from its bifurcation to a point above the origin of the inferior mesenteric, but the iliac arteries were entirely free. The spleen and the kidneys presented multiple in- farcts. Mercier^ reports also a case of dry gangrene of both legs with fibrinous clots in both the primitive iliacs, the deep femoral and the popliteal, the walls of which were healthy, and in the left auricle there were old fibrinous clots with endocarditis. This form of arterial obstruction is quite common in my table, as will be observed in the resume on page 74. It leads, 1 Prog. Med., 1875. 2 Arch. Gen., 7th series, 1878, vol. ii, 402. TYPHOID GANGRENE. 65 as would naturally be supposed, almost always to dry gangrene, because it eventually cuts off the supply of blood ; as a rule, absolutely ; though in a few cases, as in the one quoted from Hayem, a small amount of blood may still reach the distal parts and so re- strict the extent of the gangrene. The very facts, also, that the walls of the arteries were healthy and that there were multiple infarcts in the viscera, tes- tify to the cardiac origin of such emboli. In addition to this I have called attention on pages 76-78 to the remarkable difference between arterial and venous obstruction in relation to their distribu- tion to the right or left sides of the body. The al- most even balance in arterial obstruction and the great inequality in venous obstruction may point also to the heart as a factor in arterial obstruction. 2. Arterial Thrombosis. — In a ereat number of cases in the table there were no evidences of preceding cardiac disease, and yet obstructive clots Vv^ere found in the arteries, and were followed by dry gangrene. These are undoubtedly autochthonous thrombi, probably produced largely from the ferment fur- nished by the bacilli themselves, or possibly more frequently from an endarteritis, such as has been already described. The consequences of the thrombosis, as of the embolism of the arteries, will be a greater or less degree of dry gangrene, the extent of which will depend upon the completeness or incompleteness of the obstruction. Sudden thrombosis may be precipitated by very slight causes — e.g., Morax ' records the case of a man 1 Bull. Soc. Med. Suisse, 1867, quoted by Mercier. 5 66 SURGERY OF TYPHOID FEVER. of thirty-five who, when convalescent, after a walk felt sudden severe pain in his left leg, followed by gangrene from arterial thrombosis. Sometimes, even after a careful post-mortem, it may be impossible to determine the oriofin of the obstruction. Thus, Valette (quoted by Ferrand) relates a case of occlusion of the iliac arteries, gangrene of the right leg, vulva, and perineum, with bedsores on the thigh and sacral regions setting in on the forty- second day. The leg was amputated after eight weeks, and the patient, age eighteen, died twenty- three days later. The necropsy showed red hepatiza- tion of the right lung. There was neither myocardi- tis, endocarditis, nor arteritis, but in the left ventricle was a clot as large as a small &^'g, yellow, hard, and elastic, and extending to the semilunar and the mitral valves ; and at the iliac bifurcation on the right side, a whitish-gray clot obliterated the external and internal iliacs. In the Toner Lecture (see Appendix, Fig. i), I have copied a figure from Meusel, in which gan- grene (necrosis) of a large portion of the skull re- sulted from a clot in the middle menino-eal. As the patient recovered and no mention is made of any cardiac trouble, the clot was probably an autochtho- nous thrombus. 3. Venous Thrombosis. — This is much more fre- quent than the arterial form, probably from the more sluggish circulation, in addition to the infec- tious processes which undoubtedly sometimes cause a phlebitis or a periphlebitis. The phlebitis very frequently results in phleg- masia alba dolens. Usually this passes away in a TYPHOID GANGRENE. 67 relatively short time, but it may be the cause of very persistent trouble and annoyance, as in the follow- inof instance : Case I. — E. C, Milford, Del., age forty-two, first consulted me July 9, 1897, at the instance of Dr. Marshall. He is an exceedingly large, stout man, who, six years ago, had an attack of typhoid fever. During his convalescence phlegmasia developed in the left leg, from which he has suffered ever since. The leg is still swollen, especially from the knee down, is very hard, tense, and brawny, is covered with crusts of exudation, and is subject constantly to small furuncles and the formation of small ulcers and occasionally of distinct abscesses. One of these, above the internal malleolus, was opened about six months ao-o and has never healed. At this site there is a small crater, one cm. in diameter, oroino" through the entire thickness of the skin to the muscular tissues, and the seat of an exceedingly foul discharge. The itching of the limb also annoys him very much. I directed him to foment the leg sufficiently to take all the crusts off, and then to apply an ointment of resorcin, 30 grs. to the ounce. Under this treatment he rapidly improved, and w^as soon entirely well. Venous thrombosis results in gangrene in a mod- erate number of cases ; but in the majority, as in venous thrombosis from puerperal fever, pneumonia, etc., gangrene is much less apt to follow venous than arterial thrombosis. The circulation is not nearly so completely cut off by venous obstruction as by arterial, since the collateral venous channels are less frequently blocked. Moreover, in arterial obstruction the limb below the obstruction is en- tirely deprived of blood, whereas in venous obstruc- 68 SURGERY OF TYPHOID FEVER. tion the blood is dammed up in the part beyond the obstruction. The circulation may be hindered, but if it be not practically entirely arrested, a feeble nourishment goes on, sufficient at least to prevent gangrene. It is to be observed that both in venous and arterial thrombosis, especially the latter, the clots are often discontinuous. (See cases of Hayem, Mercier, and Beaumanoir.) This, possibly, may be due to isolated spots of local infection from the bacilli. The venous clots are often very extensive, much more so than the arterial, as shown by a number of cases in my table. Thus, in a case of de Santi,' the clot extended downward to the deep femoral vein and upward through the common iliac to the vena cava. Beaumanoir^ reports a case in which there were not only clots in the arteries of both legs, but also fibrinous clots in the right ventricle and pul- monary artery and its branches, in the left auricle, and in the femoral arteries and veins and in the aorta to the level of the first intercostal artery. Naturally such extensive obstruction was followed by gangrene of both lower extremities. Clots ex- tending into the vena cava are also reported by Dumontpallier,3 Sorel,"* and Bouley.^ These were all fatal, but Mackintosh,^ reports one followed by re- covery. The attack of typhoid was followed by scarlatina, but the swelling of the legs was noticed 1 Rec. Mem. de Med. Militaires, 3d series, vol. xxxv, 1879, 5°^. 2 Prog. Med., 1891, ix, 364. 3 Comptes Rendus Soc. Biol., 1879, 6th series, vol. iv, parts 2 and 3. * L'Union Med., 1882, 3d sefies, vol. xxxiv, 521. 5 Prog. Med., 1880, viii, 998. ^ Glasgow Med. Jour., 1892, xxviii, 54. TYPHOID GANGRENE. 69 before the latter. The collateral circulation was re-established by dilatation of the internal mam- mary, superficial epigastric, external pudic, internal saphenous, and circumflex iliac veins on both sides. The diagnosis seems, therefore, fairly well estab- lished. Occasionally, as would be supposed, venous throm- bosis is followed by sudden death, as in a case reported by Nauvverck,' of thrombosis of the left iliac vein, which was followed by sudden embolism of the pulmonary artery while the patient was at stool, and death occurred in ten minutes ; and in another re- ported by Bouley,^ also of thrombosis of the external iliac vein, which extended to the inferior vena cava and the right auricle of the heart, and the patient died from syncope. As would naturally be supposed also, the thrombosis, both arterial and venous, but especially the former, is apt to lead not only fre- quently to double gangrene, — for example, of both lower extremities, — but sometimes to a gangrene which is so symmetrical as to remind one of cases of Raynaud's disease. Richard ^ has reported two such cases in brothers. A curious coincidence is seen in the case of two sisters reported by Trelat,'' both of whom had double cataract after typhoid. They were both young (one twenty-five). At least one was successfully operated on. Had the bacillus of Eberth then been known, it would be interesting to know whether the cataract was due to a local mvasion. 1 Correspondenzbl. schweiz. Aerzte, 1879,485. 2 Prog. Med., 1880, viii. 998. ^ L' Union Med., 1880, 3d .series, xxix, 1025. * Gaz. des Hop., 1879, !''> 417- 70 SURGERY OF TYPHOID FEVER. When, the gangi^ene results fi^oiii venous obstriLction rather than arterial, as a rule it is moist. Not uncommonly thrombosis of the arteries and veins is either successive or simultaneous. ' In either case, the gangrene is apt to be a combination of dry and moist gangrene. Occasionally, when the venous thrombosis follows the arterial, the gangrene will be at first of the dry variety in the distal parts and when the venous obstruction occurs moist gangrene will follow in the proximal. 4. Thrombosis in the Peripheral Vessels. — In addi- tion to the three forms above recited, there are a number of cases reported in which the disease began as dry gangrene in the toes and gradually crept up the leg. The persistence of pulsation in the dorsalis pedis and other higher arteries showed that there was no arterial thrombosis or embolism in the arteries higher up, but after a time the coagula- tion, which presumably had begun at the periphery, extended centrally, and first the dorsalis pedis, then the tibials at the ankle, and later the popliteal and even the femoral were successively obstructed, re- sulting, of course, in a more wide-spread gangrene. The symptoms show that none of the three preced- ing conditions existed, but they enable us by analogy to reach the conclusion that spontaneous thrombi formed in the distal vessels. Whether the cause of this thrombosis is a bacillary infection or not has not been studied with that care which it deserves, and no absolute pathological or bacteriological confirmation of this view, I believe, has been reported. Symptoms of Gangrene. — The symptoms of gangrene are marked and characteristic. Let us TYPHOID GANGRENE. 7 1 suppose the case to be one of arterial embolism or thrombosis. Toward the end of the fever, especially in the third week or early in convalescence, as weak- ness is giving place to strength and the brightest hopes of speedy recovery are cherished, sudden, severe, and persistent pain is felt. This may be at the seat of the impending gangrene, though perhaps more commonly it is in the obstructed artery, especi- ally in the femoral, popliteal, or tibial, and radiates thence toward the periphery. It is followed by numb- ness, coldness, loss of sensation, and sometimes of motion, and in a short time discoloration and all the other usual evidences of gangrene appear. Some- times, but not usually, these local symptoms precede the pain. If the vessels of the foot or at the ankle, or even the popliteal, be examined, the pulsation will be found feeble or utterly extinguished, while higher up, at the seat of the obstruction, the artery will be changed into a moderately firm but very tender cord, in which we may sometimes differentiate the obstructed artery from the non-obstructed vein — an important point in prognosis. Week by week, sometimes day by day. the growth of the secondary coagulum may be traced upward by the progressive abolition of the arterial pulsation and by the upward march of the gangrene. If old cicatrices from burns or unhealed eczematous ulcers, old fractures, or vari- cose veins exist, all loci minoris resistentice, they will be among the earliest parts to yield. Blebs may form in the earlier stages, but generally they will dry up and the parts will mummify, although, as already indicated, moist gangrene may supervene if a large clot form much higher up, or if, in addition 72 SURGERY OF TYPHOID FEVER. to the artery, the vein also becomes extensively obliterated, thus involving great masses of moist tissue, such as the thigh, in sudden ruin. As is generally seen in cases of dry gangrene, days or weeks will elapse, if the patient live so long, during which nature, as usual, makes a powerful effort to rid herself of the dead parts by the estab- lishment of a line of demarcation. On the establish- ment of this, the pain often ceases. In case the primary obstruction is in the vein and it becomes obliterated extensively and completely by a thrombus, or a simultaneous venous and arte- rial thrombosis occurs, then the aanerene will be of the moist instead of the dry variety. It will present the usual appearance of moist gangrene. The ves- sels at the seat of the obstruction will be very tender and can be felt as hard cords. The clot will extend sometimes rapidly and widely, and the gangrene will be more extensive in the area involved and far more acute in its disastrous clinical course, as would natur- ally be expected. In the variety of gangrene beginning in the peri- pheral vessels, the symptoms will vary somewhat. It is not so uniformly in the lower extremity, and^ is much more frequently symmetrical. If small in extent, pain is not apt to be a leading feature. The onset is often earlier, and from the nature of the case its progress is more acute and its limits more quickly defined; so that usually, within a few days at least, the boundary of the gangrene is well defined. Its area also is usually much less than in those cases in which a perceptible coagulum exists, not often extending in the leg beyond the foot or ankle ; and TYPHOID GANGRENE. 73 if it occur in the nose, ears, genitals, etc., it rarely involves surrounding parts to a large extent. Some- times, however, it may extend more widely, as in a case of typhus and starvation, mentioned by Lyons,' in which the patient walked to the workhouse, and on baring his chest the whole of the right side was " a dark, olive-green, jelly-like, tremulous mass." The abdominal wall is sometimes similarly involved. The probably irregular area in which the stasis of the blood will take place in this form also accounts for the great irregularity generally seen in the line of demarcation ; whereas, if a well-defined thrombus exists in a large vessel, the gangrene is apt to be fairly evenly bounded. This sudden history is usu- ally followed by a speedily decided issue. Death follows quickly, or reaction and recovery set in within a short time, instead of long hanging in the balance. In my Toner Lecture I collected in all 113 cases of gangrene, to which Dr. Westcott has added 90, mak- ing 203 in all. Excluding from the former collection 34 cases following typhus reported by Estlander in Finland, as they were the result of special and local causes (see Toner Lecture), of the remaining 1 69 cases 1 1 5 followed typhoid fever and 40 typhus fever. Some of the latter were undoubtedly really typhoid. In the following resume I shall combine the results of the former and the latter series together. The influence of ^^'^ is not very marked. Of 140 cases, there were under fifteen, 26 cases ; from fifteen to twenty-five, 64 cases ; after twenty-five, 50 cases. ' On Fever, 191. 74 SURGERY OF TYPHOID FEVER. This will not differ much from the normal aee-distri- biition of typhoid. But sex seems to have a marked determining influence. Of 155 cases, there were, males, 90; females, 65, — or about three males to two females. The site of the gangrene is more striking than either age or sex. It attacked the Ears in 6 cases. Anus in 5 cases. Nose in 10 '' Genitals in ... 20 " Face, neck, and trunk Legs in 126 " in 47 " That is, of 214 cases in which the location is stated, in 151 it was In the lower extremities, geni- tals, and anus, and in 16 more in such peripheral districts of the vascular system as the ears and the nose, I have found in the two series 128 cases of venous coagula following typhus and typhoid, especially the latter, in which the site is stated. Only four cases involved the upper extremity alone, two of which were followed by gangrene. Two involved both arm and leg, but all the other 124 cases were limited to the lower extremities. Gangrene of both venous and arterial origin (including both thrombosis and embolism) form most frequently during or just after the period of greatest cardiac weakness, a weakness felt most at such distant points as the legs. Of 41 arterial cases, 18; and of 107 venous cases. 40, occurred in the second and third weeks of the fever — that is to say, of 148 cases 58 (39.2 per cent.) occurred in the second and third weeks. These figures, it seems to me, are most instruc- TYPHOID GANGRENE. 75 tive. In discussing the pathology, I gave marked prominence to the sluggish peripheral circulation as a mechanical factor in the production of the gangrene. Even though we admit in many cases the determin- ing influence of the bacilli of typhoid, the striking clinical fact above established must be explained by any accepted pathology. Moreover, this fact is still further emphasized when we consider the cases involv- ing the joints (Chapter IVj, of which 70 were in the lower extremities as against 17 in the upper; and those involving the bones (Chapter V), of which 112 were in the lower extremities as against 41 in the upper. If arteritis or phlebitis or emboli of cardiac origin, whether bacillary or not, were the sole or even the preponderating cause, then gangrene certainly should attack the upper extremities, the head, the neck, and trunk with far greater frequency than is in- dicated by these statistics. Just as in gangrene from other causes, often of non-bacterial origin, such as ordinary senile and diabetic gangrene ; or of prob- able bacterial origin, as in scarlet fever, measles, and the other exanthemata, the legs suffer so much more than all the other parts of the body put together, so in typhoid gangrene the familiar rule holds good. It is also in the lower extremities that venous thrombi causing phlegmasia alba dolens are most frequent in other diseases of microbic origin, as in puerperal fever, pneumonia, septicemia, pyemia, and even in tuberculosis and malarial fever. In both these classes of diseases arising from half a dozen or more different bacteria and in those entirely apart from any bacterial influence, the one 7^ SURGERY OF TYPHOID FEVER. Striking fact is that the legs stiff er far more frequently than all other parts of the body put together. It is, it seems to me then, aood common sense and eood pathological sense to seek for the efficient, the ex- citing, the actual cause determining the location of the obstruction and the frequent gangrene in the legs themselves as legs ; that is, as distal parts of the circulatory system. The distribution as to left- and right-sided gan- grene is very striking. In the early series I did not make such a differentiation, but in the present series of 90 cases I have found that of 46 cases of arterial gangrene, there occurred on Both sides, 8 cases. Right side, 19 " Left side, r • 19 " showing an exacdy even balance of the two sides. In the veins, however, the facts are strikingly different. Here the obstruction involved Both sides, 4 cases. Right side, 10 " Left side, 38 " Total, 52 cases. This, as we know, is in accordance with the usual experience in other diseases. Why the left side should be so much more subject to gangrene due to venous obstruction, as also to phlegmasia alba dolens, than the right side, has been a subject of speculation for many years. My own conviction is that the obstruction to the return of the venous blood, by reason of the compression of the left common iliac TYPHOID GANGRENE. -jj vein where it passe»s under the right common ihac artery, is the most potent factor ; shght in itself, it is true, but when tlie blood is in unstable equilib- rium between fluidity and coagulation, this slight retardation is in most cases just sufficient to pre- cipitate the coagulation upon the left rather than upon the right side. The same predominance of the left over the right side holds good in cases of venous obstruction, and the same balance of the two sides in cases of ar- terial obstruction, when they are not followed by gangrene. Excluding three involving the Sylvian artery,' all of which occurred upon the left side, pro- ducing right hemiplegia,^ and one of the right brachial artery,^ and two of the pulmonary artery,* the I s cases of aT-terial thrombosis without eanerene involved both sides in four cases ; right side in six cases ; left side in five cases. Of 47 cases of venotis thrombosis without gan- ofrene there were : Bilateral, 3 cases. Right side, 13 " Left side, 31 " Total, 47 cases. That is to say, combining together the cases of 1 Huguenin, Correspondenzbl. schweiz. Aerzte, 1879, No. 15, 449, in which there was also a tubercular meningitis ; Barberet and Chouet, Gaz. Hebdom., 1879, 2d series, xvi, 329; Vulpian, Rev. de Med., 1884, iv, 162. 2 For a later important contribution to this rare sequel of typhoid ^ee Osier, Recent Studies in Typhoid Fever, Johns Hopkins Hospital Reports, vol. v., and in the Journal of Nervous and Mental Disease, May 1896, p. 295. ■^ Sumner, Boston Med. and Surg. Jour., 1883, cviii, 200. * Nauwerck, Correspondenzbl. schweiz. Aerzte, 1879, 485, and Mayet, Ang. de la Soc. de Med. de Lyon, xxviii, 2d series, 1880, p. ill. 78 SURGERY OF TYPHOID FEVER. venous obstruction, whether followed by gangrene or not, of 99 cases (52 -|- 47) there were : Bilateral, 7 cases. Right side, 23 " Left side, 69 " While in 61 cases (46 -[- 15) of ai^teiHal obstruc- tion there were ; Bilateral, 12 cases. Right side, 25 " Left side, 24 " This extraordinarily even distribution in cases of arterial obstruction would seem to suo-^est that the cause is much more frequently embolic than has been hitherto believed, whereas in the venous obstruction the immense preponderance is on the left side and is probably due to the cause mentioned on page ']'] . The male genitals suffer very rarely as compared with the relative frequency in which the genitals in women suffer. Dr. Westcott, after a most extensive search, only found one case' in which the scrotum and the feet both suffered from o-ano-rene. A few cases were noted in my earlier lecture. Barring the or- ganic destruction, no special result follows, except possibly hemorrhage, for one case is recorded of death from a hemorrhage of fgxxx from the scrotum.^ Th&fejnale genital organs, however, suffer not in- frequently, probably from the neglected condition of many of the patients and the constant soiling of the parts, as a result of unconscious and unavoidable discharges, especially in women. I have found in all 21 cases, of which 17 followed typhoid and four ^ Tunis, Univ. Med. Mag., 1889-90, ii, 195. 2 Murcliison, p. 194. TYPHOID GANGRENE. 79 followed typhus. Fifteen cases were in young per- sons from seventeen to twenty-seven, except one child of five and five women of thirty-two years of age and over. In i8 of these cases there was gan- grene of the labia extending sometimes to the per- ineum and the thigh, and even to the lumbar region and up the back, as in a case reported by Spillmann/ The disorder manifests itself either as a distinct gangrene of the external genitals or by gangrenous ulcers forming in the vamna. The former occasion- ally is followed by complete closure of the vagina and retention of the menstrual flow, as in a case re- ported by Gueneau de Mussey,^ in which an opera- tion resulted fatally, and in another, reported by Mardn,3 in which sloughing of the upper vagina and the entire cervix uteri occurred. The vaginal ulcers appear usually on the pos- terior wall and lead occasionally to recto-vaginal fistula. One is reported by Lebert,'^ in which, durino- convalescence in the seventh week, chill, fever, and diarrhea set in, and four weeks later the fistula was discovered by injection. It was situated in front of the hym.en and was as large as a five centime piece. A month later she died of pelvic peritonitis. A second is reported by Liebermeister.^ It was caused by the sloughing of a large piece of the recto-vaginal septum, in mass. The large fistula thus produced healed without operation. A third case of vesico-vaginal fistula and gangrene of the vulva appears in the present table reported by 1 Arch. Gen., Feb. and March, l88l. ^ Gaz. Hebdom., 1867, 652. 3 Centralb. f. Gynekol., 1881. * Anat. Pathol., ii, 307, and PI. cxv. 5 Ziemssen's Cyc, Amer. ed., vol. i, 184. 8o SURGERY OF TYPHOID FEVER. Schick, ' and in the fourth, my own case, both recto- vaginal and vesico-vaginal fistulse occurred. A resume of this unique case, of which I quote the earher part from my former lecture, is as follows : Case II. — Mrs. M. D. was under my observation in St. Mary's Hospital from 1873 to 1876, and is the only case I have found of both recto-vaginal and vesico-vaginal fistulse. Up to March, 1872, she was perfectly healthy, when, at the age of thirty-four, she had a severe attack of typhoid fever for four months following exhaustive nursing dur- ing her husband's fatal illness also from typhoid. About the fourth week the labia minora slouched away to a large extent, and both urine and feces escaped by the vagina. In October, 1872, she was admitted to the hospital, under the care of my colleague. Dr. Grove, with two large vesical open- ings (separated by a slight bridge of tissue), which had destroyed the posterior part of the urethra and the floor of the bladder up to the uterus, and one rectal opening an inch in diameter, and i^^ inches above the anus. Dr. Grove operated on her three times unsuccessfully ; once on the rectal opening by the rectum, when he divided the sphincter, and twice by the vagina. From December, 1873, to Decem- ber, 1875, I ^i*^ nine operations. Thrice unsuccess- fully I attacked the fistulae proper, when, becoming convinced that the attempt to close them was hope- less, with her entire consent, after a full explanation of the consequences of the operation, I proceeded to close the vagina. At first 1 attempted to preserve and utilize the remnant of the urethra, which g-ave me great trouble and necessitated several opera- tions ; but at the twelfth operation, December 28, 1^75' I gave up the attempt, excised the useless urethra, and closed the entire vulval aperture by ten 1 Wien. klin. Wochen., 1892, vi, 413. TYPHOID GANGRENE. 8 1 silver sutures. The operation was a complete success. At the time of the delivery of the Toner Lecture, nearly seven weeks after the final closure of the vulva, I stated that she defecated, menstruated, and micturated entirely by the rectum, and without the slightest trouble. She rose usually once, sometimes twice, in the night, and micturated only five or six times during the day. My greatest fear was that the feces, softened by the urine, would pass into the vagina or bladder and give trouble, but up to that time at least, none had arisen, and she was happily rid of the annoyance which had continued four years. Soon after this, however, a small fistulous opening appeared in the cicatrix, caused probably by the feces. This healed after a thirteenth operation, and when my lecture was printed (May, 1878) she had remained entirely well for over fifteen months. In the last four operations, instead of the usual sigmoid female catheter to empty the bladder I inserted the curved branch of a pocket-case male catheter into the bladder and the vagina through the anus and the recto-vagfinal fistula, thus draininof these cavities, while I drained the rectum below the eye of the catheter by an ordinary drainage-tube inserted into the rectum, lest the feces should be softened by the urine and then pass into the vagina. They answered admirably. The difficulty in obtaining a cure, I be- lieve, lay partly in the inherent difficulty of the case and partly in her deteriorated health ever since the fever. Her later history is as follows : Menstruation ceased in February, 1887, over eleven years after the closure of the vagina. Decem- ber II, 1888, she again came to me complaining of pain in her rectum and vagina, and stated that the urine was intermittent, sometimes escaping and sometimes not. She told me that for the thirteen 6 82 SURGERY OF TYPHOID FEVER. years since the last operation she had been abso- lutely comfortable; that she was only obliged to rise about twice in the nio-ht to evacuate the rectum ; and that neither the urine nor the menstrual flow, while it had continued, had irritated the rectum, nor, so far as her sensations went, had the feces annoyed her by gaining access to the vagina. By inserting a finger into the rectum, I found that the old fistula between the vagina and the rectum had so contracted that it would barely admit the point of my forefinger. This examination showed at once that a calculus had formed in the vagfina, which acted like a ball valve. Of course I readily partly crushed it by means of a pair of curved forceps introduced through the rectum. The portion I secured uncrushed weighed "JO grains and measured ^ by S^ of an inch. She made an entire recovery in three or four days. On May 7, 1896, she called again to say that while she had been perfectly comfortable for the seven years since the removal of the stone, three weeks before she called a small abscess had formed at the former outlet of the vagina, and that that morning the urine had commenced to dribble away. Exami- nation showed the orifice of the vagina firmly closed excepting at one small point just admitting a probe, through which some urine was escaping. Rectal touch showed that the recto-vaeinal fistula was the same as before. I advised her to keep the parts clean and wear a napkin, and wait to see whether the small fistula would not close spontaneously. In two weeks this hoped-for result followed, and she is again entirely relieved of her distressing disability and has continued well up to the end of 1897. The case is particularly interesting, not only for its unusual character and its cause, but because I believe it was possibly the earliest case in which the urethra itself was entirely removed and the vagina TYPHOID GANGRENE. 83 closed, the rectum thus being made to serve the triple purpose of a reservoir for the urine, the menstrual discharoe, and the feces. It is an encouraofine fact that in any case requiring similar treatment, the later history shows that for twenty-one years she has only twice had the least trouble, once from a small calcu- lus forming in the vagina and once from a small abscess formin^f in the cicatrix, which abscess spontaneously closed. Instead of being a constant source of disgust to herself and everybody about her, a hospital patient dependent upon charity, as she could not earn her daily bread, and a Pariah cut off from all society, she has been enabled to become self-supporting as a nurse, and to enter freely into her wonted social relations. Gangrene of \k\Q.perineiun or around the anus arises in a few cases in both sexes. In women it is g-ener- ally by extension of the process from the vulva. I have notes of nine men and six women, the sex not being given in two other cases. Excepting five cases, — one of ten, two of eighteen, and one each of twenty-one and twenty-two years of age, — they all occurred, when the age is stated, from thirty-nine to seventy-four years of age, later in life than most of the other sequels of typhoid. This is presumably due to the fact that in later life the nutrition of the perineum is apt to be less vigorous than in early life. Typhoid was the cause in 14 ; typhus in three. Excepting one in the second week, they all occurred also rather later than other cases of gangrene ; namely, from the third to the seventh week — in other words, during distinct convalescence ; and to this is probably due the fact that 1 1 recovered and five died, one from 84 SURGERY OF TYPHOID FEVER. hemorrhage by sloughing into the rectum. In a number of cases the bones of the pelvis were involved as well as the soft parts, and this may have been the real origin of the trouble. This also probably par- tially accounts for the later occurrence of these cases. Most of the perineal cases resulted in perineal fistulae. Three fistulse were caused by necrosis of the pelvic bones or sacrum and nine by gangrenous ulcers, which sloughed not only externally, but in five certainly communicated with the rectum, and probably did so in others. The only case of primary invasion of the anal region I have found was com- municated to me by Dr. Betz, of Oakville, Pa., and well illustrates the sudden and extensive ravages which typhoid gangrene may produce. There can be little doubt, I take it, that such a case resulted from extensive thrombosis of the vessels supplying the tissues which sloughed. That the upper part of the rectum itself was saved is due, I suppose, to the escape of the main trunk of the hemorrhoidal arteries from participating in the thrombotic process. Case III. — " H. L., age ten, fell ill with typhoid fever August i, 1890, The remainder of the house- hold, consisting of his father, mother, a younger sister, and two servants, a man and a woman, soon were all victims of the same disease. Presumably there must have been some serious local cause. The boy's temperature rose as high as 105°, but nothing out of the common occurred until the end of the fifth week, when he complained of irritation around the anus, which parts were found to be only discolored. Within twelve hours after attention was thus first called to them the tissues in the ischio-rectal fossa separated from the surrounding tissues and dis- TYJ'HOID GANCRJCNE. 85 charged. The rectum was relaxed and protruded. It was gangrenous and speedily separated some distance above the sphincters. Retraction then took place, and a formidable cavity was left. Urina- tion, strange to say, was not interfered with. The wound healed by granulation quite rapidly under a dressing of lint saturated with carbolized oil, dusted with iodoform. Fecal evacuations were in- voluntary, of course, but the greatest cleanliness was enforced. An apparatus was needful to retain the feces at first, but was laid aside by Decem- ber. During recovery regular dilatation of the anus .was made lest cicatricial contraction should produce obstruction. His recovery was absolutely complete, not only as to general health, but as to control of the evacuations." Occasionally gangrene attacks very unusual re- gions or organs. Thus single cases are reported of gangrenous suppuration of the gland of Bartholin (Spillmann") ; of the tongue, with cyanosis of the face and great dyspnea (Gaston David ^); of the uvula (Freudenberger 3) ; of both ears after ergot, oyj, had been given in six doses (Sanda '•') ; of the lips, in which a secondary staphylococcus septicemia, ensuing probably from carious teeth, destroyed life (Spill- mann^). The cheeks are attacked more frequently, and noma or cancrum oris is noted in my table as havinor been observed nine times, and, as usual, is very fatal, five of the nine having succumbed, the result in one being- unrecorded. The lung-salso suf- lArch, Gen., March, 1881. ^ Quelques Consid. sur la Gangrene Typhoide, These de Paris, 1883. ^ Aertzlich. Intelligenzbl., 1880, xxvii, 7. * Rev. Gen. de Clin, et de Therap., 1892, vi, 401. Merc. Med., 1895, No. 13, I45. 86 SURGERY OF TYPHOID FEVER. fered from gangrene in five cases, of which three died. As to all of these, there is nothing peculiar calling for more than their mention as indicating the protean manifestations of typhoid gangrene, I append the following case of sloughing of the face, which if not one of noma was at least akin to it. The notes were kindly sent me by Dr. J. N. Hall, of Denver, Colorado : Case IV. — " Hattie J., American, eight years old, together with a brother and younger sister had severe typhoid in 1889. Course of disease norm.al until thirteenth day, when considerable swelling of genitals occurred, but disappeared after a few days. On sixteenth day small bedsore on back, and two or three more on nineteenth day. Extensive passive congestion of lungs. On twenty-ninth day tempera- ture 103°, 'swelling of right sublingual gland' (as I have it noted), ' feeling like the parotid in mumps.' On thirty-third day discharge of pus from right ear, with appearance of black slough, size of five-cent piece, on right cheek, opposite right first lower molar. On thirty-fifth day this was one by two inches, and on thirty-sixth extended to corner of mouth. Severe hemorrhage (arterial) occurred on this day and on thirty-eighth day patient died." Treatment. — To the treatment which I advocated twenty years ago little can be added. The preven- tive treatment, such as good food, fresh air, the best hygienic surroundings is the most important. Should the heart fiag, its action must be maintained at all hazards ; alcohol in liberal doses is perhaps the best remedy. Digitalis, strychnin, spartein, strophan- thus, and other cardiac tonics of the later pharma- copeia may be added. The body should be carefully TYPHOID G/INGRENE. 87 examined, especially those parts of it which experi- ence has shown likely to be attacked, pre-eminently the lower extremities, and in women, and especially girls, the genitals. The arms, neck, and head being exposed are much more likely to attract attention should they be attacked by gangrene than those which are covered by the bed-clothes [cf. Chapter IV). If baths are used, care should be taken that no mechanical injuries are inflicted, especially on the legs. Chapman's ice- and hot-water bags, alternate heat and cold, with very moderate friction and stim- ulating liniments, should be advised and the use of the constant current as a means of stimulating the collateral circulation, both in the deep as well as the superficial parts, will be of service. If gangrene is not only threatened, but actually sets in, the gangrenous parts should be kept as free as possible from infection by the use of antiseptic dressings. The question of operation naturally is one of the most important that is raised. In gangrene of the genitals, head, neck, or trunk, operation, of course, is limited to the removal of the dead and sloughing tissues and especially in the promotion of the utmost cleanliness, particularly in parts of the body soiled by urine, feces, or the menstrual dis- charge. Detergent washes and stimulating douches, the keeping of the rectum free from accumulated feces, and thorough and free incision of abscesses in the vicinity of the anus are to be especially com- mended. In the extremities, if amputation is necessary the time when it shall be done depends largely upon whether the eanet"ene arises from distinct obstruc- 88 SURGERY OF TYPHOID FEVER. tion by a palpable thrombus or embclus, or whether it arises in the peripheral vessels without such an appreciable mechanical obstruction of the main ves- sels. In the latter case, the line of demarcation is usually established quite early, and the disease is generally unlikely to advance beyond this line. Amputation, therefore, should be done as soon as the line of demarcation is well pronounced, and it may be done but little above this line, since there is no obstruction in the vessels higher up which would threaten the integrity of the flaps. In the cases where a distinct thrombus or an em- bolus has formed, however, the obstruction is very apt to extend farther and farther, as time goes on, by secondary thrombosis. At what level, therefore, the limit between the tissues which must necessarily die and those in which nature can still keep up a healthy life will occur, can not be stated definitely until the line of demarcation is well established. In a very few cases, even when gangrene seems inevitable, the patient may yet recover without gangrene. Two such cases are reported by Phillips ' and Salles.^ But the facts obtained by a study of my two series of cases aid us very distinctly in deciding the level at which amputation should be done. When the clot extends only up to the popliteal, the leg may escape gangrene altogether ; and, should it follow, I have found it limited, in 2 r cases, to the foot six tim.es, to the lower half of the leg once, and to the upper calf in 14 cases. When the clot extended into the femoral, the gangrene extended to the upper calf in 1 1 cases and to the thio-h in ei^ht cases. 1 Lancet, 1891, i, 1207. 2 Lyon Med., 1893, No. 3. TYPHOID GANGRENE. 89 When the clot extended above Poupart's ligament the gangrene was limited, in 15 cases : to the foot in one, to the calf in eight, and extended above the knee in six. Amputation in these cases, therefore, should not be done, as a rule, until a well-defined and prob- ably final line of demarcation has been formed. When operating, the leg should be made bloodless by elevation and kept so by very careful digital compression. The Esmarch bandage, as pointed out by Quervain, should not be used, partly because it may injure the vessels of the stump and so favor a new arterial or venous thrombus, and partly because it may break up an existing venous throm- bus and orive rise to a danoferous embolus. To this I would add another evident objection : that the septic fluids in the tissues should not be forced into the eeneral circulation. The hemorrhage will be slight, since certainly the artery, and often both the artery and the vein, will be obstructed, so that the " muscles will look like meat soaked in salt and water, and there will be no oozing from the marrow of the bone."' Quervain's method of operating was both in- genious and useful. After forming an anterior flap, and before making the posterior flap containing the vessels of the lower thigh, he only disarticulated the bones at the knee joint ; next he dissected the femur loose' for 12 cm. above the joint, and divided the bone ; then exposed the vessels and ligated them ; and last of all formed his posterior flap. The wisdom of ligating the artery before dividing it was shown by the fact that in the amputated part 1 Drewitt, Lancet, 1890, ii, 1023. 90 SURGERY OF TYPHOID FEVER. it was found to be filled with a loose clot, which would almost certainly have been dislodged by the manipulation if the flap had been made prior to ligation, and so have caused considerable hemor- rhage. Such patients have not a drop of blood to spare. As a general rule, therefore, it is best to wait for the line of demarcation, but the operation should not be deferred long after its appearance. If danger of septic infection or speedy exhaustion appear, amputate immediately at or above the probable limitation of the disease. The extension of the disease, if the femoral be free, will not be, in the majority of cases, above the tubercle of the tibia. If the femoral be involved, necessitating an amputation of the thigh, the resources and the safety of modern antiseptic surgery would lead us, in general, to amputate; but in some cases it may be a serious question whether expectant treatment and a relatively long subsequent amputation might not be less dangerous than an earlier operation. In two cases ' amputation of both legs was followed by recovery. 1 Butler, N. Y. Med. Rec, Sept. 28, 1889, 342 ; and Durand, Arch, de Med. et de Pharm. Mil., July, 1894. CHAPTER IV. TYPHOID AFFECTIONS OF THE JOINTS. Rheumatic Typhoid Arthritis. — Besides ty- phoid arthritis, properly so called, — which I shall shortly consider at length, — there are two other forms of arthritis which occasionally, but far less frequently, are connected with typhoid fever — viz., a rheumatic and a septic form of arthritis. While, like the usual typhoid arthritis, both may affect a single joint, more frequently they are polyarticular. Of the rheumatic variety, in the later series of cases, the case of Despaigne,' though the history is not entirely clear, was very probably an example. Multiple ankyloses were found after an interval of eighteen months. Three other cases are distinctly stated to be of this variet)-, and had a previous rheu- matic history. Freyhaus' case,^ in which the knees, ankles, elbows, and wrists were involved, but recover\' of all these joints followed, may be fully accepted as of the rheumatic variet}". That of Balzer.^ which proved fatal from a purulent arthritis of the left knee with non-purulent teno-synovitis of the left wrist, may also have been an instance. But this case probably, and still more certainly that of Robin, in spite of the opinion of the author, seems to me to be not so ^ Lapersonne, Des arthrites infectieuses, p. 120. - Berl. klin. Wochen. , 1S91, xlii, p. I. ^ Robin, Gaz. Med. de Paris, iSSi, No. 40, p. 559. QI 92 SURGERY OF TYPHOID FEVER. much rheumatic as septic in character. These, with those of Rendu ' and that of Menard," I should class tog^ether under the next variety. Septic Typhoid Arthritis. — In the case of Robin ^ there were purulent arthritis of the little toes and pus in the sheaths of their extensor tendons ; purulent arthritis of the knee-joints, of the right ankle, and of the knuckle-joint of the right middle finger, the pus again extending into the sheaths of the tendons of that wrist ; purulent arthritis of the right shoulder and of the left elbow, with suppurative periostitis of the left tibia and abscess around the larynx and trachea and the left costal cartilaees. Could one draw a more striking picture of a septic case ? No other result than death could be expected. The two other cases, though only involving one joint, seem to have been septic. In Rendu's case, the patient died from a purulent arthritis of the right hip-joint with abscesses in the thigh and osteomyelitis, and the autopsy disclosed a purulent pleuro-pneumonia and nephritis. It is much easier now to understand these septic cases than twenty years ago, before bacteriology was born. They result from a mixed infection with the typhoid and the pyogenic bacteria. In the third case this is definitely assigned as the cause, the port of entry being the sacral bedsores. In fact, every case of typhoid fever has a possibility of sepsis, since, apart from the frequent boils and bedsores, the intestinal ulcers are always an open and possible door inviting such infection, Tripier"* has especially 1 Quoted by Witzel. 2 Soc. Med. des Hop., Jan. 11, 1878. 3 Gaz. Med. de Paris, 1881, 559. * Lyon Med., 1888, p. 195. TYPHOID AFFECTIONS OF THE JOINTS. 93 insisted upon the frequent, if not constant, origin of septicemia from the external ulcers. In Menard's case it is to be observed that a rare joint — the upper articulation of the sternum — was attacked, the pus soon reaching the anterior medias- tinum. Analogous to this one case of the later series are those of Fraentzel ' and Werner ^ in the earlier series. A septic arthritis in typhoid runs the usual course of similar septic inflammations, and has their fre- quently fatal termination in spite of all treatment ; all the more so in typhoid since it follows or ac- companies so exhausting a disease. There is nothing, in. respect either of the symptoms or the treatment, to which I need call attention, except to the necessity for the most vigorous stimulation. But the occa- sional occurrence of such septic cases and their uni- formly fatal result should warn the physician to heed the very first complaint of pain in any part, especially if the complaint be made early in the case. It may be the beginning of a rheumatic or a septic case, which he may possibly be able to carry through safely. If not of either of these varieties, it may be the signal symptom of the usual typhoid arthritis, in which the danger is not of suppuration or even generally of ankylosis, still less of death, but of a totally unexpected complication — viz., dislocation, especially of the hip. ^ Ein Fall von acuter Mediastinitis in Verlauf eines lleotyphus, Berlin, klin. Wochen., 1874, xi, 97. 2 Verbreit. siniiose Geschwiire auf der Brust, Perfor. vorder Mittelfellrauni., Plotzlich. Tod an Verbkilung, Typhose Geschwiire im Darm., Med. Corresp. Wiirttemb. aerztlich. Verein, Stuttgart, 1-859, xxix, 76. 94 SURGERY OF TYPHOID FEVER. Typhoid Arthritis Proper. — [a) Polyarticular Variety. — Typhoid arthritis proper may affect more than one joint, though the monarticular form, espe- cially in the hip, is far the most frequent and the most serious. In the second table, excluding- cases involving the vertebrae, which are considered later, the polyarticu- lar cases involved: (i) Both the upper and the lower extremides in 3 cases — viz., wrist and knee, 2 ; elbow and both ankles, i. (2) The lower extremi- ties alone in 6 cases — viz., both hips, 2 ; both ankles, 2; hip and knee, i; hip and ankle, i. (3) The upper extremities alone in two cases — viz., both wrists, I ; shoulder and elbow, i. Combining these together, it will be observed that the lower extremities were involved in nine cases as against five in the upper. Not one of the cases died ; a marked contrast to the six cases of the rheumatic and septic forms, of which four died. Even, therefore, a polyarticular arthritis does not seem to add to the daneer of death in typhoid — a most comforting fact to the physician, the patient, and his friends. Even ankylosis is an infrequent result. Beside the case of Despaigne,' already considered, in one case ankylosis of both hips followed a faulty posture, persisted in long after the fever.^ This case recovered motion after forci- ble flexion under ether. In Clarke's case^ ankylosis of the elbow persisted, very possibly for want of early passive motion. ^ Lapersonne, Des Arthrites Infect., p. 120. 2 Gibney, Trans. Amer. Orthop. Assoc, 1889. * Jour. Amer. Med. Assoc, April, 1891, 473. TYPHOID AFFECTIONS OF THE JOINTS. 95 In the earlier series three other cases of ankylosis were noted, making six cases of ankylosis out of 84 cases of arthritis in the combined tables. In its symptoms, save that more than one joint is involved, the polyarticular form of typhoid arthritis does not differ from the monarticular ; and as the latter form, especially in the hip, is so important, this will be considered more fully. {b) The Monarticular Variety. — The monarticular form of typhoid arthritis affects the larger joints, such as the elbow and shoulder, the ankle and knee, but above all the hip. The pain is usually slight, though sometimes very severe and prolonged. The swell- ino- is generally readily observed in all joints except the hip and the shoulder, where it is probably ob- scured by the muscular masses about these joints combined with the tardy increase in the swelling. Usually the arthritis arises spontaneously, but occa- sionally from periostitis or necrosis extending into the joint. Pus rarely forms, and hence suppurative or fistulous openings are rare. In only one case,' in fact, of the 41 cases of the second series was there suppuration in any joint, that case involving the knee. This indisposition to suppuration is well shown in Dunin's case,^ in which, though the infection was severe enough to produce abscesses of the buttock and hip, many furuncles and suppurative otitis media with arthritis of the right elbow and shoulder, these joints themselves did not suppurate. The result is, therefore, generally a gradual return to usefulness, although in six cases 1 Tarbox, N. Y. Med. Rec, Aug. 24, 1889, 209. 2 Deutsch. Arch. f. klin. Med., 1886, xxxix, 369. 96 SURGERY OF TYPHOID FEVER. I have found ankylosis. Of 84 cases, the lower extremities were affected in 70, the upper in only 17, seven of the cases involving a joint in both ; for occasionally two large joints are affected at once. Arthritis, therefore, resembles other surgical febrile affections, such as oranerene, necrosis, etc., in affect- ing mainly the lower extremities, as do also throm- bosis and the ordinary edema. The frequency of these joint troubles is not very o-reat. Murchison does not even name this com- plication, nor do any of our text-books, either on Surgery or Practice, except a few lines by Volk- mann, in Pitha and Billroth's Handbuch. Giiter- bock/ Hellwig,' Parise,^ and Friedheim^ are the only authors who have treated them at all fully. In the literature of the last fifty years, which is practi- cally covered by my two series of tables, I have collected in all 84 cases involving the joints. That they are of great importance and demand our utmost attention will be seen at once when w^e con- sider that of the 84 cases named spontaneous dislo- cations occurred in 43 ; 40 times in the hip, twice in the shoulder, and once in the knee — /. e., more than one-Jialf of all the cases of typhoid arthritis are followed by spontaneous dislocation, nearly all of which are in the hip-joint. Dislocation of the Hip-joint after Typhoid Fever. — These dislocations require more particular notice. They are analogous to the dislocations which 1 Archiv f. klin. Chir., xvi, 58. 2 Ueber die Affect, des Hiiftgelenks bei Typlius, Marburg;, 1856. 3 Archiv. Gen., 3d series, 1842, xiv, I. * Ueber die Spontanluxation des Hiiftgelenks nach Typhus, Berlin Thesis, 1885. TVf//()/D AJ-I'ECTIONS OF 77/ A" JOINTS. 97 have been observed in locomotor ataxia, the cxanthe- matOLis fevers, hemiplegia, sciatica, and rheumatism,' as pointed out by Stanley^ in 1841. In one case ^ it was noted that for three months before the typhoid attack the child had been suffering from ordinary coxalg-ia. Unfortunately, there are on record very few exami- nations of such joints post-mortem, and ver)' few bacteriological examinations of the fluid in the joints, and these are generally either negative or reveal the presence of the pyogenic organisms. The only in- stances I have found are as follows : 1. A patient of my own, in St. Agnes' Hospital, had an attack of suppurative arthritis of the knee- joint, arising during typhoid fever, which I operated on, and the aureus and albus were found in the cul- tures made by Dr. Bevan. Unfortunately, the notes of the case have been lost, but the bacteriological examination was the chief point. 2. A case of typhoid fever, under the care of Professor Hare and Dr. Thomas G. Ashton at the Jefferson College Hospital, which I saw with them. She was a girl of sixteen, admitted on January 16, 1897, with a temperature of 105.3°. She made a good recovery and was discharged from the hospital. In the fifth week swelling and some pain were ob- 1 Spontaneous luxation has been observed after scarlatina by Dittel (Oester. Zeitschr. prakt. Heilk., 1861), Sainton (Rev. d'Orthop., 1892,354), Kirmisson (Bull, et Mem. Soc. de Chir. , 1894, xx, 213), Eisendrath (Annals of Surgery, Oct., 1897, 451); after acute articular rheumatism by Verneuil (Bull, et Mem. Soc. de Chir., 1883, 781), Seinton {loc. cit.), and Kirmisson (/of. ,://.) ; and after influenza by Eisendrath [loc. cit.). 2 On dislocation, especially of the hip-joint, Med. Chir. Trans., xxiv, 123. See also Malgaigne, Fract. and Disloc. , Paris, ii, pp. 218-226, 882-887. 3 Phocas, Gaz. des Hop., 1894, Nos. 132 and 135. 7 98 SURGERY OF TYPHOID FEVER. served in the left leg, the swelling extending from above the knee to the ankle, but she recovered from this without any especial trouble. Soon afterward, however, the swelling returned, and was accom- panied by severe pain and great tenderness, espe- cially in the knee-joint, so that motion was impos- sible. I saw her on April 22, 1897, and again on June 18th. On both occasions the knee was aspir- ated, but the fluid proved to be entirely sterile. The arthritis resulted in ankylosis in marked flexion, which will require later operative treatment. 3. Klemm ' reports the case of a girl, age fourteen, who was ill v/ith typhoid for fourteen weeks, and who had lain for two months with the knees almost touch- inp- the thorax. An iliac dislocation of the left hip-joint resulted. An abscess formed over the trochanter, which, on being opened, gave exit to a reddish turbid fluid, like that of an old hemorrhagic hydrocele. The trochanter was bare and eroded. Facial erysipelas followed, and she died nineteen days after admission. At the post-mortem typical typhoid lesions were found. The capsule of the hip- joint was much distended but without any fluid in it. The fluid of the abscess contained the typhoid bacil- lus. The hip-joint does not seem to have been ex- amined bacteriologically. 4. Schiiller ^ found, in cases of inflammation of the hip- and knee-joints after typhoid, " in the serous fluid only round cocci and some streptococci, and single small bacilli resembling those which are found not infrequently on the intestinal surface, to which atten- 1 Arch. f. klin. Chir., 1893, xlvi, 862. 2 Witzel's Gelenk- und Knochenentziind., p. 52. (No reference is given.) TYPHOID AFFECTIONS OF THE JOINTS. 99 tion was first called by Klebs, but which, however, Koch, Gaff ky, and others do not regard as absolutely characteristic of typhoid. The bacilli now regarded as the typhoid. bacilli, — the ovoid form first described by Eberth, — I could not find in the contents of the joint. In another case of typhoid which I had to examine during life, I could not find any micro- orofanisms." 5. Danlos and vStrauss ' report the case of a man of twenty-nine whose fever, even at the beginning, was accompanied by pain and swelling in the knees and elbows, and on the fifth day the patellae were "floating" from the effusion; soon purpuric spots appeared but no taches rouges. He died on the eighteenth day, his articular disease not having materially changed. The day before his death the right knee was punctured, the fluid found being apparently clear synovia. At the necropsy the lesions of typhoid were found. The right knee-joint was healthy ; cultures from the fluid in the joint and of the blood were sterile. 6. Orloff^ injected cultures into joints in dogs and rabbits, and reported that this was followed by swell- ing in twenty-four hours, with hemorrhage in the synovial membranes. A thick, tenacious, turbid fluid was produced in the joints, which later became more distinctly purulent. Microscopically, there were found pus-corpuscles, and in the earlier days after the injection, typhoid bacilli. This last result may possibly be the explanation of the impossibility of finding the bacilli in the joint 1 Soc. Med. des Hop., 1887, 3d series, iv, 35. 2 Centralbl. f. Bakteriol., 1890, 366. lOO SURGERY OF TYPHOID FEVER. affections in man, at least in some cases. Havinor done their malign work, they may have disappeared. Grancher,' however, obtained from a teno-synovitis the typhoid bacillus. The result in these five cases in man and one series of experiments in animals must leave us in doubt as to the role of the bacillus of Eberth in the joint affections of typhoid. The future must afford us the data for a certain conclusion. The need for such bacteriological examinations, at the best very rare, is most evident. It is to be hoped that this hiatus in our knowledge will be filled before long, especially as it is so easy to obtain the fluid by aspiration, an operation in itself desirable to prevent dislocation. But though we are still largely ignorant of the bacteriology of the joint effusions, yet from the analogy of the other tissues to which I have alluded it is probable that the bacillus will be found to have invaded the joints also, and possibly later to have died out. The irritation caused by the bacilli or their toxins will readily account for the slow, but steady accumulation of fluid in the joint. Parise^ has shown experiment- ally that artificial distention of the hip-joint will produce a posterior luxation. That the capsular liga- ment will stretch more readily from the slowly in- creasing distention of disease, as compared with the rapid distention in experimental cases, is evident. I well remember the astonishment and incredulity I felt twenty years ago, when I first encountered a case of dislocation of the hip-joint alleged to be due 1 Bull. Med., 1892, vi, 1271. 2 Arch. Gen. , 3d series, tome xiv, p. i. TYPHOID AFFECTIONS OF THE JOINTS. lOI to typhoid fever. But incredulity had to change to behef, as I found case after case in undoubted rela- tion to the fever as a cause, and the more than two score cases now collected leave no room to doubt either the fact or the pathological explanation. The cause and sy^nptoms of the trouble may now be considered at some length. Usually in the period of convalescence following, therefore, the prolonged exhaustion, there arises a subacute synovitis, with a gradual serous distention of the capsular ligament, which, having reached a certain point, may slowly subside, and no further evil follow. In five cases, however, this burst exter- nally, producing sinuses, but in only two of them was the discharge purulent. In both of these there was also necrosis of the bones. The main result is a slow, generally unperceived, elongation of the ligaments, — e. g., of the hip, — with perhaps also a swelling of the so-called eland at the bottom of the acetabulum. This distention will spend its force mainly poste- riorly, since the inverted Y-ligament reinforces the capsular ligament in front. Given this condition, the sliohtest force will dislocate the head of the femur, usually upward and backward on the dorsum of the ilium. In one case a fall to the floor produced •it, in three others turning over in bed, and twice the lifting of the patient in the arms from one bed to another. But in all the other 34 cases no cause was assignable, and it is, therefore, likely that it was mere muscular contraction, which becomes more vigorous as health gradually returns — the very time when these dislocations most often occur. In one of the shoulder cases a subcoracoid luxation was I02 SURGERY OF TYPHOID FEVER. caused by the patient's assuming the erect posture. Gravity had here probably some influence, together with the muscular exertion. The dislocation of the knee was also posterior, the result doubtless of the muscular traction of the hamstrings. Typhoid was noted as the preceding fever in 1 5 and typhus in 7 of the hip cases of the earlier series. In the later series typhoid is the sole preceding fever in all 13 cases of dislocation. Sex has not a very marked predisposing influence, for of 35 cases 19 were males and 16 females. The age at which they occur is much more noteworthy : 22 were under fifteen years, 10 from fifteen to twenty, 1 was thirty, i was thirty-five, and i was sixty-one years old ; that is, ^2 Old of J5 were under hventy years old. The analogy to coxalgia, it will be observed, is, therefore, very marked. Usually they were single dislocations, 12 being on the right side and 10 on the left; but in 3 cases dislocation of both hips occurred. From the apathetic condition of the patient in some cases, the subacute nature of the lesion, the absence or slightness of the pain, or in some cases its great severity which precludes any movements and therefore any thorough examination, the mask- ing of the swelling by even the wasted muscles about the joint, and, above all, the want of knowledge of any danger or even any possibility of the dislocation, and therefore the neglect to examine the parts thor- oughly, it is not surprising that this threatening evil should have been often unobserved. In 16, — that is, nearly one-half — of the cases it is distinctly stated that the actual dislocatioit was the first fact observed, and in most of the others this is probably true. TYPHOID AFFECTIONS OF THE JOINTS. IO3 The date at which the dislocation was, at least, ob- served was generally after the third week. One case occurred in the first week, 4 in the second, 4 in the third, and 17 in the fourth week or later — that is, during distinct convalescence. Pain was experienced in at least 25 cases, and probably in more. Usually it was not severe, nor was it always strictly localized in the hip, but sometimes extended to the entire leg. In only 3 cases was it referred to the knee, thus dif- fering markedly from the well-known coxalgic knee- pain. Swelling is only distinctly stated in 14 cases, though probably present here as in other joints, but either unobserved or often unrecorded in the brief statements I have found. The variety of the dislocation is not named in 12, but as in all the other 28 it was iliac, there is good reason to believe that this is probably practically always the case. One case, however, is recorded of an obturator dis- location.' Shortening is recorded in 18 cases, and where the amount is named was generally i)^ to two inches. In 6 cases the rotation was inward, in 2 outward, and in 2 of the 3 double dislocations both leers were rotated in the same direction, — that is, right or left, — thus producing a peculiar deformity when compared with the apparently reversely rotated body. The head of the bone in 4 cases was freely movable in all directions. This mobility of the head and the singular diversity in the rotation of the limb are additional reasons in favor of the distention theory of its pathology. As to treatment, in consequence of the relaxation 1 Friedheira, Ueber die Spontanluxationen des Hiiftgelenks nach Typhus, etc., Berlin Thesis, 1885. I04 SURGERY OF TYPHOID FEVER. of the ligaments of the joint, reduction is generally easy when the luxation is discovered early, but if the discovery or treatment be tardy, it is always difficult and often impossible. In 17 cases reduction was successfully accomplished, 13 times by manipulation, twice by extension, and twice by both means. In 1 1 cases reduction was not effected, — though in one, after extension for a week, two attempts at reduction were made under ether by so good a surgeon as Kronlein, — and in 12 the result is not stated. In the case of obturator dislocation two osteotomies gave a favorable result. In three cases seen late, as pro- gression with a high shoe was quite satisfactory, reduction was not attempted. Only three cases of recurrence of the luxation are noted, a rather sur- prising fact in view of the relaxation of the distended tissues ; but its possibility should be borne in mind and guarded against by the use of a stout binder surrounding the hips or by a plaster-of- Paris spica of the hips and pelvis. No snap is heard on reduc- tion, all tension and suction-power of the joint being lost. Even after reduction the leg may be somewhat longer than the other, owing, probably, to the disten- tion, to the swollen articular gland, and possibly, in old cases, to interstitial changes in the head and neck of the femur and in the acetabulum. The question of prophylaxis is perhaps the most important of all, and the indications are clear. First, a careful watching and repeated examination of the hip-joint, especially in children, to detect pain or any effusion. Physicians, having learned that dislocation of the hip is a possible, even though an infrequent, result TYPHOID AFFECTIONS OF THE JOINTS. 105 of typhoid fever, should heed die first complaint of pain, even in a semi-comatose or delirious patient, particularly if the age be under twenty. Even if the patient does not complain of pain, the hip- joints should be examined in young persons from time to time to detect the first possible sign of effusion, and therefore any danger of disloca- tion. If any exist, the position of the leg becomes of the greatest possible importance. As adduction and internal rotation favor spontaneous dislocation, the leg should be kept in abduction and external rotation. The first indication is easily fulfilled by two lateral sand-bags, which may be bridged across in front at intervals by a bandage, to keep the leg at rest, or by lateral splints. The foot may be kept in external rotation by bandages or adhesive plaster fastened to the external sand-bag or splint. Gentle extension by a weight and pulley would be useful in steadying the limb. If the effusion threatens to pro- duce dislocation, aspiration under the strictest anti- septic precautions is a safe and efficient means of prophylaxis. If pus is found, — as is almost never the case, — the joint should be opened and treated accord- ine to the existing conditions. In one case' the upper epiphysis of the femur became detached, and later was removed. In another,^ the edge of the acetabulum necrosed. The two following unpublished cases of dislocation of the hip after typhoid are the only ones I have ever seen personally. For the earlier notes of the first 1 Rivington, Lancet, 1890, i, 901. 2 Weil, Prager ined. Wochen., 1878, 61. I06 SURGERY OF TYPHOID FEVER. case I am indebted to her physician, Dr. H. W. Rihl, of Philadelphia. Case V. — In April, 1891, Miss J., age eighteen, presented herself at my clinic at the Orthopedic Hospital to see if anything could be done to remedy her lameness. Over two years before, on Decem- ber 14, 1888, at the age of sixteen, she fell ill with typhoid fever and was treated by a homeopathic physician. January 2, 1889, near the end of the third week, she was suddenly taken with two convulsions, when her father, in alarm, sent for Dr. Rihl, who writes me : " It was a well-marked case of typhoid from my first visit, on which occasion she had constant low delirium and sleep- lessness, not having slept any for forty-eight hours. It varied from ordinary typhoid in three striking particulars: the convulsions occurring at the end of the third week ; aphasia, or perhaps, more precisely, amnesia, and the great pain in the right thigh aggravated and incessant for many days, the origin of which was not suspected until after her recovery. I doubt very much, even if I had understood at the time the cause of the pain, whether I would have been able to apply any apparatus, as her pain was agonizing, and she resisted every touch of the limb. I see a record on my book, of January iith, 'left knee rigid, painful, and flexed ' ; on re-reading this, my first impression was that I had made a mistake in writing ' left,' meaning ' right,' but in thinking over the matter I remember distinctly that it was a long time before I discovered the real seat of pain, as in consequence of her amnesia and delirium we could scarcely acquire any information from her until some days after, when she pointed to the right thigh. I have no record of the time of the commencement of the amnesia ; it was certainly before January TYPHOID AFFECTIONS OF THE JOINTS. 10/ iith. The fever, as you will perceive by referring to my daily record, was January I2di, 104°, and January i8th, 106°, but these high temperatures continued but a few hours, antipyrin acting very satisfactorily in almost every instance in rapidly reducing the temperature. For so grave a case, the average temperature was remarkably low." By January i ith she could speak a word or two ; on the 23d for several days her speech had slowly improved, and by the 30th speech had entirely returned. By February 21st she was able to be up each day, and on May i6th Dr. Rihl ceased his attendance. Mean- time the pain in the thigh was at times noted as "very severe," and at other times "less," and it is curious to note that the pain seemed not seldom to increase or diminish with the degree of the fever. In November, when Dr. Rihl returned from his holiday in Europe, he first found the explanation of the pain in the right thigh, there being an iliac dis- location with marked shortening-. No interveningr accident had occurred. When she presented herself at my clinic the dis- location was evident at a glance. The right leg measured, from the internal malleolus to the anterior superior spine, 28 inches, on the left 30^ inches, but there was practically no difference in the circumfer- ence of the calf or the general development of the lame leg. As the dislocation had existed for over two years, and a high shoe fairly well remedied the lameness, I advised that no attempt at reduction should be made. Case VI. — R. McD., aged sixteen, consulted me November 4, 1897, at the Jefferson College Hos- pital. She had had typhoid fever in March, 1896. In the third week of the fever she suffered from a great deal of pain in the right hip and a little in the knee, which continued for four weeks. Movement of the leg caused pain in the hip. When she got out of I08 SURGERY OF TYPHOID FEVER. bed she found she was lame, as the ri^ht leo- was shorter than the left, and was stiff at the hip, but not at the knee. The shortening I found to be two cm., and the head of the femur was subluxated on the edge of the acetabulum. I made four attempts, under ether, to reduce the dislocation, but findino- this impossible I ordered a cork sole for this side. Case VII. — Dr. Swett, of Connecticut, has kindly given me the notes of a third case of dislocation of the hip. The patient, a woman aged thirty-five, lived ten miles away, so that he was unable to see her often, though the high temperature and extremely active delirium made frequent visits desirable. The nurse called his attention to the pain in the hip at his last visit, in November, 1892. Both he and another physician who saw her three months later, thought at first that it was due to sciatica. The pain arose in the beginning of the sixth week, the second week of convalescence. The dislocation was iliac. Two unsuccessful attempts under ether were made to re- duce it. CHAPTER V. TYPHOID AFFECTIONS OF THE BONES. Excepting the laryngeal complications and sequels of typhoid fever, the most frequent are those con- nected with the bones. In my Toner Lecture I gathered 69 cases. But since then, owing to atten- tion having been called to the subject, the recorded cases have become much more numerous, so that we have collected from the literature of the last twenty years 168 cases, making 237 in all, as a basis of my analysis. Unfortunately, no analysis in the particulars not recorded in the earlier lecture, as printed, can be made, since the detailed tables have not been preserved. This is the less to be regretted, since of the earlier series only 37 of the cases fol- lowed typhoid and four followed typhus, whereas the entire number of cases of the second series — 168 — are from typhoid, making in all 2q5__cases of all kinds loTTowing"typhoid. ^ The entire absence in the later table of bone disease following typhus and the almost entire'absence of typhus cases in the other sur- gical sequels, is doubtless partly due to improved san- itary conditions prevailing all over the civilized world, which have well-nigh banished true typhus fever. But it is very largely due also to a more accurate diagnosis of typhoid itself, and a more accurate use of language, thus vindicating what I said twenty years ago, that many of the cases recorded and, therefore, 109 no SURGERY OF TYPHOID FEVER. necessarily tabulated as following " typhus " fever, were really sequels of typhoid or "typhus abdomin- alis." If, for brevity or through carelessness, the author omitted the adjective, I did not feel at liberty to go behind the record, and, consequently, I was obliged to tabulate it as typhus, though often con- vinced, from the history and symptoms, that the case was really one of typhoid. To take such liberties with the records of cases would expose one to other possible inaccuracies, and would impair confidence in the accuracy of the later author. It is greatly to be regretted that, especially in Germany, the words "typhus," "typhosus," etc., are still used, instead of "typhoid," or "enteric" to designate the fever. Pathology. — The causes to which twenty years ago I attributed the necrosis of bone which was at that time by far the most frequently recorded sequel among the bone lesions (50 out of 69 cases), were two : First, thrombosis, or, in some cases, embolism ; and, secondly, absolute inanition, or want of nutri- tion. But modern bacteriology, which did not exist in 1876, has rendered these views almost entirely untenable, and gives the first and by far the most important place to the typhoid bacillus. It is doubtful whether inanition plays any role whatever in producing any of the typhoid diseases of bone, though it is possible that in a patient whose nutrition was at a very low ebb it might lead to necrosis, especially if any injury were inflicted on a subcutaneous bone. The poor nourishment of the bone would be a predisposing, and the injury the exciting, cause of the necrosis. Thrombosis, or occasionally embolism, can not be TYPHOID AFFECTIONS OF THE BONES. I I I SO entirely dismissed as a possible, though most probably a rare, cause of necrosis after typhoid. For example, in the Toner Lecture (Fig. i) I have given the history and reproduced the illustration of a wide necrosis of the frontal, parietal, and sphenoid bones, traced directly and positively to occlusion of the meningea majora. In the chapter on gangrene (pp. 83 and 86) I have pointed out the fact that, in a num- ber of cases of gangrene in the anal and perineal regions, the bones as well as the soft parts were in- volved, and that noma or cancrum oris was recorded nine times, of which five, and possibly six, were fatal. One can readily imagine that the gangrene of the soft parts in such a case might easily extend to the bones. This is especially true in cases of gan- grene of the lips and cheeks, and, accordingly, among the diseases of bone in the second series we find cases of extensive necrosis of the jaws, often associated with gangrene or sloughing of the cheeks. It is most probable, it seems to me, in such cases that either a single thrombus, or occa- sionally an embolus, of a main trunk, or more likely a wide-spread vascular arrest in many smaller vessels (as described under Gangrene and under the Cerebral Complications of Typhoid Fever), is the cause alike of the destruction both of the bone and the adjacent soft parts. Thus, in Mears' case ' there was a sequestrum removed consisting of the greater portion of the body or alveolar process of the upper jaw, with parts of the nasal, malar, and palatine processes, and the teeth as far forward as the canine were lost; in Franklin's case ^ there was 1 Med. Times, Phila., Aug. 28, 1880, p. 608. 2 i.ancet, 1897, i, 553. 112 SURGERY OF TYPHOID FEVER. necrosis of the whole alveolar process of the left upper jaw, with destruction of the cheek (noma) ; in Lawton's case,' with necrosis of the left upper jaw there was gangrene of the left lower eyelid and cheek, and the orbital contents were all loosened from the bone ; and in Alexander's case,' with necrosis of the upper jaw there was extensive gan- grene of the mucous membrane of the mouth. In only two cases was the lower jaw involved ; one ^ with a sequestrum extending from the canine tooth to the angle of the jaw. In the other, '^ on the twenty-first day circumscribed gangrene of the lung occurred, on the sixty-fifth day parotitis, and on the seventy-first day necrosis of the angle of the lower jaw. In spite of all these catastrophes, the patient, a young man of twenty-six, recovered. While thus it is possible that the two causes which twenty years ago I deemed most potent still should be deemed to have some influence, the real factor, in which inheres practically the chief power for mis- chief, is the specific cause of typhoid fever — the bacillus discovered by Eberth in 1880. In the in- troduction to these studies on the surgery of typhoid fever I have fully discussed the occasional pyogenic property of the bacillus of Eberth — a property which no one, in the light of the most recent re- searches and experiments, can doubt. In no one of the various complications and sequels under con- sideration is this pyogenic power more strikingly shown than in the bones. All of the earlier cases, 1 Lancet, 1879, i, 685. ^ Breslauer aertzlich. Zeitschr., 18S7, 271. 3 Heath, Med.. Times and Gaz., Dec. 18, 1869. ^ Eisenhart, Miinch. med. Wochen. , 1886, xxxiii, 163. TYPHOID AFFECTIONS OF THE BONES. 1 13 and many of the 1 68 cases which we have collected in the later table, occurred before the bacillus of typhoid was known. Its presence lias only been sought for occasionally, for the larger number of the cases have occurred in the practice of persons whose taste for knowledge or whose opportunities led them only to record the actual practical facts and not to investigate the scientific causes underlying the facts. There are, therefore, only recorded in the later table 5 1 cases in which a bacteriological exam- ination was made. In 13 the pyogenic bacteria w^ere found ; in all the other 38 the bacillus of Eberth was found. In many cases it was not stated whether it was found in pure culture or not, — and possibly in our table the word "pure" may have been omitted by oversight, — but in 14 of the 38 it is distinctly stated that the bacillus was found in pure culture. In one ' the colon bacillus was found associated with it,^ and was responsible for the presence of gas in the pus ; and in one^ the aureus and citreus were also found. In a number of cases bacteriological investigation, at a later date, after operation, showed that a subsequent infection with the ordinary pyogenic bacteria had taken place after the operation. Still more strange is the fact that in a number of cases with an open sinus for months and even years, and, therefore, one w^ould think, with an almost in- evitable ordinary pyogenic infection, there has been found a pure culture of the bacillus of typhoid. 1 Klemm, Arcliiv f. klin. Chir. , Iviii, Heft 4. 2 Dehu (Etude sur le role du bacille d' Eberth dans les complications de le fievre typhoide, Th^se de Paris, 1893) states that the colon bacillus has never been seen in bone abscess. Klemm's case has been reported since then. ^ Parsons, Johns Hopkins Hosp. Rep., vol. v. 8 114 SURGERY OF TYPHOID FEVER. Thus, Parsons ' reports a case in which, seven months after the fever began and three months after an incision over the ribs resulting in a persistent sinus, the discharge showed a pure culture of the bacillus of Eberth. In Chapter II, page 19, 1 have given Several other instances, in some of which no added infection by the ordinary pyogenic bacteria occurred, even after years. It has been suggested that there may have been a mixed infection of the staphylococcus and the typhoid bacillus, of which the pyogenic organism was the active agent in causing the suppuration, but that the staphylococcus had died out, leaving the typhoid bacillus alone. The experiments of Klemm ^ would seem to sup- port this view. Pure cultures of the typhoid bacil- lus and the staphylococcus aureus were injected into rabbits, either simultaneously or at an interval of a week. An osteomyelitis was set up in each case, cultures from which showed only the aureus and none of the typhoid organisms. But the experiments of Dehu,^ Vincent,^ Vaillard,^ and Dmochowski and Janowski,^ a most painstaking series of observations, especially the last, seem un- questionably to establish the fact that instead of a lesser viability the staphylococcus has a greater ; that when mixed with the bacillus of typhoid in a mixed infection the bacillus soon dies, leaving the staphylococcus in possession of the field. If, there- / 1 Johns Hopkins Mosp. Rep., v, 407. 2 Arch. f. klin. Chir. , Bd. xlvi. 3 Le role du bacille d' Eberth dans les complications de la fievre typhoide, These de Paris, 1893. * Ann. de I'lnstitut Pasteur, 1893, vii, 141. 5 Grancher, Bull. Med., 1892, vi, 1273. 6 Ziegler's Beitrage, 1895, xvii, 221. TYPHOID AFFECTIONS OF THE BONES. II5 fore, a pure culture of the typhoid bacilkis is found in a suppuration after typhoid, it is very unHkely that the staphylococcus ever existed there. In marked contrast to its behavior when mixed with the staphylococcus, the bacillus of Eberth and the streptococcus both grow luxuriantly together. But, as I have already shown, the so-constant pres- ence of the bacillus of Eberth in pure culture in the pus from osseous and other lesions in the human subject ; the fact that Ebermeier' has found a pure culture of the bacillus as early as the tenth and the thirteenth day of the disease (two cases in which the date was too early for the pyogenic cocci to die out) ; the cases quoted on pages 19 and 26, of long-continued existence of the typhoid bacilli alone in suppurative lesions, and the many experiments re ferred to on page 42, proving that the bacillus alone does actually produce inflammation and suppuration in bone ; — seem to set at rest the theory just alluded to. One positive case in which the typhoid bacillus has actually produced suppuration in animals is worth a dozen in which, in man, the suppuration may have been due to a presumed pyogenic organism, which, if it ever existed, has disappeared. The same argu- ment which is used in the chapter on the Cerebral Complications of Typhoid applies here. The cases are too numerous to be all classed as mistakes. The existence of a mixed infection and a pure typhoid infection are not exclusive the one of the other. Both may be true in different cases, and while the proof is decidedly in favor of the view that suppuration in bone is usually due to the pyogenic 1 Deutsch. Archiv f. klin. Med., 1889, xliv, 140. Il6 SURGERY OF TYPHOID FEVER. property of the typhoid bacillus, yet there are doubt- less cases in which a mixed infection has occurred. After a careful examination of the subject, that is the view of Chantemesse and Widal,' who ascribe the osteomyelitis of typhoid to both pure and mixed infections. That the bones offer a peculiarly inviting field for the ravages of the typhoid bacillus, and especially for its late ravages, often not weeks, but months and years after the attack, has been explained of late by the discovery of two facts : first, the remarkable vi- ability of the typhoid bacilli in general (p. 19) ; and, secondly, their especial viability in the bones (p. 26). BeincT so tenacious of life in the adverse condi- tions in which their prolonged vitality has been proved, it is not surprising that in the bones them- selves, under more favorable conditions, they should be capable of living and doing mischief for a long time. As long ago as 1872,^ Ponfick noted and described the remarkable changes in the spleen and the bone- marrow in typhoid. After the bacillus of typhoid was discovered in 1880, it was especially sought for in the spleen and in the bone-marrow, and it was soon shown that of all the organs these two and the eall-bladder are its favorite seats, and that especially in the bones the bacilli exist in the largest numbers and linger the longest. Quincke, 3 in nine post-mortems, found the bacillus eight times in the marrow of the ribs and once in 1 Bull. etMem. Soc. Med. des Hop., 1893, x, 779. 2 Virchow's Archiv, Ivi, 534 and 1874, Ix, 153. 3 Berlin, klin. Wochen., 1894, No. 15. TYPHOID AFFECTIONS OF THE BONES. 11 y the bones of the extremities. Wissokowitsch ' has called attention to the frequency of the infection of the bone-marrow by the typhoid bacilli, and ascribes to this the frequency of the bone lesions of typhoid. Chantemesse and ^Widal ' inoculated rabbits and found the bacilli only in the bone-marrow. Dmo- chowski and Janowski^ have shown the same facts. But besides cases in which the bacilli, though present, had not as yet produced any disease in the bones, there are a large number of cases in which the bacilli have been found in cases of abscess and necrosis of bone, and in periostitis and osteomyelitis, a^ very long periods after the original attack of typhoid. The case of Buschke (p. 20), in which seven years had elapsed and yet a pure culture was found, has already been referred to. The next longest cases are those of Bruni and Sultan (p. 21), in which a pure culture was obtained after six years. A number of similar cases are given in detail on pages 21 and 22. ^^ These instances, showing the accumulation of the bacilli in the bones and their persistence for months, and even years, after the fever, explain the other- wise curious fact that the cases of periostitis, osteo- myelitis, necrosis, and abscesses in the bones occur at such long periods after the fever and so much later than most of the other surgical complications and sequels of typhoid. Why in some cases, as in those of Quincke, though the bacilli are present, they do not produce any of these disorders of the bones, we do not know. Probably it is due to the 1 Dehu, loc. cit., p. 90. 2 Arch, de Physiol., 1887. ^ Ziegler's Beitrage, 1895, xvii, 221. Il8 SURGERY OF TYPHOID FEVER. fact that the general health is such that their dele- terious tendency and influences are successfully vanquished. Possibly, if not probably, most per- sons convalescent from typhoid, for a consider- able time after the fever have foci of infection which never develop disease, and in time disappear because of returning health and vigor. The cases alluded to suggest, also, the need for care during convalescence and after recovery, lest if the general health suffer or an injury be received, the latent bacilli may be aroused into a dangerous activity and cause disease of the bones. For instance, Mercier ' relates a case in which six weeks after convales- cence the patient fell, striking his fore-arm against a piece of wood. This was followed by periostitis and abscess of the ulna. As this case occurred before the bacillus was known, no bacteriological proof of its typhoid origin was obtained. These latter cases may be analogous in part to a number of instances in which, after a periostitis has arisen with all the ordinary signs of inflamma- tion, it has subsided, and restoration to health has taken place without the formation of pus, the bacilli being killed or their toxins neutralized, possibly by returninor health. Still another peculiarity of not a few of these typhoid bone cases is that a periostitis will start up, reach a certain point, and then subside, it may be for months, or even years, and then recur, reaching the point where an abscess forms after one or two, or it may be even several, such oscillations.^ 1 Rev. Mensuelle de Med. et de Chir., 1879, iii, 21. 2 Cf. Parsons, Johns Hopkins Hosp. Reports, vol. v. TYPHOID AFFECTIONS OF THE BONES. 1 19 Two other peculiar clinical features of the bone cases may be explained by the long-persisting and favorable nidus which the bacilli find in the bones. Most of the other surgical disorders of typhoid manifest themselves in a single place — Thirty to thirty-five, 3 2 5 }" 3^ Over thirty-five, . . 4 i 5 J 129 36 165 The frequency from fifteen to twenty-five (109 to 56 for all other ages) is doubtless explained by the greater prevalence of the fever at that age. Sex. — Of 148 cases in my tables there were: Males, 119 Females, 29 148 and in Liinine's table, as above, there were : Males, 129 Females, 36 ^65" Site of the Stenosis. — This was : Supraglottic, 50 Infraglottic, 36 In the glottis, 18 104 This would seem to bear out the view of Llininof that the arytenoids are the most frequent site of the perichondritis at its beginning, and that from these the disease extends to the cricoid. Date of Onset. — This is generally late and fre- 13 194 SURGERY OF TYPHOID FEVER. quently during convalescence, when the fears of the physician are apt to be lulled by returning health. First week, - 7 cases. Second week, . 23 " Third week, 3° " Fourth week to two months, 83 " 143 cases. Typhoid vs. Typhus Fever. — In my Toner Lec- ture a considerable number of cases following typhus fever (49) were tabulated ; in the second series only four. Combining the two tables there were : Following typhoid, 154 Following typhus, 53 Necrosis of the Cartilages. — This is by far the most common and also by far the most dangerous form of laryngeal affection, foi" of 75 cases 71 died — a mortality of almost 95 per cent. Of the four recoveries, two ' recovered without operation and two ^ after tracheotomy. No words can be more eloquent than these figures. In the Toner Lecture I have reproduced several illustrations of ulceration and necrosis of the car- tilages following perichondritis. To these, through the kindness of Dr. M. H. Fussell, of Philadelphia,^ I am enabled to add another from a photograph of the specimen (Plate III). The case was one of perichondritis of the cricoid, and shows well the ne- crosed cartilage. 1 Herard, quoted by Trousseau, Clin. Med. Syden. See. Trans., 2d ed., ii, 407 ; and Schiffers, Annales Soc. Med. Chir. de Liege, in Jour. Amer. Med. Assoc, 1884, 70. 2 Tiirck and Liining, Case II, p. 223. ^ Jour. Amer. Med. Asso., July 3, 1897. PLATE III. Dr. M. H. Fussell's case of necrosis of the cricoid cartilage [a, a) after typhoid fever. TYPHOID AFFECTIONS OF THE LARYNX. 1 95 Cartilao-e Involved. — This was In — The cricoid, 43 cases. The arytenoids, 32 '• The other cartilages, 7 " 82 cases. In 13 of these both the arytenoids and the cricoid were involved. In Ltininor's table the result is analoo^ous : Thyroid, 2 cases. Thyroid and cricoid, 5 " Thyroid, cricoid, and arytenoids, ... 3 " Cricoid alone, 22 " Cricoid and arytenoids, 14 " Arytenoids alone, 9 " 55 cases. As is pointed out by Liining, the broad posterior plate of the cricoid is the most frequent portion of this cartilage to be involved, and very frequently the disease extends from the arytenoids, or from their articulation with the cricoid, to the latter. Laryngoscopic Examination. — In my two tables there were only 14 such examinations made. Liining has gathered 18, and records the following results : Ulcers on the vocal chords, processus vocales, posterior laryngeal wall, etc., 8 Swelling or bulging of anterior surface of pos- terior wall, 3 Abscess above right vocal chord, i Suppurative coating of the vocal chords, ... 2 Subglottic symmetrical fixed red swelling (chorditis vocalis inferior hypertrophica (?) perichondritis of the cricoid (?) ), . • • -2 196 SURGERY OF TYPHOID FEVER. In all cases there was redness, swelling, edema of portions of the larynx, rarely of the whole larynx, but chiefly of the chords, epiglottis, posterior wall, arytenoids, and their mucous membrane. Prognosis. — Of 197 cases of all kinds of stenosis in which the result is given, 132 died and 65 recov- ered — a mortality of 67 per cent. Bad as is this showing, it is far more striking when we separate the cases which were tracheotomized from those which were not. Thus : Of 98 cases ;2c/ operated on, 21 recovered and ']'] died — a mortality of 78.6 per cent. Of 99 cases operated on, 44 recovered and 55 died — a mortality of only 55.5 per cent. In necrosis of the cartilages, the most dangerous form of stenosis, as already stated, the mortality was almost 95 per cent. To add to the eloquence of the contrast between 78.6 per cent, without operation and 55.5 per cent, with operation, I may quote the following from my Toner Lecture : " When it is remembered that in two of the fatal cases the larynx was not opened, though trache- otomy was apparently performed ; and a third, in full recovery thirteen days after the operation, on the removal of the cannula was suddenly suffocated be- fore it could be replaced ; and in another the cannula became displaced in front of the trachea [that in over half of LiAning's 14 original cases goiter was a serious complication and several times was the direct cause of death] ; that in many, if not in most, of the cases the operation was deferred until the last possible — that is, the most unfavorable — moment ; TYPHOID AFFECTIONS OF THE LARYNX. I97 that many cases that might have been rescued were plainly allowed to die from exhaustion, or even from positive suffocation, by timid doctors, cases in which the result could not have been worse had an operation been performed; — the question of opera- tion would seem to be decided." All that I said twenty years ago as to the need of an early tracheotomy the moment that the exist- ence of perichondritis is recognized and suffocative attacks occur is only reinforced by the larger results from the later added cases. Delay can not be en- tertained for a moment, for it means a speedily fatal result. The terrible facts are before us. Let us hope that the lesson they teach will be learned. Intubation. — Since my former lecture intubation has been introduced as an operative procedure. I know of no case in which it has been practised, but it may well claim attention in the few cases to which it may be applicable. In perichondritis it would evidendy be worse than useless to employ it in place of tracheotomy. It affords no means of escape for the pus, the necrotic tissue, or the fragments of the cartilage. But in the rare cases of simple edema, and in some of ulceration, its use should be con- sidered, though I fear that it would rarely afford the relief which tracheotomy gives. Final Resiilts. — Liinine has collected the most careful and complete statistics of the final results as to whether the cannula can be dispensed with and as to the value of later attempts to overcome the sten- osis by dilatation or other means. Of 60 cases which recovered after perichondritis, 1 1 were able to dispense with the use of the cannula in 198 SURGERY OF TYPHOID FEVER. periods varying from seven months to six years, but the other 49 were obHged to wear the cannula perma- nently ; some could breathe freely without it during the day but were obliged to wear it at night. One patient was known to have worn the cannula for forty years. Various means have been employed to get rid of the stricture, especially by dilatation with bougies and special cannulas. But the treatment, especially by dilatation, is wearisome, both to the patient and the surgeon, and rarely has done any good. The special cannulas do not seem to have been any more success- fully employed. In • a half dozen cases attempts have been made to better the patient's condition by a total splitting of the larynx and the adaptation of a special cannula. These seem to have been at least partially successful, but the cannula had to be worn permanently. For the details the reader is referred to Liining's paper, page 329. To the above remarks, which interest the sur- geon, the physician, and the laryngologist, I may add, as of especial interest to the last, that a number of cases of paralysis of the muscles of the larynx have been reported. Those interested in this aspect of the subject will find it well described by Przedbor- ski.' Boulay and Mendel^ have reported 17 cases, and Bernoud ^ reports another case. ^ Ueber Lahmungen der Kehlkopfmuskeln beim Unterleibs und Fleck- typhus. . Sammlung klin. Vortrage, Neue Folge, No. 182, 1897. 2 Des Paralysies Laryngees dans la Fievre Typhoide, Rev. de Laryngol. et Rhinol. , 1895, xv, 615. 3 Lyon Med., March 28, 1897, p. 453. CHAPTER XIII. TYPHOID AFFECTIONS OF THE PLEURA, LUNGS, AND HEART. One of the very first regions in whicli the pyo- genic power of the typhoid bacillus was proved was in the pleural cavity. In 1885 Rendu and de Gennes,' and in 1887 A. Fraenkel,^ found pure cul- tures of the typhoid bacillus in the pus from cases of purulent pleurisy. Dr. Westcott has gathered together in all nine cases. In five of them bacterioloorical examinations showed the bacillus of Eberth. Except one case, in which the date of onset is not given, every one arose after the third week, and in five from one to two months after the fever, thus illustrating again the late period of these typhoid sequels. In one 2 it arose from a pneumothorax, occurring on the thirty-eighth day after convalescence, both from the fever and from a broncho-pneumonia. In one case there was an abscess of the lungs,"* in an- other gangrene of the lung and abscess of the spleen, 5 apd in a third ^ there was pus in the an- terior mediastinum. 1 La France Med., 1885, ii, 1821. 2 Verhandl. Sechste Kongress inner. Med., 1887, 179. 3 Rendu, La PVance Med., 1885, ii, 1809. * Ramsey, Annals of Surgery, Jan., 1890, 39. 5 Griesinger, Infectionskrankh. ^ Barr, Liverpool Med.-Chir. Jour., 1S93, xiii, 346. 199 200 SURGERY OF TYPHOID FEVER. Only two cases died, one of abscess of the lung and one of uncomplicated empyema. The symptoms do not call for special mention, but the treatment does. At least three of the cases re- covered after puncture, including even the one with pus in the mediastinum. In three others incision and drainao^e, in one of which two ribs were resected, accomplished a cure. The fact that the patient was exceedingly weak led to the choice of aspiration in the mediastinal case just mentioned, and 70 ounces of pus were withdrawn. Even should aspiration not be followed by cure, it may give important tem- porary relief, especially if the amount of fluid (as in that case) is such as to embarrass the respiration or circulation, and may thus give the patient time to recuperate his forces for a later and more radical operation if that proves to be necessary. In one case ' two aspirations were needed and it was observed that the typhoid bacilli from the second puncture were less virulent than those from the first. Five were males and four females ; four were under twenty years old and four from twenty to thirty- three ; all arose after the third week and two as late as two months from the onset of the fever. Heart. — There are also recorded two cases of purulent pericarditis^ and one of an abscess in the wall of the heart. Of the former, one was found at the autopsy, the patient, a boy of nine, dying on the seventeenth day. The latter ^ was in a man of ^ Weintraud, Berlin, klin. Wochen., 1893, xxx, 345, ^ Zeller, La France Med., 1881 ; and Le Clerc, La France Med., 1881, 54. * Driguet, quoted by Michon, Contrib. al'Etude des Suppur. dans la Fievre Typhoide, These de Lyon, 1890. THE PLEURA, LUNGS, AND HEART. 20I thirty-six, who died on the thirtieth day, and was Hkewise found at the autopsy. In view of the so frequent and characteristic changes in the heart muscle, it is rather singular that rupture of the muscular fibers, hematomata, and ab- scess are not more frequent in the heart. Save this one case, they are conspicuous by their absence. It is to be noted, also, that the typhoid bacillus has been found in the muscular tissue of the heart itself.' The treatment of a purulent pericarditis of ty- phoid origin would differ in no way from one arising from any other cause, except that the fever, if con- valescence be not yet fully established, would seri- ously diminish the chances of recovery. 1 Chantemesse and Widal, Gaz. Hebd., March 4, 1887, 146. (See also pp. 23 and 59, ante.) CHAPTER XIV. TYPHOID AFFECTIONS OF THE ESOPHAGUS AND THE STOMACH. I. Stricture of the Esophagus. — In the exten- sive tables we have collected no cases of typhoid surgical affections of the esophagus other than "diphtheric," exudative, and ulcerative manifesta- tions have been met with. But through the kindness of Prof Osier, of Johns Hopkins University, and of Dr. Frederick A. Pack- ard, of Philadelphia, I am enabled to publish two cases, which, so far as I know, are the only cases of the kind on record. Both of them are cases of stricture of the esophagus. Presumably, they fol- lowed upon typhoid ulcers resulting in cicatricial contraction. The symptoms and treatment are the same as is proper in similar stenosis from other causes, and call for no special comment. Case XXXI (Osier).— " Mrs. Mary M. J., age thirty-six, Judith, Union Co., N. C, was admitted September 26, 1897, complaining of inability to swal- low solid food. "There was nothing in her family history of any moment. "Personal History. — She was healthy as a girl; married at twenty-one ; has had no children. She has suffered at times from dyspepsia during the past six or seven years. 202 THE ESOPHAGUS AND THE STOMACH. 203 " Her present trouble began in January, 1896. Dr. Nance, of Unionville, N. C, writes as follows : ' My first visit to Mrs. J. was January 27, 1896, and from this time until about the end of March she was ill with typhoid fever. The actual time in bed was seven weeks. The oricjinal attack lasted three weeks, during which time she had no delirium. About the end of the third week she had hemorrhage from the bowels, and passed about a pint of blood. Then she had a relapse, which was much more severe than the original attack, in which she had delirium of a wandering nature. At about the third week of the relapse she developed a considerable gastritis, with accompanying vomiting, which con- tinued, on and off, for ten or fifteen days. There was at no time any hemorrhage from the mouth or blood in the vomit. When she first came out of her delirium, about the end of the sixth week, she com- plained of some difficulty in swallowing ; at first slight, but with a steady increase -.as her general condition improved, until, at the end of the eighth week, she was nearly in the condition she was when I sent her to the hospital.' " According to the patient's statement, she has not been able to swallow solid food since convalescence. The pain, she says, was severe at first ; she located it at a spot below the outer third of the right clavi- cle, but after the passage of the stomach-tube it is relieved, and is lower down, at the right costal bor- der. At times she can swallow water or milk with- out pain ; at other times the pain is severe. She has no vomiting, except the regurgitation of food which she tries to swallow. She has never brought up any blood. On trying to swallow solid food, it goes, as she expresses it, to the " bottom of the swallow," and then comes back again. She can hold it sometimes as long as five minutes. Ever since her convalescence she has been living on milk and 204 SURGERY OF TYPHOID FEVER. thin soup. She feels well, and has no pain except when she tries to swallow. In drinkinof milk, she takes it very slowly and only a little at a time. She says that at one time there was complete stoppage, due to coffee-grounds, and she could not swallow anything for two or three days. " Condition on Admission. — Patient is a thin, dark woman. The lips are of fairly good color, the tongue has a brownish fur, and the breath is foul. In the physical examination there is nothing of special moment. "On the 28th the stomach-tube was passed easily for 34 cm., and then an obstruction was met, which could not be overcome by any of the ordinary bou- gies. " On the 29th I passed a filiform bougie not quite two mm. in diameter. It was quite impossible to pass the smallest olive-tipped probang, measuring be- tween five and six millimeters. " On the 30th it was found impossible to engage a three mm. bougie in the stricture, which stopped it exactly 34 cm. from the teeth. From this date on, daily attempts were made by Dr. Mitchell, the house physician, to pass the larger bougies, and it was not until the 13th that two filiform bougies were passed together. The next day they were passed again, and immediately afterward the smallest-sized olive- tipped probang (No. 18, French). The obstruction could be distinctly felt, and the probang seemed to pass over a sharp edge. From this time on the stricture was easily dilated, until, on the first of No- vember, the olive-tipped bougies Nos. 31 and t,^) were passed, and for the first time since her typhoid fever she was able to swallow some bread and meat." Case XXXII (Packard). — "A. B., white, male, age thirty-five years, was admitted to the Philadel- phia Hospital, October 21, 1897, suffering from great weakness and emaciation. He had been treated by THE ESOPHAGUS AND THE STOMACH. 205 Dr. Ray E. Whelan in the Youngstown (Ohio) Hospital for typhoid fever, twelve weeks before his admission to my ward. On writing to Dr. Whelan, I received a very courteous note from him giving me the following facts : The patient went through a typical attack of typhoid fever, during which he had hemorrhages from the bowels and from the stomach or esophagus. He was given sulpho-carbolate of zinc in five-grain capsules, but these had to be dis- continued owing to the difficulty experienced in swallowing them. No other trouble with swallowing was noted while the patient was on liquid diet. Be- fore his discharge from the Youngstown Hospital bougies were twice passed, and two strictures were encountered, one of which was impassable. " On his admission to the Philadelphia Hospital, the following history was elicited : The family history was entirely negative as regards his present trouble. He had malaria a year ago. Denied absolutely venereal history, traumatism, and the swallowing of hot or corrosive liquids, and showed no sign of hysterical tendency. He uses alcohol and tobacco to excess. "He was very much emaciated, pale, and weak. The tongue was lightly coated, the tonsils a little enlarged, the pharynx very red. Physical examina- tion showed absolutely no other pathological change except in the esophagus. The swallowing time was from twenty-five to thirty-five seconds. A bougie (1.5 cm. in diameter) was introduced and met with an obstruction about 14 cm. from the teeth. On the next day a smaller bougie (7.5 mm.) passed through this stricture with a little persuasion, but at a point 24 cm. from the teeth met with an impassable ob- struction. This lower stricture allows now of the engagement of the tip of an esophageal bougie with spindle-shaped bulb, the greatest diameter of the bulb being- five mm. He can swallow milk with some difficulty, at times for several hours being unable to 2o6 SURGERY OF TYPHOID FEVER. get this through. The passage of the bougie seems to assist swallowing for a time; partly, no doubt, from the fact that large quantities of mucus are ex- pelled after its withdrawal. The patient is still under treatment (Nov. 25, 1897)." II. Ulceration Causing Hemorrhage or Per- foration of the Stomach. — The only surgical com- plication I am aware of is heinorrhage from the stom- ach ; perforation is also a possibility; — both due to typhoid ulceration. Pepper' refers to such cases, and says : " Typical typhoid ulcers have very occasionally been found in the stomach. They produce no charac- teristic symptoms, but have been known to cause hem- orrhage or perforation." No case of actual perforation has come to my knowledge. Should such a com- plication arise, the only hope of the patient, as in perforation of the gall-bladder (Chap. XVI) or of the intestine (Chap. XV), is in immediate abdominal section. It is a desperate remedy, it is true, but the only alternative is absolutely certain death. The treatment of the perforation is the same as in other perforations, by inversion of the margins by Lem- bert's or other suture, provided the circumstances admit of such interference. While no case of absolute perforation has been found, Soltau Fenwick,^ records a case to which Dr. Packard has kindly drawn my attention, in which typhoid ulcers very nearly perforated (p. 286), and a second (p. 290, Case 10), in which actual per- foration presumably took place, but peritonitis was prevented by the adhesions to the liver. It is to be 1 Amer. Text Book of Med., i, 91 ; ii, 769. 2 Disorders of Digestion in Infancy and Childhood, 1897, p. 286. THE ESOPHAGUS AND THE STOMACH. 207 noted that the cause of her death was a sudden and severe hemorrhage from one of the ulcers. Case XXXIII (Fenwick). — " Figure 3 represents a drawing of a stomach taken from a girl, eight years of age, who succumbed during the third week of en- teric fever. Four well-defined ulcers were found in the pyloric region, one of which presented a loosely ^H ^B IBBSiii'.:-*- ^^^^H ^^Hy- ^B L 'J?-, '/J ^^' [^^^^^^ \...' -'-^ ^B ^B' ^H _ y' ^H , ' , '"'"s 1 \ 1 Fig. 3. — Drawing of the pyloric end of the stomach in a case of enteric fever: a. Acute perforating ulcers with clean bases; d, an ulcer with ad- herent slough (W. Soltau Fenwick). adherent slough. The edges of the ulcers were sharply defined and somewhat undermined, while their bases were situated in the submucous and mus- cular coats of the organ. On microscopic examina- tion the lymphoid tissue of the stomach was found to be enormously increased, and the supposition that 2o8 SURGERY OF TYPHOID FEVER. the ulcers originated in disease of the soHtary glands was confirmed by the appearances of the smallest one. From these facts it would appear that, under certain circumstances, disease of the solitary gastric glands may give rise to a form of perforating ulcer of the stomach which closely resembles the idiopathic type of the disease." By the kind permission of Dr. Fenwick and the publisher, the figure is reproduced (Fig. 3). Case ^XX/K (Fen wick). — "A girl, thirteen years old, was admitted into the hospital with the symptoms of typhoid fever of eight days' duration. Vomiting occurred once or twice, but there was no complaint of epigastric pain. At the end of the fourth week of the disease, when the temperature had begun to decline, the patient was suddenly seized with severe hematemesis, after which she became unconscious and died. At the necropsy the anterior wall of the stomach was found to be adherent to the under sur- face of the liver. Scattered over the inner surface of the stomach there were numerous sharply defined ulcers, the laro^est of which was about the size of a florin. The edges were thin and undermined and the base formed by the muscular or peritoneal coat. In the first part of the duodenum there was an ulcer of a similar character, while the whole of the intes- tine, from the jejunum to the rectum, was riddled with typical typhoid ulcers." HemoT-rhage from such ulceration without perfora- tion is rare. Hematemesis in Typhoid Fever. — Eichhorst mentions having once seen bleeding from the stomach in typhus, and says that Weiss has seen fatal hemorrhage. {^Cf. Case XXXIV.) There is no reference in the fifth edition (1897) of Eichhorst's THE ESOPHAGUS AND THE STOMACH. 209 Handbuch der Speciellen Padiologie and Therapie, in die section on die Stomach, under the anatomical lesions, to hemorrhage or perforation. Under the complications hematemesis is mentioned, and the possibility of typhoid ulcer occurring in the stomach is considered. Through the kindness of Prof. Osier, I am per- mitted to publish the following cases of hematemesis in typhoid fever. It is probable that, in general, expectant rather than operative treatment would be the wisest course. That two of the three cases recovered without operation would seem to vindicate this view. The same may be said of hemorrhage from the bowels, which, as it is so closely allied to the topic under discussion, may be considered here, though not belonging to the subject of this chapter. It would be extremely difificult to locate the exact point of hemorrhage in the bowel. Even at the necropsy, when the bowel is laid open it is not always easy to find the source of the hemorrhage. How much more difficult it would be to find it when the bowel is closed. The various, and, it may be, the numerous, swollen Peyer's patches would be perceptible to the touch ; but how could the surgeon determine which was the one from which the bleed- ing came? (See Plate IV, Fig. i.) Resection of all the implicated bowel would not be considered, it seems to me, for a moment; and the largre num- ber of recoveries, even after severe hemorrhages from the bowels, would warrant our concludincr that the expectant and symptomatic medical treatment is certainly the best. 14 210 SURGERY OF TYPHOID FEVER, Case X^^F(Osler).— " John M., age forty (hos- pital No. 1683), was admitted August 21, 1890, with a history of illness of some weeks' duration. The chief symptoms were headache and fever. The blood examination was negative. There was a very definite rose-colored eruption. The temperature was never high, not rising above 103°. On the 27th he vomited, and in one of the attacks he brought up a dark greenish-brown fluid containing red blood-corpuscles in a condition of disintegration and a clot of blood about three by two cm. in diameter. On the 29th, 30th, and 31st the stools were very dark in color, and evidently contained blood, and several times he vomited very dark material. He became very anemic, but made a good recovery." Case XXXVI (Osier). — " Alberta C, colored, age twenty (hospital No. 10,131), admitted June 14, 1894. This patient was admitted in the third week of the disease. On that afternoon she had had a hemorrhage from the bowels. She was bleeding quite freely on admission. Between 6 and 8 p.m. she had five large stools of almost pure blood with clots. Throughout the following day she was extremely feeble ; temperature was normal ; patient was deli- rious. On June i6th there was no further bleeding from the bowels. Toward evening the patient was delirious, and her condition was very bad. At 8.15 P.M. she vomited 100 c.c. of dark bloody fluid, which contained blood coloring-matter and red blood-cor- puscles. She sank, and died that evening." Case XXXVII (Osier).— "Dr. H., age twenty- two (hospital No. 14,933), admitted January 9, 1896 He had a very severe attack, with persistent fever, which resisted the baths. These, though given from the outset, did not check the onset of quite active de- lirium. " On January 25th, about the eighteenth day of the disease, the abdomen was a good deal distended. THE ESOPHAGUS AND THE STOMACH. 211 there was moderate diarrhea, and less deHrium. He seemed to be doing very well. He had had no special gastric symptoms. In the afternoon he quite suddenly sprang up in bed and vomited a quantity of dark blood. The amount was difficult to estimate, as it went all over the bed linen. Part of it was collected, and Dr. Parsons estimated the amount to be about 200 c.c. It contained much debris and red blood- corpuscles. The staining on the sheets was quite red. "On the 26th the temperature was between 103° and 104°, and in the afternoon at 3.05 he vomited be- tween 200 and 300 c.c. of almost pure, bright red blood. The pulse became mare rapid, but these two hemorrhages did not appear to have any injurious influence. His temperature gradually fell, and was normal on the 31st. He made an uninterrupted recovery after a most severe attack." Just as this manuscript is passing through the press I have received from Prof William Osier, of Johns Hopkins University, under date of January iith, the followinof: Glossitis. — Another very interesting and rare complication of typhoid occurred last week in a convalescent ; namely, acute glossitis. The man had an ordinary attack, no fever for ten days ; went out on December 31st. He returned three days later with his mouth open and the tongue enormously swollen and very tender. I thought at first it was going to suppurate, but in the course of three or four days it subsided. CHAPTER XV. INTESTINAL PERFORATION IN TYPHOID FEVER. The frequent occurrence of perforation of the bowel in typhoid fever has long been recognized, but it was not until Leyden/ in 1884, first proposed to treat the resulting peritonitis by operative meas- ures, which he believed to be " a most fruitful field for investigation," that surgeons seriously considered the question of its possible success. In the same year appeared an article by Mikulicz,^ in which he reported three cases of peritonitis which he had treated surgically ; one of them being, it is fairly cer- tain, a case of perforation in typhoid fever. In 1886 Prof. James C. Wilson ^ was the first writer in Eng- lish to suggest that operative measures should be instituted in typhoid perforation. I had the pleasure of being associated with Prof Wilson in this case, and we discussed most seriously the question of operation, but from day to day decided against its expediency at that time, and the patient happily re- covered without operation. The first operation in a positively known case of typhoid was reported by Liicke,'^ and in the same year Bontecou ^ operated on another patient. 1 Deutsch. med. Wochen., 1884, 258. 2 Samml. klin. Vortrage, No. 262. 3 Phila. Med. Times, Dec. II, 1886. 4 Deutsch. Zeit. f. Chir., No. 25, Heft i. 5 Jour. Am. Med. Assoc, 1888, No. 10, p. 106. 212 INTESTINAL PERFORATION. 213 Before taking up the question of operation, how- ever, there are a few points in reference to perfora- tion itself which will be of value for us to consider. I shall take the figures and some of the tables from the admirable paper of Fitz,' in which, with his usual thoroughness and accuracy, he has collected a large number of statistics from tables of 4680 cases of typhoid. The frequency of typhoid perforation is estimated variously. Thus, Schulz ^ found that peritonitis from intestinal perforation took place in 1.2 per cent, of 3686 Hamburg cases in 1886-87. This accords with the statement of Liebermeister,^ who found intestinal perforation in 1.3 per cent, of over 2000 Basle cases between 1865 ^"^^ 1872. Holscher'^ found perfora- tion In 6 per cent, of 2000 cases. Murchison ^ found its frequency was 11.38 per cent, in 1721 cases. In the 4680 cases tabulated by Fitz, the mortality from perforation was 6.58 per cent., which may be ac- cepted, therefore, as fairly representing its fre- quency. In 444 cases (Fitz), it occurred among men in 71 per cent, of the cases, and among women in 29 per cent. Certainly, it is much more frequent among men than among women ; for what reason we do not know. In children it is very rare. ^ Trans. Assoc, of Am. Physicians, 1891, vi, p. 200. 2 Centralbl. f. all. path. Anat., 1891, 11,289. 3 Ziemssen's Handb. spec. Path. u. Therap., 1874, ii, I, 161. * Miinch. med. Wochen. , 1891, xxxviii, 64. 5 Continued Fevers, second edition, 1873, 566. 214 SURGERY OF TYPHOID FEVER. Age at Which Perforation Occurs. — Fitz's table is as follows : Age. One to ten years, . . Ten to twenty years, . Twenty to thirty years, Thirty to forty years. Forty to fifty years, . Fifty to sixty years, . Sixty to seventy years, 192 Date of Occu7''rence of the Perforation. — Fitz's table is, again, as follows : Cases. Per Cent • 7 3-6 . 46 23.8 • 77 39-8 • 45 23-3 • 14 7.2 . 2 I.O . I 0-5 Week. Cases. First, 4 Second, 32 Third, 48 Fourth, 42 Fifth, 27 Sixth, 21 Seventh, 5 Eighth, 3 Ninth, 2 Tenth, 4 Eleventh, 3 Twelfth, I Sixteenth, i Per Cent. 16.5 24.8 21 14 13 193 The Seat of the Perforation (Fitz). — In 167 cases. Seat. Cases. Ileum, 136 Large intestine, 20 Vermiform appendix, .... 5 Meckel's diverticulum, ... 4 Jejunum, 2 Per Cent. 81.4 12.9 INTESTINAL PERFORATION. 21 5 Hawkins,' in 72 cases of perforation, found 61 in the ileum, 3 in the cecum, 3 in the appendix, and 5 in the colon. Adding 5 cases of perforation of the colon from other sources, of the ten cases there were 2 in the ascending, i in the transverse, and 7 in the descending colon — of which 5 were in the sigmoid flexure. If, therefore, no perforation be found in the ileum, cecum, or appendix, the next most likely point would be the sigmoid flexure. In one curious case reported by Haegler,^ in a woman, aged thirty-five, who had a hernia as large as a child's head (the result of a celiotomy performed some years before), on the sixth day after her admis- sion a perforation occurred through the wall of the hernia, followed by a fecal fistula, eventually ^ of an inch wide and two inches long. Within ten days three other fistulse formed near the first one. In spite of her excessive emaciation and a bedsore over the sacrum she insisted upon going home, where she finally recovered and the fistula spontane- ously closed. The explanation given by the author is that a loop of intestine in the hernia became the seat of typhoid ulceration, leading finally to perforation. Number of Perfoi^ations. — Fortunately both for the patient and the surgeon, if interference is de- cided upon, the perforation is almost uniformly single, but Fitz reports that there were in 167 cases : 2 perforations in 19 cases 5 - in 3 " 4 " in I case Several " in 4 cases 25 to 30 " in 2 " 1 Lancet, 1893, ii, 245. 2 N. Y. Med. Jour., July 17, 1897, 93, from Correspondenzbl. f. schweiz. Aerzte, 1896, No. 17. 2l6 SURGERY OF TYPHOID FEVER. Lebert' and Hoffman^ report the last two cases. Character of the Perforation. — If the perforation result from the ulceration of a solitary follicle, it is apt to be small and round (Plate IV, Fig. 2 ; Plate V, Fig. 2). If it result from the perforation of a patch of Peyer, it may be oval or round, and will be much larger than in the former case (Plate IV, Fig. i ; and Plate V, Fig. i), and may even involve a half of the circumference of the bowel (Plate IV, Fig. i). Sometimes shreds of tissue will be left partially closing the opening (Plate V, Fig. i) ; at others the opening is total and clean cut. Not uncommonly there is a tolerably wide area around the ulcer in which the intestinal wall has been greatly thinned (Plate IV, Fig. 2 ; Plate V, Fig. 2). This is of great importance from an operative point of view {vide infra).^ Duration of Life after Perforation. — Of 134 cases (Fitz) : Died on the first day, " on the second day, " in the first week, . " in the second week, " in the third week, " in thirty days, . . " in thirty-eight days. We should naturally expect that perforation would be more frequent in proportion to the gravity of the ^ Ueber d. Typhus- u. d. Typh.-Epid. d. Jahr. 1857 ; Friedrich, Die Para- centese d. Unterleibs b. Darmperf. im Abdominal ty ph., 1867. 2 Untersuch. u. d. path. anat. Verand. d. Organe beim abdominaltyph., 1869. ^ Plates IV and V are from specimens in the Museum of the Pennsylvania Hospital, which I was kindly allowed to have photographed. • • • 37-3 per cent • • • 29.5 . • • 83.4 '' . . . 9 cases . . . 4 " . . . I case . . . I '' PLATE IV. 11 Fig. I. — Two intestinal perforations in typhoid fever. A third small per- foration existed just above the large one. Resection of the bowel would have been the only possible mode of treating the large perforation, as lateral closure would have produced great stenosis. Observe the numerous areas of thinning of the wall of the bowel from ulceration. (Museum of the Pennsylvania Hospital.) '^■^<:^^^'>r-'^' Fig. 2. — Intestinal perforation in typhoid fever. Observe the thinned wall around the perforation. (Museum of the Pennsylvania Hospital.) PLATE V. Fig. I. — Intestinal perforation in typhoid fever. Observe the threads of tissue obstructing the opening. (Museum of the Pennsylvania Hospital.) Fig. 2. — Intestinal perforation in typhoid fever. Observe the wide-spread thinning of the intestinal wall around the actual perforation. (Museum of the Pennsylvania Hospital.) INTESTINAL PERFORATION. 2\J disease, but Fitz states tliat there is no definite rela- tion between the two. In about one-fourth of nearly 2000 cases the course of the disease was distinctly stated to be mild. Of walking typhoid there were 14 cases, and several cases have been reported in which the perforation was only found at the necropsy. Diagnosis of Perfoi'ation. — Of 80 cases in which a record was made of the symptoms, it was found (Fitz) that in 56 cases the onset was sudden, in 15 the symptoms were gradual or latent, while in five there were no symptoms whatever pointing to the perforation. Armstrong, in a personal letter, says "In none of my cases was the occur- rence of perforation indicated by those well-marked, striking symptoms so generally mentioned in text- books." In addition to this, it must be remembered that fatal peritonitis may arise during typhoid fever with- out any perforation being discovered, at operation or even by a necropsy. Herringham and Bowlby ' record a striking case in which the symptoms pointed plainly to perforation, yet the operation revealed only scybala in the colon. The patient recovered. There are also other causes for typhoid peritonitis than typhoid perforation, as I have shown in the chapters on Abscess (from rupture of the mesenteric glands, and abscesses of the abdominal wall), on the Spleen, and especially in the chapter on the Liver and Gall-bladder, from perforating ulcers of the gall- bladder. Fitz has well said (p. 207), "Since per- foration of the intestine in typhoid fever may take place without any suggestive symptoms, and since 1 Brit. Med. Jour., 1897, i, 265. 2l8 SURGERY OF TYPHOID FEVER. suggestive — even so-called characteristic — symptoms may occur without any perforation having taken place, it must be admitted that recovery from such symptoms is not satisfactory evidence of recovery from perforation." But there are certainly a number of cases on record in which perforation could not be doubted which have recovered. Murchison, how- ever, estimates that the mortality of typhoid perfora- tions in general is about 90 per cent., and in those in which general peritonitis supervenes after such per- forations it is 95 per cent. The ordinary symptoms which indicate perforation are, especially, sudden and severe abdominal pain, usually in the neighborhood of the right iliac fossa or the hypogastrium, collapse, nausea and vomiting, with occasionally a marked fall of temperature. It would be supposed that in consequence of the per- foration the intestinal gases would escape, and this would be followed by disappearance of the hepatic dulness ; but this is only rarely reported. One very important symptom, which has been ob- served only of late, is the presence or absence of leu- cocytosis. According to Thayer,' there is no increase in the proportion of the white blood-corpuscles during the fever, but rather a slight diminution in their num-- ber, which gradually diminishes until convalescence. During the fever, the number may fall even below 2000, and sometimes below 1000, per cubic centi- meter. The lowest count seems to be about the end of the third week. Sometimes the white blood-cells increased markedly in number (ieucocytosis) with the fever, even without any complication. Four cases ^ Johns Hopkins Bulletin, iv, p. 83. INTES TINA L PER FOR A TION. 2 1 9 were observed by Cabot in which the count was over 11,000, and ran as high even as 17,700 without any other than the typical typhoid lesions. But the effect of complications is very marked and undoubted. I quote the following examples in seven cases, two of typhoid perforation, from Cabot's admirable book ' : Perforation. . Case I. — (a) Five days before pertoration, 8300. {F) At time of perforation, 24,000. Case II. — At time of perforation, 18,500. Phlebitis. . . Case I. — {a) Two days before onset, 6400. (^) At time of onset, 12,900. (^) One week later, 10,100. Case II. — {a) One week before onset, 4800. (^b) At time of onset, 16,200. Otitis Media. . Case I. — {a) At entrance, 5300. {b') Mastoid abscess, 16,400. Case II. — {a) At entrance, 8400. (^) Two weeks lat-er, after opening drum membrane (sero-puru- lent discharge), 11,200. Casein. — {a) At entrance, 7320. (<5) Otitis, 14,000. In addition to this he states that " a freely discharg- ing otitis soon ceases to cause leucocytosis — e.g., a case of serous otitis media seven days after punc- ture, but still freely discharging, showed but 5320 white cells a cubic centimeter. An abscess of the buttock raised the count from 8000 to 11,200, and a hemorrhage from 8000 to 11,300." General bron- chitis and cystitis had usually no such effect. In two cases simulating otitis, with a normal blood count, the trouble turned out to be functional. ^ Clinical Examination of the Blood, 1897. 220 SURGERY OF TYPHOID FEVER. It is to be noted, however, that he adds: "It occa- sionally happens in very exhausted patients that complications fail to produce any leucocytosis, the patient — as in some fatal cases of pneumonia or puru- lent peritonitis — being unable to react against the in- fection These cases, however, are ex- ceptional." In any case of doubt, therefore, if time allows, a blood count should be made in order to assist us in the diagnosis. The result of intestnial perforation is, in a few cases, a localized abscess similar to the localized abscess which follows a perforative appendicitis ; but, in unfortunate contrast with perforative appen- dicitis, in the majority of cases no such agglutination of the intestine occurs, and, therefore, a generalized suppurative peritonitis follows speedily upon the perforation. This is very natural, since the intestinal contents are more than usually infective, both from the colon bacillus and from the typhoid bacillus as well as the ordinary pyogenic bacteria. If the per- forations are multiple, the peritonitis is, of course, so much the more certain to become general. Ordin- arily, the typhoid bacilli have not been found in the peritoneum following perforation. Possibly, as sug- gested by Finney, they have been " overgrown and destroyed by their more active and vigorous com- panions, the streptococcus pyogenes and the bacillus coli communis." There is but a single instance, so far as I know, of a bacteriological examination of the contents of the peritoneum in typhoid perforation. Finney,' in his three cases, made cover slides and cultures which showed pure colon bacilli. ^ Annals of Surg., 1897, xxv, 233. INTESTINAL PERFORATION. 221 The dangers of surgical interference are unques- tionably very great. They can scarcely be stated better than in the frequently quoted words of Wilson, written over eleven years ago : ' "Granted that the chances of a successful issue are heavily against you ; that the patient is in the midst or at the end of a long sickness ; that his tissues are in the worst state to stand the injuries from the knife; that the lesions of the gut may be very extensive ; that the vital forces are at the lowest ebb; — no one has yet hesitated to perform a trache- otomy in the laryngeal complications of enteric fever, which require it to save life for these reasons. The operative treatment of purulent peritonitis has been performed many times successfully by the gynecolo- gist in conditions less promising. In point of fact, the objections that may be urged against laparotomy in intestinal perforation in enteric fever are no more forcible than those which would have been made use of at first against the same operation in gunshot wounds of the abdomen. Unfortunately, this ques- tion is not to be settled by experiments upon animals. The investigation must be made upon the human subject, where courage to perform it will come from the knowledge that the only alternative is the patient's death." Commenting on the statement of Fitz, that "the similarity of the symptoms of perforation of the bowel and those of the appendix is striking. The symptoms are not merely similar ; they are actually identical, even to the usual localization of the 1 Phila. Med. Times, 1886, vol. xvii, 177. 222 SURGERY OF TYPHOID FEVER. consequent peritonitis in the right iliac fossa," Abbe' says : " This lucid statement by Fitz must appeal to every observer of appendicitis cases as true to the letter. Why one class of cases should be left to die while we operate on all appendicitis cases, when perforation can be recognized [except, I am sure he would say, when the patient is past hope] does not appear. " But, after all, the appeal must be to the facts in the case. This is the final arbiter. When once physicians are not only on the alert to ob- serve the symptoms of perforation, but when the knowledge that perforation of the bowel can be remedied by surgical means has permeated the pro- fession, so that the instant that perforation takes place the surgeon will be called upon, and, if the case be suitable, will operate, we shall find unques- tionably a much larger percentage of cures than have thus far been reported. But even at present we have a reasonably large number from which to draw conclusions. In the table appended to this chapter Dr. Westcott has collected 83 well-authenticated cases. This gives, as a general result, 16 recoveries,^ or 19.36 per cent, of cures and 80.64 per cent, of deaths. When this is contrasted with Murchison's unchallenged figures of 90 to 95 per cent, of deaths after perforation without operation, we may well take courage for the future. If we analyze the recoveries according to age, the result is somewhat of a surprise. 1 N. Y. Med. Record, Jan. 5, 1895, p. I. 2 Cases I, 13, 15, 25, 26, 28, 31, 40, 41, 45, 46, 47, 48, 61, 64, 68. INTESTINAL PERFORATION. 223 Under fifteen years of age there were 5 cases and 2 recoveries, or 40 per cent, of recoveries. In one of these (Case 40) resection of the intes- tine was done. If we inckide (Chap. XVI, Table II) one case of perforation of the gall-bladder with recovery, the number of cases of perforation from both causes is 6, with 3 recoveries, or 50 per cent. From fifteen to twenty-five years of age there were 23 cases and 3 recoveries, or 13 per cent, of recoveries. From twenty-six to thirty-hve years of age there were 24 cases and 5 recoveries, or 20.8 per cent, of recoveries. If we include two cases of perforation of the gall-bladder with recovery (Table II), the number of cases is 26, with 7 recoveries, or 26.9 per cent. Over thirty-five years of age there were 1 1 cases, with 5 recoveries, or 45.5 per cent, of recoveries. If we include one fatal case of perforation of the gall-bladder (Table II), the number of cases is 12, with 5 recoveries, or 41.7 per cent. This discloses the fact that, so far as the present figures go, operations for perforation of the intestine are more fatal between sixteen and thirty-five than under fifteen or over thirty-five. In Table I the following cases which have appear- ed in some former tables have not been included for the following reasons : I. Escher's,' since it seems more likely a case of 1 Wien. med. Wochen., 1887, No. 19, 607. 224 SURGERY OF TYPHOID FEVER. appendicitis. It is admitted by Finney into his table, though expressly excluded in the text. 2. Greig Smith's.' This is stricken out, not only because the diagnosis was doubtful and no post-mor- tem examination verified the fact, but because Smith himself, in his fifth edition, omits it in his chapter on typhoid perforation. 3. Taylor's,^ since the diagnosis is extremely doubtful. 4. Price's second case, ^ since, though there was a large amount of filthy contents with fecal odor, the case was more likely tubercular than typhoid, and the report of the case is unfortunately exceedingly meager. 5. The case of 111, since a personal letter from Dr. Ill assures me that it was not a case of typhoid perforation. 6. L. S. McMurtry's case ■* is rejected, since he writes me that it was a case of appendicitis. 7. A case attributed to Lejars by Monod and Vanverts, as it was not one of typhoid. 8. The case of Steel, ^ as it seems to have been a case of appendicitis at the outset of the fever, and not as a result of perforation during or after the fever. Some other cases which have been disputed are admitted, as it seems to me that the evidence is sufifi- ciently clear to do so — namely : I. The case of Mikulicz, No. i in the table. This is also admitted by Finney and by Monod and Vanverts.^ 1 Abdominal Surgery, 3d ed., 1890, 751. ^ Lancet, 1890, i, 961. 3 Med. and Surg. Reporter, Nov. 7, 1896, 577. * Price refers to it in his paper. 5 Brit. Med. Jour., 1897, i, 13. ^ Rev. de Ctiir., 1897, 169. INJESTJNAL PERI- ORATION. 225 2. 'I'he cases of Hahn, Nos. 9 and 10, since the statement is direct and positive, though for any other purpose than the fatal result they are of no value. 3. The case of Netschajew and Trojanow, No. 26. Though the case is somewhat doubtful, yet the bur- den of proof seems to be in its favor, and it is ad- mitted by both Finney and by Monod and Vanverts. 4. The case of Dandridge, No. 28, though the perforation was not found, yet gas and stinking pus were found free in the belly. This is also admitted by Finney. 5. The case of Ferraresi, No. 31. This, also, is a somewhat doubtful case, but, on the whole, with Fin- ney, I would admit it, though it is rejected by Monod and Vanverts. 6. The cases of Hill and Murphy, Nos. 40 and 41, on the basis of a personal communication from Dr. Murphy. Let us now, turning to the table, see what the results have been, and what conclusions, both as to the methods and time of operation, will show us as to its advisability. First, the time of operation should be wisely chosen. The best time is not during the immediate primary shock which lasts during the first few hours. Hap- pily, in fact, it is very rarely the case that opera- tion can be done within several hours after perfora- tion, since, the case being under the care of a physician, it requires time to obtain a consultation with the suro-eon, and, when the diagnosis has been reached, still further time must elapse before suit- able preparations for operation can be made. The table on page 227 shows \h?^\.\k\Q. second tzuehe hou7's 15 226 SURGERY OF TYPHOID FEVER. after perforation, all things considered, has been the most favorable up to this time. Abbe well says that it is essential that " the surgeon should never be so hasty in getting at his work that he enters upon it handicapped by poor assistants, poor light, poor arrangements for irrigation and sponging, or inadequate plans for restoration from shock." The earliest moment at which the operation can be done after the immediate shock of the perfor- ation, provided, of course, there has been any, as is sometimes not the case, the better it will be for the patient. Every hour then counts, since the infection of the peritoneum becomes more diffuse and more intense. On the other hand, no prudent surgeon would decide to operate in a case in which all the con- ditions, both general and local, forbade the hope of a recovery. The only contraindication recog- nized by Van Hook ' is that the patient is moribund, but I can well imagine that, as in perforation from other cause, the general state of the patient, the pulse, the temperature, and the degree of collapse and of exhaustion will all count as essential factors in formulating a conclusion. Naturally, the cases operated on after relapse or toward the end of the acute febrile attack will result better than those in which the perforation occurring earlier requires the patient not only to recover from the operation, but to have strength enough to carry him through the fever which has not as yet subsided. Yet Finney has called attention to the remarkable vitality ex- hibited by some of the cases that recover, and states 1 Med. News, Nov. 21, 1891, 591. INTESTINAL PERFORATION. 22/ of three cases "who subsequent to the operation suffered two relapses, one, of great severity, had suppurating otitis media, left-sided pleurisy, had right-sided femoral phlebitis, severe neuritis of both legs, and the painful toes so common after the cold bath treatment," and yet recovered. An analysis of the cases in which the interval be- tween the onset of the symptoms and the time of ope7^ation is stated shows us. the ereat dano-er of delay. This is stated in 60 cases as follows : Cases. Recoverkd. Within twelve hours, 15 4 Twelve to twenty-four hours, ... 20 6 Twenty-four to forty-eight hours, .13 i Two to three days, 6 2 Three to four days, 4 o Five days, i o Thirty-eight days, i o 6 o 13 In the cases operated on within twelve hours, the percentage of recoveries was 26.7 per cent. ; between twelve and twenty-four hours, 30 per cent. After twenty-four hours the mortality was total, except one after twenty-six hours (No. 64) and the two that re- covered between two and three days (Nos. 25 and 28). The last two cases we must consider as excep- tional and not impairing the rule that if the opei-a- tton is not done within about twejityfour hours after the perforation there is practically no hope of a re- covery. Technic of the Operation. — The incision may be either median or lateral. If the case, by percussion, is fairly well proved to be an encysted localized peri- 228 SURGERY OF TYPHOID FEVER. tonitis, I would very decidedly prefer the lateral in- cision, just as in an appendicitis with a similar condi- tion the lateral incision is preferable. If, however, the case is one of general peritonitis, which in typhoid perforation is far more frequent than the localized form, the incision would best be made in the middle line, since it offers far better opportunities for cleans- ing" the peritoneum, and gives us ready access to the ileum, which is the usual seat of the perforation. It should be a free incision, long enough for the neces- sary manipulations. Our first object is to find the perforation. As already shown (p. 214), this is usually in the ileum ; but if not there, then the cecum, the appendix, and the sisfmoid flexure of the colon should be examined. In the jejunum perforation is very rare, and in the duodenum it may be said almost never to take place. Sometimes the search will be facilitated by cleans- ing the abdomen of the quantities of fecal matter and foul pus which coat the intestines ; sometimes the perforation may be readily discovered without this. If flushing is done it would be best by the sterile salt solution, though Abbe used with ad- vantage a very weak bichlorid solution, i : 20,000. As soon as a perforation is discovered, it should be sutured. Sometimes the edges have been pared, but I see no reason for this, as for effective closure we must depend upon the peritoneal adhesions. To trim the edges is both a waste of time and tissue. But in case two perforations are contiguous, it may well be that excision would best prepare the bowel for suture. All of the thinned intestinal wall sur- rounding the perforation (see page 216 and Plates INTESTINAL PERFORATION. 229 IV and V) should be turned in, If diis will not pro- duce too much stenosis of the bowel. In five of the cases tabulated (Nos. 31, 40, 70, 72, 73), there was such wide destruction of tissue that a portion of the bowel was resected. If this condition is found, no other course is open to the surgeon except, it may be, the establishment of an artificial anus, which may be closed later. As a general rule, I rather prefer the latter course ; but it is an encouragement to us to find that the first two of the cases of resec- tion recovered. An ardficial anus in the ileum I have found in cases other than typhoid to be objec- donable, since the intesdnal juices are very irritadng to the skin. ^ A condnuous suture is decidedly not the best. The tissues of the bow^el are very frail and may readily tear out, and, if the suture be condnuous and it tears out at one point, it weakens the whole line of suture. Independent mattress sutures, as ad- vised by Halsted, are the best, not only because, as Abbe found, they do not so readily tear the friable dssue, but also because they shorten the operation, since there is but one knot to be tied for every two sutures. Whether one, tw^o, or three rows of sutures shall be applied depends on the case, but we must remember that every additional row narrows the lumen of the bowel. As soon as one opening has been closed, a search should be made in the regions above indicated for either a second perforation, or possibly even more than two, and also for any suspicious weakened spots which show that other perforations are imminent. In cases 5 I and 60 subsequent perforadons destroyed life in 230 SURGERY OF TYPHOID FEVER. cases which were apparently recovering, and in case 62 had Hfe been prolonged a litde while a new per- foration would have occurred and ultimately killed the patient. In two other cases (40 and 48) such suturing at points of impending perforation probably saved both lives. How far the search for multiple or impending perforations shall go must be decided by the opera- tor in each case. Very prolonged search over a large portion of the intestine involves both time and added shock. Most of the perforations occur within six feet, and especially within the first two or three feet of the ileo-cecal valve. If none are found within this dis- tance nor in the other regions of probable perforation {vide siLprd), I think, as a rule, it would be safer not to prolong the search further. Fewer lives would be lost by such abbreviation of the operation, and by avoiding the necessary mechanical injury and cooling of the intestine, than by missing a very exceptional second ulcer at another point. Whether we shall only flush the abdomen, or whether we shall clean it by wiping, is, I think, to be decided very much by later experience. Finney' has made a strong plea for systematic wiping of the bowel with pledgets of gauze wrung out of a hot salt solution in suppura- tive peritonitis from whatever cause. In no case, it seems to me, should the abdo- men be entirely closed. Drainage should be the rule. If peritonitis arise from other cause than typhoid perforation, scarcely any surgeon would think of closing the abdomen ; and the same rule should hold Qrood here. Moreover, I think well of 1 Johns Hopkins Hosp. Bull., July, 1897. fNTESTINAL PERFORATION. 23 I packinor the wound with iodoform gauze, and I would prefer that the point or points of suture in the bowel should be placed, if possible, immediately below the gauze packing, so that if a fecal fistula formed, as occurred in Abbe's case (No. 25), there should be a ready and unobstructed egress for the intestinal con- tents. In spite of the bad condition of the patients, a number of post-mortems have shown that the wounds become aeelutinated and heal as well as other simi- lar wounds in the intestine. In case after case of those that died the post-mortem showed that the stitches had held perfectly, and that no later extra- vasation had occurred, though this took place in Liicke's and Kimura's cases (Nos. 2 and 14). The very fact that such wounds of the intestine heal readily is a great encouragement. The cause of death is commonly the septic condition or the profound exhaustion which has been produced by the fever ; to which the opera- tion, unfortunately, as a rule, can but add some- thing. In every case, before the abdomen is closed the appendix should be sought and examined. Typhoid ulcers are sometimes found in the appendix. This part of the intestinal tract, therefore, should never be overlooked. If true appendicitis is present, as may occasionally happen, or if a typhoid perforation exist there, the appendix should, of course, be re- moved. This was done in several of the cases in the table. If, however, the appendix be not diseased, it should not be removed, as it adds to the length of an operation in which every minute counts. I have recently operated upon two cases of ap- 232 SURGERY OF TYPHOID FEVER. pendicitis in which the first attacks followed shortly after typhoid. As in neither case were the typhoid bacilli found in cultures from the contents of the appendix, the connection between the two diseases seems to be accidental and not causal. In the last case, over three years after the typhoid attack, the blood reacted to the Widal serum-test; the ileum showed several oval white patches, corresponding to Peyer's patches, and the mesenteric glands were greatly enlarged. The bacteriological examination showed the colon bacillus and the micrococcus pyogenes albus in a tube inoculated from the peri- toneum, the colon bacillus and micrococcus foetidus in the tube inoculated from the interior of the appen- dix, and the micrococcus pyogenes albus in pure culture in the tube inoculated from a mesenteric gland which I excised. The gland itself, Prof. Cop- lin reports, showed areas of coagulation necrosis with softening. In spite of the infection of the peri- toneum, the patient made a perfectly smooth recovery from the operation, but still has a hectic temperature — suggestive of tuberculosis, though there are no tubercle bacilli in the sputum. Unfortunately, in Case 44 intestinal obstruction followed the operation and was the cause of death. I can scarcely think that we would ever be justified in re-opening the abdomen in such a case. Possibly, a very exceptional case might justify such a proced- ure, but a typhoid patient rarely escapes with his life, even after one operation, and could not be ex- pected to survive a second. The same remark would apply to any new perforation which might occur. Such cases must, unfortunately, be left to INTESTINAL PERFORATION. 233 their fate, but if tlie surgeon has been careful to search for and suture any impending perforation, he has done much to prevent such a disaster. In Cases 40 and 48 the suturing of such an impending perfor- ation undoubtedly saved both lives. If there be such distention of the intestines that it is difficult, if not impossible, to replace them, they should be incised, and, after the gas has escaped, sutured. This was done in several cases. Mr. Gairdner, Assistant Physician of the Belvidere Fever Hospital, in analyzing 47 cases of peritonitis in typhoid fever with reference to surgical interfer- ence, in a very careful and judicious paper in the Glasgow Medical Journal, February, 1897, page 67, reaches the following conclusions, which well express my own feelings, and it is all the more worthy of con- sideration as the opinion of a thoughtful physician rather than that of an over-sanofuine surgfeon : " The treatment of peritonitis in the course of enteric fever by laparotomy has hitherto had a moderate success. There is every reason to believe that greater success is possible, and in any case the results are better than those of any other treatment. Laparotomy offers a fair chance to about 49 per cent, of cases, while 19 per cent, of the whole would certainly have a good chance. Nothing but experience can determine what the results will be — better or worse than might be expected pi^ima facie. If there is a good cause at least for attempting surgical interference, it becomes incumbent on the profession to afford every facility for making the attempt. This, of course, applies particularly to authorities responsible for hospitals in which enteric fever is treated." > O >- Z g < o p- Di U4 CL < Z w E- Z Dii O CO z O < a: Q- o uu X X O < E- 6 a p. perfora- ign. r. In 2d hen fever •leakage occurred. hours after. Ab- ' limited behind by d by adhesions to ';- O V 5 •a 5 S 3 EMARKS. 15° 'o (u o « a. u o 3-d o ^ aj 3 6 a « T3 o o «83 a3 o o E .£2 . c .3 O J3 M3 ^ X 5 S o ^1.2 . *j o-o ^ ct o XI rt v sl (U rt u u ^11 5 < V a; u CX r3 cS \o Q Oa Q Q Q^ ■^ n ml) a Crt o C5 •X7nsa>[ oi d P Q Q (^ Q d •NOIi d m « en ■^ -vaadO 5 c? o 3 3 aaodaa x: '^ j: ^VAHHXMJ CH CO CO ;* 00 " Tf (J J: c o j: 3 >-z aj 3 cs b« E 'ii 2 o < OS w o j; ^ ■" C C t/) o V V in T3 .2 '3 "S, ■B ■u >> E o U V a o c ri . c > „" 3 u o (U 3 OJ J3 u o-a ■- bi-5 3 - .^ ^ a; .b rt -o « j; o^ ^ . cs ^^ «t: ■a ■a ^' TiJ ■T3 o"o ■5 m •3 u & u a oj tn o3 '■Zj VO HH >S h « -a ? ja u ^ 01 '-' •a O 3 O < >2 = u 5 . 3 3 £ E S J3 < ^ < < r S^c u • a "5 £- - _o CM N 3 aj o u o M n; '■2 > a •xas § fc tu § § § i. ■aov ^ 03 CC 10 n ?! % ^ O '■•^ = ■'^ ? c o > o ■u 3' (U rt 00 -G C i' '3 3 (J ^f-5 5. < N.= Z S^ "_ W„ u "-.4 ^_Ut:^ z w as U [2 u 6 vr, Q.5 COp„ ■§83^ t Sill CC > 4= Su:- 4 « aj 00 ai" J 00 U T3 (LI " m a § i!>ir, i2 'bn i;> 5 = "S=Ji .2^ 3j M o be - S ^"'"< w Q -5 aj 3 M TD m 3 bid _o "3 a; i! 3 y s ^ m . £ 5 pa •^ d ^ .in h <& 3 u :3 CO T3 Cfi H § i i on i 00 CO " 1 — ^5 *^ ^ - 2rX ^ .*■. ^ 3 5 tn S "^ rs *! Q ^ i) .H ~ — .i2 V cs O) ■— 5; Q {J V 'T' =<£ « = li S 05 s-= :: "H-o -Si: " ^ u .; -"or; O • — , t/i . -S a= i • '^ U ^ w o °H Q.'o c 1/.— Q Q D o 2i! g 7. 2"« n •^ Q ■s 5 M := s be i> S rt bfl ^1 .:Q (/2 rt _ M 2-0- 5 S o^ ly a, ■5< .5 3 u r _a; ; ° ° ,; - >' s-o S ° £ -^i 2:3 - oj 3tj 01 .t; t« = m ^• CO -C.ii= CS O 1L> 3 = -t; '-■"" = '■< V ^ jf > 5 — > tc u tn O . ~ >'5 "^ C-- lo -■- t3 in -r<^ « ■"* n ■ ^ o M §, « . CT»-7 '^.■-_ - ^ § '"I '5 i5 m i; 1) fl) ^ a> > ^ ■w (U ^ > biO > 5 ej W r- ■p = ^O p o 2; ^ .j,§w§ffi > > « O O ■iinsaa Autops\ s staled, er. Had bed uiiti 3 CO < utton ase it 1 pei- -ision dealt 5 5 . 3. t^ " o = a; after, tion a rs aft ed to V after seque to at 111 ilia la to o days rfora hou onfin mZ2 1- o - MS day a sn ette abd fist 01 " y r! « - VO c" O D Death i showed Death not been rt eath ighti Id be tion t leav 0) ST5 i3° a i E 5 u '35 n; 3 a 2 o5 Si = .2 ra o " '(5'.5 5 Q Q o < O Pi w Ph H i O! W H Pi O [1, •NOIX I i2 u -vaado 1 S S ano.-ifia ji: .= 'IVAHHXNI >o \o ,o E U = S ° biC3-= OJ o >*.^ o S 5 U o ,2 0) ^ IC a 5 >^ -^ ~ rt JT3 o > rt - 5 C X s: U n ^ CS 4/ '■? S w •2. U OT3 1/, << Q <£ GO ^ go S; W Z r bi '" u <~' O K — > E o . ^i:« gx ,1 .3 CS 5 2^ en ^2.S£ -j: * 2 '5 .3 'a ^ a. > o •xag •aoy S § S E S = . CO u^ ^ U . ° n; t^ td d .^ o CO ■^ Urn • .Ji^-c > a: . _■ ^ S- .:; rt-S" >^ — 1) "^ uT ^■^ o ^ " S . 03 rt o 5J o^ CO M^i^vg i A o rt cu iS'o" >, a, u o rt rt 3 -a iS'S ovU •^ ^ 3 co.E " — c a rt.2 w Q i^'H -- ^ -o '^xi.22 a; a. sne typ s. rate S = e-ti sof onn op "5 o^ ^•^■v ^ ^ si = « Si 11 - 3 U*^ „- Xi- r « o^ _- - «.2 re i-^ M-S i; tf) « -. >. — _ j; w re II "" u a-o « = Q Q C C O- o < m_0 = ^2 rt ;5 J S|R^.2^^ S"a-^re-° ^ re 3^ ">^ »J rec;,^;:"^!^^ '3i oj::'.= o O- ai •- ." '5 _ n , • - ^ t: m O S r iSireJiu 3 M: — ^T3 J • 5~ « Ji ■" O •(/) 2 "rn Q a re o H in 3 o; 3 ;_; 0; ';; ■" 3 E - re > ^o ^ c „' t^ dj -^ 2 5 5-°" g o o - . rc-- a. ^ c ■" re o re o 5 '=« -VN 3 NO CO oi CT> Ch pa re^>'OM oy"^ - (U-- 3 ■" >^= . -oCj reftJ X Uno .^ ._■ ii CO bo '^X < % M Death 3 days after. Became delirious, got out of bed ; then abdominal pain, followed by death in 10 hours. Death 12 hours after. Death 8 hours after. Au- topsy showed 6 other typhoid ulcers in ileum, none deeper than the mucous membrane. Button voided in 17 days. Death 4]/^ hours after. Death on same day •i^nsa■a P Q Q d si Q P •NOIX -VHadO aaoaaa 'ivA"aaxMi i ■ ■ I ■ ■ I Operation. Intestine folded longitudinally on itself and sewn with Lembert sutures, continuous. Keith tube. Incision sutured. Excised affected portion, and fistula established in median in- cision. Perforation involved so large a portion of circumference of bowel that resection was made and Murphy button used. An im- pending perforation sutured and larought near abdominal wound. A fistula occurred here, but closed in 10 days. No perforation found, but much excoriation and injection over base of one ulcer. Irrigation with normal salt solution, and two quarts left in peritoneum, which was sealed. Peritoneal surface about per- foration turned in with Lembert sutures. Flushed with normal salt solution. Gauze packing and drain. Perforation closed with double row of Lembert sutures. Flush- ing with normal salt solution. z III M BS H OS < D o c • ■ -^ c! -a E If ■ ^ ^ ~ % ?■« = §0 Twenty-four in. above valve. In cecum, which was out of place in left hypochon- drium, near spleen. Perforation %. in. long. Peritonitis most marked close to the valve. Five in. above valve. Nine in. above valve. •xas •aoy (N ■ ■ ro " ^ CO w u z w (I, m OS Brit. Med. Jour., 1895, i, p. 192. Amer. Jour. Obs., 1895, Nov., p. 791. Med. Chron., 1895, Sept., p. 401. Pers. comm. to J. B. Murphy. Personal com- munication. N.Y.Med. Jour., Jan. II, 1896. Ann. of Surg., 1896, Feb., p. 198. w .5 3^' 1 3 . ■ —>.!£• lo ,01/SS.uS . xhS. uig 0\ 0\ 0\ 3 On "J 0\J2 0\« 3*0 13 i-d-^^So < a « 3(5 5 = Jo Us _o j:|<>-?f "o o ci^5'~' = x g «i ,n-° rt^ re -^ ■_ >,° «•. St; «'-2i "1 3 c re "reS^S"*^ ^ fc !< 5 .U (LI.Q > xi;.2 MJ? re r^ — >•= „ <" S? rt lU 5J Si' X j: j; ''I 0JT3 XI cd in - ^"5 'J P e< OJ oi oi a -z-"^ =-c . 3—4) - C i + -^ £ 0^3^X 3 5 tno-Jre "i "i "z ■" 1" , v re =J re > 05 ^■0 3 3 T3 re X 3 D U b£Xi sJ O' •H.2 "3.2 < 3 X re 0) "til 1) 3 ii 5 S s 5^J N 3 O'C C |8 as re S " . re c-a 3 3X ,;^^ > c re S XI M 3 C o !D re a •^^ " re ^ a"0 4J ° re^ ii j; re a u re S £ re c re M Tc. " „-• 3 0.- £ ij 3 X c 5(^5 re •c a; 3 3 3 3 5 ©"re 'E. p 5| 5 re iT re c 5 3-i '^-^':5--. 3 W f-S - 3 °'> - S>t3 • ° 1-^:2 = 3^ 5^ re "o^reSS^ 5 > ^ re D5 abi re o > Etc CO) a ■" CI 5 J a - = toco o c" re re > 5 o re 1) ^ 11 ^ re' S 3o re{j3 v- ^ ? a> 4/ X ^ourmont tack. A tack of fe' geks' dur re o "S re a 0) o re u re 3 V X >\ re ■a 5 ca; 5 "bi W •^S re ^E re a 2-5 = V > o li « S "^ 5 X re c ^0 -S a oJ 8| "re "re E re u re S (U X re N re 3 >fg. V 3 > 3 H li E re --^ ^. u re rt '— 3^ »- 1) V V X X re>„ > > o re.i: - vO - tC re-o u X a i reT; > § U. ta S S' S' o o 00 OD <3\ „ ro ro IN CN to N bi] p'lit^ bi)i>^ T3 > S I>^ ■5 . 3 3 > tn o 3 > " ON TO o\ Cvo §3 I? ^ 00 CO . 6 00 00 ai d. T3 " — 1 ^ s lO lA 10 • in in .2^ o^ ^: 01 ..; en a\ 00 "2 o 00 V ~ I-. -• "■ - ■* IT, a, vOQ, r> 00 «v •* _5; L^ ^ ^ j5 3 S s A O 5 " •£•- m « "S TD c'-d ;^ •0 /. ^ i i-i ^ V %■.— o u U o O u > 5 10 3 (u = ao E 0) ■p 0. M ? S p Si ^ m (fi -1 p 2 < o o 3 O 3 > O S jj "o E a! O _0 a 6 "3 a a t5 'J. Bi < ■s. w Oi 5 S (U CD 5 u 3 5 c 1 = 4.5 ■6 V 3 o ct: o u 3 p OJ OJ o 53 ■c a ■a 3 ■c 11 >> ■5. « ^ 3 OJ 5 p CO (U c "5 U)H IB rt£ 3 Q D. o >.'~-V o g '^ o ■5 « h: '^ b^ ■^ o o S-o ■D TJ 3 .2 >.S'S ■5.° "J s ■V V T3 5 o T3 aac > CC o-:r b/. c O 3 < ^0 id 0) 5 1^ S'^ rt u rt 5-S ^rtii •nnsHH d d d d d d d •MOIX ■5 -■ tn d £ c/5 « aaoHHa a; — 3 3 3 3 o O - ■ TVAHHiMI Tj- CO ^ N 00 "^ CN ■"* •"■ 1 U! g V H_5 O ■a Is p ■a o T3 c« Oj = " -d ai.2 s ^ o c o .S 3 5 ?• 3 rt ^ O "3 z o 3 V ■ as ■d bn c 5 ■5 85 o > 5 1) biO '5 p < w ■0 > u 3 '""a > ^ o 3 15 S -a K O OJ 15 a: 5 ■d 3 o 5 0) cr- ^- m 3 13 1) QJ ^ — >i ^ 3 '^ c/f ■d cfi 3 -i V J2 O ■d 3 in „ J2 ct u c u 3 (U O 2" J3 b« 3 u 5 3j > J2 (75 S 3 ^5 3 H T3 ;„ >i ■^ -a >N Oh ll* -a o *^ o;' •a ■c 3j yi ■f ■5 5 5 ^ C u S ji: 5 OJ W u O > , E ^ u X i/5 lZ cc-u ■u ? u OJ V 0) QJ (U Q fe- > > > > > > zo o o J3 rt « Xi n: cC n z ?^ 5 rt CS 2u2 U<-1 I f«j; 1^ X u 3 V a; > "biKU X > Jo S-3 > > > H 13 > W (3i > tn 13 > •xag ■ § ^ §■ § § ■30V in 00 r^ 00 "S -- ^ -d r^ § •■^S. a i: Ojl— 1 OJ -u." >-," s z - o\ ON 00 00 IS 00 m ON to s cg^ S (g'S ~ ■^ s ►^ S •-' •-' s *"* 3 "o" '^ '(7-< «5< 'U5< 1 — il- JC tn JO m U3 J5 tn rtSc in V a P " ■ t' >,rt £ i2 u =• ^ nj S; 2 _ 1) rt T3 ts rt = ii . uJ _ ^ y o — (U -. „ a; D 3 N w n; 55 " ' ~ ?c 5 ■ cc o -— a>T3 CO o ^ "ViB c m beg S =n3 (U'_ a .;^ .Q o S H - oi-a -uT3 ■^t^^ ^ O tj D Z^ X — ^ frl.- a; u O rt ■~ rl 5.-::; " ^ ji: = yi It 2 ^ rt ;:r r "77?. o y5 Jr — '.E i" f-'.tf .ST' =15?; — rS.S s WcS « O S.JJ ^ =>■_£= x "P £'5 m - ■S 5^ w '" , ■ 5 ~ SJ a.^ = „j u S J^ s; "= ^ m >. ^ net: .r. O _t. O -t.;^^_4 Of) > = lO d b<) i: c. vo o d§--- §S o si-r < 3 3 p t/) u c^ . IJ "- "to rt T3 v^ S U ■2 — CI rt ^ ■ S 3 - ■COS 1) 1- i- £■55 w 2 - 3 o C x; u] oT'^ rt' l^ Pi ^1 1) ^ as U3 •t; aS o| 3- XI 3 ci 0-3 -3 O rt S ■a v (U c; a J^ V u o ■V V o ■5 a C o i2 o i OJ 3 "O m 2 ^S m-C 3 3 r rt rt 3ii ■g t''* a m ■c a ■a V of in 3 IJ My: u2'> H o 53 E Xl i2 OJ — u 3 .2i -a t: OJ.-X i* S5.2h 5 b£ 3 m V bt S II .= 3-3 o • ^x; 3 rt O D > Ho 5 •o 3 O X X o X c Ex' 3 1- & j: X O O p .t; .ti o a; > 5 s^o i ■5 g| 5 a s a «£ ? & a J -X ^UU (u a; m - O ^ H Ti 5 W w c« = ^ b y ■c >, ■o h « <: D ^ 0) OJ be " u 3 0) 3 ■fei . P3 o % O J3 < g 3 3 If "5 6 OJ — ■- a; oi V- 0) o O -0 > CL, ^ ^ y a 5 5 o ^ > OJ 3 0; o OSS o 5 - rtx) > OJ OJ - rt-OTD •xas S ^' § s ?; § § •aov Ov lO ^ t^ ^ VO ^ o\ w u 3 r? K " i-J bo 3 bil . 3 — ~ ^' d ^ a z i^..; ^ d r^ rC r^ 0! 3 O I^ o ^■- X •"ii •"^' On d^ d'2 a'iS tl4 o c o M y= a 3 X ■o Pi o O '5 C ■« c 'a C ^i.o- < & •^ ^ ►JIS 1-^ l-JS t-;. hJS rC. S" CO U o O o U§- H H f^ is ijd a; o ui ^ « cu § S ^ oJQ IP s 0;5 W h be .-o l-A •—i O ■a O ■* > "S >, vd ^■ lO n! J2 X iri 3 CO_r; "^^ ^-5 5 On 1> » D 3 .S '©'"> '-" > « « S « « £s ^ -c ;; — a Q o j; — 5 ,3 '' """" "'5^ ..2- (U X •- ^-^ „ __ o u ^ b2 i-=5a 2 « Q Q u S o go " 5 - * - --a 5 JJ ^ ^ be- <-> ,41 *j 73^ "in .c/5 -^ 2-- - a; JO u< =<« i; * = X o 5 -i W (/) S. CO Cuu ^« ^ t« !ri ■ J^ = ,; --.2S • 5 «i 1- 2.2 — — '-5 >^ = n 11 11 X = -'.t; o'c r: c u 1; ■£-2Sj iinSMnS 5 - o-j Jij =>2ii o 0*5 5 OJ o = _ o'bi O ^ 1. . O 1* = So- C 5 N S * N WCU £ 33.2 -_!.£ -i! I C u tUJl" 1) [5 5- ^5«S =-Siif_gM = •?= 11 (J 11 .a OJ > p 3 5 ' ■i: (LI ra a > aT '-^ d 1. 5^ a. N c b - " — Ntn -^ — 'X — « 3 aj > ^'Ji = >, w 5. 6-3. i 5 iJ £ 2 ^11 ^ a ^ > - > a > M •i S S § ^ i § s s s i s r^ CO OS ^ « c^ >. '^ !". t. v.— u '" ■- - t~~ u u ■Jj 1! in ;- r^ ,•1^ Q_CO .5 a = -3 •5 "5 g; U j^ 5 = V 0' c c . 1^^ '5 1.: 'S V.' 'S t^ 03 ^ = ^in u 1 si .-i s^sT; ►J - r^ ►J'= r^-J r- r^ :;x: fT* "'rn --, Oh p. Cu D. 2 ■" "^ 3> '"i; U y- ^ OS- & r. cR S^ c ctjC; 1^ '0* 5 5 "o i 5 X > _5 ■3 6^ H- J X < a: < u S ¥i ^ 5- ^(> _- . • _r -'6 be oJ ^ > K " u a 1 — ^.ti 1 — tti , — 1 ; , 1 UJ 11, ^23 , — 1 J "TTO 1 1 «5 > to IC -0 z:x.= 1". 0- 1^ f> J>. t-. £» j^ 1^ t^ OC 2j CHAPTER XVI. TYPHOID AFFECTIONS OF THE LIVER AND THE GALL-BLADDER. I. Typhoid Affections of the Liver. — The intimate anatomical and pathological connection between the intestines, the liver, and the gall- bladder, especially through the portal circulation and the biliary ducts, is self-evident. The commonest cause of abscess of the liver is through an infection following dysentery and similar intestinal diseases. It is not surprising, therefore, that a disorder like typhoid fever, of which the essential lesion is inflam- mation and ulceration of numerous areas of the intestinal mucous membrane, should occasionally be followed by abscess of the liver. Holscher' found parenchymatous degeneration of the liver in 203 out of 2000 fatal cases — over ten per cent. In view of this fact, and of the thrombosis of the vessels of the liver by the typhoid bacilli actually observed by Fraenkel and Simmonds (Plate I, p. 62), it is rather surprising that so few cases of abscess should be reported, seeing the inevitable exposure of every such patient to the possibility of infection by the typhoid bacillus, the colon bacillus, and the ordinary pyogenic bacteria. Yet in my first series of cases, not one case of hepatic abscess was tabulated. In the second series only 21 cases in all could be 1 Miinch. med. Wochen., 1891, Nos. 4 and 5. 244 THE LIVER AND THE GALL-BLADDER. 245 found by Dr. Westcott, the first case being that of Louis, in 1 84 1. A number of cases alluded to by various authors, but not in such detail as to allow of tabulation, are necessarily excluded. Even of the cases tabulated, in one ' the diagnosis of typhoid is doubtful. Typhoidal hepatic abscess is in most cases primary. Whether it is the direct result of infection by the typhoid bacillus or not we have too few bacteriologi- cal examinations to decide. Dupre ^ obtained a pure culture of the typhoid bacillus from a case of angio- cholitis six months after the fever. In another, Rosenberg 3 found the staphylococcus. Most prob- ably, in the majority of cases the pyogenic bacteria and the colon bacillus are the immediate cause, while in a few the typhoid bacillus alone may produce the abscess. Instead of being a primary infection of the liver, the abscess may sometimes be secondary to typhoid lesions elsewhere, especially if these become infected by pyogenic bacteria. This is really a form of pyemia. Thus, Louis * reports the first recorded case, I believe, of hepadc abscess from typhoid, in which it arose after an abscess of the parotid. Romberg ^ refers to two others arising, one from an abscess of the fourth finder, and the second from a thenar abscess. Another case is reported by Chvostek,^ in which it was secondary to a laryngeal perichondritis. 1 Daly, Medical and Surgical Reporter, 1882, 346. 2 Les infec. biliaires, These de Paris, 1891. 3 Berlin, klin. Wochen., 1890. 192. * Recherches Anat. Path, et Therap. sur. la Fievre Typhoide, 1841, 12th ed.,p. 118. ^ Berlin, klin. Wochen., 1890, 192. « Allgem. Wien. med. Zeit,, 1866, No 37. 246 SURGERY OF TYPHOID FEVER. Burder ' has reported a similar case. In these cases the abscesses are mukiple. SoHtary abscesses are more common, but even these are very rare. Langenbuch^ refers to several cases to which I have not had access, and states that there are on record about 20 cases of typhoidal abscess of the liver. Besides the five cases of mul- tiple abscesses, Dr. Westcott has only found 16 others. To these should be added 12 cases found in the Munich post-mortems by Holscher,^ but which are only tabulated so briefly that they can not be used in my statistics. Of these 2 1 cases, all died but two. Not a few were only found at the post-mortem, since in the dulled condition of the patient no complaint was made of any hepatic symptoms. The two cases of recovery are as follows : Case XXXVIII (DQ\2dv&^). — A woman of thirty- four, when convalescent from typhoid fever, was sud- denly seized with pain in the hepatic region, followed by enlargement of the liver below the level of the umbilicus by the twentieth day. Two days later she was seized with sudden thoracic pain, and was nearly strangled by an immense quantity of pus which she expectorated, an abscess of the liver having evidently ruptured through the diaphragm and discharged throuo'h the lunor. She recovered her health en- tirely, when a year later a renewed attack of the hepatic abscess occurred, and ruptured at a spot near the right iliac spine after the use of Vienna paste. Finally, however, the abscess had to be opened, and she recovered. 1 Lancet, 1874, ii, 552, ~ Deutsch. Chir. Lief, 45 c. Erste Ilalfte, 23S. ^ Loc. cit. '' Gaz. des Hop., 1S69, No. iii, 437. 7'///: IJVIiR AND THE GALLBLADDER. 247 Case XXXIX. — SicUo ' reports the followingr case : A girl ten years old became ill with typhoid fever at the end of P'^ebruary, 1873. By the fifteenth day defervescence had occurred. On the seven- teenth day, however, she complained again of head- ache, and had marked chills, followed by delirium, enlargement of the spleen, and meteorism. On the thirty-second day she first noticed pain in the hepatic region. Three days later there was marked swell- ing, with jaundice. On the forty- fourth day there developed also fluctuation, first over the left and then over the right mastoid, and in the right temple. After these abscesses had run their course, she com- plained of pain in the region of the fifth and sixth ribs, followed by swelling. The whole axilla in a short time became a monstrous abscess, and she lost flesh to such a degree that she was little more than a skeleton. On the eightieth day the tumor in the axilla began to shrink, and on the eighty-fourth, after severe pain in the abdomen, she began to pass blood and pus by the bowel. In the afternoon of that day she had 25, and in the night 10 additional, movements. On the next day there were 20 other movements, during which scybalous masses and pus were passed. With this her liver dulness and the jaundice diminished, and on the one hundred and twentieth day she was entirely well. Surgery can do but little actively in these cases. The treatment must be entirely symptomatic. The few that recover will be most fortunate, and owe quite as much to nature as to the surgeon. Suppurative pylephlebitis occasionally, but very rarely, follows typhoid, and is sometimes the cause of abscesses. It is probably a result of throm- bosis of the vena portse. Buckling ^ found throm- 1 Der Militar Arzt, Wien, 1875, No. 23, p. 20. 2 Falle V. Leber Ab.-cesse, Berlin, 1868. 248 SURGERY OF TYPHOID FEVER. bosis of the vena portae in two cases. Such thrombi would readily become infected by any of the bac- teria above mentioned. The pylephlebitis may result in abscesses proper in the liver, as in Romberg's case/ in which the thrombosis extended from the ileo-colic veins to the portal vein and its branches in the liver. He refers to four other cases. Staphylococci were found both in the thrombi and in the abscesses. Osier, in his extensive pathological experience, has seen but a single case."" In this case multiple abscesses occurred in the mesentery, which " fluctu- ated like a sac of pus." " Outside the liver the por- tal vein was represented by an elongated abscess with thick, irregular walls." The splenic vein also was closed by a thrombus. In Lannois' case,^ a man of thirty-eight died three days after admission with typhoid pleurisy and sup- posed tubercular peritonitis. The necropsy showed adherent ante-mortem clots in the portal, splenic, and inferior mesenteric veins, with numerous abscesses in the liver, in which was found the typhoid bacillus associated with other organisms. In these cases, also, surgery can offer no help. They are necessarily fatal. II. Typhoid Affections of the Gall-bladder. — In striking contrast to the rarity of surgical com- plications and sequels of typhoid in the liver is their relative frequency in the gall-bladder. As this sub- ject is of great importance, and is comparatively new, I shall consider it somewhat fully. Dr. Westcott 1 Loc. cit. 2 Trans. Assoc. Amer. Phys., 1897, xii, 382. 3 Rev. de Med., 1895, 909. THE LIVER AND THE GALL-BLADDER. 249 has tabulated 74 cases of typhoid infection of the gall-bladder accompanying or following typhoid fever. Of these, 30 resulted in perforation. Five important papers have been published lately in connection with this complication. Curi- ously enough, two of them were presented at the same meeting of the Association of American Phy- sicians, in May, 1897, and are to be found in Volume XII of their transactions. One is by A. Lawrence Mason, on "Gall-bladder Infections in Typhoid Fever" (p. 23), the other on "Hepatic Complica- tions of Typhoid Fever," by Prof. Osier (p. 378), in which he includes affections of the gall-bladder. The most important papers preceding these two are one by Chiari,' and another presented by him to the International Medical Congress in Rome, in 1894. Another important publication is that of Dupre.^ Murchison and a number of other writers referred to suppurative or catarrhal Inflammation of the gall- bladder In the same year in which my Toner Lecture was published (1876). Hagenmiiller ^ collected 18 cases. As in so many other surgical relations of typhoid fever, the discovery of the bacillus of typhoid has thrown an entirely new light on both the etiology and pathology of the disease. Gilbert and GIrode '' first demonstrated the presence of the typhoid bacillus In a suppurative cholecystitis in 1890, and followed ^ Ueber Cholecystitis Typhosa, Prager med. Wochen., 1S93, No. 22. 2 Les Infections Biliaires, These de Paris, 1891. 3 Cholecystitis Typhosa, These de Paris, 1876. * Contribution a 1 Etude Bacteriologique des Voies Biliaires. Mem. de la Societe de Biologie, 1890, I>a Semaine Med., 1890, No. 58. 2 50 SURGERY OF TYPHOID FEVER. up the subject in a second paper in the same jour- nal ' in 1893. The bacillus of typhoid has been found not only during or immediately after the fever, but also at periods long after the fever. Thus, Dupre ^ relates the case of a woman of forty-five, who died after the operation of cholecystotomy. The typhoid bacilli were found in her gall-bladder six months after the fever, and Chantemesse,^ in a simi- lar case, found them eight months after the fever. Von Dungern '' reports the following very remark- able case, in which, after several recurring attacks of different disorders, presumably nearly all due to the typhoid bacillus, an abscess finally formed around the gall-bladder, possibly due to perforation. In the pus a pure culture of the typhoid bacillus was found fourteen and a half years after the fever, and the blood of the patient reacted promptly to the Widal serum-test. Case XL. — A woman, age forty-six, was ill of typhoid fever in November, 1882, for four weeks. There were no symptoms in the region of the gall- bladder. In i\ugust, 1887, she suffered from a mis- carriage, at the end of which she suffered from pains in the region of the heart, with severe vomiting-, but without jaundice. In May, 1888, and in February, 1889, similar attacks came on, in the last of which she had some jaundice. A similar attack again occurred in June, She was then well until July, 1895, when she fell ill with gastralgia. In Septem- ber, 1895, she had an attack of periostitis of the lower jaw, which got well after the discharge of a 1 Cliolecystite Purulente Provoquee par le Bacille d'Eberth, Mem. de la Societe de Biologie, 1893, p. 956. 2 Loc. cit. 3 Traite de Med. i, 764. * Miincli. med. Wochen., 1897, No. 26, 699. 7'///: IJVIiR AND Til i: C A LI. lU .A I) I ) I-IR . 25 I small sequestrum. On October 6, 1896. renewed attacks of colic began in the region of the gall- bladder. At the same time a firm tumor was dis- covered. By the middle of February her condition was still worse, with constant pain in the right hypo- chondrium and chills. The tumor in this region had now enlarged to the size of a child's head ; it was scarcely movable ; there was no jaundice; fluctua- tion was obscure ; the tenderness not marked. The urine showed neither albumin nor biliary coloring matter. Kraske made an incision over the tumor and evacuated 150 c.c. of brownish yellow pus not colored with bile. Efforts to determine the relation of the abscess to the gall-bladder were naturally very limited, on account of the danger of breaking down the adhesions, but a sound penetrated ten cm. upward, backward, and inward in the direction of the gall-bladder. No stones were felt. The patient made an excellent recovery. A careful examination seems to have been made of the pus, which showed unquestionably the presence of the typhoid bacillus in pure culture. The blood of the patient reacted to the VVidal test in concentration of i to 80. It is greatly to be regretted, of course, that at the time of the necrosis of the jaw no bacteriological examination was made, but in view of the many cases already noted in this monograph, there can be no reasonable doubt, I think, that this was due to the typhoid infection. It would seem, also, that the repeated attacks of pain in the region of the gall- bladder, even though they were separated by years, are unquestionably to be attributed to the infection of the typhoid bacillus which was found at the time of the operation. It is very remarkable, indeed, that after so long a 252 SURGERY OF TYPHOID FEVER. time as fourteen and a half years typhoid bacilH should be found in pure culture. I have not in- cluded the case in the table of cases of perforation of the gall-bladder, as it is not absolutely certain that it was , such, though I think the probabilities would point distinctly in that direction. Chiari reported 22 cases of typhoid, in all of which bacteriological examinations of the contents of the gall-bladder were made. In 19 of the 22 he found the typhoid bacillus, and he concluded that the pres- ence of the typhoid bacillus in the gall-bladder was the rule. Councilman, in the discussion on Mason's paper, says : "I have come to regard the gall-bladder as one of the surest places to obtain a pure culture of the organism." Welch and Blackstein' were among the earliest to demonstrate the presence of the typhoid bacillus experimentally in the bile of a rabbit as long as one hundred and twenty-eight days after recovery from the inoculation. This almost constant infection of the gall-bladder led Chiari to suggest that very possibly it bore a causative relation to relapses in typhoid in this way. When the patient is sufficiently convalescent to be allowed a more generous diet, an increase in the quantity of food taken may arouse the liver into greater activity than heretofore, and the increased flow of bile may flood the system with numerous bacilli of typhoid, which may give rise to a reinfection causing the relapse. One would suppose that the condition of the blood-serum would be a protection against the new invasion, but in certain persons this seems to fail. 1 Johns Hopkins Hospital Bull., Aug. 19, 1891, p. 121. THE LIVER AND THE GALL-BLADDER. 253 While It is perfectly true, as already indicated in a number of cases, that Eberth's bacillus may be present, there are often no apparent pathological changes caused by its presence. It is noticeable, also, that Osier states that in the histories of the seven fatal cases in which the typhoid bacilli were found in the gall-bladder the infection was so latent that there were no hepatic symptoms observed dur- ing life. Not only may the bacilli be present in the pus, but also in the walls of the gall-bladder, causing local necrosis. Thus, Chiari ' reports such a case, in which there were several necrotic patches on the walls, and the patient died from peritonitis, the direct result of the cholecystitis. Milian ^ found the typhoid bacillus itself in pure culture in gall-stones and in the wall of the gall- bladder. The case was a woman, twenty- four years of age, who died on the sixteenth day after what he calls " hypertoxic " typhoid fever. She had never had either hepatic colic or other symptoms of gall-stones, but 25 were found at the post- mortem. In this particular case he believes that the gall-stones resulted from the typhoid bacilli, but it seems doubtful whether within sixteen days 25 gall-stones could have been so formed. Prof. Welch also informs me that he has fre- quently found the colon bacillus not only in the bile, but also in gall-stones themselves. Fournier,3 \^ iqo cases of gall-stones removed at necropsies, found living or dead bacteria in the gall- 1 Loc. cit. ^ Gaz. Hebd., Nov. 26, 1896, 1 137. 3 Origine Microbienne de la Lilhiaise Biliaire, These de Paris, 1896. 254 SURGERY OF TYPHOID FEVER. Stones in 38 cases. The colon bacillus was the most frequently found, the typhoid bacillus being next in frequency. He believes that an angio-cho- litis results either from a stasis of the bile or from its infection by the typhoid bacilli. This is followed by deposition of the salts of the bile in the form of gall- stones. Possibly, even the mere presence of the bacilli may be provocative of the formation of gall- stones. Thus, Gilbert and Domenicini ' first posi- tively identified the bacilli as the nucleus of gall- stones, and Hanot^ confirmed this observation. The facts above stated make it perfectly clear, therefore, not only that the bacilli do reach the gall- bladder, and may be found in the contents of the gall-bladder, and even in gall-stones, but that they are sometimes found in its walls, and may there in- duce local necrosis. Not seldom, also, they proba- bly are the direct cause of gall-stones and the result- ing biliary attacks. Besides the bacilli of typhoid, other bacteria are frequently found in the gall-bladder. Letienne, ^ out of 42 cases, found bacteria present in 24. These were most commonly the staphylococcus and the colon bacillus. Flexner * has stated that of 1 4 cases of typhoid in which the contents of the orall-bladder were exam- ined, typhoid bacilli were found seven times, the bacillus coli communis three times, the streptococcus pyogenes once, and the proteus vulgaris once. The question now arises, By what route do the bacilli reach the gall-bladder? Naturally, two direct 1 Soc. de Biol., June i6, 1S94. 2 g^n^ Med., Jan. 22, 1896. 3 Arch, de Med. Experim., 1891. * Osier, loc. cit., p. 385. THE LIVER AND THE CALL- BLADDER. 255 modes of infection are possible, and in all probability either or both may be assumed to be the route of the infection. First, the actual finding of the bacilli in the blood itself by a number of observers (p. 58) suggests at once the possibility of infection through the circulation, and this, in Councilman's opinion, is the common method of infection. In addition to this, as the bile ducts are freely open into the intes- tinal canal, there would seem to be no reason why the infection might not be a direct retrograde one through their continuity. Through the courtesy of Dr. Mark W. Richard- son, of Boston, I am able to give the results of his as yet unpublished investigation bearing upon this point: "In three recent typhoid autopsies, cultivations from the colon, ileum, jejunum, duodenum, and gall- bladder were made, to see if a direct chain of bacilli, so to speak, could not be traced from intestine to gall-bladder. " In Case I, though the case was clinically typhoid, and, moreover, gave a marked typhoid serum-re- action, not a typhoid bacillus could be found in any orofan. "In Case II there were abundant typhoid bacilli in the eall-bladder, but none could be obtained from the intestine. "In Case III we found pure cultures of the typhoid bacillus in gall-bladder, duoden-um, and jejunum, and it was only when the ileum was reached that colon bacilli began to appear at all. "This result is quite remarkable, I think, and would seem to strengthen the theory of an ascending infec- 256 SURGERY OF TYPHOID FEVER. tion through the gall-ducts, though, of course, it is perfectly conceivable that the bacilli in the duodenum were excreled {xovi\ a gall-bladder which was infected originally through the blood." A second question requiring answer is whether the typhoid bacilli are capable of producing chole- cystitis, empyema of the gall-bladder, and ulceration independently of gall-stones. Of this I think there can be no doubt, especially in view of the facts above stated, and of the suppuration and ulceration which nearly every chapter in this book shows to be caused by them. Of the 74 cases of biliary infection in our table, in 18 cases gall-stones were found. In a few others, which did not come to a post-mortem, there may have been also gall-stones present. In 38 cases, however, no gall-stones were present, and of these 8 were in persons under twenty-five years of age and 6 under fifteen, at which period of life it is extremely uncommon to find gall-stones. In 34 of the cases reported, cholecystitis, empyema, or ulceration were found in the ^all-bladder without any gall-stones, and the typhoid bacilli were identi- fied by bacteriological examination in 1 1 cases. Not only were the bacilli present, but in several cases, some of which have been alluded to, there were present such ulcers as very soon would have led to perforation if life had been somewhat more prolonged. Another interesting question already referred to is whether the typhoid bacilli of themselves give rise to gall-stones by producing stagnation of the bile, as has been suggested by Bernheim.' Certain it is that occa- 1 Diet. Encyclopedique de Dechambre, 1889, Article Ictere. THE LIVER AND THE GALL-BLADDER. 257 sionally biliary colic occurs either during or after typhoid and suggests this possibility, as in the case of Chantemesse with a slow convalescence in which, after six months, an operation for gall-stones was done and a pure culture of typhoid bacilli was found in the gall-bladder. The most important article dealing with this aspect of the subject is the paper of Dufourt.' He refers to 19 patients with gall-stones whose first attack followed typhoid fever in varying periods : in the second month in two cases ; the third month in six ; the fourth, in three ; the fifth, in one ; and in the other five as long as ten months or later after recovery. In Osier's first case, in conva- lescence in the fifth week after the incidence of the fever, the patient, who had never had hepatic colic, had an attack of sudden and severe pain in the right hypochondrium. This was followed by four other attacks, and though an operation did not reveal a gall-stone, one was discharged nearly two months after her last attack of biliary colic and nine months after her fever. This case will be referred to again under the heading of perforation. The fact also that Dr. Welch has found the colon bacillus and Milian and Fournier the typhoid bacillus in gall-stones themselves, suggests the probability that either or both of these bacteria may bear an etiological relation to the gall-stones. It is but reasonable to suppose that a gall-bladder already irritated and, it may be, inflamed by the presence of gall-stones, would be more likely to suf- fer from any invasion of the typhoid bacillus, and 1 Rev. de Med., 1893. 17 258 SURGERY OF TYPHOID FEVER. the very fact that in 18 cases out of the 74 of biliary- infection gall-stones were found, makes it still more likely that gall-bladders containing such calculi readily fall victims to the ravages of the disease. Surgically speaking, biliary infections may be divided into two clinical forms : First, those in which cholecystitis and empyema exist with or without gall-stones, and, secondly, a very much more import- ant class, those in which perforation of the gall- bladder takes place. The symptoms in the first class of cases may be remarkable by their utter absence {cf. Osier, stipj^d), so much so that in at least one-half of the cases of biliary complications the fact is wholly unsuspected. This is partly on account of the latency of the symp- toms, but also largely on account of the stupor of the patient. In these cases the cholecystitis and gall- stones are only discovered at the post-mortem. Ordinarily, if any symptoms are observed they will be, pain in the region of the gall-bladder, and the distended gall-bladder will be discovered both by touch and on percussion. The tenderness, as pointed out by Mayo Robson,' is usually at the junc- tion of the upper two-thirds with the lower third of a line drawn from the ninth rib to the umbilicus. As a rule, no surgical treatment can be instituted, but Mason's first case is a striking illustration of the occasional value of surgical interference. In brief, this is as follows : Case XLI. — A woman, age thirty, toward the end of the third week complained of pain in the m 1 Diseases of the Gall-bladder and Bile Ducts, Brit. Med. Jour., March i"^. 1807. THE LIVER AND THE GALL-BLADDER. 259 right hypochondrium. A tumor four inches in dia- meter developed between the costal border and the umbilicus. The tumor was very painful, dull on per- cussion, and moved with respiration. A week earlier, when she was admitted, the liver dulness had been normal, and there had been no pain in this region. Rupture of the gall-bladder being deemed to be imminent. Mason at once tapped it at a point an inch below the costal margin and 4^/^ inches from the umbilicus. Three and a half ounces of sero-puru- lent fluid were withdrawn, looking more like urine than bile. No crall-stones were felt. The relief of the pain was immediate, all the urgent symptoms disappeared, and the patient made an excellent recovery. The typhoid bacilli were found in the fluid withdrawn. Pure cultures prepared from the fluid reacted to Widal's test. It is not often that such simple treatment will be followed by so happy a result, but it certainly should be employed in all cases of similar distention of the gall-bladder. The following case, treated on the conservative plan then in vogue, also happily recovered : Case XLII. — Salzmann' reports the case of a woman, age forty-two, who, in the autumn of 1865, fell ill of a severe attack of typhoid fever, which involved five members of the same family. Durino- the height of her illness a tumor was suddenly per- ceived in the abdomen between the umbilicus and the liver. This must have formed suddenly, as repeated prior examinations had not revealed it. When found it was the size of an orange. Its ap- pearance was followed very soon by an intense jaundice, which, however, gradually subsided, and 1 Med. Correspondenzbl. Wiirttemburg. Arztlich. Vereins, 1870, xl, 84. 26o SURGERY OF TYPHOID FEVER. she recovered from the typhoid fever. The tumor, however, did not disappear. In December, 1866, a year after the illness, the tumor broke through the abdominal wall and gave exit to a considerable amount of clear serum. For a year after this the tumor gradually shrank, but left a continually dis- charging sinus. In 1868, two and a half years after the onset of the trouble, the discharge from the sinus increased considerably. Toward the end of 1868 her mental condition became very bad, so that insanity was feared. On January 31, 1869, over three years after the beginning of the disease, a gall-stone, which was distinctly perceived in the fis- tula, was removed; the patient made a good re- covery, and five months later the fistula finally closed. Her mental condition, however, did not improve very much. The next case, also of operation on a distended gall-bladder, I owe to Professor Osier : Case XL//I [Osier). — " K. T., colored girl, age twenty-four, admitted to the medical department of the Johns Hopkins Hospital September 15, 1897, having been ill for nearly three weeks. Twenty- four hours after admission she had 13 stools; tem- perature 104°, pulse 112. " On September 19th it was noticed that the con- junctivae were a little yellow. She had complained of no pain, but on palpation there was great sensi- tiveness in the right upper quadrant of the abdomen, and here, just below the costal margin, a distinct mass was felt. Dr. Camac saw the patient in the evening and found the right hypochondrium very sensitive, and nine cm. below the costal margin and three cm. from the umbilicus was a rounded, resistant mass. This was aspirated and 15 c.c. of a clear fluid re- moved, examination of which showed actively motile rod-shaped bacilli. THE LIVER AND THE GALL-BLADDER. 261 " On September 20th there was still so much ten- derness that it was decided to operate, which was done by Dr. Gushing. The gall-bladder was dis- tended and very tense, and 120 c.c. of fluid were aspirated. A drainage-tube was inserted and the wound partially closed and packed with gauze. "The patient's condition was very bad from the day after admission. The temperature had been persistently above 105°, and on the i6th reached 106.4° ^nd at the time of the tapping of the gall- bladder was 106°. The patient died just twenty- four hours after the operation. " The autopsy by Dr. Livingood showed character- istic typhoid lesions in the intestines. The gall- bladder contained some clotted blood ; no gall-stones. Typhoid bacilli were obtained in pure culture from the fluid removed by aspiration, from that removed at operation, and at autopsy. " The following case of doubtful etiology is of especial interest both surgically and bacteriolog- ically : Case XLIV. — Mark W. Richardson' reports the case of an elderly woman who suffered for nearly four weeks with fever, nausea, and considerable pain and tenderness in the right iliac region. This was thought at first to be due to appendicitis. No rose- spots were seen. Later there was some cough and rusty sputum. She had a " typhoid look." There was no enlargement of the spleen. After about two weeks a firm, rounded tumor was found at about the level of the iliac spine. It was . tender, painful, and movable and extended around to the loin. The urine was negative. No positive diag- nosis was made, but it was thought, possibly, to be a pyo- or a hydro-nephrosis. About April 1st an ^ Boston Med. and Surg. Jour., Dec. 16, 1897. 262 SURGERY OF TYPHOID FEVER. incision was made in the back by Dr. Maurice H. Richardson and disclosed a normal kidney. This incision was closed and another was made over the gall-bladder, which was found to be excessively dis- tended. Over half a pint of dirty brownish fluid was evacuated. A most careful examination showed a pure culture of typhoid bacilli. The blood, a week after operation, gave no serum reaction, nor did the feces at the same time show any typhoid bacilli. A gall-stone impacted in the cystic duct was removed. The patient, when the case was reported, was recov- ering without complications. As to whether this was a case of typhoid fever followed by cholecystitis due to a typhoid infection of the gall-bladder, or possibly analogous to the case reported by Osier (see p. 48) of typhoid infection of the gall-bladder without typhoid fever, the fortunate recovery of the patient prevents a positive opinion. Perforation of the Gall-bladder. — Much more important surgically are the cases of perforation of the gall-bladder ; there are 30 of these in our table. Of these 30, four have been operated upon. This opens a new field in the surgery of typhoid fever which is of great importance and demands most care- ful study. The facts already stated as to the infec- tion of the gall-bladder, of the presence of gall- stones, of the presence of ulcers in the walls of the gall-bladder, and of necrotic areas in the wall, sug- gest the probability, and also the ways, in which per- foration may occur. The symptoins will be those usual in perforative peritonitis from any cause, such as perforation of the appendix, of the stomach, or of a duodenal ulcer- Sudden and severe pain is, of course, the most THE LIVER AND THE CALL-BLADDER. 263 prominent symptom. This pain will be most intense in the region of the gall-bladder. If the gall-blad- der is much distended and perforation takes place toward the fundus, the seat of the most severe pain may be nearer to the umbilicus or in the right iliac fossa. In such cases it is not at all improbable that it would be very difficult to differentiate it from the perforation of the bowel from typhoid ulcer or per- foration of the appendix. The difficulty of making a differential diagnosis is of less Importance than might appear at first sight, since in the present state of the surgery of typhoid fever the same treatment should be unquestionably instituted. Not only will there be severe pain, but collapse may set in very quickly. If the collapse be primary, partial reaction may fol- low. The abdomen will become distended and, unless the surgeon interferes, death will soon follow, with all the ordinary signs of perforative peritonitis. Of the 30 cases of perforation reported in our tables, 3 recovered and 27 died. All of those that recovered were operated upon. Sex. — There were: males, 11 ; females, 11, In 22 cases in which the sex is stated. Age. Recovered. Died. Under fifteen, 9 i 8 Fifteen to twenty-five, .5 o 5 Over twenty-five, ... 9 2 7 Date of onset : During the first week, i During the second week, 3 During the third week or later, 19 In a small number of cases the exact time is not 264 SURGERY OF TYPHOID FEVER. stated, but is given as " during the course " of the fever. This I have assumed to be in the third week or later. Of the cases in which perforation took place, 7 had gall-stones and in 1 6 no gall-stones were found. Of 26 cases not operated on, every one died. Of 4 cases that were operated on, 3 recovered and I died. The great mortality after perforation of the gall- bladder, without operation, and the fact that three cases out of four operated on recovered, is our strongest argument and best incentive to surgical interference in similar cases. As the four cases operated on are so important from the surgical point of view, I append a brief resume of each. Operation. — The operation for peritonitis follow- ing perforation of the gall-bladder differs in no material respect from the operation for perforation of the bowel, and I will refer the reader, therefore, to Chapter XV for the principal points. Two others need some consideration. First, the incision. The best line of incision is over the tumor, if there be one ; if not, then at the outer border of the right rectus muscle. In case the gall-bladder is distended toward the median line, a median incision may be best. In three of the four cases operated on the incisions were respectively : in the median line ; parallel with the ribs ; and the incision for appendicitis : the exact incision in the fourth case is not stated. The only other peculiarity, perhaps, that I need men- tion is the method of dealing with the gall-bladder THE LIVER AND THE GALL-BLADDER. 265 itself. If the walls of the gall-bladder in the neighbor- hood of the perforation allow of it, one or two rows of Lembert sutures, inverting the peritoneal coat, is the best method of repairing the perforation. Should this not be possible, then the best plan would be cir- cular packing around the opening with iodoform gauze, so as to form a defensive wall for the abdominal viscera, leaving in the center a sort of well leading down to the perforation. This should be separately packed. The incision should never be entirely closed, drainage being essential. The prognosis in perforation of the gall-bladder, as distinguished from perforation of the bowel, is cer- tainly very much more encouraging, if we may draw any inferences from so small a number of cases. This would naturally be the case, since the contents of the eall-bladder are less irritatingf than those of the intestine. I append a resume of each of the four cases of perforation of the gall-bladder which have been sub- mitted to operation. Case XLV (Williams and Sheild'). — "This care- fully studied and admirably reported case should be read in full. A woman, thirty-one years of age, w^as first seen by Mr. Monier-Williams, September 18, 1894, her illness having begun on September 13th. The spleen was enlarged. There was some tenderness In the right iliac fossa, but no abdominal pain. September 23d, the eleventh day of the disease, she was seized early in the morning with sudden acute abdominal pain. Mr. Williams ' found her in a semi-collapsed condition, with feeble, fluttering pulse and cold, clammy skin, complaining 1 Lancet, 1895, i, 534. 266 SURGERY OF TYPHOID FEVER. of pain in the abdomen. The temperature shortly before the commencement of the pain was 102.5°, but two hours later had fallen to 99°. Abdominal breathing was practically absent. The pain was diffused over the upper part of the abdomen, a spot a little above the umbilicus being, perhaps, the seat of its greatest intensity, and there was considerable tenderness over the reg-ion of the ascendinof colon. A possible perforation of the intestine was con- sidered even at this early date. Opium was ordered and all food by the mouth stopped. Twelve hours after the collapse the temperature rose to 104.5°. In a few days all pain and tenderness had dis- appeared. By October 28th she was practically convalescent ; the abdomen was natural in every respect. On the night of the 29th she had some slight abdominal pain, but not enough to keep her awake. On the morning of the 30th, however, she was suffering severe pain, which was referred to the region of the hepatic flexure of the colon, and there was considerable tenderness in this region ; an area about the size of an orange became decidedly dull on percussion and very tender. In- testinal perforation was then again considered. The next morning, October 31st, the patient was much worse, with decided distention of the abdomen and signs of recurrent peritonitis in the right hypochondrium. On the 31st Mr. Sheild first saw her with Mr. Monier-Williams. Along" with the symptoms already described, it is noted that ' the extremities were not cold, the tongue was clean, and the patient was rational and could converse. The face was pinched and anxious, but lacked the appearance of death-like collapse so noticeable in perforation of the intestine from typhoid ulceration. By the next day, November ist, operation was determined upon, as the abdominal conditions were worse, though her general condition had improved. THE LIVER AND THE GALL-BLADDER. 267 A free incision was made in the median line above the umbilicus. The intestines were distended, red, congested, and covered with purulent lymph. Believing that a perforation existed toward the upper part of the intestinal canal, diligent search was made, but none could be detected, and while disentangling the adhesions and sponging away the soft lymph under the liver, the gall-bladder came into view, and its appearance was peculiar and sug- gestive. This viscus was deeply inflamed, of a dark plum color, rigid, thickened, and adherent, but not much enlarged, though tightly distended. The source of mischief was soon apparent, for low down near the neck of the gall-bladder was a sharply circular sloughing ulcer, the size of a three-penny piece. Its floor was bright yellow and it was sur- rounded by a vivid red zone of intense hyperemia. On stroking it with the probe, fluid escaped at one point, showing that leakage of the contents had already occurred. The gall-bladder was opened at its fundus, evacuating f^iss of thick offensive pus not mixed with bile. Careful search for a calculus was made, but none could be detected. The slough- ino- ulcer near the neck of the gall-bladder had now ■ qmte given way, and I [Mr. Sheild] tried to unite it after the Lembert method, but the stitches cut their way out persistently, though deeply placed. It was obvious that the gall-bladder was too soft and lacerable to deal with, still less to bring it to the surface of the abdominal wound. The wound m the fundus was, therefore, attached to the parietal peritoneum and the parts under the liver cleansed by flushing with warm water and repeated sponging. A second incision was made at right angles to the former, reaching toward the right lower ribs to allow of more drainage. The intestine was relieved of flatus by puncture ; a glass drainage-tube was now inserted, and a long and liberal slip of carbol- 268 SURGERY OF TYPHOID FEVER. ized gauze packed firmly around it, so as to flatten the empty gall-bladder against the surface of the liver and shut off the intestine from contact. The rest of the abdominal wound was closed. The operation lasted an hour. The patient was fed by the rectum ; a saline purge was given two days after the operation. On the sixth day a purulent dis- charge was observed from the tube ; no bile escaped. After this the patient made a very excellent re- covery.' " Case XL VI (Alexieef'). — "A girl, age five, was taken, November 5th, with parotitis, which suppurated on the left side. By the 29th the spleen was en- larged. The patient passed through a severe attack of typhoid fever. ' During the second week in De- cember the patient became very drowsy and was delirious; there was tenderness in the ileo- cecal re- gion. The rales at the bases more numerous ; con- siderable expectoration ; the roseola diminished, but was still present. During the third week in Decem- ber the patient became markedly worse, complaining of pain, especially in the right side of the abdomen. When lying on her back there was to be made out, four or five fingers' breadth below the costal margin on the right side, a rounded tumor about half the size of a small hen's ^gg. On percussion the tumor was pear-shaped, and the dulness was continuous with that of the liver. There was marked motion with respiration ; it was elastic and somewhat tender on palpation. Distinct fremitus was found to be present on palpation between the i8th and 20th. Diarrhea. The urine by this time had begun to contain a trace of albumin. On the nights of the 20th and 2 2d the patient became much worse, com- plaining of great abdominal pain. Finally she be- came greatly excited ; jumped out of bed ; did not ^ Jour. Dietskaya Meditzina, 1896, No. 4, in the Amer. Jour, of the Med. Sciences, Oct., 1897, p. 466. THE LIVER AND THE GALL-BLADDER. 269 recognize those about her ; and became very feeble and collapsed. Temperature, 36.6° C. ; pulse un- countable. Tinct. valer. aith. was given hypoder- matically ; by the following morning she became somewhat calmer. At this time the tumor, which had been palpable the day before, was no longer to be made out. The abdomen was much distended and tender. The bowels moved only by enema. " ' On the 25th patient was worse, complaining of severe pain in the right side ; abdomen much dis- tended ; everywhere tender. Cries out with pain. There is no jaundice. From the 29th to the 31st the temperature was somewhat lower, but the patient seemed much worse ; lies on her back or on the right side, with the knees drawn up ; can take no other position. The abdomen, especially on the right side, is distended and very tender. The out- lines of the tumor, which were formerly made out, are not to be distinguished. " ' A diagnosis of cholecystitis or suppuration in the neighborhood of the gall-bladder was made, and operation advised. This was performed on the 31st, an incision nine cm. long, parallel to and two fingers below the costal margin on the right side, being made. On opening the abdominal cavity a serous fluid, colored with bile, escaped. The intestines were adherent ; there was pus in the gall-bladder and surrounding it, suppuration having extended also into the pregastric area. The pus was emptied, drainage established, and the cavity packed with iodoform gauze. After the operation the patient was excessively weak, and 20 c.c. of salt solution were introduced hypodermatically.' The patient made an excellent recovery. On February 9th, however, a relapse occurred, from which she recov- ered by the 21st. During all this time the discharge in the healing wound had gone on satisfactorily. The discharcre consisted of bile, mixed at times with 2/0 SURGERY OF TYPHOID FEVER. a little pus. The discharge stopped by the 24th and the spleen was no longer palpable, A slight attack of pneumonia occurred from March 13th to 17th, but by March 26th she was entirely well. Careful cultures from the pus showed pure typhoid bacilli. Case XLVII (Osier'). — "A woman, age twenty- nine, was admitted to the Johns Hopkins Hospital, April 22, 1895, on the fourth or fifth day of typhoid. She passed through a period of pyrexia of twenty- seven days' duration. 'On May 2 2d she had an attack of sudden severe pain in the right hypochon- driac region. The temperature rose to 102°, without a chill, and she had fever for thirty-six hours. There was no jaundice. Some time after she left the hos- pital, on June 21st, she had a second severe attack of pain in the same region, of great intensity. It was also not followed by jaundice. During the summer she had two other attacks, each lasting about eighteen hours, but without jaundice. She apparently had re- covered entirely, when at noon on December 23d she vomited, and later in the day had an attack of very sharp and severe pain in the right iliac fossa. The pain came on in paroxysms lasting for a minute or more. The abdomen was flat, but over the entire right side there was muscular rigidity and'a great deal of tenderness. The pain was localized in a small area close to McBurney's point. Any palpation in that region was very tender. Pressure on the left side of the abdomen caused a draQ^aing- sensation and pain between the navel and the anterior superior spine. The next day she had recurring attacks of pain over the whole right side.' A diagnosis was made by both Osier and Halsted of appendicitis. She became so much worse that at six o'clock the same evening Dr. Halsted operated. 'An incision was made for appendicitis. There were a few old 1 Trans. Assoc. American Physicians, 1897,, xii, 388. THE LIVER AND THE GALL-BLADDER. 27 1 bands of adhesion seen about the cecum, but the appendix was not found, and it was evident that the seat of the trouble was not here. Just above the cecum the omentum was seen, adherent to the as- cending and the hepatic flexures of the colon. In it was a small opening- from which a thin yellow mate- rial flowed. At first this was thought to be perfora- tion of the intestine in an old typhoid ulcer, but on enlarging the incision the opening was found in the gall-bladder, to which the omentum was adherent, and in the adhesions between the liver and colon there were several small pockets containing purulent yellowish material. The gall-bladder was enlarged and very tense ; 100 c.c, of a clear fluid were re- moved, after which about 30 c.c. of thick purulent matter flowed out. The cystic and common ducts were explored, and it was thought that a stone was felt in the cystic duct, but on account of the depth of the duct and the numerous adhesions, and the difficulty of preventing infection of the peritoneal cavity, the gall-bladder was packed with gauze and the opening about it closed. "'The patient did very well. On February ist, upon introducing a probe into the sinus, a stone was felt, which gradually came out. She was discharged February 19th, and has remained well ever since.' " Case XLVIII (Osier'). — "November 5, 1894, he saw a woman, age thirty- seven, at the end of the third week of a ver)^ severe attack of typhoid. The attack was very protracted and she was in bed nearly ten weeks. On January i, 1895, she had been at- tacked suddenly with severe pain in the epigastrium, passing round the right side to the back. She had no chill. On the fifth day after the onset she be- came jaundiced. On January 21st she had a severe chill ; on the 27th the temperature rose to nearly 105°, and she had nausea and vomiting. The abdo- ^ Loc. ciL, p. 390. 272 SURGERY OF TYPHOID FEVER. men was distended and so tender that it was impos- sible to make a satisfactory examination. Dr. Hal- sted performed laparotomy on the 29th, " ' The surgical note states that on opening the abdomen the liver was seen to be enlarged, the gall- bladder projected below the right margin, and on its anterior wall a rupture was seen through which bile and purulent matter were oozing. The wall of the gall-bladder in the neighborhood was quite necrotic. The gall-bladder was incised, drained, and packed. " ' Cultures were made from the contents of the gall-bladder, and the colon bacillus was found. The colonies were worked over with the greatest care with reference to the differentiation of the typhoid from the colon bacillus. " ' The temperature fell after the operation and be- came normal on February ist. She did very well for ten or twelve days ; then she began to have nau- sea and vomiting, with marked reduction in the amount of the urine. There was no change in the jaundice, and she sank and died on February 21st.' " Di 5 rt « O S ioJ c « „ vjz _c > = n- Q O < (5 0-5 CL ss |P 5^ -Su^mwH •Sri" a < •nnsHH oi « si d • cd •MOIX up 52 »j m -vaad() i ^ 5.>, _ g o . Q Q HHOdaa avAaaxNi 3.= ^ -J- OT Xi in Srt-S < oa < O z h 2 = .= ■' 'Co j:"^ — 'S-i' — 5 bfi o «^ ^ -■ ■" = .S ■6^-ibo . = = « = ^ -5 °'5'd - X H PL, w o .2 i-i § = « £ 8^"!^ rtu-^2 .2-= .-3S. O 5-S- 5 0.ti mO-i! «Ci-"'o3Do • — ■? o-s z ^q=T3 Ot/)=OD(/3S 1- «_!. i:.£ < ^i (U-^ Qi o z - 2^ H B! S .- -t; B s p- a: UJ H Bi < D Q " " U O 1' ll 11 rt ho cu **-< w- V- j_^ Di o o O Z o < %^ o--^ O jj D t.' p., J2 a; •— tu — ^ ^ z u— i2— i2 — C^ g o CsS t-3 jj-D = -? hJ ;5^ *^=i . ^^ «^ < to bo M h/J Di •XHS fc fc fc tii PJ CL •aov CO w O — r rt ^ r . o r^ cj t^ P- w u CO ''^ — r-" C/1 p o^ C/5 z w w C/) < W o ._■ ij = . CO 5 5~C" i.Sco U '-' -* '-^id ? 'S ^ B~ H S-- K S£,0 < H <■>< ^ H2 >^ 1 -a ^— oj W rt'S S^ * • 5 . PJ h ■^1 DO A. W < . ^ rt 1 — 1 1 — '*^ ^S H S l!L l!5 J* 1 i8 273 CHAPTER XVII. TYPHOID AFFECTIONS OF THE SPLEEN. Among the most constant places in which the typhoid bacilH are found are the bone-marrow and the spleen. On page 30 I have given a list of a number of authors who have found them in the spleen. It was, therefore, rather a surprise to me that I was only able to cull from my second table of over 800 cases (there were none in my former series) only nine cases of abscess of the spleen ; indeed, strictly speaking, only eight, for one of them was an abscess "about" the spleen. But as the bacillus of Eberth was found in it, and the spleen is so com- monly invaded by the typhoid bacillus, it is reason- able to suppose that the spleen was at least its origin. There were also miliary abscesses in the kidney. In one case ' the abscess ruptured, produc- ing a fatal peritonitis. In two cases there was mitral disease, one ^ from an old rheumatism; the other ^ probably originated during the typhoid attack, as the bacilli of Eberth were found in the mitral vegetations. In this case there was also cerebral meningitis. Both of these cases may easily have been embolic in origin. One case'* was complicated with gangrene of the 1 Flavio, Gaz. degli Ospit., in Dublin Jour. Med. Sci. , Nov., 1890, 445. 2 Dunin, Univ. Med. Mag., Sept., 1895, 909. * Vincent, Merc. Med., Feb. 17, 1892, 73. * Griesinger, Infect. Krankh., Virchovv's Handb. Pathol., 1857. 274 TYPHOID AFFECTIONS OF THE SPLEEN. 275 lung-, and another' with suppuration in the thyroid. One case arose " in the course " of the disease, four about the third week, and four as la~te sequels — three of them arising- as late as the seventh and eighth week. Every case proved fatal, as, in fact, would be expected. Three were only discovered at the ne- cropsy, one (Flavio) having been overlooked in con- sequence of a left pleuro-pneumonia with effusion. If discovered and recognized, the only possible remedy would be a celiotomy — a desperate remedy ; in most cases, probably, not even to be considered. Six were males and three females. The following case of leukemic spleen under my care seems to have resulted from typhoid : Case XLIX. — Mrs. S. T., of Hamburg, Pa., was admitted to the Jefferson Hospital April 7, 1896, at the instance of Dr. Nice. She is a widow, age thirty- one. Both parents and six brothers and sisters are living and in good health. Three brothers and sisters died in infancy. Her menstruation began at fifteen, and has always been regular. She had a still-born child at eighteen, was married at twenty- seven, and has had one miscarriage since. Had influenza in March, 1893, when she was in bed for three weeks. In November, 1894, she had a severe attack of typhoid fever, confining her to bed for four months. During convalescence she complained of a severe, constant pain in the left lumbar region, with a point of great tenderness midway between the anterior superior spine and the costal cartilages of the tenth and eleventh ribs on the left side. She was unable to lie on the left side on account of the pain. She also had repeated irregular chills — some- ^ Griesinger, loc. cit. 276 SURGERY OF TYPHOID FEVER. times one to three a day ; occasionally a day or two passed without any. There were also profuse sweats, most frequent at night, but without any cough or expectoration. She has never been able to walk since her typhoid fever. Her abdomen began to enlarge soon after the fever, and has steadily increased in size to the present time. On admission her temperature was 102.4°, pulse 113, respiration 32. She looked very pale ; her appetite Fig. 4. — Area of tumor in Case XLIX. was good ; the abdomen was greatly distended by a large tumor, the area of which is marked in figure 4. It extended from the ribs to the brim of the pelvis, filled the entire left side of the abdomen, and reached to within an inch of the anterior superior spine of the ilium on the right side. About an inch above the level of the umbilicus was a notch on the right border of the tumor, and one at a lower level on the left border. Change of posture does not change the position of the tumor. Its right edge is TYPHOID AFFECTIONS OF THE SPLEEN. 277 wedge-shaped. The surface of the tumor is smooth, regular, with firm resistance. The left costal carti- lages are distinctly bulged forward by it, and there are no adhesions to the belly wall. Dr. Kyle examined the blood and made the fol- lowing report : Hemoglobin, 45 per cent, of normal. Red corpuscles, per cubic millimeter, total 2,720,000. Red corpuscles, per cubic millimeter, normal, 2,500,000. White corpuscles, per cubic millimeter, 336,000. The appearance of the red corpuscles under the microscope was practically normal. A few were small (microcytes) and some slightly irregular in outline. Of the leucocytes, many were granular and degenerating, some almost dividing. There were many large granular lympho- cytes present. No malarial organisms. No typhoid bacilli. As the case was one of leukemic spleen, I decided not to operate, and she was discharged April 17, 1896. Dr. Nice writes me that she died on May 29, 1897, Nothing beyond the enlargement of the spleen was found at the post-mortem. Unfortunately, no oppor- tunity was afforded for a bacteriological examina- tion. On page 1 63 I have given a resume of a case of subdiaphragmatic abscess supposed to have arisen from the spleen. CHAPTER XVIII. TYPHOID AFFECTIONS OF THE SEXUAL ORGANS. I. The Male Sexual Organs. — Very rarely the male genitals are attacked by gangrene (see p. 78). Janzion ' has recorded a case of " malignant or ataxic fever " (typhoid ?) in which priapism was the princi- pal symptom. Andrew^ has recorded a case of abscess of the prostate. One of my medical friends tells me that in convalescence from typhoid fever when a boy, he suffered from an attack of urethritis not due to the use of the catheter. Case L. — Dr. A., at the age of fifteen, had an attack of typhoid fever followed by a relapse. No catheter was ever used. In the early part of conva- lescence a series of boils broke out over the body. A muco-purulent urethral discharge, with scalding following micturition, set in about the same time ; there was no severe pain, no swelling of the meatus. The urethritis continued for about a week or ten days and then subsided spontaneously. Later in the convalescence the right testicle swelled some- what and became a little tender. Though the swell- ing abated, this testicle has always remained some- what larger than the other. I only know of a single other published case of urethritis following typhoid fever ^r Case LI. — The patient was a soldier, -who, after 1 Ann. Soc. de Med. de Montpellier, Iv, i, 146. 2 Lancet, 1871, ii, 712. 2 Legrain, Annales des Organes Genito-Urinaires, 1889, vii, 291. 278 THE SEXUAL ORGANS. 279 typhoid, in the third week of convalescence, was attacked with urethritis. He had never had any venereal affection. For several days there was pain in urination, and later considerable discharge from the urethra, which became bloody. It was followed by cystitis of short duration. His recovery without treatment was complete at the end of three weeks. Bacteriological examination showed in-the discharge numerous cultures of various micrococci, especially the staphylococcus pyogenes aureus, but no typhoid bacilli or gonococci. Legrain himself attributed this unusual urethritis to a possible ne- crosis of the urethral mucous membrane analoeous to localized gangrene elsewhere. The most frequent typhoid lesions are orchitis and epididymitis. It is somewhat strange that in the careful and extensive search through typhoid litera- ture prior to 1876, I did not find a single case involv- ing the testicle. In 1844, Velpeau,' however, I find, alluded to typhoid orchitis. Dr. Westcott has col- lected 32 cases, of which two had been reported prior to that date, but not found by myself. The typhoid bacillus has been found in the testicle during typhoid fever, not only when it was not in- flamed,^ but has now been repeatedly found both in orchitis and epididymitis, and not only in the pus, but in the tissues. Gasser,^ in a case of orchitis without suppuration, by an antiseptic puncture obtained a drop of fluid in which numerous typhoid bacilli were found. After recovery the testicle remained indu- rated. In Girode's case'^ of epididymitis, at the necropsy the suppuration was found to be intersti- ^ Diet. En Trente Vol., Art. Testicule. ^ Dehu, loc. cit., p. 82. * Archiv de Med. et de Pharm. Milit., 1895, No. 3, 228. 4 Arch. Gen., 1892, clxix, 43. 28o SURGERY OF TYPHOID FEVER. tial and outside the canaliculi. A pure culture of the typhoid bacillus was found in the pus. The tes- ticle was not involved. Though he was twenty- nine years of age, no spermatozoids were found, at least in the epididymis. Tavel ' reports a case of suppurative orchitis in which the typhoid bacillus was found in pure culture in the pus. Menetrier ^ reports a similar case. In both of these cases the epididymis escaped. The date of onset, also, is a presumption that most of the cases were not due to a mixed infection by the pyogenic bacteria, but by the typhoid infection itself, for of 29 cases only a single one arose in the second week, seven in the third, and 21 occurred in convales- cence — /. e., after the third week. The marked ten- dency of almost all of the pure typhoid infections toward a late origin seems, therefore, to hold here also. One case was probably septic,^ in which a paro- titis arose on the fourteenth day and was followed six days later by orchitis, in a boy of four. It is not at all impossible, as Widal thinks,'* that some of the cases may arise from thrombosis of the spermatic veins — an opinion, however, which was put forth prior to the discovery of the typhoid bacillus. Girode sug- gests that the typhoid bacilli gain access to the epi- didymis and the testicle from the urine. It is well known that the typhoid bacillus is often found in the urine (p. 32), and it is possible that this may be its ^ Correspondenzbl. schweiz. Aerzte, 1887, 590. 2 Pein, These de Paris, 1890, 18. 3 Bouchut, Mai. des Nouveaux Nes, 1867. * Bull. Soc. Clinique, Paris, 1877, i, 142. THE SEXUAL ORGANS. 281 source, but the wide diffusion of infection through the blood (p. 23) seems to me to make it far more Hkely that the latter is its source. In Girode's own case the typhoid bacilli were not found in the sem- inal canaliculi (as would have been most probably the case had they come from the urinary passages) but in the inter-canalicular tissues. The infection may be confined to the epididymis alone (4 cases), to the testicle alone (15 cases), or, as happened in 6 cases, both may be involved. The right side was involved 1 1 times, the left 9, and in one instance both sides. Age.— Under fifteen there were 2 cases. From fifteen to twenty-five there were 11 " Over twenty-five there were 10 " 23 cases. Date of Onset. — This occurred — In the second week in i case. " third week in 7 cases. " fourth week in 3 " " fifth and sixth weeks in .... 8 " " seventh week and later . . . .10 " 29 cases. The symptoms need no special description, except to call attention to the fact that the disease, especi- ally in the epididymis, is often apyretic. Like lesions of the bones, where the infection is not mixed, but from the typhoid bacillus alone, the disease is local, and does not ordinarily, therefore, cause much con- stitutional disturbance. The termination of the infection is in most cases 282 SURGERY OF TYPHOID FEVER. by resolution. This is expressly stated In i6 of the cases, and it probably followed in others. In the epididymis suppuration arose only once. When suppuration occurs in the testicle itself, its effects are apt to be more serious. This took place five times, and in three of them the slouehine was so exten- sive that practically the entire testicle was destroyed. The mortality was small ; only one case certainly died,' and in this death was the result not of the disease of the testicle, but of the lungs. In another the result is not stated ; ^ but as it was probably septic, in a child of four, parotitis occurring on the fourteenth day and orchitis on the twentieth. It Is doubtful whether so young a patient would survive the continued influence of the fever and these two early and probably septic complications. II. The Female Sexual Organs. — In view of the occasional involvement of the testicle, it is strange that so few cases of pure typhoid abscess or other typhoid lesion of the ovary should have been re- corded. Yet It has not wholly escaped the indirect malign influence of this upas-like fever. Case LI I. — Thus, Anger ^ has recorded the case of a woman, age thirty-three, who died, twenty hours after entrance into hospital, from typhoid of unstated duration. At the necropsy slight traction on an ad- hesion of a coil of Intestine to the bladder at one of Peyer's patches tore a hole in the bladder at the site of a vesical ulcer. There were also abscesses In each broad ligament, due to a perforation of the rectum from ulceration. 1 Girode, Arch. Gen., 1892, i, 43. ^ Bouchut, vide ante. 3 Bull. Soc. Anat., 1865, 364. , THE SEXUAL ORGANS. 283 Werth ' describes the following case, in which an old dermoid cyst of the ovary suppurated eight months after the fever. Fortunately, a bacteriologi- cal examination was made, or the influence of the fever might well have been questioned. In the pus a pure culture of the typhoid bacillus was found. She recovered after operation. Case LIU. — A woman, age twenty- nine, entered the hospital June 2, 1892, on account of an enlarge- ment of the abdomen and pain in its right lower quadrant. The pain had suddenly seized her at the beginning of the year, while she was working, and had recurred at shorter or longer intervals ever since, later becoming more persistent and some- times very severe. Soon after the beginning of the pain the patient observed that the abdomen was swollen, and in October and November, 1891, — that is to say, about eight months prior to her entering the hospital, — she had an attack of typhoid fever which, as was ascertained from her physician, was of mode- rate severity and without complications. On entering the hospital her abdomen was markedly distended by a tumor which plainly fluctuated. It was moder- ately movable and somewhat painful. The greatest circumference of the abdomen over the middle of the tumor was 78.5 cm. It rose 21 cm. above the symphysis. The uterus lay behind it. Operation June 4, 1892. The tumor was removed with some difficulty on account of adhesions, but the operation was finally successfully accomplished. The wall tore during removal, and some masses of fat, in which were a number of dark hairs, escaped. The tumor originated in the left ovary. The right ovary had a cyst as large as a lemon. This was opened with scissors and the wound was sutured. Bacterio- 1 Deutsch. med. Wochen., 1893, No. 21. 284 SURGERY OF TYPHOID FEVER. logically the pus from the tumor showed a pure culture of the typhoid bacillus. Case LIV. — Sudeck ' reports the following similar case : A woman, age thirty-two, a widow for eleven years, suffered for several years with pain in the lower abdomen, dysuria, and constipation. Seven weeks before entering the hospital she fell ill with typhoid fever. Three weeks before her entrance into the hospital she noticed that the abdomen was swollen, and she had again pains in the abdomen and difficulty in passing water. On the 5th of Novem- ber, 1895, when first seen, a marked tumor was found in the hypogastrium, extending into the pelvis, and to a little above the navel ; fluctuation was uncertain. The uterus was antefiexed, lay somewhat to the left, and moved with the tumor. The cavity of the uterus was seven cm. long. Hectic fever set in and the diagnosis of a suppurating ovarian tumor was made. On the -I ith of November Dr. Sick operated. The tumor was in the right ovary and was as large as the head of a ten-year-old child. It was removed with- out difficulty. The walls were about one cm. thick. The contents were a thick pus and fibrin with choco- late-colored fluid, smelling very badly. No bacteria could be found by the microscope. Cultures were made and the typhoid bacilli were recognized in pure culture. In the wall of the cyst were found some diplococci. The patient made an excellent recovery. Case LV. — Pit'ha^ reports a third case of sup- puration in a dermoid cyst in which a pure culture of the typhoid bacillus was found. He attributes the suppuration entirely to the bacillus of Eberth. The patient was a woman twenty-five years of age. She was admitted to the hospital on February 6, 1897. Two years before he saw her she had suffered 1 Mtinch. med. Wochen., 1896, No. 21, 498. 2 Centralbl. f. Gynekologie, 1897, No. 37, p. 1 109. THE SEXUAL ORGANS. 285 from chlorosis, during wliich time her menstruation ceased for a year and a half. Four months prior to her admission she fell ill with typhoid and was in bed for four weeks. In the fifth week she observed on the right side of the lower abdomen a painful tumor without definite limits. Gradually it became well delimited. Her menstruation had not returned since her sickness ; appetite was poor ; bowels irregu- lar. She was evidently a poorly developed woman. In the lower half of the abdomen was a tumor which reached up to the navel, and, especially at the sides, showed fluctuation. It was not movable, and caused but little pain. A vaginal examination showed that the tumor pushed the posterior vaginal wall mark- edly forward, and the uterus was lifted and pressed against the symphysis, being covered by the bladder, which last reached half way to the navel. Examina- tion by the rectum showed that the whole pelvis was filled with the tumor, that the recto-vaginal septum was pushed downward, and both the vaginal and the rectal wall arched. The rectal wall, however, was movable over the tumor. On the right side the tumor was connected with the bones of the pelvis by a hard, tender, solid mass. Otherwise the lower part of the tumor was elastic and fluctuating. Opera- tion was done February 21, 1 897. Some of the fluid was removed by a puncture and immediately exam- ined microscopically. A great mass of polynucleated pus-cells in degenerative stages was found, but no micro-organisms. Accordingly, the tumor was opened through the posterior wall of the vagina by the thermo-cautery, evacuating three liters of pus, in which also were some hairs, making certain the diagnosis of a suppurating dermoid cyst. Examina- tion with the fingrer showed that it was a multilocu- lar cyst, and that vaginal extirpation would not be advisable, especially on account of its adhesions. It was, therefore, thoroughly washed out and the vagina 286 SURGERY OF TYPHOID FEVER. tamponed with iodoform gauze. Laparotomy was immediately done. The bladder reached a hand- breadth above the symphysis ; the uterus was small ; the dermoid cyst arose from the right ovary. There were some adhesions to the intestine, which were broken up by blunt dissection, but it was not possible to lift the tumor until the adhesions on the right side of the pelvis were broken up, which required con- siderable force. The pedicle was divided by the Paquelin cautery ; the pelvis cleansed with sterile compresses ; the raw surface of the pelvic adhesions were covered by a peritoneal flap from the right broad ligament. The left ovary was small. The opening in the vagina was closed with catgut and the abdomen entirely closed without drainage. Ex- amination of the extirpated cyst showed that necrotic processes had begun at several points. Both bones and cartilage, as well as a considerable amount of black hair, were found in the tumor. The patient made an uninterrupted recovery. No micro-organ- isms whatever were found microscopically in the pus. The contents seemed to be chiefly disintegrated epithelial cells and polynucleated pus-cells. Cultures, however, were made which showed pure typhoid bacilli, both by morphological and biological tests and also by their reaction to Widal's serum test. The conclusion of the author, therefore, was that the typhoid bacilli were the direct cause of the sup- puration, and that they were present, as shown by the culture, four months after the fever. Mabit ' records a case of pyosalpinx, which, unfor- tunately, like that of Anger which occurred in 1865, has no bacteriological proof of its typhoid origin, and the remote date of its discovery and possibilities of intervening causes make it doubtful. A young 1 Nouvelles Archives d'Obstet. et de la Gynecol., 1893, viii, 267. THE SEXUAL ORGANS. 287 woman of nineteen, when convalescent, developed recurring pains in the left side of the abdomen, with amenorrhea. She married at twenty-one, and at twenty-nine was cured of a left pyosalpinx by dilat- ing" and tamponing the uterus. It is beyond the object of this monograph to con- sider the effect of typhoid upon pregnancy, but in passing it is not without interest to observe that Freund and Levy ' report a case of spontaneous abordon at the fifth month, at the beo-inningr of defer- vescence, the mother, a multieravida, having suffered from a mild attack. They found the typhoid bacil- lus in the blood of the placenta and in the spleen and the heart of the fetus, thus proving the direct transmission of the bacillus from the mother to the fetus, which could not have taken place by any other channel than by the blood. The child died immedi- ately after birth, and the cultures were made twenty minutes later. No gross lesions were found in the fetus. Janizewski" reports a case of a woman, eight months pregnant, who, twelve days after her admis- sion into the hospital with typhoid fever, aborted of a fetus which lived five days. Bacteriological examina- tion of the fetus showed the typhoid bacilli In the spleen, intestines, mesenteric glands, kidneys, and lungs. Similar cases of ante-natal infection of the fetus are reported by Neuhass, Chantemesse and WIdal, and a number of others, to which the references are given on page 32. Periuterine Hematocele. — In addition to these 1 Berlin, klin. Wochen., 1895, No. 25. 2 Presse Med., March 24, 1894. 288 SURGEFY OF TYPHOID FEVER. cases, Guyot ' has collected seven cases of peri- uterine hematocele of typhoid origin, which, with another by Trousseau ^ originating, as he believed, in a sanguineous cyst of the ovary in a girl of sixteen, are the only cases Dr. Westcott has found. Whether, as Guyot thinks, they arose from an intestinal per- foration is a question. In Guyot's four personal cases the trouble began, in three cases, respectively in the fourth, sixth, and seventh weeks of the fever, and in the fourth at the beginning of convalescence. This last case died, un- fortunately without autopsy ; two of the other three recovered without operation, but with persistence of the tumor. In the fatal case pus was discharged both from the rectum and the bladder. No autopsy was allowed. At the present day, undoubtedly, operation would be done in such cases, and as they all occurred practically in convalescence, the mortality would probably have been much less. The symptoms were in no wise different from the same disorder arising from other causes. No bacterioloeical examination was made, as it was before the discovery of the bacillus of Eberth. Lesions of the vagina are chiefly caused by ab- scesses (see Chap. VI) or gangrene (see Chap. Ill), and result in simple perforations, vesico-vaginal and recto-vaginal fistulae, destruction of more or less of the vagina, and sometimes entire closure of the vaginal outlet. These have already been considered. 1 Etude sur I'hematocele periuterine survenant dans le cours on dans la con- valescence de la fievi-e typhoide, These de Paris, 1879. 2 Clin. nied. Hotel Dieu, 1865. CHAPTER XIX. SPECIFIC MIXED INFECTIONS. Tetanus. — Erysipelas. — Anthrax. — Malignant Edema. In addition to the ordinary pyogenic infections giving rise to complications in the joints, bones, larynx, parotid gland, etc., and producing various forms of septic lesions, there are a number of cases of other mixed infections with certain specific micro- organisms to each of which a few words will be appropriate. Some of these specific infections may find a port of entry through the intestinal lesions, but most of them probably gain an entrance through the bedsores, furuncles, suppurating parotid glands, and other similar avenues in the skin and the mucous membrane of the mouth. Some peculiar and characteristic avenues of infection in the cases of tetanus are considered under that heading. Among these infections the most frequent is ery- sipelas ; next to this is tetanus ; and there are one case of anthrax infection and two of malignant edema. Before the discovery of the typhoid bacillus and the bacteria of these various infections their occurrence was inexplicable, but now this is perfectly plain. They are all cases of mixed infection with other specific germs in addition to that of typhoid. Erysipelas. — The most important paper I have found in reference to erysipelas is Gerente's These 19 289 290 SURGERY OF TYPHOID FEVER. de Paris, 1883.' He collected up to that date 64 cases of facial erysipelas In 3910 cases of typhoid fever, as Is shown by the following table : Typhoid Facial Fever. Erysipelas. Chomel, 130 4 Louis, 134 3 Forget, 92 I Jenner, 65 2 De Larroque, 105 4 Zuelzer, 84 3 Liebermeister, 1420 10 Zuccarini, 480 18 Griesinger, 500 10 Murchison, 900 9 Total, 3910 64 The references to the several papers may be found in the original thesis. According to these figures, erysipelas is a compli- cation once in every 61 cases of typhoid. Erysip- elas, however, I believe is very frequently not mentioned, either because it Is deemed an unimpor- tant complication or because it Is infrequent. That it is an Infrequent complication is shown, I think, by the fact that the other cases In our table number only 29. There are a large number of cases of erysipelatous Infection alluded to In a general way, but these would not serve my purpose for analysis. Only the few cases stated above were found de- scribed in such detail as to be useful. The great majority do not arise in connection with the so-frequent bedsores, but more often, prob- ably, from the fissures of the lips and other solutions ^ L'Erysipele de la Face dans le cours de la Fi^vre Typhoide. SPECIFIC MIXED INFECTIONS. 29 1 of continuity about the head and face. This ac- counts for the much greater frequency of erysipelas of the face than of other parts of the body. In addition to this, the erysipelas not infrequently attacks the mucous membrane of the mouth and pharynx, and may travel down the trachea and result in either bronchitis or pneumonia, or may in- volve the vocal chords, producing- great hoarseness and also dysphagia. Of this Jenner has given two excellent illustrations," the first of which, however, occurred in a case of typhus. In the skin, espe- cially in such lax tissues as the eyelids, a local necrosis or gangrene may result. Meningitis does not seem to be a frequent sequence. The inflam- mation of the skin is sometimes stationary, or more commonly serpiginous or ambulant. Its duration may be fixed ordinarily at two weeks, but it varies very much. Two cases I have personally seen resulted in abscesses ; one, an abscess of the scalp and eyelid, the other, over the mastoid process. Case LVI. — A. C, age twenty-two, was admitted to St. Agnes' Hospital, April 14, 1891, on the fourth day of typhoid fever. She was under the care of Dr. H. A. Hare. On April 27th she developed facial erysipelas. By June 25th the erysipelas and typhoid had both subsided, but she was transferreci to the surgical ward on account of an abscess over the left mastoid. On the next day I opened the abscess and packed it with bichlorid gauze. She was discharged, cured, July 4, 1891. Case LVI I. — J. W., age twenty-five, was admitted to St. Agnes' Hospital April 21, 1891, with begin- 1 Med. Times (London), 1850, vol. xxi, p. 135 ; and Med. Times, n. s., vol. i (o. s., vol. xxii), 1850, p. 405. 292 SURGERY OF TYPHOID FEVER. ning typhoid fever, and placed in the medical ward. May lo, 1 89 1, he developed facial erysipelas and the right eyelid threatened to slough. June 3, 1891, on account of an abscess on the back of his head, he was transferred to the surgical ward, the ery- sipelas having subsided. June 4, 1891, I opened the abscess. Another developed in the right eye- brow, and was opened June 8th. Both were healed by July 2, 1891, and he was discharged cured. Unfortunately, no bacteriological examination could be made in either case. Of the whole number, 82 were in the head and face, I of the foot and leg, i began in the arm, and I, reported by Berthand ' (in 1848, be it observed), was said to be " erysipelas of the iliac and renal veins." The autopsy showed a plastic and sup- purative inflammation of these veins. Presumably this was a case of thrombosis. One case^ is remarkable for its malignant course. It broke out on the thirteenth day in a woman of twenty- five, who was four and a half months preg- nant. Beginning in one arm, it spread over both arms, the chest, face, and head within twelve hours, when the patient died. Nearly all the patients were between twenty and thirty — 19 out of 28 cases in which the age is given. Five were below twenty (one each of twelve and eighteen and three of nineteen) and four were thirty-two, thirty-eight, forty, and forty-two years of age respectively. The two sexes were nearly equally attacked — 16 males, 14 females. It begins, usually, either in the third week, when the fever is 1 Gaz. des Hop., v, 29. 2 Rosenberg, Columbus Med. Jour., 1890, 299. SPECIFIC MIXED INFECTIONS. 293 at Its height, or during- convalescence, occasionally as late as the fifth to the eighth week. Its fatality is not to be wondered at. Twenty- seven cases died and 32 recovered of the 59 cases in which the result is stated. This gives a mortality of almost 46 per cent. The later cases since the introduction of antiseptics give even a worse result, for of 23 cases of the 29 collected in addition to those of Gerente, 11 died and 12 recovered, a mor- tality of almost 48 per cent. The only bacteriological examinations that have been made in these cases are by Rheiner,' and in his two cases the typhoid bacillus alone was found. Further examination will probably prove that the streptococcus is present, as a rule. The symptoms are the usual ones of erysipelas, but Instead of being aggravated from the combina- tion with the typhoid fever, as one would suppose, they all seem to be ameliorated. There Is, as a rule, less redness, less pain, and less swelling than in other forms of erysipelas, nor does the temperature, as a rule, rise so high as we would expect. Delirium also Is not very marked. The cause of the great fatality seems to be rather the general condition of the patient, especially his double Infection. In the matter of treatment there Is nothing which calls for special mention, except as to prophylaxis. The most scrupulous cleanliness, especially in any solutions of continuity, — such as fissures of the lips, nose, etc., bedsores, abscesses, furuncles, etc. Now that the great mortality from erysipelas is shown, a still more rigid antiseptic treatment, will, 1 Loc. cit. 294 SURGERY OF TYPHOID FEVER. in all probability, avert the danger by preventing the secondary infection. Tetanus. — In the Bibliography of my Toner Lecture I recorded six cases of tetanus, to which Dr. Westcott has added nine — 15 in all. The most interesting point in connection with these cases is the port of entrance of the infection. Thus, one case of the earlier series was believed to have arisen from a bedsore ; one had a wound on his finger; one' probably developed infection through a blister; two ^ were attributed to a possi- ble abrasion of hemorrhoids by a syringe (?); one^ followed eight days after plugging of the nares for uncontrollable hemorrhage ; one "* followed the bite of a horse on the finger six weeks before ; and one ^ occurred in a cavalryman who fell out of a wdndow while delirious. In the earth where he fell the bacillus of tetanus was found. His occupation also is significant. Of the 15 cases, 13 (including all of those of the second series) followed typhoid and two typhus ; six were women, seven were men. Of the 15, ten died. Two women who recovered had menstrual irregularities, to which the alleged tetanus might have been due (?), and one man was said to have had a similar attack four years before. The remarks as to the treatment of erysipelas apply to that of tetanus as well. Anthrax. — That anthrax should complicate ty- ^ Simoneau, Jour, de Med. de I'Ouest, 1882, 8. 2 Fussell, Phila. Med. Times, Jan. 13, 1883, 263. 3 Fowler, Buffalo Med. and Surg. Jour., 1880-81, xx, 155. 4 Wolfinger, Ann. Stadtl. Allgem. Krankenh. , Miinchen, 1878, i, 44. 5 Belhomme, Arch, de Med. et Pharm. Milit., 1890, No. 6, 464. SPECIFIC MIXED INFECTIONS. 295 phoid fever is quite unexpected. Only one case is recorded, that of a soldier ' who died after having had intestinal hemorrhages and with enlarged spleen. In the stools during life, and in the blood, the intestines, the liver, and the spleen after death, were found the bacilli of anthrax. The stomach and intestines showed a number of tumors ; Peyer's patches and the solitary follicles were eroded and the mesenteric glands enlarged ; the spleen was five times the normal size. In the cecum and ileum were found the bacilli of typhoid. The anthrax infection was traced to some milk his sister had brought him from a cow which had evidently suf- fered from anthrax. Malignant Edema. — Brieger and Ehrlich^ re- port two cases in which malignant edema compli- cated typhoid. They attribute it to the use of the tincture of musk for collapse. The first was a woman of twenty-six. On the thirteenth day the musk was injected in the right thigh by a hypodermatic syringe. In two days there was severe pain and rapidly spreading gangrene, and she died the next day. The other was a woman of thirty-two in whom the same tincture was injected in the thio-h with a similar result. In both cases the bacillus of malignant edema was found. 1 Karlinski, Berlin, klin. Wochen. , 1888, No. 43, 866. 2 Berlin, klin. Wochen., 1882, 661. CHAPTER XX. OCULAR COMPLICATIONS OF TYPHOID FEVER. BY GEORGE E. de SCHWEINITZ, A.M., M.D. Histoiy. — Disregarding for the moment the spe- cific diagnosis, — typhoid fever, — a word in regard to post-febrile ocular complications in general may be in place. In 1826 Dr. A. Jacob' described Iritis as a se- quence of relapsing fever, as this was first estab- lished by Hewson in his work on Venereal Oph- thalmia. About the same time William Wallace^ contended that this inflammation could be cured by "bark or quinin." In 1846 Dr. Jacob ^ returned to this subject in a communication entitled " On Inflammation of the Eye following Fever." His paper refers especially to a form of fever epidemic in Glasgow in 1843, and similar to that which prevailed in Dublin in 1826. This fever was described by Mackenzie,"^ and the ocular complications designated Post-febrile Ophthalmitis. They manifested them- selves in a form of irido-choroiditis. Of 135 cases analyzed by A. Anderson, of Glasgow,^ 10 began during the fever or its relapse ; 34 began at once on convalescence ; 29 within a fortnight of convales- 1 Trans. Coll. of Phys. Ireland, Dublin, 1S28, v, 46S-478. 2 Medico-Chir. Trans., London, 1828, xiv, 286-322. 3 Dublin Med. Press, 1846, xv, 17-21. 4 London Med. Gazette, n.s.,vi, 1843-44, 225-236. 5 Month. Jour. Med. Sc, London and Edinb.,' 1845, v, 729-773. 296 OCULAR COMPLICATIONS. 297 cence ; 31 within the following montli ; and 31 within five or six months. Similar severe inflammation of the eye following typhus fever, as it appeared in New York in 1847— 48, has been reported by A. Dubois,' and again by Wilkes and Dubois.^ In 1870 post-febrile ophthalmitis received consid- eration from M. Charteris,^ who investiofated the cases of relapsing fever which occurred in Glasgow in 1870, and which, both from the ocular and cren- eral standpoint, were identical with those reported in the communications already referred to. The oph- thalmic disease, as already stated, was an irido-chor- oiditis, which, if neglected, passed into ophthalmitis. In 1878 Dr. N, Larionow* examined ']6'] typhus patients and typhus convalescents in order to ascer- tain the influence of the typhoid process upon the organs of vision. Among the ocular lesions which he described were conjunctivitis, iritis, keratitis, vit- reous opacities, retinitis, neuritis, and "amblyopia and amaurosis." From the preceding paragraphs it is evident that post-febrile ocular disease has been known for a long period of time as a complication of typhus and recurrent fevers, but less commonly of typhoid fever, although Larionow especially m_entions typhus abdominalis. Classification of the Ocular Complications and SequelcB of Typhoid Fever. — In an article on the 1 Trans. Amer. Med. Assoc, Phila., 1848, i, 373-386. 2 Annalist, N. Y., 1848, ii, 331-333. * Glasgow Med. Jour., 1870-71, 4th series, iii, 347-354. 4 Klin. Monatsbl. f. Augenheilk., Cassel, 1878, xvi, 487-497. 298 SURGERY OF TYPHOID FEVER. alterations of vision in typhoid fever, Galezowski ' submits the following classification: (i) Necrosis of the cornea ; (2) thrombosis of the ophthalmic and orbital veins ; (3) embolism of the central artery of the retina ; (4) optic neuritis, with atrophy of the disc ; (5) defects of accommodation. An examination of the literature justifies a more elaborate classification, namely: (i) Affections of the conjunctiva and cornea ; (2) affections of the uveal tract — iris, ciliary body, choroid — and of the vitreous humor ; (3) affections of the crystalline lens ; (4) affections of the optic nerve, retina, and retinal vessels ; (5) affections of the orbit and orbital circulation ; (6) affections of the extra- and intra- ocular muscles. Although not strictly ocular affec- tions, to this list may be added affections of the cav- ernous sinus from extension of a diseased orbital process, affections of the sympathetic, and sloughing of the lids in association with noma of the face. Relative Frequency of the Ocular Complications of Typhoid Fever. — If feebleness of accommodation as part of a general post-febrile weakness is excepted, affections of the conjunctiva and cornea are the most frequent ocular complications of typhoid fever. The cases of conjunctivitis (catarrhal and phlyctenular) far outnumber those of ulcerative keratitis. Sup- purative keratitis, while fortunately not a common complication,^ occurs with sufficient frequency to accord it more attention than it has thus far received. ^ L'Union Med., 1877, 3^ series, xxiii, 937-941. 2 August Hoelscher (Miinch. med. Wochen., 1891, xxxviii, 43; 62) has seen it twice in 2000 fatal cases ; Osier does not even mention its occurrence. OCULAR COMPLICATIONS. 299 The remaining- ocular lesions occur probably in the following order of frequency: Retinal hemorrhages, diseases of the uvea and vitreous, paralyses of the ocular muscles, neuritis and neuro-retinitis, and, finally, orbital affections. It is not unlikely that if ophthalmoscopic examinations were systematically undertaken in typhoid fever, the relative frequency of retinal hemorrhages would rise, and, indeed, the relative frequency of fundus lesions in general, because they attract attention only when they are so situated that they involve the macular region and occasion disturbances of visual acuity of which the patient complains. I. Affections of the Conjunctiva and Cor- nea. — Ordinary conjunctivitis of the catarrhal type, differing in no sense from those varieties which are common to a number of febrile states, is frequent in typhoid fever. According to Knies,^ during conva- lescence, and still more at a later period, phlyc- tenular affections, both of the cornea and of the conjunctiva, have been observed. Of more serious import are the various types of ulcerative keratitis and sloughing of the cornea, occurring usually during the convalescent period, or, at all events, after the disease has existed for a suffi- cient length of time to have seriously depressed nutrition. Ulcer of the cornea maybe preceded by the development of phlyctenules, or it may appear without such antecedents and rapidly pass into the sloughing type of keratitis with all its consequences. ^ Die Beziehungen des Sehorgans und seiner Erkrankungen zu den iibrigen Kranklieiten des Korpers und seiner Organe, Wiesbaden, 1893, P- 395- 300 SURGERY OF TYPHOID FEVER. Cases of this character are reported by Knies,' Hoelscher,^ Galezowski,^ Adolph Alt/ and a number of other observers. The following case histories illustrating- types of this affection are appended : Case L VIII. — Hypopyon Kei^atitis with Iritis Occiwring in the Fou7'-th Week of Typhoid Fever. — Notes furnished by Dr. C. A. Veasey, of Philadelphia, as follows: A married woman in the fourth week of typhoid fever, complicated with pneumonia, de- veloped a deep ulcer at the upper and inner quad- rant of the cornea, together with iritis and hypopyon. Under atropin, boric acid lotions, irrigations with formaldehyd, and, finally, the application of the actual cautery to the ulcerated surface, healing took place w^ith the preservation of vision of |, the cornea being clear except for a scar marking the position of the ulcer. There was one relapse of this ulcer two and one-half weeks after the original o treatment had been begun, which rapidly yielded to the same measures. Case LIX. — Ulceration of the Cornea Followed by Rapid Sloughing of this Structure, Occumnng at the End of the Fourth Week of Violent Typhoid Fever. — Notes furnished by Dr. W. S. McClanahan, of Woodhull, 111., as follows : A man, age twenty- three, was first seen on October 9th, with typhoid fever, his temperature at that time being 103.5°. The symptoms were severe from the very begin- ning, and in the third week the patient suffered from violent intestinal hemorrhages. Diarrhea, rapid emaciation, and delirium were prominent symptoms. Ulceration of the right cornea was first noticed toward the end of the fourth week, beeinnino- in a small point of infiltration near its lower margin. In ^ Loc. cit. 2 ]^oc. cit. 3 Loc. cit. 4 Med. Fortnightly, 3, 4, 1893, p. 47. OCULAR COMPLICATIONS. 3OI five days the entire cornea had passed into a state of ulceration, and the anterior chamber had filled with pus. Spontaneous rupture of the cornea and prolapse of the iris followed. Surgical interference was forbidden. When last seen by the reporter the inflammatory conditions were subsiding, although vision was practically nil. The question of medico-legal responsibility in such destructive lesions of the eye has recently been brought to the attention of the courts, and, accord- ing to the Journal of the American Medical Associa- tion,' has been decided as follows : ''No Duty to Provide Specialist. — In the case of Jones vs. Vroom, decided by the Court of Appeals of Colorado, May 11, 1896, suit was brought against a firm of physicians to recover damages for the loss of an eye [from an ocular complication the result of her typhoid fever], alleged to have been caused by the neelieent and unskilful treatment of the de- fendants. They had been employed to treat the plaintiff" for typhoid fever. There was no evidence, and in fact no complaint, that they did not bestow upon her all the attention and skill which the nature of the disease and her condition required. Indeed, she stated herself that she was cured of the fever as a result of their treatment. The only charge in the complaint which was proven was that one of the defendants failed to send her an oculist after he had promised to do so. The Court holds that, under the circumstances, a nonsuit was properly granted. It says that the defendants were em- ployed to treat the plaintiff for fever, and their employment imposed no duty upon them to provide her with a specialist for her eye. The Court took into account, furthermore, that she seemed to have 1 July 18, 1896, p. 169. 302 SURGERY OF TYPHOID FEVER. had no difficulty In procuring one when she set about it, and says that presumably he could have been gotten just as readily at first." According to Charles Stedman Bull,' who quotes Knies, in the somnolent or comatose staee of severe and fatal cases of typhoid fever, a rare complication is a true xerophthalmia, or xerosis cornece. The same affection has been observed in cholera, diar- rhea, and meningitis. The treatment of the conjunctivitis of typhoid fever does not differ from that which is applicable to a similar conjunctivitis occurring under other cir- cumstances — namely : a mild antiseptic lotion — for example, boric acid, or formalin, i : 6000. Severe corneal complications demand those measures which are suited to sloughing ulcers of other origins — namely : irrigation of the conjunctival cul-de-sac with a solution of formalin, i : 2000, or saturated boric acid, or bichlorid of mercury, i : 8000, atropin drops to control complicating iritis, and, if the ulcer ex- tends, touching its surface, after the sloughing mate- rial has been curetted away, with a solution of ni- trate of silver, ten grains to the ounce, or tincture of iodin, or, in severe cases, the actual cautery. If hypopyon develops, it should be evacuated by a paracentesis of the cornea. Powdered iodoform may be dusted upon the corneal surface with advan- tage. ^\\^ prognosis of suppurative keratitis is very bad, especially when it appears in aggravated cases of fever, or when the general treatment of the typhoid 1 Med. Record, New York, 1897, vol. li, p. 577. OCULAR COMPLICATIONS. 303 fever has been neglected ; as, for example, in the cases reported by Adolph Alt, which occurred in very poor patients who had been unable to obtain proper attention. Under the best of circumstances so happy a result as that achieved by Dr. Veasey may be accomplished ; under other circumstances, even with the most careful treatment, extensive sloughing of the cornea may result as in the case recorded by Dr. McClanahan, II. Affections of the Uveal Tract — Iris, Cil- iary Body, Choroid — and the Vitreous Humor. — As may have been inferred from the earlier por- tion of this chapter, affections of the uveal tract are much more frequent in relapsing and typhus fever than in pure typhoid fever. None the less, iritis, cyclitis, and choroiditis, either in the serous or the plastic form, and associated with opacities of the vitreous, are occasionally encountered during typhoid fever, especially during convalescence. F. Sorel,' in an analysis of 871 cases of typhoid fever observed during a period of ten years, notes only one case of iritis during the period of convalescence. In spite of the apparent infrequency of inflammation of the iris, or of the uveal tract generally, I am persuaded that more minute examination of the visual organs during typhoid fever would reveal a greater preva- lence of affections of this tract than might be inferred from such statistical information as has just been quoted. Alt has seen plastic choroiditis with opacity of the vitreous after a severe attack of typhoid fever, and I have observed post-typhoidal choroiditis and secondary atrophy of the disc. ^ Bull, et Mem. de la Soc. Med. des Hop., 1889, vi, 3, s., 224-246. 304 SURGERY OF TYPHOID FEVER. The floating opacities which occur in the vitreous, according to Bull, are of the punctate or stringy variety, but are not fixed and membranous. There is some evidence to show that spontaneous inflammation of the vitreous, which may manifest itself simply as an opacity, or even go on to suppuration, may be due to the exhaustion and debility conse- quent upon a low fever like typhoid, and, as Howard F. Hansell has pointed out, if during the earlier stages of the fever the discovery is made that fine flakes of opacity are beginning to appear in the vit- reous, it is possible that a vigorous supporting treat- ment may save the eye from destruction. Although Bull states that these uveal tract inflammations are serous or plastic in type, but never purulent, it would seem that this rule is subject to exceptions, and that a purulent choroiditis similar to that which is seen in pyemia, puerperal sepsis, or endocarditis, may occasionally complicate typhoid fever. A case in point is the following : Case LX. — Panophthalmitis Orctu^ring at the Be- ginning of the Third Week of Typhoid Fever and Residting in Phthisis Bidbi. Notes furnished by Dr. C. W. Hall, of Kewanee, 111. A woman, age thirty, was taken ill with typhoid fever on October 29, 1895. Durine the first week headache was severe, the tem- perature ranged between 101° and 104° F., and there were marked tympanites, abdominal tender- ness, and moderate diarrhea. On the sixteenth day throbbing pain began in the left eye, quickly followed by loss of vision. In a few days the symptoms of panophthalmitis were marked, especially edema of the lids and chemosis of the conjunctiva, and, in fact, swelling of all the tissues surrounding the eye. The OCULAR COMPLICATIONS. 305 eye gradually grew worse and sloughing of the ocular tissues supervened, followed by atrophy of the eye- ball, which gradually shrank to the size of a large hazelnut. In this case, as there is no report of external lesion of the cornea, the disease beginning with pain and loss of sight, we may assume a purulent cho- roidlds caused by embolism from a microbic area. The treatment of cases of uveal tract inflamma- tion must be governed by the type of the disease. In iritis the mydriatics are indicated, and the same remedies would be advisable in inflammations of the deeper structures. Success would depend, as has already been pointed out, upon being able to sup- port the nutrition of the patient. If purulent cho- roiditis should arise, followed by panophthalmitis, incision of the eyeball and evisceration of the puru- lent contents would be required. III. Affections of the Crystalline Lens. — As the result of inflammation of the uveal tract, the nu- tridon of the lens is interfered with and cataract may result. Without such antecedent inflammation, opacity of the crystalline lens has been attributed to thenutriuonal disturbances occurring during typhoid ■ fever. For example, Trelat ' has described double, semi-soft cataracts in a young girl, which began to develop during convalescence from typhoid fever, and Fontan" reports three cases of post-typhoid cataract (cataracta punctata) which he believes were the result of mechanical obstruction of the circula- tion. In two of these cases, one a twenty-eight-year- ^ Gaz. des. Hop., 1879, p. 417. 2 Rec. d'Ophtal., 1887, 3, s., ix, 195-200. 306 SURGERY OF TYPHOID FEVER. old man, and the other a forty-two-year-old woman, the cataract progressed to maturity and required extraction. Unfortunately, there is no evidence to show that Fontan was aware of the condition of the transparent media before the typhoid attack, Romiee ' has analyzed 44 cases of cataracta punctata, and attributes the pathogenic cause to typhoid fever in 17 of them. He seeks to explain the lenticular opacity by an increase in the density of the serum and changes in the relation of the lens to the aqueous humor. It is most likely that all cases of post-febrile cataract are originally due to disturbances of moder- ate or greater grade in the uveal tract, necessarily followed by changes in the nutrition of the lens. An interesting surgical fact in connection with these cases is that they seem to do as well after extraction, as those cataracts which have not developed through such a complication. IV. Affections of the Optic Nerve, Retina, and Retinal Blood-vessels. — Double optic neuritis may occur and end in atrophy of the nerve or in recovery; as, for example, in cases recorded by Noth- nagel, Hutchinson, Sr., Clifford AUbutt, and in our own country by Augustus P. Clarke^ and J. A. White. ^ The last observer not only gives his own experience in this particular, but has gathered the observations of a number of American ophthalmic surgeons who have from time to time noted cases of neuritis and optic nerve atrophy attributed to typhoid fever. 1 Rec. d'Ophtal., 1879, 3, s., i, 586-593. 2 Jour. Amer. Med. Assoc, 1891, xvi, 473-476. 2 Trans. Oplith. Section Amer. Med. Assoc, Chicago, 1893, 215-223. OCULAR COMPLICATIONS. 307 Some doubt in regard to the reality of this typhoid neuritis has been expressed, especially by Leber and Stellwag von Carion, who have suggested that the cases in which it occurred may have been meningitis instead of typhoid fever. Commenting on this, how- ever, Gowers points out that neuritis does occasion- ally follow other acute specific diseases. Neuritis of other nerves than the optic has been observed in typhoid. Robert P. Oglesby ' has never met with a case of optic nerve trouble after typhoid fever unless there have been symptoms of meningitis. In his opinion, the condition is not one of actual neuritis, but of so- called subacute neuritis. According to this author, cases of typhoid fever amblyopia are more frequent among women than among men, and especially among child-bearing women. A history of cerebral neuralgia and meningitis can always be obtained. Gowers, on the other hand, referring to the fact that cases of typhoid .fever accompanied by hyper- emia of the discs have been supposed to be cases complicated by meningitis, points out that menin- gitis, except as secondary to suppuration in the ear, is exceedingly rare in this disease, and that it is not warranted to infer meningitis because there is ex- treme delirium or coma. Meningitis not arising from ear disease, but from direct microbic infection, however, is recorded by Keen in Chapter VIII. Braine-Hartnell^ has reported a case which proves that bilateral optic neuritis may complicate typhoid 1 Brain, London, 1882, v, 197-203. 2 British Medical Journal, May 29, 1897 ; also Medical Record, New York, vol. lii, p. 349. 308 SURGERY OF TYPHOID FEVER. fever when there is no meningitis. His patient was a boy, eleven years old, who suffered from fever, diarrhea, photophobia, cerebral irritation, retraction of the abdomen, dry tongue, and sordes on the teeth. There, were no spots, however, and the spleen was not enlarged. There was never any strabismus, nor were convulsions present. Two days before death there was slight inequality of the pupils, and well-marked bilateral optic neuritis developed. Neither aural nor nasal discharge was detected. The post-mortem examination revealed distinct in- flammation of Peyer's patches, with decided enlarge- ment of the mesenteric glands and solitary follicles. Nothing was found in the brain to explain the optic neuritis. In my examinations of typhoid fever cases in the Philadelphia Hospital, while I have seen hyperemia of the discs, I have never observed actual neuritis in cases uncomplicated with meningitis ; in fact, in one case in which the diagnosis was somewhat uncertain, and which came to autopsy, the lesions of a dissemi- nated tubercular meningitis were present, but no signs of the typhoid process. I have therefore come to regard optic neuritis as in a certain sense a valu- able differential diagnostic point in cases of low fever of uncertain origin. Optic nerve atrophy, either partial or complete, may follow the neuritis, or, either single or double, may be present without preceding inflammation. These cases are usually noticed first in the convalescent period and come under more exact examination as post-typholdal phenomena. A matter of some Im- portance in determining the etiology of cases of OCULAR COMPLICATIONS. 309 post-febrile atrophy is to ascertain what treatment the patient has undergone, because it is well recog- nized that the excessive use of quinin during the fever may occasion amblyopia and even partial optic nerve atrophy. Intestinal hemorrhage may. also be the exciting cause of permanent blindness from atrophy of the optic nerve, precisely as this occurs after hematemesis. Amblyopia has also fol- lowed severe epistaxis (Ebert, quoted by Knies) and menstrual hemorrhage during typhoid fever, as re- ported by C. Williams.' Instead of intraocular optic neuritis, temporary or permanent impairment of vision may be due to retrobulbar neuritis, which may perfectly recover or eventuate in optic nerve atrophy. These cases have been referred to by Knies, and, as has been suggested by Bull, are difficult to study because the patient is usually too ill to permit perimetric exami- nation, which, no doubt, would reveal a central sco- toma. Occasionally the blindness may be due to a retrobulbar neuritis, caused, probably, by a hemor- rhage into the optic nerve, as in a case reported by Leber and Deutschmann, which is quoted by Knies. Amblyopia without ophthalmoscopic changes, simi- lar to the blindness occurring after or during scarlet fever, has been recorded, for example, by Ebert ^ and by Nothnagel,- and presents a favorable prognosis, the affection, according to Gowers, usually passing away in the course of several weeks. Leber has described anesthesia of the retina, and ^ Archives of Ophthalmology, New York, 1884, xiii, 397-399. 2 Berl. klin. Wochen., 1868. 2 Deutsch. Archiv f. klin. Med., 1872, ix, 470. 3IO SURGERY OF TYPHOID FEVER. Hersing an annular defect in the visual field. J. Stewart ' has observed, in a case of typhoid fever in a man aged thirty-two, setting in with men- ingitic-like symptoms, an island-shaped scotoma. The symptoms were attributed to blood intoxication. Neuro=retinitis with macular hemorrhages has been described by von Petershausen,^ and Munier^ has reported double blindness from neuro-retinitis. In his case there was probably a complicating meningo- encephalitis. According to Charles Stedman Bull, retinal hemor- rhages are by no means uncommon in the height of typhoid fever. They vary in size, shape, and ap- pearance, according to the portion of the retina in which the extravasation takes place, and are said usually to appear about the third week of the dis- ease. They may burst through the limiting mem- brane and involve the vitreous. Sometimes they manifest themselves in association with intestinal hemorrhage. The exact cause of retinal hemorrhage in this dis- ease has not been determined, but it probably de- pends, as Bull has suggested, either ilpon a weak- ened condition of the blood-vessel walls, or a per- verted quality of the blood, or both combined. Sometimes, no doubt, there is rupture of the vessel wall itself and sometimes a diapedesis. A micro- bic invasion of the vascular walls has been suggested by Dr. Keen (pp. 60 and 172) as a possible explana- tion of these and kindred hemorrhages. I am con- 1 Montreal Med. Jour., 1S94-9S, xxiii, 752-758. 2 Detroit Rev. Med. and Phar., 1873, viii, 533-541- s Th^se de Paris, 1874. OCULAR COMPLICATIONS. 31I fident that retinal hemorrhages are much more com- mon in typhoid fever than is generally supposed. The subject appears, in large measure, to have escaped the attention of clinicians. Finally, a few cases of embolism of the central artery of the retina have been observed during the conva- lescence from typhoid fever ; for example, by Gale- zowski ' and Snell.^ V. Affections of the Orbit and Orbital Cir- culation. — Galezowski refers to the fact that Bur- geois and Trousseau, among other complications, have reported thrombosis of the orbital veins, and Caron du Villards, phlegmon of the orbit. Orbital cellulitis as a complication of typhus is well known. It is possible that some of the cases may have been due to typhoid fever. Indeed, Swanzy and one or two other authors mention typhoid fever as a cause of inflammation of the orbital tissue, but orive no details. Panas 3 details the following remarkable case: A patient, seven years of age, who five years previ- ously had been under treatment for an angioma of the orbit, developed, during the course of typhoid fever, in the third week, phlegmonous inflammation of the orbit and panophthalmitis. When the bulbus was enucleated an angioma was found, the center of which had undergone suppuration. In the midst of the suppurating tissue bacteriological examination developed the presence of the bacillus of Eberth. Panas points out that this process must be explained on the theory of endo-infection, the thrombotic con- 1 Loc. cit. 2 Ophthalmic Review, i, 403. '^ Congr^s Frangais de Chirurgie, 5th session, Paris, 1891, 63-69. 312 SURGERY OF TYPHOID FEVER. ditions in the orbit presenting a particularly favorable field for the development of suppuration under the influence of the micro-organisms. A most interesting case of spontaneous orbital and intraocular hemorrhage occurring in the course of ty- phoid fever has been reported by C. A. Finlay.' It occurred in a boy, ten years of age, in the third week of typhoid fever, and was associated with the appear- ance of ecchymotic spots, not only in the conjunctiva, but all over the body and limbs. The cornese of both eyes sloughed. The patient recovered. Dr. Finlay has collected 26 cases of spontaneous orbital hemorrhage, but this is the only one which occurred during the course of typhoid fever. Finlay suggests that in his case there may have been some degenera- tive chancre in the walls of the blood vessels in con- nection with the oreneral lowerincr of the nutrition, or else the condition should be considered as a compli- cating purpura. VI. Affections of the Intra- and Extra-ocular Muscles. — As has already been stated, during the period of convalescence dilatation of the pupil and paresis of accommodation is not an uncommon affec- tion, Segal ^ describes mydriasis in typhoid fever with normal accommodation and normal vision, and con- siders the dilatation due to an irritation of the sym- pathetic. Paralyses of the extra=ocular muscles during the height of typhoid fever, unless there is some grave intracranial complication, are exceedingly rare. Nothnagel has reported double ptosis and right 1 Archives of Ophthal., New York, 1897, xxvi, 42-47. 2 Archiv f. Augenheilk., Wiesbaden, 1889, xix, 386. OCULAR COMPLICATIONS. 313 abducens paralysis at the beginning of the third week. In the period of convalescence they have been observed more frequently, and, according to Knies, may perhaps be attributed to a chronic nephritis, which in his belief is a frequent sequel of typhoid fever. According to this author, these paralyses recover quickly and also relapse quickly, and are nuclear in character. Finally, there may be muscular paralyses occurring at long periods after typhoid fever ; for example, a case of left trochlear paralysis reported by Rune- berg, which appeared one and one-half years after fever. The etiological relationship of the typhoid state to these palsies is very questionable. If there should be a complicating meningitis at the base of the brain, then, naturally, orbital muscle palsy might be expected, exactly as we find it in ordinary menin- gitis ; and, indeed, cases of this kind are not infre- quent. For example, Samuel West ' observed during a mild attack of typhoid fever in a child, aged ten, retraction of the head and strabismus, which disap- peared within a few days, the case resulting in recovery. A complicating meningitis of the cortex, or at the base of the brain, might produce hemianopsia, which, according to Knies, is a very rare phenomenon. 1 St. Barth. Hosp. Rep., 1S86, vol. xxii, p. 224. CHAPTER XXI. CONCLUSIONS. If now, by way of review, we cast our eyes back over the general results of all the complications and sequels we have studied, we may arrive at some useful and important conclusions. 1. Typhoid, probably from its usually longer duration, is by far the more prolific source of such surgical troubles, except parotitis, especially wdien we consider that many cases tabulated as typhus are really typhoid. Of 1699 cases, typhoid was the preceding fever in 11 39, typhus in 494, and other forms of continued fever in 66. Of the 494 after typhus fever, 352 were cases of parotitis. In the paragraphs which follow I have entirely omitted these, as they would so warp the figures as to give false results. The statistics are therefore based nearly entirely upon the typhoid cases. The former tables not having been preserved, the typhoid and typhus cases in each lesion could not be discriminated ; but besides the cases of parotitis there were only I 19 in all. 2, The surgical troubles to be apprehended in typhus, apart from parotitis (352 cases), are mainly restricted to gangrene and laryngeal stenosis, 103 out of the 1 19 cases after typhus being due to these two classes of disease, while typhoid bears in its train any and all of the forms of disease described. 314 CONCLUSIONS. 315 3. When the infection is a mixed iiifection of the typhoid bacillus and other bacteria, the result is a complication rather than a sequel, and the course of the disease is apt to be early in its onset, acute, and of a febrile character. When the infection is by the typhoid bacillus alone, the result is a sequel rather than a complication, and the course of the disease is apt to be late in its onset, chronic, and afebrile. In the pure typhoid infections the disease is often local rather than general, and the patient's general health suffers but little. 4. The cause of nearly all these surgical results (using this word to include both the complications and the sequels) of typhoid fever is the typhoid bacillus, and not, as I thought twenty years ago, the presence of a clotor of mechanical conditions. True, these mechanical conditions do influence the site of the lesions in many cases, as also does the existence of a clot, but the etiological factor of most impor- tance is the bacillus itself. The bacilli have not so far been found generally in the joints, in parotitis, otitis media, or the laryngeal lesions, and often not in gan- grene, abscesses, and hematomata; but their almost universal presence in the lesions of the bones, men- ingitis, abscesses, the gall bladder, and the spleen, would lead us to suspect their influence in the other cases, at least at some period of the disease. To many of the regions and organs of the body in which they are not usually found the pyogenic bacteria find a ready access, and undoubtedly exert a potent influence. But most of the surgical results can be attributed directly to the bacilli of the fever itself. 3l6 SURGERY OF TYPHOID FEVER. aided by odier bacteria and by unfavorable mechan- ical condidons. 5. The clinical course of the surgical results of typhoid is worthy of a word. It is often peculiar in that the same complication or sequel affects multiple regions of the body — ^-g-, a number of different bones — either simultaneously or successively; or, again, that two or more complications may attack the same patient — ^-g-, gangrene and an osseous lesion, or a laryngeal complication, and abscesses in different regions of the body. 6. The period of development is not the initial period of the fever, but, first, from its height to its close — that is, the complications, especially gangrene and stenosis of the larynx ; and, secondly and most frequently, during convalescence — that is, the se- quels. Of 622 cases, only 12 arose in the first week, 113 in the second, and 78 in the third, a total of 203. If we may assume that convalescence, on the average, begins at the end of the third week, then 419 occurred during or after convalescence. Many of them occur months, and even years, after the fever. This is especially true of the lesions in the bones. That the typhoid bacilli may cause such late manifestations of disease has naturally been doubted. But the array of proof, bacteriological as well as clinical, in the preceding chapters would seem to be complete and to set at rest any linger- ing doubt. The pure typhoid infections are, as a rule, later in their onset; the mixed infections occur much earlier. 7. The lower half of the body is the especial seat of such surgical troubles. With the exception, of CONCLUSIONS. 317 course, of the cerebral, laryngeal, aural, thyroid, and thoracic cases and parotitis, and the cases of biliary and intestinal perforations, of 942 cases of general disorders, such as gangrene, osseous lesions, etc., 515 occurred in the pelvic region and legs, as against 427 in all other parts of the body. Moreover, the diseases attacking the upper half of the body are limited almost entirely to local gangrenes and osteo- myelitis, caries, and necrosis, and they are usually far less severe in type and more limited in extent than those in the lower half. Here whole limbs are blighted by gangrene ; here occur most of the dis- locations, the hematomata, the fistulse ; here the severest necroses and largest abscesses ; and were we to add the loner catalooue of bedsores and phlegmasiae, the preponderance of the lower half of the body in importance would be still further increased. 8. The ao^c is about the usual agfe of greatest fre- quence of these fevers.' From fifteen to twenty- five years is by far the most frequent decade, count- 1 Liebermeister gives the ages in typhoid as follows : Fifteen to thirty, 1,310 Thirty to seventy-one, 394 Total, 1,704 None under fifteen were admitted. In typhus : Fifteen to thirty, 39 per cent. Murchison gives in typhoid : Fifteen to twenty-five, 2,752 All other ages, 3,i59 Total, 5,911 And in typhus : Fifteen to twenty-five, 5,332 All other ages, 12,806 Total, 18,138 3l8 SURGERY OF TYPHOID FEVER. ing 361 cases against 353 at all other periods of life. One singular exception is to be made — viz., the articular troubles, and especially dislocation of the hip, 32 out of 35 cases being under twenty years of age, of which 21 were in children under fifteen — in striking analogy to the frequency of coxalgia in children. 9. Sex is an unexpected and important factor in the predisposition to febrile surgical troubles. Of 745 cases in which the sex is named, 488. are males and 257 are females, or nearly two to one. What is the normal proportion of the sexes in fever it is difficult to determine. In nearly 6000 cases of typhoid, Murchison gives the proportions as pre- cisely equal, and in over 18,000 cases of typhus the females were in a decided majority (8871 to 9267). Estlander's figures would give us a slight prepon- derance of males, while Liebermeister, in over 2000 cases of typhoid, gives 1300 males and 750 females. Unfortunately, I omitted to tabulate the number of cases arising in military practice, which I am sure is not inconsiderable; but while this will ac- count to some extent for the predominance of males, it could not be adduced in the cases of arthritis and dislocation, since most of these patients were chil- dren, yet the males were in the preponderance. 10. To the sura-eon the most interesting recent de- velopments are those relating to biliary and intestinal perforation. We may even take courage as to these formerly almost uniformly fatal complications. Of four cases of perforation of the gall-bladder thus far submitted to operation, three have recovered. Nat- CUNCL US IDA'S. 3 1 9 urally, the outlook in intestinal perforation is far less encouraging-, but it is far from hopeless. Of 2>2, cases operated upon, 16 have recovered, or 19.3 per cent. If, knowing the possibility of recovery, physicians more frequently call in the surgeon, and do so at once, the future will show better results. I can not too strongly urge that the essential mor- tality of operations for typhoid intestinal perforation is not accurately estimated by the mortality of ail the cases (80.7 per cent.). 7 he real mortality tlms far is only 6g.^ per cent. ; that is to say, the mor- tality of the cases operated on within practically the first twenty four hours. After that nearly all hope is gone. The table on page 227 shows that, includ- ing case 64, operated on after tweht^^-six hours, there were, within this period, 36 cases with 1 1 re- coveries (30.6 per cent.). When every case of intes- tinal perforation {except the moribund) is operated upon zvithin twenty-four hotirs, I believe that we shall save at least one-third of the cases and possibly more. II. The diagnosis is, in general, moderately easy. The danger is not that difficulty of diagnosis may obscure the case, but that the diseases may be en- tirely overlooked. They occur most frequently in parts of the body covered by the bedclothes ; parts which require time and trouble to expose and ex- amine in the routine of an ordinary visit. More- over, the patient is frequently so apathetic and in- sensible to pain that he does not complain, or, if he do so, it is ascribed to the ordinary pains so frequent in the belly and legs in such fevers, or else to the delirium itself. Hence, the most important hint I can give in the 320 SURGERY OF TYPHOID FEVER. diagnosis — and where, indeed, does the same rule not hold good ?: — is that time and trouble must be taken, and that no patient suffering from a continued fever, and especially from typhoid, should escape frequent, minute, complete, physical examinations, in which every part of the body from head to foot should be questioned. Especially should the physi- cal condition of the larynx, the belly, the legs, and the toes, and, in children, the hip-joint, be exactly as- certained. This should be done at least every sec- ond day ; and that, too, not only in severe, but in mild cases, and not only during the fever, but es- pecially in early convalescence, for it is in just such mild and convalescent cases that the wariness of the doctor is the patient's surest reliance. Particularly should attention be paid to hoarseness or even the slightest change in the voice, and if these be pres- ent the larynx should be examined at once with the greatest care, from day to day, by the eye, the finger, and the laryngoscope, lest sudden edema or the more insidious and more fatal necrosis of the carti- lages be impending. The eye should seize upon any hindered movements, even without discomfort, and no complaint of pain should fall upon a deaf ear, especially if it be in the throat, the belly wall, the buttock, the hip-joint, the legs, or the toes. True, it may mean nothing. It may be the vagary of a wandering mind. But it may also be, as we have seen, the herald of the bravest dan o-ers, whose attack may be entirely repelled or their force broken by heeding this timely warning, 1 2. ^\\& prognosis is naturally unfavorable, yet not to the extent we would suppose from the addition or CONCLUSIONS. 321 sequence of such serious disease. Of 1037 cases in which the result is named, 456 died and 581 recov- ered — a mortaUty of 44 per cent. 13. The treatment must be bold, but not rash ; conservative, but not timid ; prompt, but not hasty ; thorouorh, but not reckless. POSTSCRIPT. The following- cases have been published since the foregoing pages were already in print, and are added to make the treatment of the subject as complete as possible. Dr. Hodenpyl's paper, referred to on page 45, has been published in the British Medical Journal for December 25, 1897, page 1850. Typhoid Infection without the Intestinal Lesions of Typhoid Fever (page 43). — Chiari, ' before the Pathological Section of the Moscow Inter- national Medical Congress, read a paper on cases of typhoid infection without infection of the mesen- teric glands or the intestine. He characterizes such cases as " typhus-septicemia." He reported the following case : Case LXI. — The Gruber-Widal serum reaction confirmed the diagnosis of typhoid, but at the necropsy no characteristic intestinal changes were found, but the bacteriological investigation showed the presence of typhoid bacilli. 1 Centralbl. f. alleg. Pathol, and patholog. Anat. , Oct. 15, 1897, viii, 790. 21 322 SURGERY OF TYPHOID FEVER. Case LXII^ — A man, age twenty-five, was admitted to the hospital, July 8, 1897, ^^ an am- bulant case of typhoid fever. He had suffered with headache, loss of appetite, and general weak- ness. The abdomen was distended, tense, and tender. Fading rose spots were visible. The spleen was palpable ; bowels constipated. The pulse was dicrotic. The blood gave the typical serum reaction. From the 8th to the 13th he was semi-comatose. Just before death his temperature reached 106.6°. Cultures made from the blood the day before death were sterile. He died on the 21st. The necropsy was made eight hours later by Drs. Adami and Nicholls. The mesenteric glands, espe- cially those about the ileo-cecal region, were en- larged, congested, and succulent. " The lowest three Peyer's patches of the ileum were very slightly raised above the general surface, but showed no signs of inflammation. The remaining Peyer's glands were normal. There was no evidence of ulcer- ation anywhere in the intestine nor any evidence of healed typhoidal lesions." By the microscope, clumps of the typhoid bacilli were found in the intestine and in the mesenteric grlands. A section through one of Peyer's glands which presented slight swelling showed small clumps of bacilli re- sembling typhoid. The blood-serum taken at the necropsy gave the typical serum reaction. Cultures from the spleen and the liver showed the typhoid bacillus and reacted to the serum-test. All these tests were made by Nicholls and Adami indepen- dently, and agreed exactly. Osteomyelitis of the Skull and Abscess of the Brain (Chapter VIII, p. 169). — The following ^Nicholls and Keenan, Montreal Med. Jour., Jan., 1898, p. 9. CO NCL US IONS. 323 case of presumed osteomyelitis and abscess of the brain following- typhoid fever occurred in 1889, but, owing to its defective title, I discovered it too late to insert it in the proper place. Case LXIII. — Terrillon ' reports the following case: On December 24, 1888, Richard was called to see a boy of thirteen with violent pain in the head, vomiting, and intense fever. After eight days his sickness apparently ceased, and it was believed that he had been ill of scarlet fever. Five days after defervescence — i. e., January 3, 1889 — "^^ ^'^^ seized with convulsions. The urine showed no albumin. The fever and the pain in the head re- turned, and he was delirious for five or six days. Richard was then convinced that the child's illness was typhoid fever. On the 20th of January con- valescence began, and appeared to be complete by February ist. On February 14th he began to complain of pain in the left temple, where a slight swelling was found. On the 20th an incision was made, which evacuated only blood. On the 21st, aphasia and paralysis of the right arm were observed, with a temperature of 38° C. Terrillon first saw the child February 23d. He found marked tumefaction in the left temple, with fluctuation and surrounding- edema. The boy was in a profound torpor. Paralysis of the right face and arm was still evident. An incision was immediately made over the left temple, evacuating a considerable amount of thick, grumous pus. The bone was denuded, and the base of the cavity lined with fungous granula- tions. On the 25th a temporary improvement which had taken place disappeared. The child was imme- diately trephined. The dura was not opened, but three punctures were made, and at the third, passing forward and downward, more than a tablespoonful 1 Bull, et Mem. Soc. de Chir. Paris, 1889, n. s. xv, 555. 324 SURGERY OF TYPHOID FEVER. of greenish, creamy pus was evacuated. An inci- sion was then made and drainage estabHshed. On awakening from the anesthesia he could move the right arm, and the facial paralysis had almost en- tirely disappeared. He was able also to pronounce several words. In spite of this apparent improve- ment, however, he soon became worse, and died on the 3d of March, five days after the operation. The conclusion of Terrillon was that an osteomyelitis of the bones of the skull had griven rise to both of the abscesses. Two very unfortunate omissions, however, are notable in the case : First, no necropsy was made, so that while the case was presumably one of typhoid, it is by no means certain ; and, secondly, and still more important, no bacteriological exami- nation was made, although the bacillus of Eberth had been demonstrated as the cause of typhoid nine years before. Suppuration Around the Pituitary Body with Thrombosis of the Right Sylvian Vein and Both Cavernous Sinuses (Chapter VIII, p. 169). Case LXIV. — The following case of this very unusual condition after typhoid fever is kindly fur- nished me by Dr. Joseph Sailer, of Philadelphia. A young man, twenty years of age, suffered a moderate attack of typhoid fever in the autumn of 1897, when under the care of Drs. Henry Morris and G. M. Marshall in St. Joseph's Hospital, Philadelphia. All the characteristic symptoms had been present, including the Widal serum reaction, at three different examinations. Durine defervescence he was sud- denly attacked by a severe chill, which lasted with intermissions for about forty-eight hours. During this period and three days later the Widal reaction was negative. Subsequently it reappeared, and was readily obtained in a dilution of i to 30. A few CO NCL US IONS. 325 days after his chill, swelling was noticed in the right parotid gland. This rapidly increased, and in a short time the patient developed bilateral exophthalmos, with considerable subconjunctival effusion. Fluc- tuation was then detected in the parotid gland ; the gland was incised and several ounces of extremely fetid pus removed. This was given me [Dr. Sailer] for examination, and found to contain a great variety of micro-organisms. It was not possible to isolate any, however, that resembled the typhoid bacillus. Death occurred two days later. I made the autopsy within five hours ; found a few typhoid ulcers in the ileum which were beginning to heal ; a purulent ex- udate in the left pleural cavity, also due to a mixed infection, and a suppurative condition about the hypo- physis cerebri, with thrombosis of the right Sylvian vein and both cavernous sinuses. Both retro-bulbar spaces contained a large effusion of liquid. Cultures of the bacillus pyocyaneus were obtained from the mesenteric o-lands. In the thrombi of the cerebral veins a number of species of micro-organisms were found, all of which have not been identified, but none of which resembled the typhoid bacillus. Cultures from the spleen were negative. Cholecystitis following Typhoid Fever (Chap- ter XVI, p, 244). — The following case of probable perforation of the gall-bladder has also been pub- lished by Dr. James Bell in the Montreal Medical Journal for January, 1896. Case LXV. — Miss C, age thirty-five, at the end of the second week of typhoid fever was seized with pain, vomiting, and a fall of temperature to 94.5°, early in the morning on September 21, 1897. The abdomen was opened September 24th, at 4.30 P.M. There' was no general peritonitis, but the 326 SURGERY OF TYPHOID FEVER. gall-bladder was distended and covered with patches of lymph, as also were the lower border of the liver and adjacent coils of intestine. There was no per- foration. By aspiration he withdrew six ounces of pus, which showed the typhoid bacillus in pure cul- ture. The gall-bladder was then incised and 152 gall-stones removed ; a drainage-tube was inserted and bile flowed freely. In the lower angle of the abdominal w^ound a drainage-tube and iodoform gauze packing were carried up along the under sur- face of the liver. She did well until the morning- of the 26th, when symptoms of perforative peritonitis set in, and she died at 4 a.m. on the morning of the 27th. An incomplete post-mortem examination showed a general purulent peritonitis, and four gall- stones were removed from the lower angle of the wound. The small intestine showed the typical lesions of typhoid. " In the absence of a complete post-mortem examination of the abdomen, my. [Dr. Bell's] interpretation of the sudden termination in this case is that ulceration of the deeper part of the gall-bladder or of the cystic duct had taken place into or upon the adjacent under surface of the liver, and that it was the bursting or emptying of this abscess cavity which set up the fatal peritonitis. In no other way can I account for the presence of the four gall-stones in the peritoneal cavity, as I am sure they did not escape into the abdomen at the time of the operation, and the steady flow of bile externally for hours after the fatal symptoms set in showed that there could not be any direct communication with the abdominal cavity. Moreover, the wound was exam- ined and the gall-bladder sutures found intact five hours after the onset of the symptoms." Leukemic Spleen following Typhoid Fever (Chapter XVII, p. 274). — While correcting the CONCLUSIONS. 327 proofs, the following case, almost the duplicate of Case XLIX, page 275, came under my own obser- vation. Figure 4, illustrating that case, was practi- cally exactly duplicated in the present case. Case LXVI.—E. L. P., of Mt. Holly, N. J., first consulted me, with Dr. R. H. Parsons of the same place, January 22, 1898. His age is thirty-three ; his average and present weight is 124 pounds. Three years ago he only weighed 95 pounds. His father is living and in good health ; his mother died of hemorrhage after a miscarriage. His paternal grandmother died of hemorrhage of the lungs at seventy-three ; his paternal grandfather is still living at ninety. His maternal grandmother died at eighty-one of old age ; his maternal grandfather of some unknown disease. For some two or three years he has suffered with alternate constipation, when he would often not have a movement for a week, and a loose condidon of the bowels, when he would have two or three movements a day; the latter gave him much relief. The patient has suf- fered from several attacks of grippe, notably a very severe attack in the spring of 1895. This was followed by typhoid fever, and from July to October, 1895, by an attack of inflammatory rheumatism. On his recovery from the inflammatory rheumatism his weight was only 95 pounds. In July, 1895, while under treatment for the rheumatism, and shortly after his attack of typhoid fever, his attending physician discovered a lump in his left side, and pronounced it an enlarged spleen. Not long after his recovery from the rheumadsm he had severe pain in the abdominal tumor, "so severe that he was almost crazy " for two or three weeks. From January to March, 1896, he was under the care of Dr. William Pepper, of Philadelphia, who confirmed the diagnosis of an enlarged and leukemic spleen. He has never 328 SUR GER V OF TYPHOID FE VER. had any blood in the urine or other indication of trouble with the kidney. For some time past he has been suffering daily from fever, his temperature rising to ioi° or 102°. In spite of this, however, ever since passing from Dr. Pepper's care he has been attending to his business, and, on the whole, seems not to have lost much ground. An examina- tion of the abdomen shows a tumor almost identical with that shown in figure 4, page 276. An ex- amination of the blood made by Dr. Kyle gives the following" result : Hemoglobin, . . 70 per cent. Red corpuscles per cubic mm., . . .4,066,000 " " " " normal, 3,000,000 White corpuscles per cubic mm., . . . 200,000 The case being one of leukemic spleen, I declined to interfere surgically. APPENDIX. TONER LECTURE, NO. V. REPRINTED BY THE KIND PERMISSION OF THE SMITHSONIAN INSTITUTION. SMITHSONIAN MISCELLANEOUS COLLECTIONS 300. THE TONER LECTURES INSTITUTED TO ENCOURAGE THE DISCOVERY OF NEW TRUTHS FOR THE ADVANCEMENT OF MEDICINE. Lecture V. ON THE SURGICAL COMPLICATIONS AND SEQUELS OF THE CONTINUED FEVERS. BY WILLIAM W. KEEN, M.D. OF PHILADELPHIA. Delivered February IT, 1876. WASHINGTON: SMITHSONIAN INSTITUTION, March, 1877. ADVERTISEMENT. The " Toner Lectures " have been instituted at Wash- ington, D. C, by Joseph M. Toner, M.D., who has placed in charge of a Board of Trustees, consisting of the Secre- tary of the Smithsonian Institution, the Surgeon- General of the United States Army, the Surgeon-General of the United States Navy, and the President of the Medical Society of the District of Columbia, a fund " the interest of which is to be applied for at least two annual memoirs or essays relative to some branch of medical science, and containing some new truth fully established by experiment or observation." As these lectures are intended to increase and diffuse knowledge, they have been accepted for pubhcation by the Smithsonian Institution in its " Miscellaneous Collections." The First Lecture of this series was delivered March 28, 1873, by Dr. J. J. Woodward, "On the Structure of Cancerous Tumors and the Mode in which Adjacent Parts are Invaded." Published by the Smithsonian Institution, November, 1873. 44 pp. 8vo. The Second Lecture was delivered April 22, 1874, by Dr. C. E. Brown-Sequard, " On the Dual Character of the Brain." Published by the Smithsonian Institution, January, 1877. 25 pp. 8vo. The Third Lecture was delivered May 14, 1874, by Dr. J. M. Da Costa, " On Strain and Over-action of the Heart." Published by the Smithsonian Institution, August, 1874. 32 pp. 8vo. The Fourth Lecture was delivered January 20, 1875, by Dr. Horatio C. Wood, " On a Study of the Nature and Mechanism of Fever." Published by the Smithsonian Institution, February, 1875. 48 pp. 8vo. Joseph Henry, Secretary Smithsonian Institution. Smithsonian Institution, Washington, April, iSyj. LECTURE V. Delivered Febmary 17, 1^76. ON THE SURGICAL COMPLICATIONS AND SEQUELS OF THE CONTINUED FEVERS. By William W. Keen, M.D. ok philadelphia. The province of the physician and that of the surgeon are, in general, sufficiently sharply defined and differenti- ated, yet they have many points of contact. . While some diseases belong exclusively to the province of the one, and some to that of the other, other diseases may fall with equal propriety under the care of either practitioner. Still another class of cases, however, beginning in the domain of medicine, may terminate in that of surgery, and we may lack their complete history from the very fact of this division of their care and interest. Among the diseases classed as strictly medical, none de- serve the appellation more definitely than the continued fevers, and especially typhus and typhoid. Yet I hope to show that fevers are not infrequently the cause of the gravest and least expected surgical troubles, mention of which is generally omitted, even in our best text -books on medicine, still more rarely noticed in works on surgery, and, where noticed, it is only with the greatest brevity. ^ 1 " The cases of constitutional disease discovered by fever might serve to illustrate a laraje part of the convalescence of fever, a subject of the highest interest and full of promise of utility to one who will carefully study it. The sequelse of scarlet fever are commonly enumerated ; those of typhoid fever, especially those seen ia surgical practice, are scarcely less numerous, but seem less known." Just as this is going to press, I find the above remarks by Sir James Paget, in his extremely interesting Clinical Lectures and Essays, London, 1875, p. 378. 333 334 SURGEI^y OF TYPHOID FEVER. My attention having been called to the matter by sev- eral personal cases, I have been led to study the subject, and I desire now to record briefly the results of an exten- sive search of medical and surgical works, as well as the records of individual cases, in the hope that by grouping together many isolated instances I may be able to con- tribute somewhat to our exact knowledge of the surgical complications and sequels of the continued fevers, both as to their causes, the means of their early recognition, the best methods of treatment, and, if possible, that still higher ob- ject — the averting of dangers which otherwise may prove disastrous to health, and too often to life itself The exanthematous fevers are better known as causes of surgical troubles, and I have therefore carefully excluded them, as well as a few cases following intermittent fevers. I shall omit entirely all well-known results of a semi- surgical character, such as hemorrhage from the nose and bowels ; peritonitis, with or without perforation ; erysipelas, a not infrequent complication about the face or when bed- sores exist ; and cases of thrombosis of the veins, which cause a variety of phlegmasia deserving a more extended study than it has yet received. Bedsores and the ordi- nary abscesses are too well known to demand other than passing allusions. Much as I regret to do so, I must also omit, from want of time, the consideration of the forms of disease which especially interest the ophthalmic surgeon. Ulceration and perforation of the cornea are briefly, but I may say completely, treated by Trousseau. ^ Post-febrile ophthalmia, or amaurosis, — a peculiar retino-choroiditis which follows only relapsing fever, first described by Hew- son, in 1814, and by Wallace in 1827, — has been so care- fully studied of late by ophthalmic writers as to leave but little further to be said. I shall include only such cases as diseases of the joints ; edema glottidis and necrosis of the cartilages of the larynx, which often require tracheotomy ; necrosis of the bones ; gangrene of the extremities and other parts ; fistulje of various kinds, and the like. The records of many cases are extremely imperfect ; some, in fact, are mere allusions, and I have been compelled, there- 1 Clinique Med. de I'Hotel-Dieu, 2d ed., p. 271, and Gaz. des H5p., 1856, 1 70. APPENDIX. 335 fore, in tabulating them, to come as near tlie truth as may be. The frequency of many symptoms is therefore greater than appears from my tables. Especially is it difficult to discriminate between typhus and tj'phoid fevers as causes. The earlier cases, before the essential abdominal lesion of typhoid was recognized, are all classed as typhus, and even to-day many cases, especially in German books and jour- nals, are briefly called "typhus," meaning "t}phus abdominalis " — /. e., typhoid. If any error exist, therefore, it will consist in assigning too many cases to typhus proper, for I did not feel permitted to go back of the record unless plainly authorized to do so by the history or the post- mortem. I. Dl.SEA.SE-S OF THE JoiNTS. Two forms of disease of the joints are found : first, a poly- articular inflammation, which may assume either a rheu- matic or a pyemic form ; and, secondly, a monarticular inflammation. The rheumatic variety I shall at once dismiss. The pyemic form of inflammation is not very common, for Mur- chison, with his immense experience in the London Fever Hospital, has seen but one case. It follows the usual course of pyemia, both in its symptoms and its usually fatal issue. Huss and others have referred it to suppurative phlebitis from bedsores, parotitis, etc., but it has been ob- served in cases in which no such complication existed. Pyemic arthritis, like the gangrene from pressure, parotitis, etc., is most apt to occur in severe cases, in which the blocd change is at its maximum, and the "typhous crasis," as Stokes has expressed it, possibly becomes converted into pyemia. • It is, however, the monarticular form which will most interest us. It affects the larger joints, such as the elbow and shoulder, the ankle and knee, but above all the hip. The pain is usually slight. The swelling is generally readily observed in all joints except the hip and the shoul- der, where it is probably obscured by the muscular masses about these joints combined with the tardy increase in the swelling. Usually it arises spontaneously, but occasionally from periostitis or necrosis extending into the joint. It rarely produces suppurative or fistulous openings. The 3 3 6 SUE GER Y OF TYPHOID FE VER. result is, therefore, generally a gradual return to usefulness, although in three cases I have found ankylosis. Of 43 cases, the lower extremities were affected in 39, the upper in only seven, three of the cases involving a joint in both, for occasionally two large joints are affected at once. Ar- thritis, therefore, resembles other surgical febrile affections, such as gangrene, necrosis, etc., in affecting mainly the lower extremities, as do also thrombosis and the ordinary edema. The frequency of these joint troubles is not great. According to Giiterbock,^ in a series of years in the Charite (Berlin) and the Hamburg Hospitals, not a case occurred, and in the Vienna General Hospital, from 1868 to 1871, only two cases among 3130. Murchison does not even name this complication at all, nor do any other of our text- books, either on surgery or practice, except a few lines by Volkmann in Pitha and Billroth's Handbuch. Giiterbock and Hellwig^ are the only authors who have treated them at all fully. Yet that they are of great importance, and demand our utmost attention, will be seen at once when we consider that of the 43 cases named, spontaneous dislocations oc- curred 27 times in the hip, twice in the shoulder, and once in the knee. These dislocations require more particular notice. From their similarity to febrile arthritis in the same and other joints their pathology seems clear, although — in singular contrast to the strangely fatal laryngeal stenosis I shall soon consider — not a single death has occurred, and there- fore no post-mortem verification has been possible. They belong to the class of " distention luxations." That the cause is not the specific poison is evident, since similar results follow other and dissimilar diseases, such as loco- motor ataxia, the exanthematous fevers, hemiplegia, sciatica, and rheumatism, as pointed out by Stanley in 1841.^ Usually, in the period of convalescence, following there- fore the prolonged exhaustion, there arises a subacute synovitis, Avith a gradual serous distention of the capsular ligament, which, having reached a certain point, may slowly ^ Ueber spontan. Luxat. und einige ander. Gelenkkrankh. bei Ileotyphus, Langenbeck's Archiv, xvi, 158. 2 Ueber die Affect, des Hiiftgelenk. bei Typhus, Marburg, 1856. ^ On Dislocation, Espec. of the Hip-joint. Med.-Chir. Trans., xxiv, 123. See also Malgaigne, Fract. and Disloc, Paris, 1855, ii, pp. 218-226, 882-887. APPENDIX. 337 subside, and no further evil follow. In three cases, how- ever, this burst externally, producing sinuses, but in none of them was the discharge purulent. The main result is a slow, generally uiipcrceivcd, elongation of the ligaments, — e.g., of the hip, — with perhaps also a swelling of the so- called gland at the bottom of the acetabulum. This dis- tention will spend its force mainly posteriorly, since the inverted Y-ligamcnt reinforces the capsular ligament in front. Given this condition, the slightest force will dislo- cate the head of the femur upward and backward on the dorsum of the ilium. In one case a fall to the floor pro- duced it, in three others turning over in bed, and twice the lifting of the patient in the arms from one bed to another. But in all the other 21 cases no cause was assignable, and it is, therefore, likely that it was mere muscular contrac- tion which becomes, at the time when these occur, more vigorous as health gradually returns. Seitz has recorded one of the most remarkable cases, in which, from extensive bedsores, the abdominal decubitus was maintained for nearly a month, and he supposes that this was the imme- diate cause of the dislocation. But as in no other case is this posture noted, it can not be regarded as correct. In- deed, if posture have any influence, as the dislocation is generally if not always iliac the dorsal decubitus would be the most favorable for its production. In one of the shoulder cases a subcoracoid luxation was caused by the patient's assuming the erect posture. Gravity had here probably some influence, together with the muscular exer- tion. The dislocation of the knee also was posterior. A remarkable case, corroborative of the non-specific character of the lesion and the probable influence of gravity, I have lately seen in the service of Dr. Wm. G. Porter, at St. Mary's Hospital. The child was about two years of age, greatly exhausted from malnutrition, and for about six weeks was kept alive by inunctions of sweet oil, no other nourishment whatever being given. It had large abscesses in different parts of the body, and at present has necrosis of the left humerus. Early in the period of returning strength, and before the necrosis appeared, spon- taneous luxation of the left humerus into the axilla oc- curred. It was easily reduced by manipulation, and has not since recurred. 338 SURGERY OF TYPHOID FEVER. Typhoid was noted as the preceding fever in 1 5 and typhus in 7 of the hip cases. Sex has a marked pre- disposing influence in this, as we shall find in other diseases, for of 23 cases, 15 were males and only 8 females. The age at which they occur is still more noteworthy : i 5 were under fifteen years, 6 from fifteen to twenty, i was thirty, and one was sixty-one years old; that is, 21 out of 23 were under twenty years old. The analogy to coxalgia, it will be observed, is therefore very marked. Usually they were single dislocations, 6 being on the right side and 6 on the left ; but in 3 cases dislocation of both hips oc- curred. From the apathetic condition of the patient in some cases, the subacute nature of the lesion, the absence or slightness of the pain, the masking of the swelling by even the wasted muscles about the joint, and, above all, the want of knowl- edge of cause or probability of the dislocation, and therefore the neglect to examine the parts thoroughly, it is not sur- prising that this threatening evil should have been often unobserved. In 9 — that is, one-third — of the cases it is dis- tinctly stated that the actual dislocation was the first fact observed, and in most of the others this is probably true. The date at which the dislocation was, at least, observed, was generally after the third week. One case occurred in the first week, 4 in the second, and 9 in the fourth week or later — that is, during distinct convalescence. Pain was ex- perienced in 13 cases. Usually it was not severe, nor was it always strictly localized in the hip, but sometimes extended to the entire leg. In only two cases was it referred to the knee, thus differing markedly from the well- known coxalgic knee pain. Swelling is only distinctly stated in 6 cases, though probably present here as in other joints, but either unobserved or often unrecorded in the brief statements I have often found. The variety of the dislocation is not named in 10, but as in all the other 17 it was iliac, there is good reason to believe that this is prob- ably always the case. Shortening is recorded in 1 1 cases, and where the amount is named was generally i ^ to 2 inches. In 5 cases the rotation was inward, in 2 outward, and in 2 of the 3 double dislocations both legs were rotated in the same direction, — that is, right or left, — thus producing a peculiar deformity when compared with the apparently APPENDIX. 339 reversely rotated body. Tiie head of the bone in 4 cases was freely movable in all directions. This mobility of the head and the singular diversity in the rotation of the limb are additional reasons in favor of the distention theory of its pathology. Flexion and adduction Dr. Sayre has shown to be the position of the limb which produces the greatest capacity of the capsular ligament of the hip, and we ought to see this position, therefore, as a rule, in distention luxations. But I only find two cases in which there were adduction and flexion. In the other cases the position is not stated, except in one in which the limb was extended. As to treatment, reduction is generally easy when the luxation is discovered early, but if the discovery or treat- ment be tardy it is always difficult and often impossible. In II cases reduction was successfully accomplished — seven times by manipulation, twice by extension, and twice by both means. In 8 cases reduction was not effected, and in 8 the result is not stated. Only 2 cases of recurrence of the luxation are noted, a rather surprising fact in view of the relaxation of the distended tissues ; but its pos- sibility should be borne in mind and guarded against by the same prophylactic means that I will name directly. No snap is heard on reduction, all tension and suction-power of the joint being lost. Even atter reduction the leg may be somewhat longer than the other, owing, probably, to the distention, to the swollen articular gland, and possibly in old cases to interstitial changes in the neck of the femur. The question of prophylaxis is perhaps the most impor- tant of all, and the indications are clear. First, a careful watching and repeated examination of the hip-joint, espe- cially in children, to detect any effusion. If any exist, the position of the leg becomes of the greatest possible impor- tance. As adduction and internal rotation favor spontaneous dislocation, the leg should be kept in abduction and exter- nal rotation. The first indication is easily fulfilled by two lateral sandbags, which may be bridged across in front at intervals by a bandage, to keep the leg at rest between them, or by lateral splints. The foot may be kept in external rotation by bandages or adhesive plaster fastened to the external sandbag or splint. If the effusion threaten to produce dislocation, it may well be a question whether aspiration would not afford a safe and efficient means of prophylaxis. 340 SURGERY OF TYPHOID FEVER. II. Diseases of the Bones. A popular name for necrosis is "fever sore," but, as Nathan Smith long since pointed out, more because it caused fever than because it was caused by fever. That it does follow fever and is caused by it is certainly true, but it is not a very frequent though a very important sequel. I have collected thus far 50 cases of necrosis proper follow- ing continued fevers, but among these are 19 reported by one single author, — VVhately, — the histories of which are exceedingly brief and unsatisfactory. He states, indeed, that he has seen 30 cases — an incredible statement, I think, in view of the fact that from all other sources, after an extended search, I can only gather 31 more. "Fever" with him, however, may include a very wide range. One element of unavoidable uncertainty in the history is seen at once. The osseous disease usually falls under the eye of the surgeon at a period distinctly subsequent to the fever, and, knowing nothing personally as to the previous medi- cal history, he must depend upon the statement of the patient — often a most unreliable means of information. Two causes for such necroses and other forms of disease, such as periostitis and caries, are to be found : first, throm- bosis, or in some cases possibly embolism ; and, secondly, absolute inanition or want of nutrition. The role assigned of late to the marrow together with the spleen as a source of the red corpuscles, would seem to be confirmed by the similarity of the changes observed by Ponfick 1 and others in the spleen and marrow in typhoid. In later convalescence, or shortly after recovery, we find in the marrow many mother-cells holding numerous blood- cells, enormous masses of large cells filled with pigment in complete analogy with the observed metamorphoses of extravasated blood. These are especially seen at the sides of the cavernous veins, and must retard still further a circulation already impaired in force by a weakened heart. Nutrition is here at its lowest ebb, and as the vessels, from the nature of the tissue in which they run, can not enlarge in proportion to the needs of the circulation, and are them- 1 Ueber die sympathischen Krankh. des Knochenmarks bei inneren Krankh., Virchow's Archiv, Ivi, 524. Cf. also Anatom. Studien iiber den Feb. Recurrens, Virchow's Archiv, 1874, Ix, 153. APPENDIX. 341 selves more or less involved in fatty degeneration, we may readily understand how the lack of nutrition alone, as in Dr. Porter's case previously cited, would cause gangrene ot the bone even more readily than in the soft parts, in which we know it to be so common. That the bones should suffer from vascular clots, and especially the bones of the lower extremities, where such clots are most frequent, as we shall' see, in gangrene, is probable both from analogy and experiment, and from one case in which it has been actually observed in typhoid. 1 There is no reason to suppose, when throm- bosis is so frequent elsewhere, that the bones would escape. Virchow has shown that in relap.sing fever we frequently have infarcts in the marrow. Volkmann ^ gives an ex- cellent case and illustration of necrosis of the tibia and talus from embolism, the result of endocarditis. We need a few similarly exact observations in cases of necrosis from fever, in which death or amputation affords the desired opportunity to settle the question positively ; but generally the examination, if made at all, is of the most superficial character. Hartmann ^ has shown, experimentally, that obliteration of the nutritious artery causes necrosis of the inner lamella of bone — a strong point it must be admitted, in favor of Whately's theory that after fever the result is not ordinary necrosis, but a central necrosis of the inner lamella which he limits to the tibia. Blocking of the veins is evidently not so dangerous in bones as blocking of the arteries, since the collateral venous circulation, especially toward the extremities, is abundant, while the collateral arterial circulation is scanty. 1 have found 69 cases of diseases of bone following con- tinued fevers. Of these, 50 were cases of necrosis, 12 of caries, 3 of periostitis, and 4 of indeterminate or doubtful nature. Three cases of necrosis following typhoid combined with small-pox I have excluded. Typhoid, as usual, claims the larger share ; for of 41 cases, 37 followed typhoid and ^ See Meusel's case, p. 344. 2 Pitha and Billroth's Handbuch, Bd. ii, Abth. i, Lief, i, p. 287 ; and Langenbeck's Archiv, 1864, v, 330. See also Molliere, Lyon Med., 1870, pp. 12, 149, 256; 1871, p. 38. ^ Nekrose herbeigefiihrt durch Verstopfung des Foram. nutrit., Virch. Archiv, viii, 114. 342 SURGERY OF TYPHOID FEVER. only 4 followed typhus. Males also are in the preponder- ance,counting 38 to 14 females. Age has not a very marked influence, as 19 were under twenty years, 11 from twenty to thirty, 1 1 from thirty to forty, and 5 over forty. Scarcely any region of the body escapes : 22 cases in- volved the head, 7 the trunk, 6 the upper extremities, and 42 the lower, a result strikingly in accord with the cases of arthritis and gangrene. In the head I have found 12 cases of necrosis of the alveoli and jaws. Among these per- haps the most remarkable, although somewhat doubtful, case is the one I saw in a soldier at Frederick, Maryland, in 1862, in which, after typhoid fever followed by pneu- monia, the entire right upper jaw with a part of the palate bone and the intermaxillary bone necrosed and separated. The case is remarkable, both from its being a striking example of the limitation of disease by the embryonic development, 1 and also from the extraordinary series of operations subsequently done by Dr. Gurdon Buck, of New York, 2 to remedy the frightful deformity which had been produced. It is but proper to say that the man was reported to have taken about two drams of various mer- curials during his preceding illness ; but from the facts I have stated, as well as his scanty history, I think it toler- ably clear that the fever, and not the mercury, caused the necrosis. Mercury or syphilis complicated two or three of the other cases I have tabulated, but they were not, apparently at least, the cause of the trouble. Mr. Salter ^ has pointed out the relation of alveolar necrosis to the eruptive fevers, especially scarlet fever, and believes that as these structures are dermal in character they partake with the skin in the eruptive mischief While this relation remains undisturbed, yet I do not think the necrosis exists as a specific sequel of these fevers only. Of the 12 cases cited, 7 occurred as follows: i at six- teen, I at twelve, and 5 at ten years of age and under — that is, during the period of dental development and 1 H. Allen, Studies in the Facial Region, Phila., 1875, ^'^^ specially- called attention to this point. 2 Trans. N. Y. State Med. Soc, 1864, p. 173; Circ. No. 6, S. G. O. Surg. Sec, Spec. 557, p. 53; Med. and Surg. Hist. War of the Rebel., Ft. i, Surg, vol., pp. 375-377, and Buck on Reparative Surgery. 3 Holmes' Syst. Surgery, 1st ed., vol. iv, p. 50. APPENDIX. 343 growth. That such cases are more frequent in the exan- themata is natural when we consider the relative infre- quency of the continued fevers under fifteen years of age. The period at which these diseases of the bones arise varies greatly. Of 47 cases, 10 arose in the first two weeks, 27 in from three to six weeks, and the remaining 10 fol- lowed often months after the fever. The earlier cases in- clude, probably, most of those from clots, and the later ones those arising from enfeebled nutrition, whose effects, especially in structures which vary so slowly as the bones, may readily extend over such long periods. Especially does this enfeebled nutrition show itself in cases where too early strain is put upon the parts and justi- fies the remark of Aitken that " no man can be considered fit for work or for general military service for three or four months after an attack of severe typhoid fever." The fol- lowing case illustrates the wide-spread mischief that may follow in the osseous system when put to the test by labor, months and even years after such a fever. [For the full history of this case, see Case IX, H. W., P- 123.] The symptoms need scarcely be alluded to, for they are those of ordinary necrosis, although Whately endeavors to differentiate them. In 13 cases of necrosis of the long bones other than Whately's in which the description en- ables me to judge, I find only 3 distinct cases of central necrosis, ^ and these differ in no especial manner from other cases. That it is limited to the tibia, as asserted by Whately, is disproved by the fact that of 77 bones affected, the tibia was attacked only 30 times, including in these the 19 reported by Whately. The results of necrosis vary with the situation. The ^ The third of these cases I have had in private practice while the MS. is passing through the press. A. W., a rather feeble girl, age eleven, was taken sick with typhoid May lo, 1876. After three to four weeks in bed she began to walk, but soon had to stop on account of weakness, and especially of pain in her left tibia. After three weeks' poulticing it broke in two places, and has discharged ever since. I saw her first in December, 1876, and found two small sinuses which extended into the bone, but no dead bone had ever been discharged. After building up her general health by tonics and cod-liver oil, on February 17, 1877, I operated on the bone, using Esmarch's apparatus in the manner I have suggested (Phila. Med. Times, Sept. 26, 1874), and after making an opening into the medullary canal with the chisel and gouge, I removed a small, loose spicula of necrosed bone (central necrosis) y% of an inch long. At this date, March 5, 1877, she is doing well. 344 SURGERY OF TYPHOID FEVER. ordinary sinuses, etc., I need not mention further. If in the sacrum, coccyx, or innominate bone, perineal fistulae may result, of which I have found three cases. If in the mastoid or petrous bone, the brain and its membranes may be involved. The following resume of the case of Meusel is of especial interest, as it throws so much light on the cause of the necrosis, the clot in the meningea magna, and is as extraordinary for the audacity of the treatment as for the success of the result : A student in the gymnasium, age nineteen, at Easter, in Fig. I. — Necrosis of frontal (A), parietal (B), and greater wing of sphenoid (C) bones, following typhoid. In B and C the grooves for the middle menin- geal artery and its branches are seen. Natural size. (Meusel, Deutsche Klinik, 1872, page 266.) 1868, had an attack of typhoid fever, went home when convalescent, but did not improve, and suffered much from headache. In August, four months after the fever, he had a large fluctuating abscess over the right parietal region, which was opened, and dead bone found. By October ist the bone was loose, and on the 5th an incision of three inches was made and a loose piece of the frontal was re- moved. The rest of the dead bone was firm, but the APPENDIX. 345 incision was extended backward until the whole of the necrosed portion was exposed. It was then carefully chiseled loose and separated at the squamous suture. At the anterior inferior angle the necrosis was there found to extend on the internal surface only ; with a fine chisel this internal lamella, a piece 1^X2 cm., was chiseled away from the great wing of the sphenoid. In it was a groove in which lay the anterior branch of the middle meningeal, filled with the detritus of a clot. The whole piece was 5 j^ X 9 cm. The dura mater was but slightly injected. The scalp and the dura mater united, and in fourteen days he was nearly well, having recommenced his Latin and Greek with the greatest zest eight days after the operation. Two small pieces of loose bone afterward caused threatening symptoms, but improvement followed immediately upon their discharge. In March he was en- tirely well, and went to Gottingen to study philology at the University. Epileptiform attacks followed during 1869, but then disappeared, and had not reappeared in 1872. As to treatment, the ordinary operation for the removal of necrosed bone is to be done at the proper time, especial care being taken to remove any small central sequestrum. Occasionally the disease of the bone may cause extensive disease in the soft parts, or may extend to a neighboring joint, though either complication is rare. Amputation then becomes imperative. Only four such amputations occurred in the cases reported ; two died, one recovered, and one was under treatment. About the face not infrequently extensive plastic operations are required. III. Diseases of the Larynx. The laryngeal complications are noted very briefly by several medical writers, such as" Murchison, Flint, Lieber- meister, Griesinger, etc., but it is mainly the laryngeal ulcers themselves which are treated of, their surgical results being scarcely mentioned. Gross and Gray barely allude to typhoid as a cause of edema glottidis. Even systematic writers on the larynx scarcely notice them. Gibb ^ and Ruble ^ refer to two or three cases. Cohen 1 Dis. of the Throat and Windpipe, 2d ed., 292-294. 2 Die Kehlkopfskranldi. , Berlin, 1861, 157, 257, and Fig. 2. 346 SURGERY OF TYPHOID FEVER. simply names fever. Tiirck ^ gives, however, eight valuable cases. I have collected 169 cases, of which at least 67 (and probably many more) certainly involved the cartilages themselves. The troubles which may demand surgical interference are all allied, and are the result of a low grade of inflam- mation. The entire respiratory mucous membrane (as is shown by the frequency of bronchitis) is in a more or less catarrhal condition, like that of the bowels, and occasion- ally other mucous membranes, such as those of the gall- bladder, urinary bladder, and vagina. It is not, therefore, a matter of surprise that serious trouble should arise in the larynx, especially as slight variations in its mechanical condition gravely embarrass so vital a function as respira- tion. Pathologically, the troubles may be grouped into three varieties — viz.: (i) Edematous laryngitis ; (2) ulcerative laryngitis ; (3) laryngeal perichondritis. Practically it is often exceedingly difficult to separate these various forms, even at the post-mortem, so far do they overlap each other. Edema may exist alone or it may result from either of the others ; ulceration may march steadily deeper until the cartilages are involved ; or the perichondritis may pro- duce an abscess which will burst, and so form an ulcer. How much more difficult, nay often impossible, then, is it to diagnosticate precisely the form of the disease, when, happily, the patient recovers. Dyspnea, suffocation, — this is the one great overshadowing clinical fact which groups them all together, whatever the form of the disease or of the preceding fever. That simple asthenic edema may arise just as edema of the lower extremities is not only probable but has been pos- itively observed by Emmet ^ and Buck. ^ It has also been observed after diarrhea, bronchitis, and other diseases ; but this is a much rarer form than those cases in which it is secondary to erysipelas, or parotitis, or laryngeal ulcers, often of small extent. I can not help suspecting, also, very strongly that more careful future examinations will 1 Klinik d. Kehlkopf., Wien, lS66, 215-235. 2 Amer. Jour. Med. Sci., July, 1856, xxxii, 63. 3 Trans. Amer. Med. Assoc, 1848, 135. APPENDIX. 347 show in not a few cases that local venous thrombosis has been the cause- of the edema. The other two forms especially merge into each other. Rokitansky believes that the ulcers are a peculiar form of typhus — the so-called laryngo-typhus. Others, and 1 cer- tainly agree with them, do not beheve that they are specific in their origin, but belong "to the common cortege of septic diseases" and other allied disorders in which the low grade of inflammation readily runs into ulceration, and even into local gangrene. How much influence local stasis of the blood or even clots in the vessels may have has not been carefully investigated, but I believe them to be no unimportant factors. These ulcers are sometimes very common. Thus, Grie- singer ''^ met with them in 31 out of 118 autopsies, Hoff- mann 2 in 28 out of 250, and Louis believes that "if found on the body of one who has died of an acute disease, they will establish with nearly perfect certainty, and without going any further, that the affection is typhoid fever." At other times they are so rare that in nearly 13,000 typhus cases at the London Fever Hospital, Murchison records but 21 of laryngitis, of whom 8 died ; and in typhoid he has only seen three or four cases. Where the cartilages are involved, Moritz-Haller ^ and others believe that it follows the ulceration which destroys the mucous membrane and eats down to the cartilages, while Sestier ^ has gone so far as to declare that the ulcers which accompany perichondritis are not primary but in all cases secondary. Both, I believe, are right, but both go too far. So far as the history and post-mortem appear- ances would enable me to judge, I have found in 20 cases that the perichondritis preceded the ulcers and caused them, while in 10 cases the ulceration had caused the perichondritis. In cases of perichondritis in which death takes place early, there i^ no opening in the mucous mem- brane, but a submucous abscess will be found surrounding the necrosed cartilage. If death takes place at a later date, a small opening will exist, through which the probe ^ Infectionskrankh., 1857. Bd. ii, Abth. ii, s. 160. ^ Verand. d. Organ, beim Abdom. Typhus. ^ Oesterr. Zeitschr. prakt. Heilkunde, 1856, No. 19. * Arch. Gen., 1850, 4me ser. xxxiii, 385 ; xxiv, 35, 297, 441. 348 SURGERY OF TYPHOID FEVER. will enter into a much larger cavity. In other cases the surface mischief will be by far the most widely spread, the ulcers being roughly conical, involving not only the mucous membrane, but eating deeply down to the cartilages. Simi- lar necrosis of the nasal cartilages also sometimes results from fever. Those cases in which there is considerable cough, or the patient in his delirium has cried aloud, or sung much, or those in which, after distinct convalescence, there has been exposure to wet and cold, are predisposed to laryngeal troubles. They are exceedingly rare in children. In 94 cases in which the age is recorded, I have found but 6 under fifteen years of age, 60 from fifteen to twenty-five, and 28 above twenty-five years. Sex is potent here as in the other diseases considered. Lisfranc thought them more common in women than in men, but of 1 10 cases, I' find 86 in men and only 24 in women, or 31^ to i. The cause of the stenosis is various. It may be : (i) from edema ; (2) the swelling produced by the abscess about the cartilage ; (3) the sides of the glottis may fall together if the cricoid be destroyed and in pieces ; (4) the perma- nent approximation of one or, more rarely, of both, vocal chords from destruction of the fixed points of origin of the muscles ; (5) as in two remarkable cases given by Hoff- mann, ^ shreds of sloughing tissue, on which blood coagu- lates, may form a sort of polyp, which suffocates the patient even in spite of tracheotomy (Fig. 2). The seat of the stenosis is threefold. Most frequently (25 cases) it is'supraglottic — that is, in the epiglottis and ary-epiglottidean folds, especially where the edema is pri- mary, or where it is caused by ulceration or arytenoid peri- chondritis. The next most frequent site is subglottic — /. e., about the cricoid (22 cases). This is always, I believe, the result of cricoid necrosis or perichondritis. Russell^ re- ports two cases following typhus, which he regards as examples of Gibb's " subglottic edema." That the second was a case of ulceration and perichondritis is quite certain from the history, and most likely the other was too. The larynx was normal down to the chords, tracheotomy res- cued both when suffocation was imminent, and both were 1 Op. ciL, pp. 253 and 255. 2 Glasgow Med. Jour., Feb., 1871, 209. APPENDIX. 349 followed by stricture, requiring the permanent use of the cannula. The least frequent site of the edema is in the glottis proper, since, edema of the vocal chords is named iDut nine times. The date of the development is generally here, too, in the later fever, or more frequently in distinct convalescence. Of 1 02 cases only 4 occurred in the first week, 13 in the second, 19 in the third, and 66 from four weeks to two months. They follow typhoid far more frequently than typhus, in the proportion of 106 to 49, some of the latter Fig. 2. — Laryngeal ulcer after typhoid. Polypoid hematoma hanging from it and causing death by suffocation after tracheotomy, a, upper end of incision. The smaller cut, b, is a section of the hematoma showing its two layers, the center consisting of shreds of dead tissue hanging from the ulcer, and the outer layer of clotted blood. (Hoffmann, Verand. d. Organ, beim Abdom. Typhus, Tafel v. Fig. i6.) being probably really typhoid, while 14 arose from other forms of continued fever. The position of the ulcers in the larynx is noteworthy. Wherever they may be, from the arytenoid to the cricoid, they are almost invariably posterior. Rheiner ^ has shown that the posterior wall of the larynx is the richest in ves- sels, and that ossification begins here often as early as the twentieth year. Here, then, we should expect the most frequent inflammations and thrombosis of the smaller ves- 1 Beitrage zur Histologic des Kehlkopfs ; Wlirzberg, 1852. 350 SURGERY OF TYPHOID FEVER. sels ; and when we add to this the effect of gravity, from the continuous dorsal position, and the mechanical effects of frequent use of the voice, and, therefore, repeated move- ment of the arytenoid cartilages in some delirious cases, we have a sufficient explanation of the phenomenon. Emphy- sema of the neck and trunk is an occasional result of such ulcers where they penetrate the mucous membrane. This was first pointed out by Wilks.^ Other cases are reported by Steiner^ and Loeschner.^ All three were children. X \±ii'hik L$^ Fig. 3. — Perichondritis laryngea following typhoid. Ulcers on the pos- terior wall of the larynx. At a, a piece of the necrosed left arytenoid cartilage shows. (Tiirck, Krankh. des Kehlkopfes, p. 216, Fig. 78.) Necrosis of the cartilages is the most important form to recognize, in consequence of its excessive gravity ; for, of 56 cases in which the result is given, 54 died. One recov- ered after tracheotomy,^ and one without it. ^ We can scarcely agree with Tiirck, therefore, that the prognosis is " doubtful." The seat of the necrosis in the majority of the cases is the cricoid (38 tiines), next, the arytenoids (19 1 Med. Times and Gaz. , 1862, ii, 276, and Trans. Path. Soc, London, 1857, ix, 34. 2 Djs. of Children, 1874, 363. 2 Prager Vierteljahr., 1856, iv, 23. * Xurck, p. 223. 5 Herard, I'Union Med., July 14, 1859, quoted by Trousseau, Clin. Med., Syd. Soc. Trans., 2d ed., vol. ii, p. 407. APPENDIX. JD times), while the otiier cartilages were affected but 5 times. In 10 of the cases the cricoid and arytenoid were involved simultaneously. It is to be specially observed that j^robably a number of the cases which recovered were also really cases of peri- chondritis, of which the positive evidence was wanting. Fig. 4 — Perichondritis larynges following typhoid ; abscess opened from esophagus and seen from behind : a, b, Necrosed and partly destroyed cricoid cartilage ; between a and b the dark area indicates the point where the abscess communicated with the trachea ; it did not communicate with the esophagus ; c, crico-arytenoideus posticus muscle. (Tiirck, Krankh. des Kehlkopfes, page 218, Fig. 80.) Thus, in 8 cases in which recovery followed tracheotomy, the patients spat up gangrenous or purulent matter, besides having other symptoms of cricoid necrosis ; but as the ex- pectoration of any pieces of necrosed cartilage was not posi- tively observed, I have not included them in my statistics of necrosis. Were they included, the result, and especially the result after tracheotomy, would be far more favorable. 352 SURGERY OF TYPHOID FEVER. Whatever the origin of the necrosis, the cartilage is soon destroyed, either by molecular disintegration or is even broken in pieces. Sometimes it undergoes ossification ; at others, caseous degeneration. The articulations of the car- tilages are also often destroyed, especially those of the cri- coid, with the arytenoid or with the thyroid ; and thus again voice is impaired. The function of the muscles, especially those which open the glottis, is impaired or de- stroyed, from direct implication of the muscles or from destruction of their cartilaginous attachments, or of the Fig. 5. — Perichondritis after typhoid: Opposite a the edematous aryepi- glottidean folds are seen. Below the vocal chords the larynx was narrowed by thickening of the connective tissue. Opposite b a movable piece of the destroyed and broken cricoid, which has perforated the esophagus, is seen. (Riihle, Kehlkopfkrankh., page 178 and Plate I, Fig. 2.) articulation ; and thus the vocal chord of that side is immo- bilized, and altered voice and stenosis of the larynx follow. If an abscess form about the cricoid, it may not only burst into the larynx but also into the pharynx, and a fistulous opening be established by which food may enter the larynx and trachea. This, Dittrich ^ thinks, is the most frequent point of opening ; but I have only found it recorded in six instances, though such an abscess would have burst here in several other cases had life been prolonged. An addi- tional complication may follow also in the pharynx. The 1 Prager Vierteljahr., 1850, iii, 117. APPENDIX. 353 cricoid presses upon its posterior wall, both from swelling and from ^^ravity, and this pressure, together with the foul purulent discharge, may cause an ulcer ; or, as in a case recorded by Armstrong, ^ a retro-pharyngeal abscess. Hoff- mann '-^ records another case of retropharyngeal abscess extending from the base of the skull to the diaphragm, laying bare the left subclavian artery. This, however, did not result from a laryngeal necrosis. The earliest symptom of grave laryngeal disease is usually an altered voice. I have only found it distinctly stated as unaltered in three cases. Generally it is hoarse, some- times higher, but usually lower, in tone, probably from involvement of the crico-thyroid muscle. Sometimes com- plete aphonia sets in. Stokes ^ has supposed the hoarse- ness and deafness both to be due to the muscular degenera- tion, to which I shall allude hereafter ; but it is more likely to be due here, at least, to edema and inflammatory swell- ing, and, at a later period, to the mechanical destruction of the parts involved. Soon after this hoarseness is observed the d)-spnea sets in. This is paroxysmal, the attacks being generally at night. With each succeeding attack the severity increases, until life is destroyed ; but even the very first attack m.ay be unexpected, sudden, and fatal. Especially does this seem to be the case in typhus and in supraglottic edema. Emmet and others have recorded a number of cases in which, even without the least previous dyspnea, on simply assuming the erect posture sudden suffocation came on, and life was only saved by instantaneous laryngotomy. The delay of " a few minutes " caused death in one case which otherwise would probably have recovered. Most frequently the dyspnea is inspiratory, but I can not find that this is of any decided diagnostic value. The expectoration, curiously enough, aids us but little ; in but few cases did it attract sufficient attention even to be named ; but if it be purulent or gangrenous, it should arouse instant attention. Pain and tenderness, though often masked by the mental condition, are generally pres- ent, especially in perichondritis. As we have the resisting vertebral column behind the cricoid, I would strongly urge 1 Pract. Illustr. of Typhus Fever, 1819, 399. 2 Op. ciL, p. 388. ^ On Fevers, Phila., 1876, p. 105. 23 354 SURGERY OF TYPHOID FEVER. that both by direct and lateral pressure on the cricoid, and also by sliding it sidewise, we may often elicit pain which might otherwise be overlooked. Lateral pressure will also often produce dyspnea, or aggravate it, especially if the cricoid be broken, or nearly broken, in two. Dysphagia is noted as present 21 times and absent 5 times, and is especially present in cricoid and arytenoid necrosis. Rarely is there any external swelling to attract attention, for I have only found it noted thrice. Nor can the pharynx be relied upon to warn us of impending evil, for in 16 cases in which its condition was observed, it was normal in 10 and inflamed in only 6. Most of the cases occurred before the days of the laryn- goscope, so that I have only 13 such examinations from which to draw any inferences, 7 of which are recorded by Tiirck. In several instances there was nothing what- ever abnormal down to the vocal chords ; and the swelling of a cricoid abscess on the posterior wall is not visible. But the usual facts observed were the fixation of at least one chord in the middle line, diminished mobihty of the other, swelling of the ary-epiglottidean folds, stenosis of the larynx increased by lateral pressure, a depression of the mucous membrane in case of destruction of the arytenoid, and sometimes the opening of an abscess, usually near the processus vocalis. A few such positive facts with any additional positive symptoms should lead to an equally positive treatment. And first the mortality is so great that the treatment is of the greatest possible moment. Of 146 cases of all kinds of stenosis in which the result is recorded, loi died and 45 recovered, a mortality of over 69 per cent, but not a surprising result when we add the laryngeal disease to the exhausting fever. But when we separate the cases operated upon from those in which no operation is named, or was certainly not done, the importance of the treatment becomes even more appreciable. Of the ^6 cases not operated on, in which the result is stated, — and, be it ob- served, I have included in these the cases of mere scarifica- tion, — 17 recovered and 59 died, a mortality of over 'jj per cent. Of the 70 cases operated on by some form of bronchotomy, 28 recovered and 42 died, a mortality of 60 per cent. And when it is remembered that in two of the APPENDIX. 355 fatal cases the larynx was not opened, though tracheotomy was apparently performed ; and a third, in full recovery thirteen days after the operation, on the removal of the cannula was suddenly suffocated before it could be replaced ; and in another the cannula got displaced in front of the trachea ; that in many, if not in most, of the cases, the operation was deferred until the last possible — that is, the most unfavorable — moment ; that many cases that might have been rescued were ^\2av\\y allozvedX.o die from exhaus- tion, or even from positive suffocation, by timid doctors, in which the result could not have been worse had an opera- tion been performed, the question of operation would seem to be decided. Yet I would not be understood as an advocate of rash and indiscriminate bronchotomy. Its dangers are great, and not to be undervalued. The question, however, is often between a dangerous operation and a more dangerous refusal. In case the attack is sudden and severe, so that life is in immediate and positive peril, no question can arise as to the propriety of an operation, wanting which the patient perishes on the spot ; nor any question that crico-thyroid laryngotomy is the easiest, safest, speediest operation. Delay here means death. Of 14 such operations, 8, or 57 per cent., recovered, and in such cases as are recorded by Emmet and Anderson ^ no words can add force to the fact that after life was apparently extinct, laryngotomy and arti- ficial respiration saved five, the delay of a few minutes re- sulting fatally in the sixth case. A cut throat here is not over-dangerous, and the operation is so simple and may be so imperative that every medical man, as well as sur- geon, should stand ready to do it in case of impending death. But it is in the less suddenly threatening cases that judg- ments may differ, and here I hope to be able to assist in forming a decision. The moment, in a case of typhus or typhoid, that hoarseness, aphonia, dyspnea, or dysphagia sets in, the larynx should be examined with the utmost vigilance both from without and by the laryngoscope. If edema or ulceration be found, but the danger be not as yet severe, leeches, iodin, ice in rubber bags, or, possibly, a blis- 1 Ten Lectures on Fever, London, 1861, 46. 356 SURGERY OF TYPHOID FEVER. ter may be used externally, and astringents, nitrate of silver, etc., internally, together with proper general treatment. In 1819 Lisfranc proposed scarification and operated success- fully in six non-febrile cases, and in 1847 Buck revived the practice and devised an appropriate knife. The laryngo- scope has made such treatment far more certain, and it should first be tried in suitable cases. But, should these means fail ? Then an early rather than a late tracheotomy, for otherwise we add to the previ- ous enfeebling disease a prolonged battle for breath, with its ensuing pulmonary congestion and general exhaustion. Especially is this to be commended in the peculiarly fatal necrosis of the cartilages. Of 67 positive cases, 41 of which occurred in men and only 10 in women, all died but 2, one with and one without an operation ; 22 were oper- ated on, 45 were not. But, as before mentioned, 2 died from displacement of the cannula, at least one of which had practically recovered ; 8 cases of recovery after tracheot- omy are not included, since, though the presumption in favor of necrosis is very strong, yet the evidence is not positive. Were only these 8 included, and it is certainly fair to do so, it would stand 30 operations and 10 recov- eries, a mortality of 67 per cent., and 45 not operated and I recovery, a mortality of nearly 98 per cent. Once, then, that perichondritis is established, death is almost unavoidable if no operation be done. If bronchot- omy be resorted to, the chances are greatly improved. Indeed, it is probable that if the dangers w'hich surround such cases be recognized in the future, and a prompt attempt at relief be made, far more favorable results will be ob- tained. I would, therefore, join with Sestier in urging an immediate operation the moment that perichondritis is rec- ognized and serious dyspnea sets in, without waiting for repeated attacks to exhaust the slight store of strength, all of which will be needed during the subsequent separation of the necrosed cartilage, and the sloughing of the soft parts. In other cases than those of perichondritis such haste will not be necessary : yet if the respiratory murmur be progressively enfeebled ; if pulmonary congestion set in ; if the paroxysms of dyspnea increase in frequency and severity, especially if orthopnea arise ; if the local disease APPENDIX. 357 be extensive or rapidly increasing ; or if the general feeble- ness be so great that a little further interference with the respiration will destroy life ; then no time is to be lost. Doubt is certain death. What operation shall be performed ? If an instant operation be needful, crico-thyroid laryngotomy is the best ; if time allow, tracheotomy. But if the cricoid be involved, with Beck,i I would advise laryngo-tracheotomy, — i. e., tracheotomy prolonged through the cricoid, — since it would allow readier access to the seat of the disease for the dis- charge of the pus, the removal of any loose piece of car- tilage, and the treatment of any ulcers or granulations. These I regard as greater advantages than the danger of possible collapse of the lateral halves of the cricoid, which is prevented in part by the cannula, and would not impede the respiration even if it occurred. Unless necessary, it is best not to operate during a paroxysm ; since the mechan- ical difficulties of the operation are then largely increased, and the danger of entrance of air into the veins is appar- ently much greater. In 36 operations for laryngeal angina, two such accidents occurred ; whereas, in 245 non-anginose cases, not a single similar accident arose (Sestier). Hemorrhage, as would be supposed from the condition of the blood, is sometimes a serious compHcation, both at the operation and subsequently, and caused death in three cases. A curious and unexpected complication arose in two cases reported by Mohr^ and Laennec,^ the^ knowledge of which should guard us against a similar error. The operation having been apparently achieved and the cannula inserted, respiration was not bettered nor did air pass through the cannula. In a few minutes the patients died suffocated. At the post-mortem it was found that the cannula had entered, not the larynx, but the abscess around the cricoid. In Mohr's case the vertebra were felt through the incision, and a probe and the cannula moved freely about in what was naturally believed to be the trachea but proved to be the abscess cavity.* 1 Verhandl. Phys. Medic. Gesellsch., Wiirzbur^, 1868, i, 27. 2 Casper's Wochen., 1842, p. 192. Also in Dittrich, Prag. Vierteljahr., 1850, iii, p. 129. ^ Bayle, Nouveau Journ., t. iv, p. 37. 4 Green, Brit. Med. Jour., Dec. 17, 1870, p. 649, and Marsh, St. Earth. Hosp. Reports, iii, 368, report cases (not following fevers, however) in which the tube was inserted in the cellular tissue in front of the trachea. 358 SURGERY OF TYPHOID FEVER. In three cases of edema the cannula was removed in six, eight, and nine days respectively. But after such serious loss of substance and extensive organic mischief as are in- volved in the cases of perichondritis, it is not a matter of wonder that the stenosis of the larynx is generally per- manent. In 17 cases of probable or actual perichondritis, the cannula was removed in one case after seven months, but in the other 16 cases, when last seen, the patients were still wearing them. Once, after seven years' use, a piece of the cannula wore away, broke off, and fell into the trachea, whence it was successfully removed by Albers. Busch, Russell, and others have attempted to dilate the stricture, both from above and below, but without any success. ^ IV. Gangrene. The cases' of gangrene may be divided into two classes : . A, those from pressure ; and B, cases of spontaneous gan- grene. A. Those from pressure, or the ordinary bedsores, are not peculiar to the continued fevers, as is well known, but arise from any prolonged debilitating disease or accident. They are more common, therefore, in typhoid fever than in typhus, on account of its greater duration. But they not infrequently follow typhus, if it be prolonged by any com- plication. The only points in addition to the greater dan- ger of pyemia, to which I desire to call attention, are as follows : First, as pointed out by Nelaton,^ Blandin,^ and others, if they penetrate deeply they may destroy the ligaments uniting the sacrum and coccyx, and so penetrate into the spinal canal and set up meningitis, etc. This complication, I believe, arises much more frequently from bedsores, what- ever their cause, than is generally known. Recently I have had two instances : one arising from a bedsore follow- ing confinement, the specimen which I show you, and which I owe to the courtesy of Dr. Schell, my colleague at St. ^ By the courtesy of Drs. Otis and Woodward, of the Army Medical Museum, the casts and specimens of Dr. Buck's case, p. 342, and of several cases of laryngeal stenosis, were shown. 2 Path. Chir., Paris, 1844, i, 256, 257. * Anat. Top., 2me ed., p. 437. See also Charcot, Mai. du Syst. Nerveux, 2me ed., i, 89, 90. APPENDIX. 359 Mary's Hospital ; and the other in a boy who injured his knee and died some weeks after from tetanus induced prob- ably by this complication. I have found six cases of teta- nus recorded ; four following typhoid and two typhus. Four of them were females. In one it was clearly caused by a bedsore. 1 Four of them died, but the two women who recovered had had menstrual irregularities, which probably caused the alleged tetanus. ^ Secondly, large bedsores, as in two cases reported by Chenu in the Crimea, ^ may greatly hinder free motion of the legs and trunk by the extensive cicatrices. Thirdly, the treatment first proposed, I believe, by Brown- Sequard, of ice poultices for fifteen minutes, followed by hot flaxseed poultices for two to three hours, often stimulates the most indolent bedsores to heal with surprising rapidity. During and since the Civil War I have repeatedly and suc- cessfully tried this plan of treatment. Sometimes gangrene results from the slightest pressure, as in a case reported by Stokes,* in which there were 30 such spots, two or three new ones appearing every morn- ing at points of such trifling pressure as where the mammae leaned on the arms, or one leg on another, and a black hand appearing where the face had rested on the hand. Strange to say, the woman recovered after a month's abdominal decubitus. For such cases Liebermeister recom- mends an almost continuous and complete bath, the body resting and reclining on sponges. B. But the cases of so-called spontaneous gangrene, though less frequent, are of far greater interest from a sur- gical point of view. They vary greatly in frequency. Thus, neither Flint nor Trousseau ever saw a case ; Nelaton does not name fever as a cause of gangrene ; Murchison, though he has seen a few. does not cite a single English post-mor- tem. Yet Estlander ^ reports 34 cases, and I have collected in all 113 cases. The frequency varies in proportion to 1 Maclagan, Edinb. Med. Jour., 1S67, 297. 2 Delairiere (Jour, de Med. Chir. et Pharmac, xiii, 19) reports also a case of hydrophobia, which became ataxic, following a quotidian fever. The patient had been bitten by a healthy dog three mdnths before. R. Reid (Pathol, and Treat, of Fever, Trans. Queen's Coll. Phys. Ireland, iii, 41) alludes to the similarity of hydrophobia and the excitable stage of fever. 3 Rapport, pp. 520, 524. * On Fever, Phila., 1876, p. 210. 5 Archiv klin. Chir., 1870, 453. 360 SURGERY OF TYPHOID FEVER. the severity of the case and of the epidemic, and espe- cially to the preceding conditions as to bodily nourishment, mental depression, and general mode of life. In former wars especially, from the time of Thucydides to that of Napoleon, fierce epidemics, especially of typhus, have deciminated armies and often displayed a most frightful tendency to gangrene. But of late, whether in civil or military prac- tice, if we may judge from the scanty gleanings I have been able to obtain from the journals and the experience in our own Civil War as well as in the late European wars, the condition of the sick has been so ameliorated that gangrene is happily a rare complication. The history of the extraordinary series of cases reported by Estlander well illustrates these predisposing causes. In Finland, a financial crisis and a series of bad harvests from 1862 were followed in 1865—67 by sporadic cases of fever, mainly typhoid ; but from the thrifty habits of the people and governmental support, the epidemic was at first neither severe nor extensive. Then came the cold and rainy summer of 1867, followed by a very bad harvest. That winter typhus raged in almost every household, so that often the well were not numerous enough to nurse the sick. The death-rate rose from 2.74 per cent, to 7.69 per cent. Instead of an annual increase in the population of over 15,000, it decreased in 1868, nearly 94,000 ; and this in a population of less than 2,000,000. Of 105 doctors, 30 sickened and 8 died. Up to 1868 not a case of gangrene occurred, but in the first seven months of that year 28 cases occurred. Then came the bountiful harvest of 1868, and by August the epidemic had almost disappeared. Yet the lingering effects of the previous want were seen in six later cases of gangrene. But such an experience is altogether exceptional. From other writers I have rarely obtained more than two or three cases. Estlander's 34 cases were all, except one, from typhus ; but of the remaining 79 cases, 43 followed typhoid, 22 typhus. The influence of age is not very marked, as is seen in the fact that of 76 cases, 8 occurred before fifteen, 27 from fifteen to twenty-five, and 32 after twenty-five years of age. But sex, as usual, has a marked determin- ing influence. Of 81 cases, 56 were males and 25 females. This is the more curious when we consider that the APPENDIX. 361 number of deaths in men, and therefore presumably of cases, does not hold at all the same relation. In 1868, in Finland, 31,000 males and 28,000 females died ; yet of 31 cases of gangrene of the legs, 25 were males, and only 6 females. The site of the gangrene is very suggestive also. In 5 cases it was in the ears, 10 in the nose, 27 in the face, neck, and trunk, 5 in the arms, 7 in the genitals, and 72 in the legs; that is, of 126 localities, in "jj it was in the ex- tremities, and in 22 more in other peripheral districts of the vascular system — ears, nose, and genitals. As far as the pathology of the cases is concerned, they may be divided into two classes : (i) Those with a discover- able clot and (2) those without such a clot. Murchison believes that all cases of spontaneous gangrene arise from arterial thrombosis, but the careful post-mortem examina- tions of Estlander and others show that, at least in the larger visible vessels, sometimes no such thrombus exists. I. Those with clot. The cause of such clots, as Hum- phrey 1 and others have shown, is not the condition of the blood-vessels. But seldom have I found it stated that the arterial walls were diseased, and when they were it was presumably a secondary process, the result and not the cause of the clot. Few, if any, pathologists will now attribute such results, with Bourgeois, ^ to a metastasis, especially when arising in convalescence, as these so fre- quently do. Gigon ^ has attributed them to chemical altera- tions in the blood which give it an irritative character, and this, with friction at points of curvature, produces inflammation and coagulation. If so, a fair proportion of cases should be seen in the upper extremities, where the same irritating blood circulates and similar curves exist. How rare this is we have already seen. Although the precise factors in determining the throm- bosis in any individual case may be somewhat doubtful, as also why it is frequent in one epidemic and rare in another, apparently frequent in Germany and rare in Britam, and especially rare in the United States, yet three causes clearly exist which may vary inter se in producing the result : (i) The altered blood ; (2) the weakened heart ; and (3) the 1 Brit. Med. Jour., 1859, p. 582. 2 Arch. Gen., Aug., 1857, 149, and L' Union Med., 1S61, xii, 80, 249. 3 L'Union Med., 1861, xi, 577, 611, and xii, 127. 362 SURGERY OF TYPHOID FEVER. mechanical difficulties in carrying on the circulation, especi- ally in distant parts. That the blood is profoundly altered, and probably has an increased coagulability, is conceded. In some cases, even, air is found in the veins, as noted by Crisp ^ and Lebert. ^ That every such change, besides its depressing effect upon the nutrition, and therefore upon the vitality of the tissues themselves, would interfere more or less with its circulation, and consequently predispose to thrombosis, is most prob- able. But when we look at the seat of the cases of gan- grene of both varieties which are under consideration, I think the conclusion is inevitable that the last two causes are the more immediately determining factors. The heart, as Stokes showed, is softened in its texture, and therefore weak. Hayem ^ has shown that myocar- ditis is extremely frequent, and not rarely involves the endocardium. From the sixth to the fourteenth day is its weakest period, and not only is the general force of the circulation diminished at this time, but, all the blood not being squeezed out of its cavity, clots may form in the heart, and then, or at -a later period, when the heart regains somewhat of its force, be washed into the circulation and lodge as emboli. Such seems to have been the origin of the clot in a remarkable case related by Patry.* A decolorized adherent embolus was found high up in the left external carotid, on which a secondary thrombus had formed nearly down to the bifurcation of the primitive carotid. Pain appeared from the jaw to the temple on the twentieth day of typhoid ; two days later the ear was cold and violet, the artery pulseless, and the gangrene rapidly extended to the entire left side of the head and face, involv- ing even the bones. I have found, however, but eight other cases in which the embolic nature of the primary ob- struction was clear ; but often the want of a minute exam- ination of the clot renders the report useless, and sometimes, probably, the primary embolus is so overshadowed in size and importance by the secondary thrombus as to be overlooked. ^ Dis. Blood-vessels, p. 18. 2 Prag. Vierteljahr., 1858, i, 33. Moorehead, Trans. Med. and Phys. See, Bombay, 1843, P- 68, also reports a case. ^ Lepons clin. sur las Manifest. Cardiaques de la Fievre Typhoide, 1875, 49- ^ Archiv. Gen., 1863, i, 144. APPENDIX. T>G^ The third factor, the mechanical difficulties of the distant circulation, combines almost inextricably with the weakened heart in producing the spontaneous coagula or thrombi. It is, nevertheless, clearly the principal factor in precipitat- ing the gangrene in the lower extremities. Not only, however, are the inferior parts of the body thus involved in gangrene, but the frequency of venous thrombi, and the resulting phlegmasiae in the same region, is a strong argu- ment in the same direction. Bouchut ^ found in 5 i cases of non-puerperal venous coagula that 44 were situated in the pelvic, femoral, or tibial veins. I have memoranda of 63 cases of venous coagula following the continued fevers in which the site is stated. Only two cases involved the upper extremity alone, and both were followed by gan- grene ; one involved both the arm and leg ; all the other 60 cases were limited to the lower extremities.^ Both forms of coagula — the arterial and the venous — form most fre- quently during or just after the period of greatest cardiac weakness — a weakness felt most at such distant points, as the legs. Of 18 arterial cases 12, and of 43 venous cases 24, occurred in the second and third weeks of the fever. Moreover, the preceding circumstances — such as famine, in- dividual poverty, and the deprivations of war — are such as impair the nutrition and the circulation in the peripheral districts of the body. The coagulation also takes place at points mechanically favorable to slowing of the currents — e. g., the bifurcation of arteries and the valves in the veins. ^ In the veins, at least, as described by Humphrey, the clots are sometimes laminated, the outer layers of decolorized fibrin, and therefore the oldest, and the center, a bar-like recent coagulum of dark or black blood. Once that the obstruction exists in the artery, it extends by additional coagulation, so that the collateral circulation may be widely and rapidly cut off. The progress of the clot can often be watched from day to day by the pro- gressive annihilation of the pulse — first, for example, in the tibial, then in the popliteal, then in the femoral or higher — ^ Gaz. Med. de Paris, 1845, p. 241. ^ See a very interesting case which got well after a second attack of typhus thirty years later, Stokes on Fevers, Phila., 1876, p. 249 (republished in Med. News and Library). 3 See a carefully reported case of Phlegmasia by Cole, Med. Times and Gaz., 1875, '> 5- 364 SURGERY OF TYPHOID FEVER. and by the parallel progress of the gangrene. In cases of recovery this cessation of the pulsation and the hard tender cord in the course of the vessels are, of course, the only, but sufficient, proof of their occlusion. That gangrene follows so much more frequently in febrile thrombosis than after the traumatic thrombus which accompanies ligation is not surprising, in view of the condition of the blood, the general enfeeblement, and the more wide-spread arrest of the collateral circulation. Yet, on the other hand, pyemia, which has so much to favor it, especially in the cases of venous thrombi, is a rare sequel. Even when, it does follow, it is in most cases apparently the secondary result from the septic influences arising from the gangrenous parts. The circulation in the artery being cut off, it is not strange that clots should follow in the veins ; but even where both are obstructed moist gangrene rarely follows. The foot especially generally mummifies. But this is not always the case. Occasionally the gangrene is moist from the beginning, from early obliteration of the vein, or, having begun as dry gangrene, — e. g., of the foot from a popliteal clot, — suddenly both the femoral artery and vein may be obstructed, and a moist gangrene of leg or thigh be added. Gangrene from venous obstruction alone is very rare. It is more apt to follow in the arm than in the leg.^ Coagulation of the blood may also be caused occasionally by direct mechanical causes in fevers, as in a case given by Jaesche, in which a swollen gland surrounded the common iliac artery at its bifurcation and caused a clot, probably by direct pressure or by induced arteritis. 2. The second variety of spontaneous gangrene is that in which no clot apparently exists — certainly no such clot as is commonly designated either an embolus or a thrombus ; that is, a local clot of some size in an arterial trunk, which cuts off the circulation in the tissues supplied by its branches. But even in these cases I believe that the con- ditions affecting the circulation, already so fully considered, will more readily and rationally explain the causation of the gangrene than any specific action of the indefinite though ^ Hueter (Virchow's Archiv, xvii, 48) records, however, a very interesting case of gangrene of the right leg following a spontaneous clot without assign- able cause, the vein wall being healthy. APPENDIX. 365 undoubted poison of the fever. Coagulation I believe still to be the cause, but not in the larger trunks. It begins, rather, as a blood stasis in the capillary circulation. The parts in which the often extensive coagulation takes place are at once struck with gangrene, and, as the blockaded vessels themselves are all involved in the general destruction of the gangrenous tissues, all evidence of the nature of the lesion is thus destroyed. This form of gangrene occurs generally in the nose, ears, penis, perineum, labia, feet, and occasionally the fingers ; that is, in parts supplied by no one large vascular trunk, but by many smaller branches — not only in parts distant from the center, such as the feet, but in parts which lose their heat most readily by reason of their thinness and small size, and parts irritated, it may be, by local discharges. Very probably, also, it may be due to the fatty degeneration of the smaller arteries, as observed by Hoffmann, Zenker, and Ponfick. Raynaud ^ (and, fol- lowing him, Fischer and Estlander) ascribes it to a spastic ischemia, from contraction of the arterioles. The frequent bilateral or symmetrical character of this variety, to which Raynaud has called especial attention, would indicate at least the probability of some such central cause. Whether, if it exist, it be the direct result of irritation of the nerve- centers, as is seen in the other nervous phenomena of fever, or whether it be a reflex spasm caused by the circulation of deteriorated blood, similar to that to which Dr. George Johnson has attached so much importance in Bright's disease, we can at present only surmise. The symptoms of gangrene are marked and character- istic. Toward the end of the fever, especially in the third week, or early in convalescence, as weakness is giving place to strength, and the brightest hopes of speedy recovery are cherished, sudden, severe, and persistent pain is felt. Usually it is at the seat of the impending gangrene, though not uncommonly at the clot itself, radiating thence to the periphery. In the lower extremities it is often felt in the ball of the great toe or in the heel. It is followed by numbness, coldness, loss of sensation, and sometimes of motion, and in a short time discoloration and all the other usual evidences of gangrene appear. Sometimes, but not 1 De I'Asphyxie locale et de la Gangrene Symmetrique des Extrem., Paris, 1862. 366 SURGERY OF TYPHOID FEVER. usually, these local symptoms precede the pain. If the distal vessels be examined, the pulsation will be found feeble or utterly extinguished, while higher up, at the seat of the obstruction, they will be changed into moderately firm but tender cords, in which we may sometimes differentiate the artery from the vein — an important point in prognosis. Week by week, sometimes day by day, the process of the coagulum may be traced upward by the abolition of the pulsation and by the upward march of the gangrene. If old cicatrices exist, they will be among the earliest parts to yield. Blebs may form in the early stages, but most frequently they \\\\\ dry up, and the parts will mummify, although, as already indicated, moist gangrene may super- vene if a large clot form higher up, or if the veins are exten- sively obliterated, thus involving great masses of moist tissue, such as the thigh, in sudden ruin. Life may be rapidly destroyed, as, in a case recorded by Barker and Cheyne,^ in two and one-half hours after gan- grene began in the nose ; but more commonly days or weeks will elapse, during which nature, as usual, makes a powerful effort to rid herself of the dead parts by the establishment of a line of demarcation. On the establishment of this the pain often ceases. If recovery follow, the circulation is carried on by col- lateral branches, or, in very rare cases, the artery again be- comes partially pervious. ^ This last result Humphrey has shown to be not infrequent in veins, and Petres ^ has recently elucidated its mechanism through the extension and coalescence of the vasa vasorum. In the variety of gangrene without a thrombus, the symptoms will vary somewhat. It is not so uniformly in the lower extremity, and is much more frequently symmet- rical. If small in extent, pain is not apt to be a leading feature. The onset is often earlier, and from the nature of the case its progress is sharper, and its limits much more quickly defined, so that usually, within a few days, at least, the boundary of the gangrene is pronounced, since it does not progress with any gradually growing thrombus. For the same reason it less frequently returns in the stump after 1 Account of the Fever lately Epidemic in Ireland, London, 1821, vol. i, p. 232. 2 Patry, Archiv. Gen., 1863, i, 136. 3 Edinb. Jour., Aug., 1875, p. 175, from Le Progres Med. APPENDIX. 367 an amputation. Its area, also, is usually much less than in those cases in which a thrombus exists, rarely extending in the leg beyond the foot or ankle ; and it rarely involves surrounding parts to a large extent if it occur in the nose, ear, genitals, etc. Sometimes, however, it may extend more widely, as in a case of typhus and starvation mentioned by Lyons,! jj-i which the patient walked to the workhouse, and on baring his chest the whole of the right side was " a dark, olive-green, jelly-like, tremulous mass." The abdominal wall is sometimes similarly involved. The probably irreg- ular area in which the stasis of the blood will take place in this form also accounts for the great irregularity generally seen in the line of demarcation ; whereas, if a clot exists, it is apt to be fairly even. This sudden history is usually followed by a speedily decided issue. Death follows quickly, or reaction and recovery set in within a short time, instead of hanging in the balance for months. The results of spontaneous gangrene vary much, according to its situation and extent. In the extremities, if life be saved, the result is usually an amputation, either by nature or by the surgeon. In the nose, it may perforate the septum or destroy the entire organ to a greater or less extent. During some civil, as well as military, epidemics of typhus, this seems to have been a favorite spot for its beginning, so that the disease was popularly known early in this centur}^ as the "Blue Nose," ^ and inspired terror whenever it appeared. In 1834, Mauthner says, it was an extremely common result, seen in all the military hospitals, and " all hope was gone as soon as this dreadful symptom was seen." Another not infrequent form is noma, or cancrum oris. This is especially frequent in children and in the army. Murchison speaks of it in the Crimea as frequent and invariably fatal ; Chenu, however, in his report does not name it. Its ravages are extremely extensive, often involv- ing even the bones. The ear, also, and the eyelids are sometimes destroyed. 1 On Fever, p. 191. 2 See Mauthner, Ueber das typhose Fieber mit Nasenbrand, Hufeland's Jour., 1834, Ixxviii, 46; Kraft Ueber Typhus BelHcus u. die blaue Nase, Hufeland's Jour., 1815, xli, 81 ; Gutberlet, Die blaue Nase bei dem Typhus Bellicus, Hufeland's Jour., 1816, xlii, vi, loi ; Wendelstadt, Die blaue Nase beim Typhus Bellicus, Hufeland's Jour., 1816, xliii, v, 131, and Barker and Cheyne, loc. cit. , i, 232. 368 SURGERY OF TYPHOID FEVER. From each of these, singly, or all together, the most fright- ful deformities often follow, which require the utmost ingenuity in the plastic operations necessary to remedy them. In many cases the gangrene is local and subcu- taneous, producing necrobiotic masses of tissue, which are, I believe, often, if not generally, the cause of the abscesses so commonly seen in all parts of the body. Sometimes even the mediastina are opened, — the anterior from the chest wall, the posterior from the deep tissues of the neck^, — unless, by a timely surgical operation, the danger be averted. The male genitals are occasionally destroyed to a greater or less extent. Except the organic destruction, no special result follows, except, possibly, hemorrhage, for one case is recorded of death from a hemorrhage of fgxxx from the scrotum.^ That the perineum and the female genitals are not more frequently the seat of gangrene is rather surprising, when we consider the neglected condition of many of the patients and the constant soiling of the parts, as a result of uncon- scious and unavoidable discharges, especially in females. The troubles of the female generative organs are either distinct external gangrene, or gangrenous ulcers in the vagina. I have found 9 cases, — 8 from typhoid and one from typhus, — all in young persons from seventeen to twenty-seven years of age, except one of thirty-four. In 6 of the cases there was gangrene of the labia, extending sometimes to the perineum and the thigh. At least one case was followed by contraction of the vulva. ^ In another, reported by Gueneau de Mussey,^ there was com- plete occlusion of the vagina and menstrual retention, necessitating puncture, with a fatal result. The ulcers are generally on the -posterior wall of the vagina, and in three cases recto-vaginal iistulae have resulted. One is reported by Lebert ^ in which, when convalescent in the seventh week, chill, fever, and diarrhea set in, and four weeks later the fistula was discovered by injection. It was situated in front of the hymen, and was as large as a five-centime piece. A 1 See Fraentzel, Berlin, klin. Wochen., 1874, xi, 97 ; Werner, Med. Cor- resp. Wiirttemb. Aerztl. Verein, Stuttgart, 1859, xxix, 76, and Hoffmann, loc. at., p. 388. 2 Murchison, p. 194. 3 Russell, Glasgow Med. Jour., 1864-65, xii, 165. * Gaz. Hebdom. , 1867, 652. ^ Anat. Path., ii, 307, and pi. cxv. APPENDIX. 369 month later she died of pelvic peritonitis. A second is reported by Liebermeister. ^ It was caused by the slough- ing of a large piece of the recto-vaginal septum, in mass. The large fistula thus produced healed without operation. The third case has been under my own observation in St. Mary's Hospital for three years past, and is the only case 1 have found of both recto-vaginal and vesico-vaginal fistuLne. [For this case in full, see Case II, p. 80.] The perineum suffers mostly in males as 8 to 3, while in 2 cases the sex is not stated. Typhoid was the cause in II, typhus in 2. Although not all cases of gangrene, they may be surgically grouped together, since all but one produced perineal fistula;. The exception '^ was a case fatal from a large abscess around the membranous urethra. Three fistulie were caused by necrosis of the pelvic bones or sacrum, and nine by gangrenous ulcers, which sloughed not only externally, but in five certainly communicated with the rectum, and probably did so in others. Except two cases of twenty-one and twenty-two years of age, they all occurred (when the age is stated) from thirty-nine to seventy-four years of age, later in life than most of the other sequels. They arose from the third to the seventh week, — that is, during distinct convalescence, — and to this is probably due the fact that 10 recovered and 2 died, one from the peri-urethral abscess, the other from hemorrhage upon sloughing into the rectum. The question of treatment of gangrene is,' after all, the most important in a practical point of view, and is divided naturally into the preventive and remedial. The general supporting treatment of the disease is, of course, the most important preventive. Next, a careful and repeated exami- nation of the body, especially the parts most likely to be attacked. If gangrene is specifically threatened, stimula- tion of the circulation, both at the center and at the threat- ened spot, is imperative. To stimulate the center, alcohol in liberal doses is the best remedy, and two extremely in- structive cases are given by Stokes.^ In one, "the surface was cold, and the pulse imperceptible. From the middle of the calf of each leg downward over both feet the sur- 1 Ziemssen's Cyc. , Amer. ed., vol. i, p. 184. 2 De Change, Arch. Belg. de Med. Mil., 1861, xxviii, 126. 3 On Fever, Phila., 1876, p. 205. 24 370 SURGERY OF TYPHOID FEVER. face was black, the skin hanging in loose wrinkles, giving an appearance as if the patient had on a pair of black socks." Sixteen ounces of brandy in the first eight hours saved his life. Digitalis might also possibly be used with advantage. The peripheral circulation must be stimulated by such means as will assist the threatened circulation by inducing alternate dilatation and contraction of the arteri- oles. Permanently wrapping up the part in cotton, and other similar means, will but assist permanent vascular dilatation and stasis. The alternation of the two is the condition of health, and its artificial production will tend to restore healthful reaction. Chapman's ice- and hot-water bags to the spine, alternate heat and cold directly to the parts, with proper friction and stimulating liniments, at once commend themselves to us. The constant current battery also may prove an extremely useful aid, since it dilates the deep as well as the superficial vessels, and will aid the collateral circulation. But suppose gangrene actually occurs, what then ? Est- lander gives most judicious counsel here. W emust re- member that good results follow both to life and limb zvWi- oiit operation, especially if the gangrene be limited and the patient not too exhausted. We must not, therefore, be rash in our interference. If amputation has to be done, the question as to where it should be done depends on the probable extent of the gangrene ; as to when, on the line of demarcation. In the non-thrombotic cases, as the line of demarcation is usually established within two or three weeks, and the disease is not then likely to be progressive, the amputation maybe done but little above or even through it. It is, therefore, usually best to wait for its formation. In the thrombotic cases, the clot and the gangrene are apt to be progressive. Until the line of demarcation forms, therefore, it is impossible to say precisely where the disease will stop. Yet we can gain some idea of the probabilities of the case from past experience. If the clot extend no further than the popliteal, the limb may escape gangrene altogether, and if it follow, I have found it limited in 9 cases — to the foot 4 times and to the upper calf in 5 ; if the clot extend into the femoral, I find the gangrene extended to the upper calf in 6 and to the thigh in 4 ; if the clot extend above Poupart's ligament, I APPENDIX. 371 find in 10 cases it was limited to the foot in i, the calf in 3, and extended above the knee in 6. The results of am- putation are good, giving 2 i recoveries to 2 1 deaths, but the recoveries are largely after amputations in the foot. Before demarcation was established, 5 out of 8 died ; after demarcation, 12 out of 22 : a mortality, respectively, of 63 and 55 per cent. As a rule, therefore, wait for the line of demarcation, but amputate soon after its appearance ; but if danger of septic poisoning or of speedy exhaustion should appear, amputate at once, at or above the probable limitation of the disease, which, if the femoral be free, will not be, in the majority of cases, above the tubercle of the tibia ; but if the femoral be involved, amputation would probably be more dangerous than the expectant treatment. As dead parts slough, they should be removed to prevent septic poisoning. Fortunately, there is but little danger of hemorrhage, either primary or secondary, in the throm- botic cases, since the arteries are all plugged securely. Of course, the ordinary treatment of the gangrenous ulcers and abscesses, especially of the perineum and geni- tals, should be pursued, but I would particularly urge the importance of free incision, especially in abscesses in the vicinity of the anus, and the use of detergent and stimulat- ing washes in the vagina in case of sloughing of the labia, in order to prevent in both cases the establishment of fistulse. V. Hematomata. The muscular system suffers, in typhus and typhoid fevers, in common with almost every other tissue of the body, undergoing a peculiar form of degeneration, resulting sometimes in rupture and the formation of hematomata. These, although not so strictly surgical as some of the other diseases noted, yet, as their proper surgical treatment is so important, I shall notice briefly. Apparently, the first published case was observed by that shrewd surgeon Velpeau,i ji^ 18 19, in the post-mortem examination of a soldier at Tunis. " Rupture of the mus- cles of the belly," says he, " is not surprising. The organs become so fragile in advanced stages of putrid fever that their rupture is a phenomenon which is easily conceived 1 Diet, en trente Vol. Art. rAbdomen, Rupture de. 372 SURGERY OF TYPHOID FEVER. when the patient in his delirium moves so irregularly." In 1844 Rokitansky noted their relation to typhoid. Virchow studied them also in 1857.^ In 1864, however, Zenker ^ first studied the subject thoroughly. Since then, but espe- cially within the last five years, they have been fi-equently observed or studied, mostly, however, from a pathological standpoint. The muscular changes to be described are so fi-equent as to be almost an essential part, at least, of typhoid. Yet they are not peculiar to these fevers. They are said to have been met with in phthisis, scurvy, scarlet fever, cholera, pneumonia, dysentery, measles, tetanus, Bright's disease, cerebro-spinal meningitis, muscular traumatism, and I have seen a similar change in the muscles of the abdomen in cases of large ovarian tumors. There are two independent forms : (i) Agranular degen- eration of the muscular fibers, which is least frequent ; and (2) a waxy change, which is by far the commonest. Under the microscope the muscular tissue presents a glassy, trans- lucent, slightly opalescent, shiny appearance, the fibers being swollen to even double their usual size and changed to fragile cylinders. Sometimes the muscular tissue resembles even the flesh of fish. The nature of the change is as yet greatly disputed. Erb, ^ Bernheim,^ and others attribute it simply to post-mortem imbibition ; Hayem,^ to proliferation of the tunica intima, which, with granulo-fatty change in the arterial walls, produces an obstructive arteritis ; Zenker ascribes the degeneration to the disturbance of a center which regulates the nutrition of the muscles; Waldeyer, ^ Hoffman,'^ Ranvier, and Weihl^ believe that it is a coagu- lation of the myosin ; and Liebermeister that it is due to the long-continued high temperature. Whatever the cause, the muscles become extremely fragile, and when they are called into play by the distention from meteorism, by 1 Wurzburg, Verhandl., vii, and Virchow's Archiv, iv. , ^ Ueber die Verand. der willkiirl. Muskeln im Typhus Abdom., Leipzig, 1864. 3 Virchow's Archiv, 1868, xliii, io8. 4 Gaz. Med. de Strasb., 1870, No. 7. 5 Gaz. Med. de Paris, 1866, 698. 6 Centralbl. med. Wissensch., 1865, 97, and Virchow's Archiv, 1865, xxxiv, 470. , 'Virchow's Archiv, 1867, xl, 505. * Virchow's Archiv, 1874, Ixi, 253. APPENDIX. 373 the efforts at coughing and other violent respiratory acts, by defecation, rising in bed, the movements of the legs, etc., they rupture with the greatest ease. Spasm or direct vio- lence does not seem to have been noticed in any case. The arteries, which have also undergone an analogous change, are involved in this rupture, and muscular hemorrhages result. These assume three forms, according to their size and mechanical limitation: (i) Ecchymoses ; (2) diffuse infiltration into the muscular tissue, soaking it with blood ; or (3) distinct hematomata, the last being the most impor- tant and probably the most frequent. The effused clot, at first hard, well defined, and sharply limited, gradually softens, and not infrequently suppurates, thus producing serious abscesses which, unless opened, may even burst into the peritoneal cavity. ^ Meanwhile the swollen muscular fibers gradually undergo reabsorption, until finally they disappear entirely, and a new formation of cells takes place in the perimysium, which, according to Hoffmann, first become spindle-shaped, then coalesce endwise with one another, and gradually assume the appearance of striated muscular fiber. Complete repair is then effected. The resemblance of these spindle-shaped cells, which are nas- cent muscular fibers, to the muscular fiber-cells is most striking, and seems to form a link connecting the two forms of muscular tissue, the striated and non-striated, such as I have long taught to be probable. Almost all of the muscles may be thus invaded, but the favorite seats both for the degeneration and the hemato- mata are in the recti abdominis and the adductors of the thigh, then in the pectorals, and, as Hoffmann has noticed in 16 cases out of 22, in the diaphragm. The influence of the phrenic lesion in enfeebling the respiration is, perhaps, more serious than has been recognized. Zenker gives the adductors the first place, and Hoffmann reports the adduc- tors involved in the degenerative changes in 75 out of 107, the recti in "^J out of 127. While this may be true of the degenerative process, yet the hematomata are certainly most frequent in the recti. Of 60 positions in cases I have collected from every side, they were in the recti in 27, and 1 Wenzel Gruber, in Jacops, Etude clinique sur les Absces. muse, qui survieunent pendant la Convalesc. de la Fievre Typhoide, Th^se de Paris, 1S73. P- 42. 374 SURGERY OF TYPHOID FEVER. the " abdominal muscles" in 9, in the adductors but 5 times, and the upper extremities but twice. ^ If in the adductors, they may burrow so as even to strip off the periosteum from the bone. Hematomata are even found n the interventricular septum of the heart itself Stokes suggests that febrile deafness and hoarseness may result from a similar degeneration of the muscles of the ear and the larynx. There are no post-mortem examina- tions on which to found such a hypothesis, and the fact that hoarseness and deafness are so often not seen, and that, as I have shown, ^ other and sufficient causes are found, at least in the larynx, render the idea scarcely tenable. Typhoid was the preceding fever in 44 out of 46 cases, but the severity of the fever seems to have but little in- fluence. Nineteen out of 25 cases occurred from fifteen to twenty-five years of age, and 22 were males as against 8 females. They rarely appear before the third week, since the muscular fragility is then at its height. Of 23 cases I find 19 arose in the third, fourth, and fifth weeks of the fever. Regeneration of the muscles usually begins in the third or fourth week, and is accomplished by the seventh, after which time they do not appear. Their period of development is, therefore, quite sharply defined by the anatomical history. As in dislocation of the hip-joint, the symptoms are often nil. Indeed, of 47 cases, I find 10 were wholly unsuspected until revealed at the post-mortem. The position of the tumor accounts in part for this. Both in the thigh and in the abdominal wall they are almost always in the posterior part of the muscle — a position due, probably, to the effect of gravity in the recumbent posture. Often, indeed, they are so deep as to extend to the pelvic and iliac muscles, and, in two cases, under the serous coat of the bladder. Hence there is usually little or no discoloration of the skin, though Foucault ^ reports a case with ecchy- mosis in the hypogastrium, extending later to the scrotum, thighs, and buttocks. Swelling is only reported 1 3 times, and fluctuation but 10 times. Suppuration and softening are but rarely attended with any special fever. Pain is 1 In the recti they are, I believe, invariably below the navel, possibly on account of the absence of the support derived from the linse transversce. 2 Ante, p. 353. 3 Bull. Soc. Anat., 1869, 498. APPENDIX. 375 mentioned in 14 cases. Flexion of the legs to relax the abdominal wall, which we would suppose to be frequent, is named but once. The size of these blood tumors varies from that of a bean to that of an orange. If small, they may be obscured by meteorism ; the symptoms then being •so indecisive, as in many of these surgical sequels, the necessity for frequent and rigid physical examinations is at once apparent. If a sudden and fixed pain exist in the recti below the navel, or even if movements be only hin- dered or uneasy and painful, a close examination should be made, and if a tumor or only hardness be found, it should be carefully scrutinized from day to day, especially for the pasty feel and other signs of edema and of fluctuation. The differential diagnosis is not usually very difficult. The most likely error, if in the rectus, is that of mistaking it for a distended bladder, but the catheter will at once unmask this error. If in the right iliac region, it may be mistaken for perityphlitis ; or in the adductors, for a simple abscess ; but as in point of practice the treatment of all three would be more or less similar, the error is of less moment than might be supposed. From aneurysm, an abdominal tumor, and peritonitis, the differential diagnosis is suffi- ciently easy. The treatment is important, especially when we consider the results. Of 13 cases opened by incision, only 2 died ; of 34 in which there is no mention of an operation, all died. If small, they will either be overlooked until the post- mortem reveals their existence, or, if recovery takes place, absorption of the clot and regeneration of the muscle will follow, independent of treatment. If large, every possible effort should be made by poultices, etc., to bring about early softening, and as soon as softened they should be opened. That the aspirator may be of service is probable, but as yet it is, I believe, untried. VI. Parotitis. Parotitis is occasionally an exceedingly important surgical complication, whose onset is always to be dreaded, lest it bring" in other evils worse than itself Murchison believes with Graves that the inflammation begins in the areolar tissue between the lobules of the gland itself, but Hoffmann 376 SURGERY OF TYPHOID FEVER. has unquestionably shown that, at least in typhoid, the pancreas and all the salivary glands are in a state of rapid cell-proliferation in nearly every case, and that parotitis proper is merely "an exaggeration of the changes that usually take place in this gland during typhoid fever, and bears the same relation to these changes that ulceration and perforation of the intestine do to the infiltration of the intestinal follicles." This exaggeration he believes to be due to the dense parotid fascia which compresses the gland. But this is not the only role this dense investing fascia plays. The compression of the swollen tissues not rarely produces gangrene, so that the entire gland may slough out in great masses like tow. In a case related to me by Dr. Grove, it involved both glands and proceeded so far that the fingers could almost meet behind the pharynx. The compression also is very favorable to thrombosis, which may extend to the brain by the diploic veins or even to the internal jugular itself. Necrosis and septicemia not rarely follow in its track. In two cases I have found facial palsy, from involvement of the seventh nerve. Facial deformity and ankylosis of the jaw are sometimes seen. In none does hemorrhage from the carotid appear to have followed. The death-rate is largely increased in such cases, since of 352 cases, 125 died and 227 recovered; a mortality of nearly one-third. The sex is named in only 19 cases, of which 14 were males. Contrary to the fact in other com- plications, except in perineal fistulae, this disease is most common after thirty. Of 211 cases, the average age, according to Murchison, was thirty-one and a half. It is certainly very rare in children, for I have found but 2 cases under fifteen. Typhus was the preceding fever in 352 cases, and typhoid in only 26. Most cases do not go on to suppuration, for of loi, I find 40 suppurated and 64 did not. The abscesses generally discharge by one or often by several openings, the external meatus being frequently one of them. As Nelaton has pointed out, even where it has thus opened, if we would avoid burrowing and other subsequent troubles, we must open it still more freely, in order to divide the parotid fascia. APPENDIX. 377 Conclusions. If now, by way of review, we cast our eyes back over the general results of all the complications and sequels we have studied, we may arrive at some useful and important conclusions. 1 1. Typhoid, probably from its usually longer duration, is by far the more prolific source of such surgical troubles except parotitis, especially when we consider that many cases tabulated as typhus are really typhoid. Of 433 cases, typhoid was the preceding fever in 252, typhus in 119, and other forms of continued fever in 62. 2. The surgical troubles to be apprehended in typhus are mainly restricted to gangrene and laryngeal stenosis, 103 out of the 1 19 cases being due to these two classes of disease, while typhoid bears in its train any and all of the forms of disease described. 3. The age is about the usual age of greatest frequence of these fevers.^ From fifteen to twenty-five years is by far the most frequent decade, counting 133 cases against 129 at all other periods of life. One singular exception is to be made — viz., the articular troubles, and especially dis- location of the hip, 21 out of 23 cases being under twenty years of age, of which 15 were In children under fifteen, in striking analogy to the frequency of coxalgiain children. 4. Sex is an unexpected and important factor in the pre- disposition to febrile surgical troubles. Of 303 cases in which the sex is named, 218 are males and 85 are females, or over 2^ to i. What is the normal proportion of the sexes in fever it is difficult to determine. In nearly 6000 cases of typhoid, Murchison gives the proportions as pre- cisely equal, and in over 18,000 cases of typhus the females were in a decided majority (8871-9267). Estlander's figures would give us a slight preponderance of males, while Liebermeister, in over 2000 cases of typhoid, gives 1300 males and 750 females. 1 In this summa.ry I have not included the cases of parotitis in the figures. 2 Lieliermeister gives the ages in typhoid as follows : fifteen to thirty, 1310 ; thirty to seventy-one, 394 ; total, 1704. None under fifteen were ad- mitted. In typhus, fifteen to thirty, 39 per cent. Murchison gives in typhoid : fifteen to twenty-five, 2752; all other ages, 3159; total, 591 1 ; and in typhus, fifteen to twenty-five, 5332 ; all other ages, 12,806; total, 18,138. 3/8 SURGERY OF TYPHOID FEVER. Unfortunately, I omitted to tabulate the number of cases arising in military practice, which I am sure is not inconsid- erable ; but while this will account to some extent for the predominance of males, it could not be adduced in the cases of arthritis and dislocation, since most of the patients were children, yet the males were in the preponderance. 5. The period of development is not the initial period of the fever, but first, from its height to its close — that is, the complications, especially gangrene and stenosis of the larynx ; and, secondly and most frequently, during conva- lescence — that is, the sequels. Of 240 cases, only 1 2 arose in the first week, 38 in the second, and 48 in the third, a total of 98. If we may assume that convalescence, on the average, begins at the end of the third week, then 142 occurred during convalescence, when health is apparently in the near future. 6. The lower half of the body is the especial seat of such surgical troubles. With the exception, of course, of the laryngeal cases and parotitis, of 307 cases 216 occurred in the pelvic region and legs, as against 91 in all other parts of the body. Moreover, the diseases attacking the upper half of the body are limited almost entirely to local gangrenes and caries and necrosis, and they are usually far less severe in type and more limited in extent than those in the lower half Here whole limbs are blighted by gangrene ; here occur most of the dislocations, the hematomata, the fistulae ; here the severest necroses and largest abscesses, and were we to add the long catalogue of bedsores and phlegmasiae, the preponderance of the lower half of the body in importance would be still further increased. 7. The diagnosis is, in general, moderately easy. The danger is not that difficulty of diagnosis may obscure the case, but that the diseases may be entirely overlooked. They occur most frequently in parts of the body covered by the bedclothes ; parts which require time and trouble to expose and examine in the routine of an ordinary visit. Moreover, the patient is frequently so apathetic and insen- sible to pain that he does not complain, or, if he do so, it is ascribed to the ordinary pains so frequent in the belly and legs in such fevers, or else to delirium itself Hence the most important hint I can give in the diag- nosis — and where, indeed, does the same rule not hold good ? APPENDIX. 379 — is that time and trouble imisl be taken, and that no patient .suffering from a continued fever, and especially from typhoid, should escape frequent, minute, complete physical examinations, in which every part of the body from head to foot should be questioned. Especially should the physi- cal condition of the larynx, the belly, the legs, and the toes, and in children the hip-joint, be exactly ascertained. This should be done at least every second day, and that, too, not only in severe, but in mild cases, and not only during the fever, but especially in early convalescence, for it is in just such mild and convalescent cases that the wari- ness of the doctor is the patient's surest reliance. Particu- larly should attention be paid to hoarseness, or even to the slightest change in the voice, and the larynx be examined at once with the greatest care, from day to day, by the eye, the finger, and the laryngoscope, lest sudden edema or the more insidious and more fatal necrosis of the cartilages be impending. The eye should seize upon any hindered movements, even without discomfort, and no complaint of pain should fall upon a deaf ear, especially if it be in the throat, the belly wall, the buttock, the hip-joint, the legs, or the toes. True, it may mean nothing. It may be the vagary of a wandering mind. But it may also be, as we have seen, the herald of the gravest dangers, whose attack may be entirely repelled or their force broken by heeding this timely warning. 8. The prognosis is naturally unfavorable, yet not to the extent we would suppose from the addition or sequence of such serious diseases. Of 383 cases in which the result is named, 220 died and 163 recovered, a mortality of 571^ per cent. 9. Still more clearly, I think, after such a review, do we see the powerful influence of mechanical causes as the proximate factors in the production of such troubles, work- ing in conjunction with the profoundly vitiated blood. With the exception, perhaps, of the almost constant mus- cular degeneration, and its not infrequent subsequent hema- tomata, these surgical results are not usually primary but secondary processes ; not dependent directly on the fever poison, but its indirect and often distant results ; not con- stantly seen, but incidental, indeed, often rare ; not parts of the fever, but its complications and sequels. 380 SURGERY OF TYPHOID FEVER. Pathologically, all these results may be grouped into two categories — viz.: (i) Those in which a clot exists; (2) those without any clot. 1. Those in which emboli of cardiac origin or, more frequently, local thrombi exist are, unquestionably, most of the cases of extensive gangrene and phlegmasia. In many other cases in which such a clot is at present unsuspected, I believe that more careful examination will reveal its pres- ence in the smaller vessels, and prove that, if venous, it may be a cause of edema glottidis, and, if arterial, of the local necrobiotic processes which result in necrosis of the bones, and probably of the cartilages of the larynx, and gangrene of the soft parts, with its abscesses, fistulae, etc. 2. Those in which no clot exists, and yet edema glottidis, dropsy, and dislocation of the hip, gangrene, ulcers, necro- ses, perichondritis, and other similar troubles occur. These are especially often ascribed to the fever poison itself, actmg locally, and producing, for instance, the so-called laryngo- typhus, the abscesses and ulcers in the skin and subcuta- neous tissues, etc., which are regarded as specific. While not denying this view outright, and especially in some cases, I feel still more strongly disposed to look upon them as allied disorders, the immediate results, as in the case of the pneumonia of fevers, of mechanical conditions, which produce a local stasis of the blood, followed by edema, low forms of inflammation, or gangrene. True, these results of fever are most frequent in severe cases and severe epidemics, in which the poison would be the most virulent, but it must also be remembered that such epidemics and such cases are themselves, as a rule, the result of excep- tionally depressing pre-existing causes, such as famine and war, want and sorrow. Even simple inanition alone will produce identical results in many cases. But it is especially when we consider the position of the troubles that this mechanical factor is apparent. Their posterior position, as is seen in the laryngeal ulcers, the perichondritis, the vaginal ulcers, the fistulae, and in the hematomata the posterior surface of the recti and adductors, is most significanl. Likewise is the fact that all such com- plications, as we have seen, are especially frequent in the lower extremities ; that is, in parts mechanically un- APPENDIX. 381 favorable to a ready return of the blood, and eminently favorable, if not to thrombosis, at least to stasis. 10. The treatjnent must be bold, but not rash ; conser- vative, but not timid. Note. — After the portion on Diseases of the Joints was stereotyped I received a letter from Dr. V. P. Gibney, of the Hospital for Ruptured and Crippled, New York City, giving the results in 860 cases of disease of the joints. The following is tlie only case which followed any continued fever, and it is not tabulated with the others: " William H , age twelve, presented himself at the outdoor department of the Hospital for Ruptured and Crippled, May 2, 1876. His general condition was good. The right hip was ankylosed, with the thigh abducted, semiflexed, and rotated inward, the trochanter carried upward, and he pelvis tilted to the right side. There was apparent shortening of the limb, but the real shortening was not ascertained. The thigh was atrophied three inches. Immense cicatrices of bedsores were found, one over each posterior superior spine of the ilium, one over the right natis, and one over each trochanter major, that over the right being the deeper, and covered by a scab l^ by ij/^ inches. "Prior to October, 1S75, he was in perfect health, but was taken that month with typhoid fever, and lay very ill for six weeks, during which illness the bedsores formed, and during convalescence the deformity at the hip was observed. This history I obtained from the mother, who was very intelligent. At the time I saw hira the disease was practically arrested." NDEX Abscess, 147. abdominal, 156. of abdominal wall, 167. " bouton de chemise," 135. of brain, 169, 175, 322. ileo-cecal, 156. ischio-rectal, 160. of mesenteric glands, 162. of ovary, 282. perinephric, 151, 152. psoas, 153. renal, 152. subdiaphragmatic, 1 63. Accommodation, paresis of, 312. Amblyopia, 319. Anthrax, 294. Anus, gangrene near, 83, 369. Appendicitis, 221, 23 1. Appendix vermiformis, 156, 330. Arthritis, monarticular, 95, 335. polyarticular, 94, 335. rheumatic, 91, 335. septic, 92. Bacilli of typhoid in the arteries and veins, 24, 60. blood, 23, 58. bones, 26. brain, 27. connective tissue, 25. fetus, 32. gall-bladder and bile, 30- heart, 24, 29, 59. joints, 26, 97. Bacilli of typhoid in the kidney, 31- liver, 29. lungs, 29. mesenteric glands, 31. muscles, 25. orbit, 28. otitis media, 28. ovary, 32. parotid gland, 28. peritoneum, 29. perivascular tissues, 63. placenta, 32. pleura, 29. skin, 25. spleen, 30. synovial sheaths, 26. testicle, 32. thrombi, 24, 62. thyroid gland, 28. urine, 32. mixed infections of, 33, 289. mixed infections of, with sta- phylococci and streptococci, 114. mixed with other special bac- teria, 289. pure cultures of, 37. pyogenic faculty of, 40. viability of, inside the human body, 19. viability of, outside the human body, 19. Bacillus, colon, differentiation from the typhoid bacillus, 39. Bones, central necrosis of, 135, 343. injury of, as a cause of infection, 122. 383 384 INDEX. Bones, late infection of, 117. multiple lesions of, 1 1 9. muscular strain as a cause of perios- titis, 123, 343. oscillation in disease of, 143. typhoid affections of, 109, 322, 340. variety of disease in, 127. Brain, abscess of, 169, 175, 322. typhoid lesions of, 169, 322. C. Cancrum oris, 85. Cartilages of larynx, necrosis of, 149, 347- Cerebral complications, 169, 322. Choroid, typhoid affections of, 303. Ciliary body, typhoid affections of, 303- Conclusions, 314, 377. Conjunctiva, typhoid affections of, 299. Cornea, typhoid affections of, 299. Death, sudden, after venous throm- bosis, 69. Dislocation of hip-joint, 96, 336. E. Ear, typhoid disease of, 181. Embolism, arterial, of cardiac origin, 64, 362. of central artery of retina, 311. Epididymitis, 279. Erysipelas, 289. Esophagus, stricture of, 202. Eye, typhoid affections of, 296. Fistula, fecal, after typhoid, 157. perineal, 84, 369. recto-vaginal, 79, 369. vesico-vaginal, 79, 369. Gall-bladder, perforation of, 262. typhoid affections of, 248, 325. Gall-stones, typhoid bacilli in, 253. Gangrene, 52, 358. of cheeks, 86, 367. of female genitals, 79, 368. of male genitals, 78, 368. pathology of, 63, 361. of perineum and anus, 83, 369. symptoms of, 71, 365. treatment of, 87, 369. Genitals, gangrene of, male, 78, 368. female, 79, 368. Glossitis, 211. Gonorrhea, typhoidal, 278. H. Heart, typhoid affections of, 200. Hematemesis, 208. Hematocele, periuterine, 287. Hematomata, 166, 371- Hemianopsia, 313. Hemorrhage from the bowels, 209. from the stomach, 208. intra-ocular, 312. orbital, 312. retinal, 310. Hip-joint, dislocation of, 96, 336. Infections, specific mixed, 289. Intestine, perforation of, 212, 319. Intracranial veins, thrombosis of, 176. Intubation, 197. Iris, typhoid affections of, 303. Joints, typhoid affections of, 91, 335. K. Kidney, typhoid disease of, 15 1, 152. INDEX. 38; L. Laryngoscopic examination, I95, 354- Larynx, typlioid affections of, 186, 345- Lens, crystalline, typhoid aflections of, 305. Leucocytosis, 218. Liver, abscess of, 244. typhoid afTections of, 244. Lungs, typhoid affections of, 199. M. Malignnnt Edema, 295. Mediastinum, involvement of, 148, 191, 192. Medico-legal obligations, 301. Meningitis, 152, 169. Mesenteric gland, abscess of, 162. Muscles, ocular, typhoid affections of, 312. typhoid degeneration of, 371. N. Neuritis, optic, 306. retro-bulbar, 309. Neuro-retinitis, 310. Noma, 85. Optic nerve, typhoid affections of, 306, 308. Orbit, phlegmon of, 31 1. typhoid affections of, 3 1 1. Orchitis, 279. Osteomyelitis, 127, 322. Otitis media, 181. Ovary, abscess of, 282. dermoid cyst of, 283. P; Paralysis of ocular muscles, 312. Parotidean sweating, 184. Parotids, 183, 375. 25 Perforation of the gall-bladder, 262, 325- of the intestines, 212. of the stomach, 206. Pericarditis, 200. Perichondritis, 194, 350. Perineum, gangrene of, 83, 369. Peritonitis, see Chapters VI, Nil, XIV, XV, XVI, XVII, for its various causes. Phlebitis, 66. Pituitary body, suppuration about, 324- Pleura, typhoid affections of, 199. Pott's disease and typhoid fever, 153. Pylephlebitis, 247. R. Rectum, perforation of, 83, 160. Retina, typhoid affections of, 306, 3'^9. 310. 3"- Ribs, typhoid disease of, 137 S. Sexual organs, typhoid affections of female, 78, 282, 368. male, 78, 278, 368. Shattuck Lecture, 10, il. Sinus, cavernous, thrombosis of, 324. Skull, necrosis of, 344. osteomyelitis of, 322. Spleen, typhoid affections of, 274, 326. Stomach, hemorrhage from, 206. perforation of, 206. ulcer of, 206. Sweating in parotid region, 184. Testicle, typhoid affections of, 279. Tetanus, 294. Thrombosis, arterial, 65. of orbital veins, 31 1. 386 INDEX. Thrombosis of peripheral vessels, 70. of Sylvian vein and cavernous sinuses, 324. venous, 66. Thyroid gland, typhoid infection of, 186. Toner Lecture, 2,2i'!)- Typhoid fever, mixed infection in, 33. infection without intestinal lesions, 43, 321. U. Urethritis, 278. Uveal tract, typhoid affections of, 303. V. Vagina, lesions of, 79, 288, 368. Vein, Sylvian, thrombosis of, 324. Veins, intracranial, thrombosis of, 176. Vitreous, typhoid affections of, 303, 304- Vulva, lesions of, 79, 288, 368. X. Xerophthalmia, 302. SAUNDERS* BOOKS on Skin, Genito-Urinary Diseases, Chemistry, and Eye, Ear, Nose, and Throat W. B. SAUNDERS ^ COMPANY 925 WALNUT STREET PHILADELPHIA London : 9. Henrietta Street, Covent Garden MARVELOUS FACILITIES WE are often asked to account for our extraordinarj' success. We can but point to modern business methods, carefully perfected business machinery, and unrivalled facilities for distribution of books. Every depart- ment is so organized that the greatest possible amount of work is produced with the least waste of energy. The representatives of the firm are men with life-long experience in the sale of medical books. Then, too, we must not overlook that major force in the modern business world — advertising. We have a special department devoted entirely to the planning, writing, and placing of advertising matter; and we might mention that the money annually spent in advertising now far exceeds the entire annual receipts of the house during its earlier years. These extraordinary facilities for dis- posing of large editions enable us to devote a large amount of money to the perfecting of every detail in the manufacture of books. To physicians of approved credit any of the books on our list will be sent, carriage paid, on the following terms : ^5.00 cash upon delivery of the books, and monthly payments of $5.00 thereafter; payments to be made free of all expense to the publishers. SPECIAL OFFER A Complete Catalogue of Our Publications will be Sent upon Request SAUNDERS' BOOKS ON StelwagonV Diseases of the Skin A Treatise on Diseases of the Skin. For Advanced Students and Practitioners. By Henry iW. Stelwagon, M. D., Ph.D., Clinical Pro- fessor of Dermatology, Jefferson Medical College and Woman's Medical College, Philadelphia ; Dermatologist to the Howard and to the Phila- delphia Hospitals. Handsome octavo of 1115 pages, with 220 text- cuts and 26 full-page colored lithographic and half-tone plates. Cloth, ^6.00 net ; Sheep or Half Morocco, I7.00 net. COMBINING A THOROUGH TREATISE WITH A COMPLETE ATLAS In this work diagnosis, being the most difficult and confusing part of cuta- neous medicine, has been wisely accorded considerable attention. Treatment has been detailed with unusual clearness and accurateness, the author, in addi- tion to the remedies and methods used in his own practice, having referred fre- quently to those employed and advised by others. The clinical and pathologic aspects are further elucidated by a large number of very beautiful illustrations, mainly from the author's own collection, besides a number of full-page half-tone and colored lithographic plates of exceptional merit. Indeed, the work, though ■originally planned for the student and general physician, will be found of material assistance to the dermatologist, as presenting the most recent advancements in the subject. PERSONAL AND PRESS OPINIONS Qeorge T. Jackson, M.D., Chief of Clinic and Instructor iti Dermatology, Cohimbia University, New York. " I have no doubt about its being a good book, and will take pleasure in mentioning it to my students. I would especially commend the black and white illustrations, which are un- usually excellent." William F. Breakey, M.D., Lecturer {in charge) of Dermatology, University of Michigan, Ann Arbor. " Can unhesitatingly recommend it both for student and practitioner. I shall take pleasure in adding it to the text-books for my classes." Boston Medical and Surgfical Journal " We can cordially recommend Dr. Stelwagon's book to the profession as the best text- book on dermatology, for the advanced student and general practitioner, that has been brought Strictly up to date. . . . The photographic illustrations are numerous, and many of them are of great excellence." DISEASES or THE EYE. DeSchweinitz*s Diseases of the Eye Fourth Edition, Revised, Enlarged, and Entirely Reset Diseases of the Eye : A Handbook of Ophthalmic Practice. ByG. E. DeSchweinitz, M.D., Professor of Ophthalmology in the Uni- versity of Pennsylvania, Philadelphia, etc. Handsome octavo of 773 pages, 280 text-illustrations, and 6 chromo-lithographic plates. Cloth, ^5.00 net; Sheep or Half Morocco, ^6.00 net. WITH 280 TEXT-ILLUSTRATIONS AND 6 COLORED PLATES In this new edition the text has been thoroughly revised, and the entire work has been reset. Many new chapters have been added, such as Thomson's Lantern Test for Color-BHndness ; Hysteric Alopecia of the Eyelids ; Metastatic Gonor- rheal Conjunctivitis ; Grill-like Keratitis (Haab); the so-called Holes in the Macula ; Divergence-paralysis ; Convergence-paralysis, and many others. A large number of therapeutic agents comparatively recently introduced, particularly the newer silver salts, are given in connection with the diseases in which they are indicated. The illustrative feature of the work has been greatly enhanced in value by the addition of many new cuts and six full-page chromo-lithographic plates, all most accurately portraying the pathologic conditions which they represent. PERSONAL AND PRESS OPINIONS Samuel Theobald, M.D., Clinical Professor of Ophthalmology, Johns Hopkins University, Baltimore. " It is a work that I have held in high esteem, and is one of the two or three books upon the eye which I have been in the habit of recommending to my students in the Johns Hopkins Medical School." J. William White. M.D., Professor of Surgery in the University of Pennsylvania. "A very reliable guide to the study of eye diseases, presenting the latest facts and newest ideas." British Medical Journal " A clearly written, comprehensive manual. One which we can commend to students as a reliable text-book, written with an evident knowledge of the wants of those entering upon the study of this special branch of medical science." SAUNDERS' BOOKS ON American Text-Book qf Eye, Ear, Nose, and Throat American Text=Book of Diseases of the Eye, Ear, Nose, and Throat. Edited by G. E. deSchweinitz, M. D., Professor of Ophthal- mology in the University of Pennsylvania ; and B. Alexander Randall, M. D., Clinical Professor of Diseases of the Ear in the University of Pennsylvania. Imperial octavo, 125 1 pages, with ^66 illustrations, 59 of them in colors. Cloth, ;^7.oo net ; Sheep or Half Morocco, ^8.00 net. WITH 766 ILLUSTRATIONS, 59 IN COLORS The present work makes a special claim to favor based on an encyclo- pedic, authoritative, and practical treatment of the subjects. Each section of the book has been entrusted to an author especially identified with the subject, and who, therefore, presents his case in the manner and with the attending authority of an expert. The work is essentially a text-book on the one hand, and, on the other, a volume of reference to which the practitioner may turn and find a series of articles written by representative authorities on the subjects por- trayed by them. Therefore, the practical side of the question has been brought into prominence. Particular emphasis has been laid on the most approved methods of treatment. OPINIONS OF THE MEDICAL PRESS American Journal of the Medical Sciences " The different articles are complete, forceful, and, if one may be permitted to use the term, ' snappy," in decided contrast to some of the labored but not more learned descriptions which have appeared in the larger systems of ophthalmology." Annals of Ophthalmolog'y " This text-book is the most valuable single volume that has ever appeared on these branches of medicine." The Medical News " This unusually complete and thoroughly prepared work is essentially a text-book, and as such brings into prominence the practical side of the subjects treated." SYPHILIS AND VENEREAL DISEASES. Hyde and Montgomery's Syphilis and Venereal Second Edition, Revised and Greatly Enlarged Syphilis and the Venereal Diseases. By James Nevins Hyde, M. D., Professor of Skin, Genito-Urinaiy, and Venereal Diseases, and Frank H. Montgomery, M. D., Associate Professor of Skin, Genito- urinary, and Venereal Diseases in Rush Medical College, in Affiliation with the University of Chicago, Chicago. Octavo volume of 594 pages, profusely illustrated. Cloth, ^4.00 net. CONTAINING MANY BEAUTIFUL COLORED PLATES This work has been prepared with the intent of meeting the special needs of the student and of the practitioner. The aim has been to supply in a compen- dious form, and with detail, all practical facts connected with the study and the treatment of syphilis and the venereal diseases. In the present edition every page has received careful revision ; many subjects, notably that on Gonorrhea, have been practically rewritten, and much new material has been added through- out the book. With a view to better illustration of the subjects considered, a number of new cuts have been introduced, and also a series of beautiful colored lithographic plates. The revision has greatly enhanced the practical value of the v/ork and enormously increased its field of usefulness. OPINIONS OF THE MEDICAL PRESS Boston Medical and Surgical Journal " In the arrangement of subject matter it is conspicuously good, in style concise and lucid, and its practical quality is notable." Bristol Medico-Chirurgical Journal "The authors lay before their readers in a clear and concise form our present knowledge of the study and treatment of syphilis and the venereal diseases." American Journal of Cutaneous and Genito-Urinary Diseases " It is a plain, practical, and up-to-date manual containing just the kind of information that physicians need to cope successfully with a troublesome class of diseases." SAUNDERS' BOOKS ON GET A .-.^ ^* ^^