thin, which is a dangerous type of pus. It is the same with acute troubles of the liver and the gall bladder, acute infection will allow the patient to recuperate more, and in the removal of the gall bladder the excision of the common duct can be accomplished with safety. In regard to the length of the incision, I think it does make quite a difference if we drain through the incision, so that now through a large incision after the seventh day I would remove the appendix if the adhesions are firm, and not drain through the wound, but make a stab wound and go through the aponeurosis, get about an inch incision, which goes through all the muscles and comes where the appendix has been removed. There is no epithelial suture applied for perfect approximation. This drain can be left six or eight days, it will not make a particle of difference for the length of time the patient is in bed. He will be ready to go home on the twelfth or fourteenth day, just as if there had been no drainage. I think it is rather a pernicious practice to drain through the original incisions of the abdomen. Make every effort to heal up the long incision first. Now the point about infection. There is one type of infection I have seen in operations between the fifth, sixth or seventh days in acute cases, and cases that had a history of a few weeks, where the pus is thin, and in those cases about the eighth or twelfth day, you have a sudden high temperature, quicker pulse, a flat abdomen, no gas, no distention, no tenderness on pressure, you are liable to have sudden rupture. In a mediastinal abscess it has put into circulation a pus that under aspiration shows the colon bacillus, and it lies in the lung without any apparent symptoms; you do not know where the temperature comes from.

DR. WALTER COURTNEY-1 was much pleased to hear Dr. Moore's paper and the discussion of the subject. There are two or three points I would like to say a few words about. In regard to this matter of chronic appendicitis and operation without previous acute attack, I am very glad to hear the necessity for operation emphasized. We see many cases that have been troubled for months and years, and when you come to search their cases you can generally elicit some tenderness, sufficient sometimes to diagnose appen- « dicitis, and perform operation with results often, happily, satisfactory. I am glad to hear what the Doctor has said in that regard, because many cases go on and lead to serious results. I have seen lives spoiled for many years awaiting an acute attack. In regard to this question of fistula, I think there are probably two classes of fistula that we might consider. I might name them for the purpose of discussion, the mucous and the fecal. The mucous fistula would be a fistula consequent on the perforation of the appendix. Now that appendix may still be attached to the bowel, or it may have slipped from the bowel and the contents of it be disseminated. Then we have the regular fecal fistula, which all of us have met and will continue to meet in spite of the line of treatment of abscess cases. I scarcely agree with the Doctor, however, as to the treatment of these cases. I find they invariably heal of their own

accord if you give them time enough, but usually the doctor or patient becomes impatient. I remember one case that opened and closed spontaneously after a period of six months. There were reasons why I never operated. The patient had nephritis, and the opening closed after a period of six months, and I have not heard that he had appendicitis since.

DR. J. E. MOORE (Essayist)-I am very grateful to the gentlemen for the criticism of my paper. In regard to what Dr. O'Brien said about palpation. When it was first suggested I discounted very largely what was said, and still do, yet there are cases in which you can palpate the appendix. In this case it was as big as the cigar Dr. O'Brien has in his mouth. It could be mapped out distinctly. He suggests that bellyache is no longer a cause in diagnosis. We do not have it as a disease, but as a symptom of appendicitis it is very common sometimes. The Doctor misunderstood me in regard to the long incision. I do not recommend a long incision in chronic appendicitis, simply one into which I can put my finger. I used to require one in which I could put both my hands and feet. I do not limit my incision to one inch, but I made the point that it should be made large enough and then close it all but one inch. Dr. O'Brien says he knows that gauze does drain. I might be just as dogmatic as he and say I know it does not drain-it does not drain true pus. Put a dressing over the wound and we will find a discharge of serum, because gauze does drain serum, but no man ever saw a lot of pus float up through the wound through gauze. When he speaks of an acute case of appendicitis that drains in spite of his gauze it may be true, but it does not drain because of it. I appreciate what Dr. Bacon said about recognizing the gist of the paper. We have frequently got the cart before the horse in thinking that the first was necessarily an acute attack. I think it is frequently a secondary condition. Dr. Mann's case of a long sinus reminds me of a case Dr. Stone frequently told me of. A patient came to him with fistula, and he told her to go home and it would shortly heal. He said, "She has been coming back for fifteen years and I am still telling her the same thing." (Laughter.) In reference to Dr. Mayo's remarks, we do not find many silk ligatures in the West. The leading eastern brethren are learning something from the West, but they are still digging out silk ligatures, and we are still digging out silk ligatures in the west that were planted in the east, but we use it so rarely that it is not adapted to this climate. Dr. Courtney, I am glad to see, appreciates the paper in the matter of chronic overacute cases. There was one point in my paper that was rather obscure. I made out two cases of fistula in my paper. I spoke first of that caused by an old appendicitis. I operate on those cases early, because while I know they will heal, if a patient has chronic inflammation of the appendix he is liable to have a dangerous acute attack of appendicitis, and not because he has a fistula, but because he has a chronically inflamed appendix I operate to remove that.

REPORT OF A CASE OF PERFORATIVE TYPHOID ULCER-DIFFUSE SUPPURATIVE PERITONITIS-WITH OPERATION AND

RECOVERY.

H. B. SWEETSER, M.D., MINNEAPOLIS.

The history of the case which has called forth this paper, and which I wish to report briefly, is as follows:

A young man, 20 years of age, was seen in consultation with Dr. A. C. Tingdale at 3 a. m., March 22, 1903. The patient had been feeling slightly sick for between two and three weeks, but has been up and about until ten days previously, when he became so much worse that he went to bed and called a physician. His symptoms were headache and increasing sense of weakness. A diagnosis of grip was made, and under treatment he improved enough to get out of bed and for two days previously had gone out of doors and to his father's store, a block away. During the afternoon of the 21st he ate some preserved fish, and at 5:30 p. m. was taken with such intense abdominal pain that he lay doubled up on his side and unable to move. He was seen for the first time by Dr. Tingdale at midnight, and was given 14 grain of morphin hypodermically. His pulse was 100, temperature 102. When I saw him three hours later his condition was as follows: lay on his side with legs drawn un, absolutely refusing to move because of the pain; pulse remained at 100, but temperature had fallen to 99.5; abdomen rather flat, but rigid as a board; mind clear; pain extreme; no collapse.

He

The diagnosis of intestinal perforation was concurred in, either of the appendix or, what was more likely because of the previous history, of a typhoid ulcer. He was removed to the Swedish Hospital, and operated on under ether narcosis at 8:30 a. m., fifteen hours after perforation, Dr. Tingdale assisting. Incision was made through the right rectus muscle,

increased to about six inches. The abdomen was found full of foul-smelling, grayish, thin pus, under such pressure as to spurt several feet when the peritoneum was opened. There were no adhesions, and the large amount of pus filled the entire abdominal cavity. The peritoneal coat, however, had not lost its luster.

The appendix was first sought for and removed. Its condition precluding the possibility of its being the cause of the extensive peritonitis, a perforation was sought for in the ileum commencing at the ileocecal valve. About twelve inches proximal to the valve a perforation was found, about three-eighths of an inch in diameter, with thick ragged gray sloughing edges. This was closed by two layers of fine silk mattrass sutures. The abdomen was then flushed out with a large quantity of hot normal salt solution, much of the bowel being delivered to get at the region around the spleen and left kidney. Gauze drains were carried into the lumbar regions, and a large rubber tube to the bottom of the pelvis. The abdominal wound was closed down to the drains by throughand-through silkworm sutures, the cavity being left full of the salt solution. The operation lasted about an hour, but the shock was very little. The head of the bed was raised about twelve inches, both to gravitate the infection to the less dangerous pelvic region and to give better drainage. Food and drink were given by the rectum, and it was a week before he could take food by the mouth without vomiting. For a week or more the tympanites was quite marked, and relieved by turpentine enemata. The temperature varied between 99 and 101, and the pulse between 80 and 100, but became normal at the end of two weeks.

The edges of the abdominal wound became infected, and all the stitches had to be removed. This allowed the coils of the intestine to protrude somewhat, but they were restrained by strips of oxide of zinc plaster. The pus showed bacteriologically only the colon bacillus. The Widal reaction was positive. He left the hospital after two weeks, and put on flesh rapidly. The wound has entirely healed, and he is out and around wearing a hard-rubber pad and bandage.

The importance to be accorded intestinal perforation in typhoid fever may be appreciated from the fact that the census of 1900 records 35,379 fatalities from this disease, of which it is fair to assume that at least 3,500 were due to intestinal perforation. Under medicinal treatment the mortality from this complication has always been practicallv 100 per cent., so that the only hope seems to lie in surgical intervention. In my opinion no plan of treatment is to-day open to discussion except that by operation.

Operation for this condition is of comparatively very recent origin, only one successful case being recorded up to 1891. By 1896 seventeen cases had been tabulated with a recovery rate of 17 per cent. Since then every year has given a steadily increasing number of cases, and also a much diminished death rate. In 1898 Dr. Keen ("Surgical Complications and Signs of Typhoid Fever") collected 83 cases with a mortality rate of 80.7 per cent., and in 1899, 75 additional cases with a mortality of 72 per cent. In 1901 Cushing reported 12 cases from Johns Hopkins with deaths, a recovery rate of 41.6 per cent., and in the present year (1903) Hayes of Pittsburg reports 7 cases with 4 deaths, or 42.8 per cent. recoveries. This is a most remarkable and gratifying improvement in the recovery of this hitherto hopeless condition, and that within the short period of five years.

When we analyze the various series of cases we find the mortality most markedly influenced by the time elapsing between the perforation and its closure. In the early days it was strongly advised that time be allowed for recovery from the initial collapse. It is now, however, well established that collapse does not occur immediately following the perforation, but it is rather a symptom of the secondary diffuse suppurative peritonitis, and that with its advent the chances of recovery have become reduced to almost nil. Inasmuch as death in these cases is the result of this secondary septic peritonitis, it seems axiomatic that the earliest possible closure ought to give the best results, and the latest statistics prove this to be true. Armstrong of Montreal, in a large personal experience -34 operations-(Annals of Surgery, Vol. xxxvi, p. 735),