Full text of "The surgical complications and sequels of typhoid fever"

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THE

SURGICAL COMPLICATIONS AND SEQUELS
OF TYPHOID FEVER

WILLIAM W. KEEN, M.D., LL.D.

PROFESSOR OF THE PRINCIPLES OF SURGERY AM) OF CLINICAL SURGERY, JEFFERSON MEDI- ,

CAL COLLEGE, PHILADELPHIA ; VICE-PRESIDENT OF THE COLLEGE OF PHYSICIANS

OF PHILADELPHIA J MEMBRE CORRESPONDANT STRANGER DE LA

SOCIETB DE CHIRUKGIE DE PARIS; MEMBRE HONORARIE

DE LA SOCIETB BELGE DF. CHIRURGIE.

BASED UPON TABLES OF 1700 CASES

COMPILED BY THE AUTHOR AND KY

THOMPSON S. WESTCOTT, M.D.

INSTRUCTOR 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

GEORGE E. DEJ5CHWEINITZ, 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

'ibrary

TABLE OF CONTENTS.

CHAPTER I.
INTRODUCTION, 10

CHAPTER II.

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, 147

CHAPTER VII.
TYPHOID HEMATOMATA, 166

CHAPTER VIII.
CEREBRAL COMPLICATIONS OF TYPHOID FEVER, . . . . .169

CHAPTER IX.
OTITIS MEDIA IN TYPHOID FEVER, 181

CHAPTER X.
TYPHOID PAROTITIS, 183

CHAPTER XL
TYPHOID AFFECTIONS OF THE THYROID GLAND, 186

693468

8 TABLE OF CONTENTS.

CHAPTER XII.
TYPHOID AFFECTIONS OF THE LARYNX, 188

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, 278

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, ling. 8, for anus read arms ; line 9, for 20 cases read 21 ; line 13, for

757 read 14.7 ,- line 14, dele and anus.
Page 183, line 7, for 362 read jj-^.

SURGICAL COMPLICATIONS AND SEQUELS

TYPHOID FEVER.

CHAPTER I.
INTRODUCTION.

THE present monograph had its origin in two
lectures. On February 17, 1876, I delivered 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.

INTR O D UCTION. 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. 10, 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 in the 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 infrequent use

INTRODUCTION. 15

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-galled " 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 been 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
single surgical 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 long been recognized and de-
scribed. But up to 1876, when I published my
Toner Lecture, surgical troubles after typhoid

1 8 SURGERY OF TYPHOID FEVER.

and other continued fevers were deemed rather
among the curiosities of literature, 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 bacteriological laboratory- the
typhoid germs may live indefinitely : but in unfavor-
able conditions, also, their viability is remarkable.
Thus Losener ' found that the bacillus only disap-
peared from the body ninety-six days after burial. In
feces they mayjive even for months.^ Remlinger and
Schneider 3 have found them in the feces of five out
of ten patients who had never had typhoid fever.

SchjlLer 4 impregnated threads with the bacillusj-and
found them still active in periods of from one to. two

Uffelmann 5 found them still living and active after
eighty-two days in dry sterile sand...

(b) Their Viability Inside the Human Body. 6
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 1'Institut Pasteur, 1897, xi, 55.

4 Arbeit, kaiserlich. Gesundheitsamte, v, 312.

5 Centralbl. f. Bakteriol., 1894, Nos. 5 and 6.

6 Schnilzler, Centralbl. f. Bakteriol. und Parasitenk., 1894, 270, in a case
of old osteomyelitis, found the staphylococcus pyogenes aureus after thirty-
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 that of von Dungern. 1 Fourteen [ _years and a
half after , the fever the bacillus was found in an
abscess about the gall-bladder, A resume of tin-
case fs'given in Chapter XVI.

Buschke 2 reports the case of a woman of sixty-
six who fell ill of typhoid in October, 1886. Before
Christinas, when she left her bed, she complained
of swelling, pain, and tenderness in the fifth and
sixth ribs and cartilages on the right 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
swelling the size of a hen's egg, 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 Munch, med. Wochen., 1897, No. 26, p. 699.

2 Lebensdauer d. Typhusbacillen in ostitischen Herden, Fortschritte d.
Med., 1894, 57 j.

PATHOLOGY. 21

bodies the typhoid bacillus was obtained, thus com-
pleting the circle of proof.

Bruni 1 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. 2
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 3 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 4 reports a pure
culture in the case of a sinus open and discharging
for three months ; Pean and Corriil, 5 in a tibial peri-
ostitis and abscess after eight months ; Chantemesse, 6
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.

4 Johns Hopkins Hosp. Reports, v, 417.

5 Bull. Acad. Med., Paris, 1891, 3d series, xxv, 599.

6 Bull, et Mem. Soc. Med. des Hop., 1893, x, 779.

22 SURGERY OF TYPHOID FEVER.

another after eleven months ; Chantemesse and
Widal, 1 in an abscess after fifteen months; Orloff, 2
in a case of periostitis after eight months ; Klemm, 3
in an osteomyelitis after a year ; Chantemesse and
Widal, 4 after eighteen months ; Werth, 5 in an ov % a-
rian cyst after eight months ; Berg, 6 in a case of
chondritis of the costal cartilages after three years ;
Lockwood, 7 in a tibial abscess after fifteen months ;
Hintze, 8 in a " cold " periosteal abscess after ten
months ; Fraenkel, 9 in a pleural effusion after five
months, and in an abdominal abscess I0 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, 1891, i. 2 Deutsch. med.Wochen., 1890, p. 1806.
3 Arch. klin. Chir., 1893, x ' vi . 862 - 4 Sem - Med., 1893, 542.

5 Deutsch. med. Wochen., 1893, No. 21.

6 Centralbl. f. Chir., 1896, 153.

7 Lancet, 1895, i, 531. 8 Centralbl. f. Bakteriol., Oct. 10, 1893, 445.
9 F.uschke, loc. ci(., 581. 10 Deutsch. med. Wochen., 1894, p. 152.

11 Munch, med. Wochen., 1888, No. n.

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 bacilli. 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 bacilli have been found are the following :

I. The Blood. The bacilli 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. 1 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, 2 in which he found them in
the mesenteric glands, the spleen, the liver, the bile,
the kidneys, the 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-

1 Dehu, Le role du bacille d'Eberth dans les complications de la fievre
typhoide, These de Paris, 1893. p. 59.

2 Jour, of Pat hoi. 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 x also give's 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.

Neiihauss, 2 Riitimeyer, 3 Achalme, 4 Kiihnan, 5 Ander-
son, 6 Guarnieri, 7 and Block 8 have also found them
in the blood, and in some instances proved their
activity by injection into animals.

Kanthack and Tickell 9 and Ohlmacher 10 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 1'Institut Pasteur, 1893, vii, 141.

2 Berlin, klin. Wochen., 1886, Nos. 6 and 24.

3 Centralbl. f. klin. Med., 1887, No. 9.

4 Comptes Rendus Soc. de Biol., June 21, 1890.

5 Berlin, klin. Wochen., June 23,1896.

H Med. News, Aug. 8, 1896, 155. 7 Revist. Gen. Clin. Med., 1892, 234.

* Johns Hopkins Hosp. Rep., June, 1897.

9 Edinb. Med. Jour., July, 1897, 22.
111 Cleveland Med. Gaz., May, 1897.
1 ! Gaz. Hebdom., March 4, 1887, 146.

PATHOLOGY. 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, 1 Raymond, 2 Rosin and Hirschel, 3 Jahradnicky. 4

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 5 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, 6 the
pus of an abscess over the tibia contained only the
bacilli of Eberth fifteen months after the fever.

Raymond, 7 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 8 and Tinctine. 9

7. Skin. Most of the infections of the skin are
probably pyogenic, but Rheiner I0 has found the
typhoid bacillus in the skin in cases of post-typhoid
erysipelas. See also Valentini " and Raymond 12 for
other facts. Sittmann I3 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 Fein, L' Action pyogenique du hacille typhique, p. 88. 2 Ibid., p. 58.
3 Deutsch. med. Woollen., 1892, No. 22. 4 Centralbl. f. Chir., 1896, 336.
5 Merc. Med., Feb. 17, 1892, p. 73. 6 Lancet, 1895, i, 531.

7 Pein, These de Paris, 1891, p. 58. * Chronica Lekarska, 1894, No. 8.
9 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 1
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., 1892, vi, 1271.

PATHOLOGY. 2J

Dupraz, Arch. Med. et Anat. Pathol., Jan. i, 1892,
76.

Buschke, 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 11, 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, 73.

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,
767.

Aclenot, Lyon Med., 1889, Nos. 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. 73.
Tinctine, Arch, de Med. Exp. et d'Anat. Pathol.,

1894, vi, i.

Fernet, Bull. Soc. des Hop., 1891, No. 23, 361.

Daddi, 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.
15, 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.

1 4. 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. i5th.
Vincent, Ann. de 1'Institut Pasteur, Paris, 1893.

PATHOLOGY. 29

1 6. In the heart-muscle :

Chantemesse and Widal, Gaz. Hebdom., 1887, 146.

I 7. In the lungs :

Flexner, Jour. Path, and Bacteriol, Nov., 1894, iii,
206.

1 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. Wochen., 1889, 368.

Spirig, Mittheil. aus klin. und med. Instit. d.
Schweiz, Basel, 1893-94, 77 l -

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 :

Guarnieii, 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.

Cygnaus, Ziegler's Beitrage, etc., 1890, vii.
Flexner, Jour. Path, and Bacteriol., Nov., 1894, iii,
202.

Lannois, Rev. de Med., 1895, No. n, 909.

Vincent, Merc. Med., Feb. 17, 1892, 73.

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, No. 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, Edinb. Med. Jour., July,
1897, 22.

Vincent, Merc. Med., Feb. 17, 1892, 73.

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-

Kiihnan, 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, 173.

Vincent, Merc. Med., Feb. 17, 1892, 73.

Gilbert and Girode, Comptes Rendus Soc. Biol.,
May 2, 1891.

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., 1881, 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, 1891.

Karlinski, Prag. med. Wochen., 1890, xv, 437.

26. In the ovary :

Werth, Deutsch. med. Wochen., 1893, No. 21.
Sadeck, Munch, med. Wochen., 1896, No. 21.

27. In the testicle and epididymis :

Girode, Arch. Gen., 1892, i, clxix, 43.

Tavel, Correspondenzbl. schvveiz. 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, Fortschritte 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, Munch, med. Wochen., 1893.

PATHOLOGY, 33

Frascanni, Jahresb. Fortsch. Path. Microorganism.,
1892.

Neuhauss, Berl. klin. Wochen., 1886.

Reher, Arch. Exp. Pathol. et Pharmacol., xx, 420.

Giglio,, Centralbl. f. Gynekol., 1890, No. 46.'

Griffith 2 reports an interesting 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 I3th, 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 utero.

A still more remarkable case is reported by
Etienne. 3 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. 1 6.

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 e. g., Schede ' in ten cases
of abscess of bones found only the pyogenic bacteria,
and Dunin 2 found the same bacteria in eight 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 3 com-

1 Munch, med. Wochen., 1888, No. II.

2 Deutsch. Arch. f. klin. Med., 1886, xxxix, 369.
8 British Med. Jour., 1891, i, 18.

PATHOLOGY. 35

menced with a crural phlebitis relatively early in the
disease (the ninth day), death occurring from pyemia
on the eighteenth day. In another, reported by
Spillman, 1 gangrene of the lips occurred, probably
due to carious teeth, and the 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 2 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 3 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 mucpus membrane of the mouth, and the
bedsores which are so frequent in typhoid, afford
favorable ports of entry. 4

Mixed infections, by co-existing pyogenic and
typhoid bacteria, as would be expected, are not un-
commonly met with. Thus Lehmann 5 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.

3 Guyot, Etude sur 1'Hematocele periuterine, etc., dans la Fievre
Typhoide, These de Paris, 1879.

4 See Introduction for a fuller'discussion of tliese points.

5 Centralbl. f. klin. Med., 1891, 649.

36 SURGERY OF TYPHOID FEVER.

Spirig T records a case of suppuration in the thy-
roid with a mixed culture of the typhoid bacillus and
the staphylococcus albus, and Parsons 2 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 3 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 4 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 5 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 suggested 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 6 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.

4 Bull. Soc. Med. des Hop., 3d series, vol. viii, p. 90.

5 Jour. Pathol. and Bacteriol., 1894, iii, 202.

6 Internal, klin. Rundschau, 1890, Nos. 3 and 4.

PATHOLOGY. 37

two weeks) for us to suppose that the pyogenic
bacteria coulcl 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
o( 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, 1 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 1'Institut Pasteur, 1893, vii, 141.

38 SURGERY OF TYPHOID FEVER.

the contrary, when mixed with the streptococcus,
the typhoid bacillus 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 1 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.

Orloff 2 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 to ascribe 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. 37) is 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 tissues ; 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, Quervain, 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." 1

In at least once case of superficial necrosis of the
femur, Klemm 2 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, 3 Fraen-
kel, 4 and Tavel. 5

1 Flexner, Jour. Pathology and Bacteriology, 1895-96, 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. 3 La France Med., 1885, ii.

4 Sechste Kongress Inn. Med., 1887.

5 Correspondenzbl. schweiz. Aerzte, 1887.

PATHOLOGY. 41

(a) In Man. The objections have been consid-
ered in the preceding section.

As already stated, there are at least 63 cases in
which the typhoid bacillus alone existed in various
suppurative disorders, and 19 more in which 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 organisms 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 fingers 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.

(d) 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, loc. cit., p. 187.

Achalme, Soc. Biol., June ii, 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, 1890.

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 in
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 1 reports the case of 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 i3th, 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 Avere
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 2 re-
ports a very carefully examined case of typhoid fever
without ulceration of the intestine in which both the
"Widal serum-test during life and the bacterio-
logical 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
1 9th, 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. t 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. * * * * The
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 Gaff ky 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 glands 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, 1 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 2 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, 148.

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 1 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 regarded as
typhoid bacilli.

6. In the Spleen. Karlinski 2 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 swelling or ulceration of either large
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 3 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., 1887, 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 1 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 2 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 infiltrating the
brain for there was no pus the bacillus of Eberth
was found in pure culture.

10. In Pleuritic Pus. Charrin 3 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 Tavel 4
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

1 Virchow's Arch., 1887, cix, 477.

2 Lyon Med., 1889, Nos. 34 and 36.

3 Soc. Med. des Hop., March 17, 1891. 4 Rev. de Chir., 1891, 507.

48 SURGERY OF TYPHOID FEVER.

exhaustive. The patient made an excellent re-
covery.

12. In the GalUbladder. Osier 1 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 inclol
reaction to this and to another culture of typhoid
bacilli.

13. In the Liver, Spleen, and Blood. Guarnieri 2 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 3 gives the following
references : In a case of Pick's 4 the sero-diagnosis

1 Trans. Assoc. Amer. Phys., 1897, xii, 396.

- Baumgarten's Jahresbericht, 1892, vol. viii, 234. from Revist. Gen. di
din. Med., 1892, p. 234.

3 Etude sur le Serodiagnostic, etc. Ann. de 1'Institut Pasteur, May,
1897, p. 426.

4 NVien. 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. In
the case of Chambon and Menard, 1 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 2 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, the 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.

might 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 Remlinger and Schneider. 1 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, 2 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 1'Institut Pasteur, vol. xi, p. i.

2 Riforma Med., 1893,95,10 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 probably it is
as yet an unsolved problem.

Frangulea, 1 in a paper at the recent Moscow Con-
gress, accepts the last very frankly.

Hiss, in an important recent paper, 2 has pointed
out the means of differentiating the two with ap-
proximate certainty. Flexner 3 has done the same.

1 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. 1

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 gangrene of the lung and 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 2 mention it. Barwell 3 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, 4 Hildebrand, 5 Ali-
bert, 6 and Fabre 7 mention sporadic cases of gan-
grene, but attention was first seriously called to its
occurrence in typhoid fever in 1857 by Bourgeois 8

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. 3 International Encyclopedia of Surgery.
4 Mem. et Campagnes, iii, 72. 5 Typhus Contagieux, 1806.

6 These de Paris, 1838. 7 Gaz. Med. de Paris, 1851, 539.

s Bull. Soc. Med. des Hop., Paris, 1857, iii, 311.

TYPHOID GANGRENE. 53

and Bourguet. 1 The next papers of any importance
were by Gigon in 1861 and i863. 2 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 3 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, 4 Gaston
David, 5 Barie, 6 Deschamps, 7 Haushalter, 8 Flexner, 9
and Quervain, 10 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 priori 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.

4 Gangrene des Organes Genitaux de la Femme, Arch. Gen., 1881, 7th
series, vi, 150.

5 La Gangrene Typhoide, These de Paris, 1883.

6 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-

9 Johns Hopkins Hosp. Rep., Nov., 1894, 120; and Jour. Path, and Bac-
teriol. , Nov., 1894, iii, 202.

10 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, 1 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, 2 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. 3 Since 1876, Dr. Westcott has
found 90 cases of actual gangrene, of which 72 fol-
lowed typhoid, in addition to which he has tabulated
2 1 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 37 after
typhoid and four after typhus, or a total in typhoid
alone of 205 cases of bone lesions to 133 of gan-
grene.

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 186267, 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 1 or seven years. 2 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, 3 and the latest in the
seventh week. 4 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.

3 Donald, Lancet, 1892, i, 417.

4 Forgues, Rec. de Med. Mil., 1880, 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 1 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.

1 We do not appreciate how much a continued high temperature alone
exhausts a patient. Were the 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
X77 2 foot pounds). A girl of 100 pounds weight, simply lying still in bed,
suffering from such a fever, does daily the work of two or three men.

TYPHOID GANGRENE. 57

In my Toner Lecture I 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
with 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 thorough bacteriological 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 making such examinations.

In two cases in my tables ergot had been freely
given in consequence of hemorrhage. 1 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 gangrene. 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, 1 in both of which the pyemia followed a
phlebitis without gangrene.

Turning 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; (b] 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, i, 18 ; and Spillman, Merc. Med., 1895,
No. 13, 145.

TYPHOID GANGRENE. 59

(b] In the Endocardium. 1 Viti 2 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 3 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 4 made a
similar observation. Gilbert and Lion 5 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, 6 Beaumanoir, 7 Fritz, 8 and Val-
lette (quoted by Ferrand 9 ) 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, 10 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.

2 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. 5 Comptes Rendus, 1889.

6 Rec. de Mem. de Med. Mil., 1880, 3d series, xxxvi, 386.

7 Prog. Med., 1891, ix, 364. 8 Charite Annalen, vi, 169.
9 Contrib. a 1' Etude de la gangrene des membres pendant la cours de la

Fievre Typhoide, 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 2 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, 3 Met-
tler, 4 Barie, 5 Quervain, 6 and Haushalter. 7 With the
exception of the last two, the descriptions are pa-
thological, but without bacteriological confirmation.
Ferrand 8 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 obliterating 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

1 Delia Arterite Tifosa in Dehu, loc. cit.

2 Merc. Med., Sept. 20, 1893, 453. 3 These de Paris, 1886.
4 Phila. Med. Times, Feb. 19, 1887, 339, and N. Y. Med. Jour., March

9, 1895, 289. *> Rev. de Med., 1884, iv, 7.

6 Centralbl. f. inner. Med., Aug. 17, 1895, 793.
~ Merc. Med., Sept. 20, 1893, 453. 8 These de Paris, 1890.

TYPHOID GANGRENE. 6 1

of the intima, the irregularities of its surface, and the
diminished caliber from the swelling 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 a,s 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 rule, 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 Flexrier, 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, 1 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.

(e) 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, 2 shows

1 For a number of cases in which bacteria were found in the vasa vasorum,
see Lockwood, Traumatic Infection, London, 1896.

2 Die retiologische Bedeutung des Typhusbacillen, Leipzig, 1886.

PLATE 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 ot Fig. I, u, 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.

(_/") In the Peri vascular 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. 1
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,
together with the demonstration of actual thrombi
caused by the typhoid bacilli 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 m 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 2 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 ol
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 I'rog. Mecl., 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 great number of cases
in the table there were no evidences of preceding
cardiac disease, and yet obstructive clots were 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.

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 origin 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 egg, 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 meningeal. 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-
ing instance :

Case I. E. C., Milford, Del., age forty-two, first
consulted me July 9, 1897, at tne instance of Dr.
Marshall. He is an exceedingly large, stout man, t
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 ago and has never healed. At this site
there is a small crater, one cm. in diameter, going
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 was
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 Beaurnanoir.) 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, 1 the
clot extended downward to the deep femoral vein
and upward through the common iliac to the vena
cava. Beaumanoir 2 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, 4 and Bouley. 5 These were all
fatal, but Mackintosh, 6 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 -

2 Prog. Med., 1891, ix, 364.

3 Comptes Rendus Soc. Biol., 1879, 6th series, vol. iv, parts 2 and 3.

4 L' Union Med., 1882, 3d series, vol. xxxiv, 521.

6 Prog. Med., 1880, viii, 998. 6 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 Nauwerck, 1 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, 2 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 3 has reported two
such cases in brothers. A curious coincidence is
seen in the case of two sisters reported by Trelat, 4
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
invasion.

1 Correspondenzbl. schweiz.' Aerzte, 1879,485.

2 Prog. Med., 1880, viii. 998.

3 L' Union Med., 1880, 3d series, xxix, 1025.

4 Gaz. des Hop., 1879, 1 4*7-

70 SURGERY OF TYPHOID FEVER.

When the gangrene results from venous obstruction
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
-anorrene are marked and characteristic. Let us

O O

TYPHOID GANGRENE. J\

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 resistenticz, 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 gangrene will be of
the moist instead of the dry variety. It will present
the usual' appearance of rnoist 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, 1
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
169 cases 115 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 age 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.

3 On Fever, 191.

74 SURGERY OF TYPHOID FEVER.

This will not differ much from the normal age-distri-
bution 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 IV), 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

76 SURGERY OF TYPHOID FEVER.

striking fact is that the legs suffer far more frequently
than all other parts of the body put together. It is, it
seems to me then, good common sense and good
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, 19 "

showing an exactly 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. 77

vein where it passes under the right common iliac
artery, is the most potent factor ; slight in itself, it
is true, but when the 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, 1 all of which occurred upon the left side, pro-
ducing right hemiplegia, 2 and one of the right
brachial artery, 3 and two of the pulmonary artery, 4
the 1 5 cases of arterial thrombosis without gangrene
involved both sides in four cases ; right side in six
cases ; left side in five cases.

Of 47 cases of venous thrombosis without gan-
grene 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 see
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-

3 Sumner, Boston Med. and Surg. Jour., 1883, cviii, 200.

4 Nauwerck, Correspondenzbl. schweiz. Aerzte, 1879, 485, and Mayet,
Ann. de la Soc. de Med. de Lyon, xxviii, 2d series, 1880, p. in.

7 8 SURGERY OF TYPHOID FEVER.

venous obstruction, whether followed by gangrene or
not, of 99 cases (52 -f- 47) there were :

Bilateral, 7 cases.

Right side, 23 "

Left side, 69 "

While in 61 cases (46 + 15) of arlerial 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 suggest 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 77.

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 1 in which the scrotum and
the feet both suffered from gangrene. 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 fxxx from the scrotum. 2

r \\\^ female 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

1 Tunis, Univ. Med. Mag., 1889-90, ii, 195. 2 Murchison, 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 18 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. 1
The disorder manifests itself either as a distinct
gangrene of the external genitals or by gangrenous
ulcers forming- in the vagina. The former occasion-

o o

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, 2 in which an opera-
tion resulted fatally, and in another, reported by
Martin, 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, 4 in which,
during 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 hymen and was as large as a
five centime piece. A month later she died of pelvic
peritonitis. A second is reported by Liebermeister. 5
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. Gn., Feb. and March, 1881. 2 Gaz. Hebdom. , 1867, 652.

3 Centralb. f. Gynekol., 1881. 4 Anat. Pathol., ii, 307, and PI. cxv.

5 Ziemssen's Cyc., Amer. ed., vol. i, 184.

80 SURGERY OF TYPHOID FEVER.

Schick, ' and in the fourth, my own case, both recto-
vaginal and vesico-vaginal fistulae occurred.

A resume of this unique case, of which I quote the
earlier 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 ^76, and is
the only case I have found of both recto-vaginal
and vesico-vaginal fistulae. 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 sloughed
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 did nine operations. Thrice unsuccess-
fully I attacked the fistulse 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 gave
me great trouble and necessitated several opera-
tions ; but at the twelfth operation, December 28,
I 875, 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-vaginal fistula, thus draining 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 11, 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

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 night 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 vagina, 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
70 grains and measured ^ by 5^ 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-vaginal 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
discharge, and the feces. It is an encouraging 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 forming 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 the perineum or around the anus arises
in a few cases in both sexes. In women it is gener-
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 othercases. 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 fistulae 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-

TYPHOID GANGRENE. 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 1 ) ; of the tongue, with cyanosis of the face
and great dyspnea (Gaston David 2 ) ; of the uvula
(Freudenberger 3 ) ; of both ears after ergot, 5vj,
had been given in six doses (Sanrda 4 ) ; of the lips, in
which a secondary staphylococcus septicemia, ensuing
probably from carious teeth, destroyed life (Spill-
mann 5 ). The cheeks are attacked more frequently,
and noma or cancrum oris is noted in my table as
having been observed nine times, and, as usual, is
very fatal, five of the nine having succumbed, the
result in one being unrecorded. The lungs also suf-

iArch, Gen., March, 1881.

2 Quelques Consid. sur la Gangrene Typhoide, These de Paris, 1883.

3 Aertzlich. Intelligenzbl., 1880, xxvii, 7.

4 Rev. Gen. de Gin. et de Therap., 1892, vi, 401.
Merc. Med., 1895, No. 13, 145.

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 normal
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 flag, 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 GANGRENE. 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 gangrene 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. 2

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 1 cases, to the foot six
times, 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 thigh in eight 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 1 5 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 give rise to a dangerous embolus. To this
I would add another evident objection : that the
septic fluids in the tissues should not be forced into
the general 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." 1

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.

go 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 J 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, 1 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 variety, and had a previous rheu-
matic history. Freyhaus' case, 2 in which the knees,
ankles, elbows, and wrists were involved, but recovery
of all these joints followed, may be fully accepted as of
the rheumatic variety. That of Balzer, 3 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

1 Lapersonne, Des arthrites infectieuses, p. 120.

2 Berl. klin. Wochen., 1891, xlii, p. i.

3 Robin, Gaz. Med. de Paris, 1881, No. 40, p. 559.

92 SURGERY OF TYPHOID FEVER.

much rheumatic as septic in character. These, with
those of Rendu * and that of Menard, 2 1 should class
together under the next variety.

Septic Typhoid Arthritis. In the case of Robin 3
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 cartilages. 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 4 has especially

1 Quoted by Witzel. 2 Soc. Med. des H6p., Jan. n, 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 2 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.

1 Ein Fall von acuter Mediastinitis in Verlauf eines Ileotyphus, Berlin,
klin. Wochen., 1874, xi, 97.

2 Verbreit. sinuose Geschwiire auf der Brust, Perfor. vorder Mittelfellraum.,
Plotzlich. Tod an Verblulung, Typhose Geschwiire im Darm., Med. Corresp.
Wtlrttemb. aerztlich. Verein, Stuttgart, 1859, 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
extremities 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 danger 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, 1
already considered, in one case ankylosis of both
hips followed a faulty posture, persisted in long after
the fever. 2 This case recovered motion after forci-
ble flexion under ether. In Clarke's case 3 ankylosis
of the elbow persisted, very possibly for want of early
passive motion.

1 Lapersonne, Des Arthrites Infect., p. 120.

2 Gibney, Trans. Amer. Orthop. Assoc., 1889.

3 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.

(6} 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-
ing 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, 1 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, 2 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 gangrene, 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
great. 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, 1 Hellwig, 2 Parise, 3 and Friedheim 4 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 we 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 i. e., more
than one-half of all the cases of typhoid arthritis
are followed by spontaneous dislocation, nearly all of
whicJi 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. Cliir., xvi, 58.

2 Ueber die Affect, des Hiiftgelenks bei Typhus, Marburg, 1856.

3 Archiv. Gen., 3d series, 1842, xiv, I.

4 Ueber die Spontanluxation des Hiiftgelenks nach Typhus, Berlin Thesis,

1885.

TYPHOID AFFECTIONS OF THE JOINTS. 97

have been observed in locomotor ataxia, the exanthe-
matous fevers, hemiplegia, sciatica, and rheumatism, 1
as pointed out by Stanley 2 in 1841. In one case 3 it
was noted that for three months before the typhoid
attack the child had been suffering from ordinary
coxalgia.

Unfortunately, there are on record very few exami-
nations of such joints post-mortem, and very 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), Seinton (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. '/.), and Kirmisson
(/of. cit.} ; and after influenza by Eisendrath (loc. fit.).

2 On dislocation, especially of the hip-joint, Med. Chir. Trans., xxiv, 123.
See also Malgaigne, Fract. and DislocT, Paris, ii, pp. 218-226, 882-887.

3 Phocas, Gaz. des Hop., 1894, Nos. 132 and 135.

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, an< ^ again on
June 1 8th. 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 with typhoid for fourteen weeks, and who
had lain for two months with the knees almost touch-
ing 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. Schuller 2 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 \Yitzel'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-
organisms."

5. Danlos and Strauss ' 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 2 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. Bakterio!., 1890, 366.

100 SURGERY OF TYPHOID FEVER.

affections in man, at least in some cases. Having
done their malign work, they may have disappeared.

Grancher, 1 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 2 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. IOI

to typhoid fever. But incredulity had to change to
belief, 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 symptoms 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 gland 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 slightest 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

102 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, i was thirty, i was
thirty-five, and i was sixty-one years old ; that is,
32 out of 35 were under twenty 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 clanger 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 dislocation was the first fact observed,
and in most of the others this is probably true.

TYPHOID AFFECTIONS OF THE JOINTS. 103

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 i 7 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. 1 Shortening is recorded in 18 cases, and
where the amount is named was generally \y 2 to
two inches. In 6 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 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 Friedheim, Ueber die Spontanluxationen des Hiiftgelenks nach Typhus,
etc., Berlin Thesis, 1885.

104 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 the 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-
ing to the existing conditions. In one case ' the
upper epiphysis of the femur became detached, and
later was removed. In another, 2 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.

106 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 e d 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 nth, 'left knee
rigid, painful, and flexed ' ; on re-reading this, my
first impression was that I had made a mistake in
writing ' left,' meaning l 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. IO/

1 1 th. The fever, as you will perceive by referring
to my daily record, was January I2th, 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 3Oth speech had entirely returned. By
February 2istshe 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 intervening
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

108 SURGERY OF TYPHOID FEVER.

bed she found she was lame, as the right leg 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 finding

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 beoinninor o f the sixth week, the second week

O c5

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 205 cases of all
kinds following 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

1 10 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. 1 1 1

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,
amonof 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 2 there was

1 Med. Times, Phila., Aug. 28, 1880, p. 608. 2 Lancet, 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, 1 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, 2 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 3 with a sequestrum extending from the canine
tooth to the angle of the jaw. In the other, 4 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. 2 Breslauer aertzlich. Zeitschr., 1887, 271.

3 Heath, Med. Times and Gaz., Dec. 18, 1869.

4 Eisetihart, Munch, med. Wochen., 1886, xxxiii, 163.

TYPHOID AFFECTIONS OF THE BONES. 113

and many of the 168 cases which we have collected
in the later table, occurred before the bacillus of
typhoid was known. Its presence has 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 51 cases in which a bacteriological exam-
ination was made. In 13 the pyogenic bacteria were
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 J
the colon bacillus was found associated with it, 2 and
was responsible for the presence of gas in the pus ;
and in one 3 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 would think, with an almost in-
evitable ordinary pyogenic infection, there has been
found a pure culture of the bacillus of typhoid.

1 Klemm, Archiv f. klin. Chir., Iviii, Heft 4.

2 Dehu (Etude sur le role du bacille d' Eberth dans les complications
de le fievre typhoide, These de Paris, 1893) states that the colon bacillus
has never been seen in bone abscess. Klemm's case has been reported
since then. 3 Parsons, Johns Hopkins Hosp. Rep., vol. v.

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 2 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, 3 Vincent, 4 Vaillard, 5
and Dmochowski and Janowski, 6 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 Hosp. 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. 4 Ann. de 1'Institut Pasteur, 1893, vii, 141.

5 Grancher, Bull. Med., 1892, vi, 1273.

6 Ziegler's Beitrage, 1895, xvii, 221.

TYPHOID AFFECTIONS OF THE BONES. 115

fore, a pure culture of the typhoid bacillus is found
in a suppuration after typhoid, it is very unlikely 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 1 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, 1 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).

Being 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 1 872," 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 gall-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
eio-ht times in the marrow of the ribs and once in

1 Bull, et Mem. 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. 1 1/

the bones of the extremities. Wissokowitsch l 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 2 inoculated rabbits and
found the bacilli only in the bone-marrow. Dmo-
chowski and Janowski 3 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,
at 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 pfiven' 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. cif., p. 90. 2 Arch, de Physiol., 1887.

3 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
returning 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. 2

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 -> a mon-
articular arthritis, gangrene of one leg, etc. While
occasionally two joints or both legs may be involved,
yet it is rare. In the bones, however, multiple foci
of disease are common. Thus, Mercier ' reports a
case in which the left tibia, left scapula, left femur,
right humerus, and right tibia were all affected re-
spectively on the seventieth, eighty-eighth, ninety-
fifth, ninety-seventh, and one hundred and first days
after convalescence began ; Pean and Cornil, 2 one
involving the left tibia, and, five months later, two
places in the other tibia ; Park, 3 one involving all
the bones of both legs, the pelvis, and the spine ;
Chantemesse and Widal, 4 one involving the right
tibia, left femur, a finger on the left hand, and
the left ulna, at eight weeks, eleven weeks, eight
weeks, and nearly a year respectively ; Hulin, 5 one
involving the tibia, the ribs, and the clavicle at the
tenth week, nineteen months, and about two years
respectively. Caspersohn 6 reports a case involving
the left parietal, left tibia, and left ulna, respectively
during the course of the fever and three and five
months after the fever, with suppurative parotitis on

1 Rev. Mens. de Med. et de Chir. , 1879, iii, 21.

2 Bull. Acad. de Med. Paris, 1891, 3d series, xxv, 599.

3 Annals of Surgery, 1891, ii, 491.

4 Bull, et Mem. Soc. Med. des Hop., 1893, 3^ series, x, 779.

5 Contrib. a 1' Etude des Complic. Osseuses de la Fievre Typh., These de
Paris, 1885.

6 Festschrift Fr. v. Esmarch, 1893, 455.

120 SURGERY OF TYPHOID FEVER.

the forty-eighth day; Catrin, 1 a case in which the
left tibia, left temporal, and the right tibia (twice)
were attacked, respectively on the fifty-sixth, sixtieth,
sixty-fifth, and eighty-third days ; and Fiirbringer 2
reports a case in which there were seven successive
attacks in the course of four months, involving ten

different portions of the body, but followed by com-
plete recovery and disappearance of all evidences
of disease. In addition to these cases there are a
larcre number of cases in our tables in which two

bones were involved.

Besides this, it will have been observed that in the
multiple attacks above referred to the various bones
are not involved all at the same time, but successively,
and not seldom after long intervals, sometimes even
in apparent later health. (Cf. case of H. W.,p. 123.)
So long as the bacilli remain in the bones, so long is
the patient in danger. He is only safe when they
are totally eradicated, and as to the date when this
has happened, we can, apparently, only tell by the
cessation of the attacks. The following case illus-
trates repeated recurrences of periostitis and super-
ficial necrosis prior to an attack of typhoid, and that
the fever did not, apparently, cause a renewal of the
disease in the bone :

Case VIII. R. W. P., clergyman, age thirty-one,
first consulted me November 5, 1877. At nine years
of age, presumably from exposure to cold, he had
several attacks of periostitis of the entire left tibia
and of the left humerus, the latter only in one spot.
In both of these places this was followed by necrosis.
He lost several pieces of bone from the tibia at

1 Gaz. des. Hop., 1896, No. 42. 2 Brit. Med. Jour., 1890, i, 1033.

TYPHOID AFFECTIONS OF THE BONES. 121

various times until he was fifteen years old. At
twenty-eight he had another attack of periostitis of
the tibia, followed by suppuration which was entirely
superficial and was not followed by necrosis. At
twenty-five he had typhoid fever, during which he lost
flesh very rapidly, he thinks as much as 30 pounds
in three days, the cerebral symptoms being the most
prominent. He was in bed for a month, but returned
to his college duties in two months. No periostitis,
necrosis, or any other trouble occurred in the bones
after his typhoid fever. About September i, 1877,
six years after the fever, two small spots of perios-
titis appeared again in the middle of the tibia, and at
present (Nov. 5, 1877) there are two points at which
the bone is exposed one y 2 of an inch in diameter,
the other only a pin's point in size. The bone is
dry, red, and tender, but is not painful in walking.
The bone later discharged, since which time he has
been well.

Park T has called attention to the rapid growth
which often follows an attack of typhoid in adoles-
cents, sometimes as much as a millimeter a day, and
ascribes it to the typhoid irritation of the osteogenetic
tissues. The long persistence of the bacilli in the
bones may readily explain this, especially if they are
present in such small numbers as to produce only a
mild irritation but are not numerous enough to cause
inflammation and suppuration.

In a few cases the osseous lesions have arisen at
the seats of old fractures or strumous cicatrices.
Thus, Routier and Terillon 2 report a case of perios-
titis of the left ulna and right tibia at the seat of
previous fractures in childhood, and Finlayson 3 a

1 M litter Lectures on Surg. Patliol., 260. 2 Prog. Med., April 12, 1884.
3 Amer. Jour. Med. Sci., March, 1891.

122 SURGERY OF TYPHOID FEVER.

case of necrosis of both tibiae at the site of old
strumous lesions marked by a scar.

Recent injury seems to be the cause which has
precipitated the osseous lesions in some cases.
Thus, Mercier 1 and Levesque 2 report three cases in
which the 'osseous lesions followed a fall after the
fever, and Clarke 3 one in which a fall on the knee
preceded the fever. As the suppurative periostitis
of the lower end of the femur did not occur until the
fifth week after defervescence, the relation of the two
is doubtful. A case reported by Jackson 4 in a man
of forty-two is, curiously enough, attributed to the
injury inflicted by the use of the stethoscope. Peri-
ostitis of the third rib followed five months after the
beginning of the attack, and when he was in complete
health he alleged that while in bed he felt soreness
at that point from the pressure of the stethoscope.

Colzi's experiments 5 may throw some light upon
this phase of the disease. The injection of two c.c. of
a pure culture in a rabbit's ear always gave negative
results, but if the injection was preceded by a sub-
cutaneous fracture an abscess resulted in 1 1 out of
14 cases. The well-known development of tubercu-
lar "abscesses" after injury would reinforce this
view.

Witzel 6 has called attention to the as he believes

much greater recent frequency of the bone lesions

of typhoid, and attributes them to the more frequent

1 Rev. Mens. de Med. et de Chir., 1879, iii, 21.

2 De la periostite dans la convalesc. de la Fievre Typhoide, Paris, 1879.

3 Jour. Amer. Med. Assoc., April 4, 1891,473.

4 Brit. Med. Jour., 1885, i, 428.

s Jordan, Beitr. klin. Chir., 1893, x. 6 Park's Lect.

TYPHOID AFFECTIONS OF THE BONES. 12$

injuries received from the sides and edges of the
bath-tub, since this method of treatment has been
introduced. While this may not be so, yet the cases
above cited would seem to show that an injury is
quite capable of precipitating such troubles in the
bones, and that great care should be taken that in
bathing no accidental injury, even a slight one,
should be received, and also that injury should be
carefully avoided, even long after recovery.

Allied to the influence of injury is that of muscular
strain. To illustrate this, I quote from my earlier
lecture a case in point, with the history for two years
later. It 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.

Case IX. H. W., a remarkably stout, healthy lad
of sixteen, was attacked Dec. 17, 1871, with typhoid.
He was delirious for four weeks, was in bed four
months, and first got out of doors in May, 1872. Bed-
sores had formed, but were kept in check by inces-
sant care. In the autumn of 1872, not yet being
strong, he went to work at riveting in an iron works,
which required him to stand and use a ten-pound
hammer, the main strain being naturally on the
right arm and leg. His right arm soon began to
swell, and finally four fistulse formed. After the
removal or discharge of several pieces of bone, this
arm recovered in about a year. Returning then
to the same work, his health being still impaired, his
right thigh began to trouble him, and broke out and
healed several times, discharging several pieces of
bone. He came under my care in July, 1875. He
had then a scar and five open sinuses in the thigh,
all leading in the direction of the bone, and in one,

124 SURGERY OF TYPHOID FEVER.

just above the knee, a fragment of dead bone an
inch long was found. This sinus and a second just
below the patella, an offshoot from it, threatened to
invade the knee-joint. Meanwhile, in the fall of

1874, though he had not done any work on account
of his right leg, the left thigh broke out, and a sinus
in the direction of the bone was established, but no
dead bone was ever actually found here. In Jan-
uary, 1875, an abscess also appeared in the left arm,
and after the discharge of some bone finally healed.
I enlarged all the existing sinuses in the right thigh,
removed the dead bone, and, after I had treated the
case carefully for four months, all the sinuses healed.
A new one, however, appeared early in 1876 in the
right thigh, but no dead bone was found. In Febru-
ary, 1876, it healed, broke out again in July, and did
not heal until December, after a counter-opening
had been made. In July, 1879, periostitis again
manifested itself at the insertion of the internal ham-
string tendons of the right leg. An incision was
made down to the bone, giving exit to pus. An-
other abscess also developed over the sternum at
the origin of the right pectoralis major. This also
was opened and the pus evacuated. He had gone
to work as an engineer meantime. I have not seen
him since. His health markedly improved early in

1875, and since my various operations he has grown
to be exceedingly robust and hearty again. His
right knee, which was stiff from the sinuses among
the muscles of the thigh and near the knee-joint, be-
came as mobile as ever, and he works with ease.
The abscesses in the two arms were at or near the
deltoid insertion ; of those in the right leg, the first
was at the insertion of the glutens maximus, the last
at the insertion of the hamstrings, that in the left leg
near the lesser trochanter, and one at the origin of
the great pectoral muscle, all points at which muscu-
lar strain would come in standing and hammering,
and later in his work as an engineer.

TYPHOID AFFECTIONS OF THE BONES. 125

In this case the recurring attacks of periostitis
leading to abscesses and superficial necrosis covered
a period of at least eight years, and very possibly
continued after I lost sight of him. They involved
the right humerus, t>oth femurs, and the sternum in
eight or ten successive attacks, and were nearly all at
points of muscular attachment, and, therefore, of
strain. At the same time, it is to be observed that
they were all essentially local attacks, the general
health being good. They may easily be explained
on the theory that the bacilli being present in the
bones (the case was observed before the bacillus
of typhoid was known), a local irritation was caused
by muscular strain, and the bacilli were re-stimulated
to the point of abscess formation, and even of
necrosis.

On looking over our tables I find that a consider-
able number of cases would seem to justify the
inference that muscular strain may have been the
immediate factor in producing the periostitis or other
lesion. Of all places in the body to be attacked by
periostitis, such points as the anterior superior spine
of the ilium, the tuberosity of the ischium, and the
Sfreat trochanter of the femur would be the last to be

thought of. Indeed, I do not remember myself ever
to have seen them involved in any case of ordinary
periostitis or in any case I have seen recorded in
medical literature. But in our tables I find that
Sacchi x records a case of osteo-periostitis of both
anterior superior spines of the ilium, of the tuberosity
of the left ischium, and of the sacral and coccygeal
regions, the right-sided troubles developing during

1 Revista Veneta, Jan., 1889.

126 SURGERY OF TYPHOID FEVER.

convalescence, the left two months later. Now, all
of these points are points of attachment of large and
powerful muscles of the thighs and hips, which would
be among the first called upon for a relatively severe
exertion, as with returning health the patient would
begin to stand, walk, and work.

Ebermeier ' records another case involving the
tuber ischii and another of the inner side of the head
of the tibia (inner hamstrings). Hulin 2 records
another case of a suppurative periostitis of the left
great trochanter.

Turgis 3 attributes an osteo-periostitis of the hu-
merus eight months after the fever, partly to a blow
and partly to excessive muscular action. Martha 4
records a case involving the inner side of the head
of the tibia and the inner condyle of the femur, the
tibia being so enlarged at the point of disease as to
prevent full extension of the knee. The bone dis-
ease arose two and a half months after the patient
had gone to work, and the points attacked were
those of muscular attachment.

Another case, reported by Verchere, quoted by
Turgis 5 is curious by reason of the alleged cause,
and may be an illustration both of traumatism and
muscular strain. A periostitis of the sternum, in a
woman of sixty-eight was attributed to pressure
from cutting bread while holding the loaf against the
chest. In a large number of other cases there is no

1 Deutsch. Arch. f. klin. Med., 1889, xliv, 140.

- Contrib. a 1'Etude des Compile. Osseuses de la Fievre Typhoide, These
de Paris, 1885.

3 Contrib. a TEtude de 1'Osteo-periostite Conseq. a la Fievre Typhoide,
These de Paris, 1884.

4 France Med., April 4, 1888. 5 These de Paris, 1884.

TYPHOID AFFECTIONS OF THE BONES.

127

doubt that the periostitis developed at points of
muscular attachment, but no mention is made of the
precise point involved; often only "the humerus,"
" the thigh," etc., are mentioned, because the atten-
tion of the reporter probably had not been called to
the possible relation between the disease and mus-
cular strain. The cases described are, however, I
think, sufficient to establish the probability, if not
the certainty, of the inference. In the shaft of the
tibia, however, the most frequent site, this reason
can not be assigned.

Varieties of Disease of Bone after Typhoid.
The two series of cases show a marked contrast
as to the frequency and infrequency of the various
forms of osseous lesions reported up to 1876 and
after that date.

SERIES SERIES

DISEASE.

OF 1876. OF 1896.

Necrosis, 50 35

Caries, 12 i

Periostitis, 3 107

Osteitis (bone abscess,) . - 12

Osteomyelitis, - 10

Granuloma, 2

Exostosis, i

Uncertain, 4

69 168

TOTAL.

12
10

237

The table is not absolutely accurate. Many of
the cases may overlap e. g., a periostitis may result
in caries or an osteomyelitis in a necrosis. Many
of the terms are used loosely by the reporters, who
often do not nicely or accurately distinguish be-
tween caries and necrosis, caries and osteomyelitis,
or osteomyelitis and periostitis. The importance of

128 SURGERY OF TYPHOID FEVER.

osteomyelitis especially has not been recognized by
the profession at large until of late years, and its
distinctive symptoms, and even its existence, twenty
years ago were for the most part unrecognized. In
fact, in typhoid bone lesions, as in the same lesions
from other causes, the two essential forms of dis-
ease of the bone are (t) osteo-periostitis and (2)
osteomyelitis ; while caries, necrosis, bone abscess,
etc., according to various circumstances, may result
from either. But taking the table as it stands, peri-
ostitis is undoubtedly by far the most frequent form
of osseous lesion.

Case X. The following case, the report of which
I also owe to the courtesy of Dr. D. S. Rice, of
Hastings, Pa., who has had an unusually rich experi-
ence in the surgical results of typhoid fever, is a
good illustration of typhoid osteomyelitis :

"Grace D., German, age fifteen, when twelve years
of age had a severe attack of typhoid, lasting five
weeks. She then convalesced rapidly, when suddenly,
in the third week of convalescence, she complained
of exceedingly severe pain in the middle third of the
left tibia, without swelling or rise of temperature. A
week after the pain began the temperature quickly
rose to 105, but the leg was only slightly swollen
and was not discolored. An incision six inches
long was immediately made, and the bone was tre-
phined, evacuating three ounces of dark pus. The
medullary cavity of the bone was then chiseled open
for six inches, irrigated, and packed with gauze. The
patient made an uninterrupted recovery, and has
been well ever since."

In the ribs especially, I suspect that many of the
cases classed as periostitis were really instances of
osteomyelitis. Necrosis is most frequent in the tibia,

TYPHOID AFFECTIONS OF THE BONES. 129

but in the ribs, as Paget T has pointed out, necrosis
does not occur. On the contrary, it may occur, though
rarely, in the costal cartilages. Helferich 2 and Berg 3
have especially called attention to the age and loca-
tion in typhoid ailments of the ribs and costal carti-
lages. Periostitis, osteomyelitis, and chondritis are
the usual forms of disease in the ribs and their car-
tilages. As the chest wall is thin, operations here
are apt to be less thoroughly done than elsewhere
on account of the danger to the pleura, the lungs, or
the pericardium, or even of opening the pleura or
pericardium, and hence these cases are peculiarly
apt to be chronic and to require repeated opera-
tions. Stephen Paget 4 has related a case of
periostitis of tfoth tibiae and the lower left costal
cartilages, which only healed in the latter place after
four or five operations in two and a half years. The
following cases are good illustrations, both of the
character and chronicity of the bone lesions of
typhoid, in one of which the pleural cavity was
widely opened without collapse of the lung or other
disaster :

Case XI. J. K., age forty-two, of Patton, Cambria
Co., Pa., was kindly sent to me at the Jefferson
Medical College Hospital by Dr. D. S. Rice, of
Hastings, Pa., February 19, 1895. His father died of
some gastric trouble; his mother of dropsy. Three
sisters are living, all fairly healthy. No family history
of tuberculosis or cancer. He was in good health
until eighteen years ago, when he had an attack of
typhoid fever which confined him to bed for ten weeks.

1 St. Bart. Hosp. Rep. , 1876.

2 Berlin, klin. Wochen., Oct. 20, 1890, 979.

3 Centralbl. f. Chir., 1896, 153. 4 Surgery of the Chest, 137.

130 SURGERY OF TYPHOID FEVER.

Toward the end of this period he had some pain in
the right sixth and seventh costal cartilages. When
he got out of bed he discovered a small hard mass
at the junction of these cartilages and their ribs.
This gradually increased in size and was finally laid
open, but no pus escaped. The wound closed, but the
mass still grew larger and more tender, but without
discoloration. In July, 1894, Dr. Rice incised the
tumor and removed part of one rib and a portion of
the sternum. The operation resulted in a small
sinus, which never closed. A second operation was
done in October, 1894. In January, 1895, tne wound
meantime never having healed, he was operated on
again at the Pennsylvania Hospital by Dr. Thomas
George Morton, who also removed a portion of the
sternum and the parts of some ribs, but the wound
never healed.

Status Prassens. There are two sinuses, the upper
one directly over the sternum and on a line with the
nipple ; the second about two inches below, at the
right border of the sternum. Three inches from the
nipple is a point of exquisite tenderness ; all the tis-
sues are indurated and thickened. His general
health is good ; he has neither cough nor night-
sweats and has gained fifteen pounds in weight.
There is no history of tuberculosis.

Operation, February 20, 1895. An incision four
inches long was made over the sternum down to the
bone. Two horizontal incisions were then made
from the ends of the first to the line of the right
axilla. The quadrangular flap thus made was dis-
sected away, disclosing the sternum and ribs. The
fifth, sixth, and seventh ribs were all found softened
with osteomyelitis. Between three and four inches
of each rib were removed as well as a large part of
the sternum. In removing the fifth rib, in spite of
the utmost care in loosening the tissues on the in-
ternal surface, a rent was made in the pleura in the

TYPHOID AFFECTIONS OF THE BONES. 131

fifth intercostal space. This was closed by a finger
while further dissection was being carried on, and
later was stuffed with some iodoform gauze. In spite
of this, however, the air was sucked in and out during
respiration to a considerable amount. When the
ribs had been finally removed, the gauze was
removed and the opening inspected. It had then
gradually been torn to an opening nearly 4 cm. in
diameter. Through this with each inspiration the
lung made a moderate hernia, and fell away again
from the chest wall on expiration ; no collapse of the
lung occurred. During expiration I attempted to
draw the edges of the pleura together with a needle
(the pleura was entirely healthy), but it was so firmly
attached to the margins of the opening that the
attempt to tie the stitches simply made the hole
larger by an additional tear in the pleura. Accord-
ingly, I again stuffed the opening full of iodoform
gauze and replaced the flap over it, allowing the end
of the gauze to protrude at its lower border. His tem-
perature on the day after the operation rose to 102,
fell by the next day to 101, beyond which it never
went, but reached the normal on the nth of March,
nearly three weeks after the operation. There
was considerable local pain, the result of traumatic
pleurisy, at the point where the pleura was opened.
A few days after the operation, however, he was
able to be out of bed. He was discharged on April
7, 1895. The wound, which at first had entirely
closed, had reopened at two points, and there was
evidently still further disease of the bone. In fact,
at the time of the operation I was quite doubtful
whether 1 had removed all of the diseased ribs, but in
view of the probable pleurisy and of the very exten-
sive removal of bone which would be required, and
the possibility of a traumatic pleuro-pneumonia, I
thought it best at the time to restrict the operation
as already described. Cultures were made at the

132 SLRGERY OF TYPHOID FEVER.

time of operation from the sternum, ribs, and pleura,
but they failed to develop any growth.

On December 24, 1895, Dr. Rice reported that the
patient's general health was very good. The ends of
the ribs, where they had been excised, were solid, and
he could stand firm pressure against the chest wall
without pain. The only discharge then existing was
over the sternum.

He returned to the hospital on March 23, 1896,
when I found a sinus leading down to the sternum,
with a tumor the size of a pigeon's egg at the bor-
der of the ribs on the right side. The chest wall,
where I had excised the ribs, was quite firm. The
ends of the excised ribs could be felt, but the tissue
between was filled up with firm fibrous tissue, which
resisted pressure quite well. No evidence of the
old pleuro-pneumonia resulting from the first opera-
, tion could be detected.

Operation, March 25, 1896. A rectangular flap
was turned up, the middle of which was at the sinus
leading down to the sternum. An incision was then
carried from the earlier one along the border of the.
ribs on the right side into the tumor already de-
scribed. A soft spot was found in the line of the
nipple on the seventh rib. After chiseling into this,
I found that the spongy tissue was entirely broken
down, the bony trabeculae gone, and the medullary
cavity filled with granulation tissue, which tunneled
under the skin from the soft spot mentioned all the
way up to the sinus leading to the surface. This I had
not observed when I was operating on the diseased
sternum. With the double rongeur forceps I re-
moved the whole of the anterior wall of this tunnel,
scraped out the medullary contents with a sharp
spoon, and then used the Paquelin cautery to de-
stroy any possible infection which had escaped the
curette. His recovery was steady, but very slow.
He went home, however, June 19, 1896, nearly three

TYPHOID AFFECTIONS. OF THE BONES. 133

months after the operation. Even then there was
still a small superficial ulcer, from which, however,
no sinus could be detected leading down to the
bone.

Inoculations from the diseased bones were made
by Dr. Kyle, and only staphylococci were found to
be present.

In December, 1897, Dr. Rice stated that the patient
is entirely well, and doing light manual labor.

Case XII. I am indebted to Dr. Rice for the fol-
lowing additional case of presumed osteomyelitis of
the ribs after typhoid fever : " A man, age forty, had
a severe attack of typhoid fever in 1894, from which
he made a good recovery. Three months after the
attack a large inflammatory area formed over the
sternum and ribs, and the ribs on the right side be-
came so softened that they bent under very little pres-
sure, and were so flexible that he was obliged to wear
a bandage in order to ease his breathing. A small
effusion of clear serum formed at the junction of the
eighth and ninth ribs with their costal cartilages.
This was drained aseptically, and under treatment
with the phosphates the ribs became quite solid.
But at the middle of the sternum, and at two points
in the right chest and one on the left, the disease
has recurred in December, 1897."

Case XIII. I am indebted to Dr. D. S. Rice
also for the following case of osteomyelitis of the
left tibia : " A girl, age thirteen years, suffered from
an attack of typhoid fever for thirty days. Two
weeks after entire recovery she was seized with
severe pain over the left tibia, four inches above the
ankle. The temperature rose to 105 and the pain
was so severe that six days after the onset opera-
tion was advised. The leg was but little swollen
and there was no discoloration. The shaft of the
tibia was exposed by an incision eight inches long
and trephined. A large quantity of dark pus

134 SURGERY OF TYPHOID FEVER.

escaped from the medullary cavity. The bone was
chiseled out for a distance of six inches. She made
an excellent recovery and has remained well for
over a year."

Case XIV. H. M. age eighteen, was kindly sent
to me at the Jefferson Hospital March 19, 1896, by
Dr. Hollenbeck, of Shamokin, Pa. At twelve years
of age he suffered from a severe attack of typhoid
fever, which lasted for ten weeks. While convales-
cing from the fever two weeks after defervescence,
the inner surface of the left thigh just above the knee
became swollen and slightly tender. In April, 1895,
the swelling was lanced, and in October an opera-
tion was performed under an anesthetic. Eight
months after the attack of fever the right ankle en-
larged and suppurated. It ruptured spontaneously
a year and a half ago, when fragments of bone
were discharged and the abscess healed. The dis-
ease never interfered with his walking. The sinus
above the knee has discharged continuously since
the operation of last October, and is still open.

Operation, March 31, 1896. An incision was
made from above the inner condyle of the left femur
12.5 cm. long, and the sinus traced from the inner
border of the shaft of the femur some distance up
the shaft, and also across the posterior surface of
the shaft in the upper portion of the popliteal
space. At this point a sequestrum was found 32
mm. long, triangular in shape, the base being 1 2
mm. in breadth. The femoral artery was exposed
at the upper portion of the wound. The granula-
tion tissue of the sinus was given to Dr. Kyle to
examine for typhoid bacilli, who reported as follows:
" No typhoid bacilli were found, but a pure culture
of staphylococcus pyogenes aureus was obtained."

The bones seemed to have healed after the
separation of the sequestrum, as no bare bone was
discovered. All the granulation tissue was thor-

TYPHOID AFFECTIONS OF THE BONES. 135

oughly removed and the wound packed with iodo-
form gauze. His temperature only once rose to
99.2. The wound, however, like all typhoid
wounds, was very sluggish in healing. He went
home May 21, 1896, after two months in the hos-
pital, the wound even then not being quite closed.

Necrosis of a lamella of bone lining the wall of
the medullary cavity e. g., of the tibia, or what in
my Toner Lecture I called "central necrosis," and
of which I then collected three cases does not seem
to have been observed since 1876, except by Klemm,

Fig. I. Two foci of osteo-periostitis (A and B] following typhoid fever
" Shirt-stud Abscess" (botiton de chemise).

in a man of thirty-nine, whose left femur showed a
sequestrum, 2 X i cm., lying in the pus. Very pos-
sibly this may be due to faulty observation, for I
suspect it occurs, though only very occasionally.
Colzi 2 has observed it also in one experimental
case after five weeks of suppuration.

A not infrequent form of bone abscess which, if
not understood, may be very imperfectly and in-
completely treated, is that to which Chantemesse

1 Arch. f. klin. Chir., 1893, xlvi, 885.

2 Jordan, Beitrage klin. Chir., 1893, x.

136 SURGERY OF TYPHOID FEVER.

has given the happy description " bouton de chemise"
or " shirt-stud abscess." Cornil and Pean ' give a
very good illustration of this form of abscess, which,
with their kind permission, I have reproduced (Fig.
i). In this form there is a localized abscess out-
side the tibia, probably under the periosteum, and
another similar one under the outer layer of the
bone or even in the medullary cavity, the two
abscesses being connected by a cloaca or sinus
through the wall of the bone the shank of the
" button." To treat only the external abscess will
be fruitless. The bone must be trephined or chiseled
into and the second abscess thoroughly evacuated,
and its walls chiseled away if we wish a cure.

Sex. As in the other surgical typhoid disorders,
males largely preponderate, counting, in the two
series :

Males, 123

Females, 63

Total, 186

Age. Park 2 is in error when he says that two-
thirds of the osseous lesions of typhoid occur, in
children and adolescents. This is true of even a
much greater percentage in the joints (p. 102), but
my tables show that in the bones there were under
twenty, 56; from twenty to thirty, 71; from thirty to
forty, 23 ; over forty, 16. Total, 166.

Taking thirty, however, as a dividing line, there
were 127 cases thirty years of age and under, and
39 cases over thirty.

1 Bull. Acad. de Med., 1891, xxv, 602. 2 Mutter Lectures, 260.

TYPHOID AFFECTIONS OF THE BONES. 137

So far as I have observed, there is only one part
of the body in which osseous disease occurs almost
uniformly later in life the ribs and costal cartilages.
The table shows that not a single case of disease of
the ribs or their cartilages occurred before twenty.
Of 32 cases, the age is given in 18: 5 were from
twenty to thirty, 6 from thirty to forty, 7 over forty ;
that is, there were 13 over thirty 7 of whom were
even over forty to 5 under thirty.

Helferich, ' who has observed eight cases, has
called attention to the fact of the late appearance
of disease in the ribs. Most of these probably
should be added to the cases over thirty (for as the
age is not given they could not be tabulated), and
this would markedly increase the disproportion. He
attributes it to the changes which occur, at least
in the cartilages, in later life, an explanation which
seems reasonable. It is noteworthy, also, that when
disease attacks the ribs it quite as frequently attacks
two or three or even four as a single rib.

Paget 2 twenty years ago noted, as has also Helfe-
rich, that, in sharp contradistinction to tubercular
disease of the ribs, typhoid periostitis and osteomye-
litis do not depress the general health. Indeed, in
most of the bone cases this is true. The disease
seems to be almost purely local. This naturally
raises the question whether this may not be due to
an acquired " immunity" of the .system at large as a
consequence of the fever. This seems at least a
probable explanation of the undoubted fact that all
of the lesions which occur during or after convales-
cence from typhoid cause the patients to suffer almost

1 Berlin, klin. Wochen., 1890, 979. 2 St. Bart. Hosp. Rep., 1876.

138 SURGERY OF TYPHOID FEVER.

wholly locally and to manifest but little febrile reac-
tion.

Locality. I have gone over the cases in the
table and tabulated the various regions involved.
Where more than one bone was attacked, each bone
has been entered upon the list, and I find the results
as follows :

Skull, i

Mastoid, 3

Frontal, i

Parietal, 2

Superior maxillary, 5

Inferior maxillary, 2

Head, total, 14

Sternum, 3

Ribs, 40

Vertebrae, 6

Trunk, total, 49

Clavicle, 5

Scapula, 2

Humerus, n

Forearms, 2

Radius, 2

Ulna, 15

Hands, 4

Upper extremity, total, 41

Pelvis, 8

Femur, 22

Tibia, 91

Fibula, 3

Foot, _8

Lower extremity, total, 112

Total number of bones attacked, .... 216

The first thing that strikes one upon comparing the
distribution of disease of the bones in the different

TYPHOID AFFECTIONS OF THE BONES. 139

parts of the body is, as is noted in the chapters on
the Joints, Gangrene, etc., the extraordinary fre-
quency of bone disease in the lower extremities, 1 1 2
as against 104 in all other parts of the body, this,
also, in spite of the fact that the part of the tibia most
often involved the antero-internal part of the shaft
has no muscles attached to it. This may be partly
accounted for by slight accidental injuries, a possibility
which can hardly be invoked in case of the femur
except at the condyles. But as insisted upon in the
chapter on Gangrene, I believe it is to be ascribed to
the legs, as legs ; i. e., as the most distant part of the
peripheral circulation, where nutrition is most slug-
gish and its activities most easily disturbed and im-
paired. That, as Parsons ' has remarked, the foot,
as well as the hand, is less often involved than most
other parts of the body is to be ascribed, I think,
largely to the more active circulation in bones, many
of them at least made up largely of spongy tissue.

Taking the superficial bones those of the head,
sternum, clavicle, ulna, tibia, ribs, hands, and feet
as contrasted with the deep, the vertebrae, scap-
ula, humerus, radius, pelvis, femurs, the relative
number is as 180 to 51. Whether this has any sig-
nificance in relation to the possible influence of acci-
dent is a question.

Date of Onset. The facts here are both signifi-
cant and instructive.

Of 1 86 cases, there arose :

In the first two weeks, 16

From the third to the sixth week, 66

From months to years after the fever, . . .104

1 He only found one case in the feet.

140 SURGERY OF TYPHOID FEVER.

Bone disease is, therefore, rarely a complication
of typhoid, but is, in the vast majority of cases, a
sequel. It rarely arises during the course of the
fever (the earliest case 1 arose on the tenth day),
but almost always in convalescence, and, in fact, in
over one-half the cases after convalescence was well
established. It is at this time that muscular strain be-
gins by the patient's commencing to stand and walk,
and later by his return to ordinary manual labor ; it
is then that blows and other usual slight accidents
may occur ; it is then that the slow changes in the
bones begin to show themselves; it is then that the
bacilli, driven, so to speak, from other parts of the
.system, take refuge in the bones, and lie in wait,
ready to avail themselves of any unfavorable con-
ditions of fluctuating health or varying circulation,
or of anything causing a locus minoris resistentice.

The experiments of Dmochowski and Janowski 2
are exactly in point. If the bacilli were injected
under the sound skin of an animal no suppuration
occurred, but if the tissue had been weakened by
inflammation, by scars, or by local bleedings, then
suppuration followed, or in some cases the animals
died before any local changes could manifest them-
selves. In all pathologically-altered tissues suppu-
rative action was apt to follow.

The inferences from these facts are plain. The
subsidence of the fever, and even the establishment
of full convalescence, do not justify the physician in
relaxing his vigilance. No patient recovered from
typhoid fever should be allowed to resume the ordi-
nary activities of life except very gradually, and

1 Ebermeier, Deutsch. Arch. f. klin. Med., 1889, xliv, 140. 2 Loc. cit.

TYPHOID AFFECTIONS OF THE BONES. 141

should be cautioned as to even slight accidents and
warned against any severe physical exertion for
several months after he has apparently recovered.
At the very first sign of trouble he should return to
his physician for careful examination and advice.

Symptoms. These will vary somewhat accord-
ing to the type of disease, but only within rather
narrow limits. The constitutional symptoms are
rarely very pronounced, and fever especially is most
commonly absent. In fact, so pronounced is this in
the true typical typhoid cases, as distinguished from
those arising from a pyogenic or a mixed infection,
that Chantemesse and Widal ' call this type of ab-
scess " cold abscess," though it has, of course, no
relation to the tubercular abscesses commonly de-
scribed by this "name. A possible explanation of
this peculiarity of post-typhoid lesions has been ad-
vanced on the preceding page.

The cases may all be classed as either acute or
chronic. Even in the acute cases, fever, anorexia,
dry tongue, and constipation may be absent, the local
symptoms predominating. Occasionally, however,
in an otherwise chronic case, a temporary exacerba-
tion may be attended with moderate constitutional
symptoms.

Usually the first symptoms will be local pain, ten-
derness, and swelling, the latter being much more
extensive than the bone disease which is its cause.
In not a few cases resolution will follow after a rela-
tively slow subsidence of the disease. But if, in a
few days, or more likely a week or two, recovery

1 Bull, et Mem. Soc. Med. des Hop., 1893, x, 779.

142 SURGERY OF TYPHOID FEVER.

does not follow, the parts will become red and then,
or soon after, may fluctuate.

In other cases, after an apparent subsidence of
the disease, and even after weeks and occasionally
months of supposed health, the pain and swelling
will reappear at the same spot, and then go on to an
abscess. Sometimes more than one such oscillation
or recrudescence will take place, finally resulting
either in suppuration or a permanent cure.

For some excellent examples of such oscillating
cases see Osier and Parsons. 1 Routier and Terril-
lon 2 record a case in which the tibia was attacked in
the ninth week during convalescence ; the attack
subsided, but was followed after some months by a
relapse and an abscess, which was opened and the
bone scraped. Two subsequent relapses and opera-
tions were required to effect a cure. Chantemesse
and Widal 3 report a case illustrating both the multi-
plicity and the recrudescence of the bone lesions.
Lockwood 4 reports a similar case of disappearance
and reappearance of the swelling in an abscess. On
pages 20 and 1 18 I have given some other instances
of a similar character illustrating this curious ten-
dency to the swinging of the pendulum between
apparent health and renewed disease, and the case
of H. W. (p. 123) is not dissimilar.

Treatment. Fortunately, surgical treatment in
most cases is needed, not during the typhoid attack,
but after return to health. When fluctuation can be
perceived, unquestionably immediate operation should

1 Johns Hopkins Hosp. Reports, vol. v. 2 Prog. M6d., April 12, 1884.

3 Dull. Soc. Med. des H6p., 1893, 3d series, x, 779.

4 Lancet, 1895, i, 535.

TYPHOID AFFECTIONS OF THE BONES. 143

be clone. It is better, however, to operate even
before fluctuation arises unless spontaneous resolu-
tion is fairly certain to follow. By such early inter-
ference suppuration may be avoided and the case
cut short. If pus is found, then the cavity must be
thoroughly treated. The bacilli are more often found
in the tissues forming- the wall of the abscess cavity
than in the pus. Hence, if the abscess exists only
in the periosteum and soft parts, these must be
entirely excised and the bone be chiseled away. If,
as not seldom happens, the medullary cavity is in-
volved, then the bone must be widely chiseled away
so as to expose and remove all the diseased osseous
tissue. For want of thoroughness, repeated opera-
tions may be needed, the earlier attempts not having
entirely removed the disease. Sometimes, although
no pus is found, extensive operations are required be-
fore definite healing takes place. Thus, Chantemesse r
relates a case in which for osteomyelitis the tibia was
three times trephined. No pus was found, but the
disease persisted, and the patient was only cured, a
year later, by opening the tibia by an extensive
operation forming a long gutter in the bone. Even
then no pus was found.

In no region are these remarks more true than as

o ,

to the ribs and sternum. From their very situation
and their important relations to the pleura, pericar-
dium, and lungs, incomplete, and therefore insuf-
ficient operations are apt to be done, and conse-
quently have to be repeated. As a rule, the ribs
must be resected in their entire thickness, and not
merely partly gouged away. Sometimes it may be

1 Bull, et Mem. Soc. Mecl. des Hop., 3d series, vii, 1890, 655.

144 SURGERY OF TYPHOID FEVER.

difficult to say just where the disease stops (cf. Case
XI, p. 129). The same rule applies to the sternum.
If the pleural cavity is widely opened, as in my
case just referred to, little or no mischief may be
done, even in a suppurative case, provided the sur-
geon uses rigid antisepsis.

The form of abscess already described as " bou-
ton de chemise" or as I would prefer as perhaps
more accurate, ''dumb-bell" in shape, must not be
forgotten, and the inner as well as the outer abscess
be treated as above directed.

The occurrence of this form of abscess again sug-
gests the probably more frequent occurrence of " cen-
tral necrosis " than is mentioned in the recorded
cases. The sequestrum being small and bone chips
from the chiseling being present may account for its
not having been observed. Only those who know of
its possibility would probably be on the lookout for
it. Probably Parsons' Case III was an example in
point.

Incomplete operations or neglected disease lead
to sinuses, which may persist for years. In Sultan's
case this had extended to six years, and yet no pyo-
genic infection of the sinus had occurred, a pure
culture of the typhoid bacilli being found.

In Anger's case 1 the sinus continued for ten years,
and only healed after the removal of a sequestrum.

The tendency to chronicity, to persistent sinuses,
and especially to recurrences, are among the most
marked characteristics of the bone disorders following
typhoid. Occasionally the disease of the bone may

1 Turgis, Contrib. a 1'Etude de I'Osteoperiostite Conseq. da la Fievre Ty-
pho'ide, These de Paris, 1884.

TYPHOID AFFECTIONS OF THE BONES. 145

cause extensive disease in the soft parts ; or may ex-
tend to a neighboring joint, though either complica-
tion is rare. Amputation in the latter case becomes
imperative. Only four such amputations occurred in
the cases reported in the first series ; two died, one
recovered, and one was under treatment. In the
second series no case came to amputation.

The prognosis is almost always favorable. Of
the 1 68 cases in the second series, only u died;
recovery followed in 122 cases, the result not being
given in 35. Of all the 1 1 fatal cases, not one
can be said to be a pure case of typical bone dis-
ease from typhoid. Every one suggests either a
pyogenic or a mixed infection. In only two were
bacteriological examinations made. In Klemm's x
case the colon bacillus, as well as that of typhoid, was
present ; the periosteum was destroyed and the bone-
marrow red and hemorrhagic. Half a liter of fluid
was found. In Dunin's 2 case there was also a paro-
tid abscess, and a mixed infection with the staphylo-
COCCLIS aureus was found. In another, 3 a mixed in-
fection certainly occurred, as the patient had also
erysipelas. In three, 4 the jaws were attacked and
the tissues of the cheek became gangrenous. In the
first there was also suppurative parotitis. These were
quite surely mixed infections. Three others were
probably cases of septicemia, 5 combined, in the first,

1 Arch. f. klin. Chir., xlviii, Heft 4.

2 Deutsch. Arch. f. klin. Med., 1 886, xxxix, 369.

3 Armieux, Rev. Med. de Toulouse, 1875, ix, 42.

4 Franklin, Lancet, 1879, i, 553; Lawton, Ibid., p. 685; Alexander,
Breslauer aerzt. Zeitschr., 1887, No. 23, 271.

5 Mercier, Rev. Mens. de Med. et de Chir., 1879, iii, 21 ; Rondu, quoted
by Witzel ; Robin, Gaz. Med. de Paris, 1881, No. 4, 559.

146 SURGERY OF TYPHOID FEVER.

with diffused violent phlegmonous periostitis of the left
femur and i */ liters of pus. The other two have al-
ready been referred to (p. 92) under diseases of the
joints, as both bones and joints were involved. In a
case of Furbinger's, 1 there was hemato-pyo-pneu mo-
thorax from perforation of a necrotic pulmonary
focus. In the eleventh case, 2 the patient died from
erosion of the popliteal vessels after operation on a
femoral periostitis which had persisted for four years.
These complicated cases show that in purely
typhoid cases a fatal issue can be practically ex-
cluded. Recovery is assured, but is apt to be slow.

1 Verhandl. Neunte Kongress inner. Med., 1890, p. 207.
2 Terrillon, Prog. Med., 1884, 285.

CHAPTER VI.
TYPHOID ABSCESSES.

ONE of the most frequent accompaniments of
typhoid fever are small abscesses in the skin, or furun-
cles. So far as I know, their bacteriology has not
been investigated, but the probability is that they
would be found to contain only pyogenic bacteria.

Other abscesses arise from various causes. For
instance, in the abdominal wall they may arise from
muscular degeneration in the recti muscles (see
Hematomata); or, again, they may arise by invasion
from the intestine at a point of adhesion and possi-
ble perforation ; e. g., in Vance's 1 case, which arose
in the seventh week, there was an abscess which
opened at the umbilicus and was found to extend
from the ribs to the ilium and posteriorly to the
loin. Possibly they may arise independently of
either, by the lodgment of the typhoid bacillus in the
connective tissues, as in the case of Raymond. 2 In
this case an abscess was found in the abdominal wall
extending from the umbilicus to the mons Veneris.

and the sole bacterium found was the bacillus of
Eberth. In the loose connective tissue elsewhere we
may have the same phenomenon. For example, in
Harrison's 3 case, in which there were three relapses,
a cellulitis of the neck developed two and a half
months after the third relapse and in the seventh

1 Med. and Surg. Reporter, 1893, 281.

2 Pein, loc. cit., p. 58. 3 Lancet, 1891, i, 1207.

148 SURGERY OF TYPHOID FEVER.

month after the beginning of the fever, and extended
even to the apex of the lung, but did not go on to sup-
puration. Fraenzel ' records a fatal case of mediastin-
itis in a man of fifty-two. Werner 2 also reports a
case in which several sternal ulcers existing prior to
the fever extended and perforated into the anterior
mediastinum. The patient died from profuse hem-
orrhage, the cause of which was not ascertained even

o '

by a necropsy. Brieger 3 reports cases of abscesses
in both axillse, the post-anal region, and the thigh. In
another case, reported by Daly, 4 an abscess devel-
oped to the left of the trachea an inch above the
clavicle. In another 5 there were abscesses about
the larynx and trachea, but the case was septic. In
another, reported by Tuthill, 6 an abscess developed
under the deltoid in which the Eberth bacillus was
found in pure culture. In another, by Hanquet, 7
there was an abscess in the left axilla along with
thrombosis of the right femoral vein, periostitis of
the left femur, and necrosis of the right ulna. The
following unreported cases have been seen by
myself or by friends :

Case XV. Mr. S., Haverford College, Pa., age
thirty-four, has a scrofulous family history, with possi-
ble inherited syphilis, as indicated by necrosis of the
turbinated bones. He is of a nervous temperament,
an excessive smoker, habits good. He was first seen,

1 Berlin, klin. Wochen., 1874, 97.

2 Med. Correspondenzbl. Wiirttemb. aerzt. Verein, 1859, xxix, 70

3 Zeitschr. f. klin. Med., 1886, xi, 263.

4 Med. and Surg. Reporter, 1882, 346.

5 Robin, Gaz. Med. de Paris, 1881, 559.

6 Trans. Med. Soc. State of New York, 1895, 222.

7 Arcb. Med. Beiges, 1892, 305.

TYPHOID ABSCESSES. 149

in consultation with Dr. G. E. Abbot, October 19,
1890. Without prior illness, and following severe
mental strain and unusual physical exercise and
exposure to wet, he was taken with three heavy
chills, September 19, 1890. This ushered in a severe
attack of typhoid fever. For five days his tempera-
ture ranged from 105 to 106, though the pulse
only once rose above 100. The maximum daily
movements of the bowels was nine. There was
no hemorrhage from the bowels, but he suffered
three hemorrhages from the nose at the end of the
second week. He was delirious for two nights, had
considerable frontal headache, but neither temporal
nor cervical pain. After the decline of the fever
his recovery was rapid, and by October i5th he was
out driving. On October 8th, the twentieth day after
the beginning of the fever, he complained of sore-
ness at the angle of the jaw on the left side. This
was followed by moderate swelling and slight red-
ness, which, however, were stationary. On October
1 6th, while driving, an accident occurred which
caused him much excitement and fatigue but no
physical injury. On the iyth the swelling had
markedly extended. There was some trouble in
swallowing and the voice was slightly hoarse. When
I first saw him I found a very tense condition of
the tissues of the neck from the ear to the level of
the cricoid. There was only moderate tenderness,
and at no point was it clear that an abscess was
tending to point, though such an abscess, of course,
was immediately suspected. His general condition
was good, strength and appetite satisfactory, pain
not severe, and though it lessened his sleep, it did
not entirely prevent it. The progress of the case
was slow. At the end of a week there was some
edema below the angle of the jaw, the voice and
deglutition were a little more affected, and there
seemed to be every reason to suppose that sup-

150 SURGERY OF TYPHOID FEVER.

puration was taking place, in spite of the fact that
he had not had any more pain and there was no
fluctuation.

Operation, October 26, 1890. On that morning a
small amount of pus escaped through the external
meatus. The abscess was reached at a depth of 4
cm. of tense edematous tissue under the deep fascia,
and four ounces of pus were evacuated. The ab-
scess skirted the larynx and pharynx. In a week
he was entirely well. I regret very much to add
that no bacteriological examination was made.

Case XVL Dr. D. S. Rice, of Hastings, Pa.,
sends me the notes of the following similar case of
abscess of the neck :

" Mrs. R., age twenty-three, contracted a severe
attack of typhoid fever in the early part of October,
1897. On the sixteenth day she had a severe hemor-
rhage from the bowels, when her temperature fell to
94, but afterward rose to 105.5. By the thirty-fifth
day the temperature had fallen to the normal. A
week later she had a chill and a rapidly developing
deep abscess on the left side of the neck. In one
week there was fluctuation. An incision evacuated
half a pint of dark turbid pus. The abscess had
extended under the trachea. She made a good re-
covery."

Occasionally these abscesses are multiple, as in
Quaife's case, 1 in which they were situated over the
tendon of the biceps, in the left thigh, over the ten-
don of the left peroneus tertius, over the left scapula,
and in the substance of the left soleus. In Dunn's
case 2 they arose at various points over the body,
arms, and legs. In another, 3 there were abscesses

1 Australas. Med. Gaz. , Aug., 1885, 271.

2 Univ. Med. Mag., Sept., 1895, 909.

3 Laveran, Bull. Soc. Med. des Hop., 3d series, v, 90.

TYPHOID ABSCESSES. I 5 I

on the dorsum of the right hand, in the right arm,
and the left fore-arm, with muscular degeneration in
the recti abdominis, but no suppuration in the latter
place. In the abscess only the staphylococcus aureus
was found, although the typhoid bacilli were found
in large numbers in the spleen.

In a number of cases, in such regions as the
buttock and the thigh, it is often impossible to de-
termine whether the abscesses arose from direct
infection of the typhoid bacillus or from muscular
degeneration followed by rupture and hemorrhages
in the rectus abdominis ; and whether they owed
their origin to the pyogenic or to the typhoid micro-
organisms was only occasionally determined by a
bacteriological examination. In a few cases, how-
ever, we can reach definite conclusions on these
points. Thus, an abscess in the muscles of the
thigh ' showed a pure culture of the Eberth bacillus.
In a gluteal abscess, 2 also, a pure culture was ob-
tained. The abscess in Hirsh's case 3 probably was
secondary to arthritis of the hip-joint, which was
followed by dislocation.

In Senter's case 4 a case of abscess in the muscles
of the thigh thrombosis of the pulmonary artery
caused sudden death. It may readily have been a
direct result of the abscess.

There are three cases 5 of perinephric abscess re-
corded, but in none was a bacteriological examina-
tion made. As all arose during convalescence, it is

1 Tinctine, Arch. Med. Exp. et d'Anat. Pathol., 1894, vi, i.

2 Tinctine, loc. cit. 3 Annals of Surgery, 1896, 212.

4 Des Absces muse. dans, la Fievre Typhoide, These de Paris, 1880.

5 Alrich, Univ. Med. Mag., Feb., 1890; Pearson, Brit. Med. Jour., 1891,
i, 86l ; Adam, Australas. Med. Jour., 1887, ix, 182.

152 SURGERY OF TYPHOID FEVER.

not improbable that they were due to a true typhoid
infection. 1

One lumbar abscess 2 seems clearly to have been
connected with an old psoas abscess, and was

1 The two following cases, one of a perinephric abscess originating in a renal
abscess, and the other of renal abscess and meningitis, were published after the
tables were completed. They are so important and interesting that I append
resumes of both from the Bull, et Mem. Soc. Med. des Hop., 1897, No. 2.
Their typhoid origin was conclusively shown by cultures.

Fernet and Papillon record the case of a man who entered the hospital on the
sixth day of the fever. On the thirteenth day he complained of pain in the left
flank at the level of the enlarged and tender spleen. By the twenty-first day the
temperature had fallen nearly to the normal, yet his general condition was
worse. In the lumbar region was a tumor, rounded, elastic, dull on percus-
sion, in front of the spleen, yet reaching to the lumbar region. On the twenty-
fifth day Turner operated, evacuating a liter of pus. The transverse colon
had to be displaced to reach the tumor. By the thirty-second day peritonitis
developed, and he died a week later. The necropsy showed that the abscess
had begun in the renal tissue, had dilated the pelvis of the kidney, and, rup-
turing, had produced also a perinephric abscess. Other renal abscesses were
present.

Cultures from the pus evacuated at the operation and from the pus of the
renal abscesses showed pure cultures of the typhoid bacillus ; cultures from the
dressings some days after the operation and from the renal pelvis at the
necropsy showed the colon bacillus and saprophytes. Evidently, there had
been a prior intermittent hydronephrosis, as shown by a marked kink in the
ureter. The typhoid infection readily seized upon such a weakened organ,
and all the rest is clear.

[Not only is this case interesting from the pathological and clinical side,
but it teaches the lesson that if any abnormal condition, such as movable kid-
ney, exist, it should be remedied at once, in order not only to cure the existing
malady, but to avoid later indirect dangers which may easily follow.]

Troisier and Sicard report a case of renal abscess and meningitis of typhoid
origin as follows : A man entered the hospital about the fifteenth day without
characteristic symptoms of typhoid. He was suffering from lead palsy and
the nervous symptoms of saturnism, including headache. The urine was
markedly albuminous. Five serum-tests responded positively. Four days
before death symptoms of meningitis appeared. He died on the thirty-second
day. The intestine showed typical typhoid lesions, the spleen was diffluent.
At the base of the brain in a yellowish fibrino-purulent exudate, and, also, in
an abscess of the kidney, the bacillus of Eberth was found in pure culture. . No
symptoms attributable to the renal abscess, other than the albuminuria, are
mentioned.

2 De Lannoy, Phila. Med. Times, July 15, 1882, 707.

TYPHOID ABSCESSES, 1 5 3

probably only lighted up afresh by the typhoid
attack.

The following case of typhoid during an absolutely
latent Pott's disease is of the greatest interest, both
from the perhaps excusable error in diagnosis, owing
to the peculiarly misleading history and symptoms,
and as illustrating the value of a bacteriological
and microscopical examination, without which a
finally correct diagnosis would not have been made :

Case XVII. George W., age twenty-seven,
entered the Jefferson Hospital August 27, 1897,
under the care of Dr. J. A. Salinger, on the fifth
day of an attack of typhoid fever. Typical tdches
rouges appeared on the next day. By the sixth day
the temperature was normal. A slight relapse, with
a second crop of spots, occurred from the thirteenth
to the seventeenth day. He left the hospital Septem-
ber 22d. He re-entered my surgical ward on the
ist of November. He stated that for two weeks after
leaving he took moderate exercise, ate heartily, and
felt very well. Early in October some sharp pains
were felt in the right groin at intervals for a week, and
then ceased. They seemed to follow short walks.
The pain extended into the thigh, and was especially
noticeable on rising from the sitting to the standing
posture. On October loth he first noticed a pain-
less tumor in the right groin. On his re-admission,
November ist, there was a soft oval tumor, 6 by 4.5
cm., just above Poupart's ligament on the right side,
and just to the right of the internal ring. The tumor
was globular, and showed distinct impulse on cough-
ing to touch and to sight. When he lay down it dimin-
ished and almost disappeared. It could be reduced,
and then two fino-ers could be inserted into an oval

aperture in the belly wall which exactly resembled
a hernial ring. There was no discoloration of the

154 SURGERY OF TYPHOID FEVER.

skin. Manipulation of the tumor was not painful.
The temperature did not exceed 99. My impres-
sion was that it was a hernia.

Looking back on it, I think I ought to have been
put on the right track by considering : First, that
no known case of hernia attributable to the fever is
on record, so far as I know. Secondly, abscesses
are quite common. Third, had it been a hernia, it
was too soft for omentum and also lacked the doughi-
ness of such a tumor. If bowel, it should have been
tympanitic, but it was distinctly dull. When reduced,
also, no gurgling occurred, but this I attributed to
the apparently wide open ring. I think I should also
have been put on my guard somewhat by the fact that
it was not precisely in the position of the internal
ring, and, in addition to that, one does not usually
feel the internal ring as distinctly as this was felt.

My impression was that the hyaline degeneration
of the muscles of the belly wall, so constantly seen
in typhoid fever, had been followed by a rupture of
the muscular fibers, and this had led to the hernia.
If this were the origin of the hernia, I deemed it
wise to wait until distinct regeneration of the mus-
cular fibers had occurred, which would give greater
assurance of a cure. After a week in bed, however,
as the tumor was increasing in size, I thought best
to proceed at once to operate.

Operation, November 10, 1897. An incision par-
allel with Poupart's ligament very quickly opened an
abscess. Not less than a pint and a half of pus
was evacuated. The pus was not fetid, nor did it
have any fecal odor. A probe passed upward 15
cm. almost to the level of the umbilicus. It also
passed downward toward the true pelvis, but did not
reach it. The finger introduced into the cavity dis-
covered nothing except the ring above described
and a very large cavity beyond. I curetted away
considerable granulation tissue from the walls of the
cavity, flushed with a hot saline solution, and drained

TYPHOID ABSCESSES. 155

with a rubber tube and a small amount of iodoform
gauze.

The scrapings and a culture from the pus were
given to Prof. Coplin for bacteriological examination.

My impression now was that instead of a hernia
we had to deal with a typhoid abscess arising in
the 'connective tissue between the iliacus internus
muscle and the iliac fascia. One other possibility
occurred to me : that it might have arisen from a
perforation of the appendix by a typhoid ulcer, and
that this had been followed by an abscess with
a quiet afebrile course, as one sees not uncom-
monly after typhoid fever. I asked Prof. Coplin, of
course, to make a very careful test to determine the
presence or absence of the typhoid bacillus. After
four weeks no growth occurred in the culture. In
the scrapings from the abscess cavity, tubercle bacilli
but no other organisms were found. I received
the preliminary report at the end of a week, and
this at once suggested to me that it was possibly a
case of Pott's disease, followed by a psoas abscess.
In conjunction with Prof. H. Augustus Wilson, I ex-
amined the man's back with the greatest care. Up
to that time he was not aware that he had ever had
any trouble whatever with his back. He had never
suffered any pain, and had it not been for the micro-
scopical demonstration of the cause of the abscess,
I would never have suspected that it arose from
vertebral caries. A very careful examination, how-
ever, showed unquestionably that he had a Pott's
disease at the dorso-lumbar junction, and I placed
him under Prof. Wilson's care.

All of the symptoms were now perfectly explicable.
From the surgical point of view they are of no little
interest, as one might easily be deceived, as I was ;
and from the pathological side it is also of interest, as
it showed that a man who has had Pott's disease for
a period of time long enough to produce a psoas
abscess containing a pint and a half of tubercu-

156 SURGERY OF TYPHOID FEVER.

lar " pus," and to travel from the spine down to the
level of Poupart's ligament, can pass through an
attack of typhoid fever and a relapse without having
any infection in the abscess or the bones from the
typhoid bacillus ; without aggravating the Pott's
disease in the slightest degree ; and, indeed, without
the patient's ever knowing that he had any disease
whatever in the spine.

In the abdominal cavity abscesses may arise from
several causes, and in any particular case it may be
often difficult and not seldom impossible to deter-
mine definitely the cause.

They may arise as localized abscesses from per-
foration when the adjacent coils of intestine become
adherent by a protective peritonitis and thus form
a localized abscess. Eisner ' and many others report
such cases. They resemble the familiar form of
an appendicular abscess, in which the coils of in-
testine become agglutinated with a similar re-
sult. In fact, both the appendix, as in non-typhoid
cases, and the cecum in typhoid, may be perforated
when no such adhesions exist, 2 and thus require
operative measures (see Chapter XV, on Perfora-
tion) ; or, in other cases, perforation and adhesions
may only be suspected and can not be proved.

Thus, in one case, 3 after a protracted course and a
severe relapse an " ileocecal abscess" formed, and the
pus had a fecal odor. In another, 4 a man of thirty-
eight is said to have had a " perityphlitis " on the

1 Trans. Med. Soc. State of N. Y., 1892, 314.

2 For perforation of the appendix, see Bontecou, Jour. Amer. Med.
Assoc., 1888, i, 106; Alexandroff, quoted in N. Y. Med. Jour., 1894, ii, 341.

3 Pearson, Brit. Med. Jour., 1891, i, 861.

4 Adam, Australas. Med. Jour., 1887, ix, 182.

TYPHOID ABSCESSES. 157

twenty-eighth day, and on the fiftieth to have passed
two ounces of pus by the bowel. In a third, 1 " typhli-
tis " is said to have occurred. All three recovered.
The following is the only similar case I have seen :

Case XVII I. Mrs. Mary B., age twenty-six,
Bellewood, Pa., entered the Jefferson Medical Col-
lege Hospital January 5, 1893. She had always been
well until two years ago, when she had an attack of
typhoid fever lasting for four or five weeks. In her
early convalescence (the exact time is uncertain)
an abscess about the size of a goose egg formed in
the right side and opened into the ascending colon.
She did not have very severe pain. She passed a
considerable amount of very offensive green-colored
pus in her stools. About two months later a second
abscess formed lower down than the first. It was
very painful, and was opened by her physician in
October, 1892. Fecal matter then began to be dis-
charged with the pus, and a fecal fistula still exists.

Operation, February 11, 1893. An incision was
made parallel with Poupart's ligament, the center of
the incision corresponding to the fistula. After a
very troublesome dissection, the fistula was found to
end in a somewhat globular mass under the abdom-
inal wall. This mass was seven cm. in diameter ;
the exterior was smooth and covered with perito-
neum on the surface next the abdomen. On the
other side it was attached to the surrounding tissues.
The interior was made up of granulation tissue
and pultaceous matter. No opening could be de-
tected leading into the bowel.

Unfortunately, it did not occur to me at the
moment to inflate the colon with hydrogen gas or
air, which would probably have shown the intestinal
end of the fistula. I suspected that the appendix
was imbedded in the mass ; that during the fever per-

1 Alrich and Pepper, University Med. Mag., Feb., 1890

158 SURGERY OF TYPHOID FEVER.

foration of the appendix had taken place ; and that this
was the source of the fecal fistula. After searching
as long and widely as I deemed prudent, but unsuc-
cessfully, to find either the appendix or the opening
into the bowel, the mass was curetted, disinfected,
and packed. The peritoneal cavity had been freely
opened, but the intestines were protected by iodo-
form gauze and no ill result followed. The fistula
slowly contracted after the operation, so that when
she was discharged, April 22, 1893, often two or
three days elapsed without any discharge. Her
general health, however, was poor. She died from
general debility nine weeks later.

Typhoid ulcers in the appendix or caput coli may
easily have produced such conditions, and even if no
perforation take place, it is not impossible that the
colon bacillus may pass through the intestinal wall
during an attack of typhoid and produce an abscess,
as has been frequently demonstrated in other condi-
tions than typhoid. I believe there is no case yet
recorded of the typhoid bacillus having been found
free in the peritoneal cavity except where its pres-
ence has been readily accounted for, not by penetra-
tion through the intestinal walls, but from such
sources as a perforation (Chap. XV), the rupture of
abscesses of the liver (Chap. XVI), spleen (Chap.
XVII), of the gall-bladder (Chap. XVI), or rup-
ture of a mesenteric gland. In fact, just as in
general surgery peritonitis is now believed to arise
only as a positive result of a direct injury or of some
usually demonstrable lesion in an abdominal organ,
so peritonitis during or after typhoid fever always
has a similar positive, but not always a demonstrable,
cause. In a number of other cases perforation has

TYPHOID ABSCESSES. 159

been suspected as the cause of an abscess without
its being possible to be sure of one's ground. Thus,
in Major's case, 1 on the eighteenth day the symp-
toms of collapse occurred. Three weeks later an
abscess burst through the rectum, and the patient
recovered. The author believes that a perforation
led to the abscess. In Low's case, 2 in the third week
the symptoms of collapse and peritonitis led the
author to diagnosticate a perforation. These symp-
toms gradually subsided, and finally a residual ab-
scess burst through the abdominal wall, gave vent
to horribly fetid pus, and this patient also recovered.
While both very likely resulted from a perforation,
recovery prevented demonstrative proof. They are
good illustrations of the witty dictum that " no case
is complete without a post-mortem."

This complete proof, unhappily, however, is not
always wanting. Thus, in a case of Lehmann, 3 in
the third week perforation occurred. The patient
died at the end of a month, and the healed scar of
the perforation and the resulting encapsulated ab-
scess were both found. There was also a suppura-
tive parotitis due to a mixed staphylococcus and
typhoid infection. The pus of the abdominal abscess
showed a pure culture of Eberth's bacillus. This
fact is worthy of especial note, as the perforation pre-
sumably gave ready exit to the colon bacillus. In
another case 4 a man of twenty-five, just recovered
from scarlatina, suffered from a mild attack of
typhoid. At the necropsy, only six Peyer's patches

1 Brit. Med. Jour., 1891, i, 18. 2 Brit. Med. Jour., 1881, ii, 122.

3 Centralbl. f. klin. Med., 1891, 649.

4 Potain, Gaz. des Hop., June 9/1891, 621.

l6o SURGERY OF TYPHOID FEVER.

were found to be inflamed, but all extended to the
peritoneal coat of the bowel. He perished from
a perforation which, not having any prior protective
inflammation, led to general peritonitis, as in so many
cases of perforative appendicitis without adhesions.
In Eisner's case, 1 in spite of such a protective peri-
tonitis marching in front of perforation, the patient,
a young man of twenty-seven, died from profuse
hemorrhage.

Tiingel 2 relates a case in which a suppurating
mesenteric gland near the cecum gave rise to an
abscess which perforated a branch of the superior
mesenteric artery and caused death.

Perforation of the rectum has already been men-
tioned (p. 159, Major's case). In this case a pelvic
abscess burst into the rectum.

Case XIX. The following case of ischio-rectal
abscess following typhoid, perforating the rectum
and resulting in a fistula, is kindly furnished me by
Dr. I. C. Schureman, of Toms River, N. J. :

Miss X., age twenty, had a severe attack of
typhoid fever for six weeks in the spring of 1897.
In the third week she complained of intense pain in
the region of the anus and sacrum. A few days later
an abscess was discovered, and was opened half
an inch to the left of and posterior to the anus, giving
vent to a large quantity of very offensive pus. In
the fourth week of the fever another point of fluc-
tuation was discovered three inches above the anus
near the sacrum. The pus was evacuated, and the
two abscesses were found to communicate with each

1 Trans. Med. Soc. State of N. Y., 1892, 314.

2 Klin. Mittheil. aus dem Kaiserlich. Hamburg, allgemein. Krankenh.,
Hamburg, 1864 ; quoted by Langenbuch, Deutsche Chirurgie, Leif., 45 c.
Erste Ilalfte, 238.

TYPHOID ABSCESSES. l6l

other. The tissues over the left natis near the
anus sloughed over an area i^ inches in diameter,
and were a long time in healing after convales-
cence was established. Her vitality was so low that
nothing further than symptomatic treatment could
be carried out. She was advised to enter a hospital
after she entirely recovered, in order to have the
abscess fully laid open and treated, but declined to do
so. In July, 1897, during an absence from home, she
was very ill for several weeks. Ten days after the
illness began she passed pus from the rectum for
three days, and has passed it at intervals ever since
until a month ago (November, 1897), when it appar-
ently ceased. During her convalescence she suf-
fered a great deal of pain in the lower abdomen, but
only a small amount of pain in the rectum.

But the results are not always so happy, especially
when the perforation proceeds from within outward.
In one case, 1 on the forty-first day, as a result it was
supposed of cough, a perforation occurred on the
anterior face of the rectum (sigmoid flexure ?), nine
inches from the anus. The case resulted fatally.
Another case 2 of perforation of the anterior wall
was followed by further complications, but finally
ended in recovery. The perforation of the rectum
occurred between the twelfth and the twentieth days,
and resulted in a pelvic stercoral abscess. Between
the thirty-sixth and the forty-fourth days this abscess
burst into the bladder. The feces, it is surprising to
note, gave rise to no special trouble in the bladder.
The case was operated on by the gorget and thermo-
cautery. The opening in the bladder then healed
spontaneously, and the patient recovered.

1 Cockle, Lancet, 1882, i, 178.

2 Debongnie, Arch. Med. Beiges, 1893, 225.

1 62 SURGERY OF TYPHOID FEVER.

Still another case ' shows the extensive ravages
which may result from a perforation of the rectum.
In a man of thirty-six, a posterior perforation of the
rectum on the twenty-sixth day was followed by an
abscess in the meso-rectum, and finally led to his
death by erosion of a hemorrhoidal artery. (Cf.
Tungel's case above.) But this was far from all :
the leTt leg was swollen and emphysematous all
the way to the ankle. The post-mortem explained
the reason. Pressure on the leg forced fluid and
gas from the leg into the pelvis. The pelvis was
full of feces, and the abscess had burrowed its way
out of the pelvis between the pyriformis and the
gemelli into the thigh after perforating the pelvic
fascia. A pelvic abscess in a case of Bosnieres 2
also burst through the vagina in a young woman of
eighteen. Though she suffered also from necrosis
of both tibiae, she made a good recovery.

Another cause of such an "abdominal abscess" is
a suppurating mesenteric gland. Of this, too, the post-
mortem table has given us convincing proof. Thus,
in a case of Lehmann, 3 an abscess due to such a
gland was found, and the pus showed a pure culture
of Eberth's bacillus. In Fraenkel's case 4 an abdom-
inal abscess was due, presumably, to a mesenteric
gland, four and a half months after the onset of
the fever. This first attack had been followed by
two relapses, by facial erysipelas, and in the seventh
week by symptoms of perforation. The abdomen
was opened and \y 2 liters of pus evacuated, in

1 Pryor, Buffalo Med. and Surg. Jour., 1881-82, xxi, 555.

2 These de Paris, 1890. 3 Centralbl. f. klin. Med., Aug., 1891, 649.
4 Verhandl. Kongress inner. Med., 1887, 179.

TYPHOID ABSCESSES. 163

which only the typhoid bacillus was found. The
patient died later of ileus.

In at least one other case the proof has been at-
tained by an abdominal section which, instead of fol-
lowing, prevented the patient's death. Michie, 1 by
a timely section in the fourth week, evacuated and
drained an abdominal abscess due to such a sup-
purating gland. Thomson, 2 by the aspirator, re-
moved five drams of grumous matter, which the
author attributed probably to a mesenteric gland.
The case is obscured, not only by the mode of treat-
ment, which, however, a happy recovery fully justi-
fied, but also by the fact that the patient was of a
strumous predisposition, and eight days before the
development of the disease (which was about the
period of defervescence) had wrenched his back.
Low's case 3 was very likely a similar one. In the
fourth week after defervescence the temperature
gradually rose ; a lymphatic gland in the neck sup-
purated ; a tumor as large as a cricket ball formed
to the right of the umbilicus and discharged into the
bowel.

The following case of sub diaphragmatic abscess is
the only one I have found:

Case XX. Klein 4 reports a case of left-sided sub-
phrenic abscess, probably arising from the spleen,
following typhoid fever, in which the typhoid bacillus
was found in pure culture in the pus.

A man, age thirty-four, on June 24, 1895, fell ill

1 Brit. Med. Jour., 1888, i, 1388.

2 Glasgow Med. Jour., 1882, xvii, 244.

3 Brit. Med. Jour., 1881, ii, 122.

4 Ueber die Pyogene Wirkung des Eberthschen Bacillus bei Typhuskom-
plikationen, Inaugural Dissertation, Bonn, 1896.

1 64 SURGERY OF TYPHOID FEVER.

after drinking some stagnant water. By the 3d of
August he was free from his fever and left his bed
on the 8th. On the I3th he again went to bed
with a temperature of 103, with increased dulness
over the spleen, but without tenderness. From this
date the dulness and a distinct tumor in the region
of the spleen increased. On his admission into the
hospital, under the care of Dr. Schmidt, on the 226.
of August, the left lower half of the thorax was
markedly rigid in the line of the nipple, with but
little respiratory movement upon that side of the
chest. The dulness posteriorly began at the lower
border of the scapula. Nothing abnormal in the heart.
The diagnosis was made of a subdiaphragmatic ab-
scess, probably arising from the spleen. Aspiration
on the 23d of August showed the presence of pus.
On the 26th of August Dr. Sartoris operated. A
portion of the seventh rib was removed in the axil-
lary line. A puncture was made and pus was
found. The puncture showed, however, that access
to the suppuration was not direct, but that the
pleura lay between. Accordingly, the costal pleura
was opened without disclosing any pus. The dia-
phragmatic pleura was seen to be markedly arched
forward and was in direct contact with the costal
pleura, but without any adhesions. The two layers
of the pleura were carefully sutured and an incision
was then made into the abscess, which discharged a
thinnish, clear brown pus without any fecal odor. A
catheter was introduced, and by means of this a
second incision for drainage was made above and to
the left of the umbilicus. The amount of pus evacu-
ated was three liters. The surgeon endeavored to
recognize the spleen, but neither this nor any other
viscus was recognizable. The wound was drained

and the patient made an excellent recovery. The
bacteriological examination seems to have been
made with great care, and showed only typhoid
bacilli, and the author adduces the case as an excel-

TYPHOID ABSCESSES. 165

lent evidence of the pyogenic faculty of the typhoid
bacillus.

Of the symptoms and treatment of these ab-
scesses I need not say much, as they differ little if
any from the symptoms and treatment of similar
ordinary abscesses. Any operation during or im-
mediately after so serious a fever as typhoid is to be
deprecated unless it be unavoidable. The dangers
of either alone may be great, but of both combined
must be great. But, on the other hand, to allow a
patient to die from an abscess, be it in the abdo-
men, the neck, the thigh, the buttock, or elsewhere,
is still more to be deprecated. Unless, therefore,
the associated conditions prohibit it, such abscesses
should be treated, on general surgical principles, by
antiseptic evacuation and, usually, drainage. The
need for strict disinfection is especially evident, since
if it be not carried out we may add a staphylococcus
or, worse still, a streptococcus infection to an existing
typhoid infection, and further and gravely imperil the
patient's chances of recovery.

CHAPTER VII.
TYPHOID HEMATOMATA.

IT is rather strange that while in the earlier table
(see Toner Lecture, " Hematomata ") I was able to
collect so many cases of hematoma, in the second
collection, even larger than the former, Dr. West-
cott found only 1 7 cases. These add but little to
the facts collected in the Toner Lecture. I must,
therefore, refer the reader to that chapter, adding
only a few data.

The abdominal wall was, as before, the principal
seat of the degeneration. The recti were involved 1 3
times, the " abdominal wall " twice, the great pectoral
and the superficial muscles of the neck each once.
The last patient died of septicemia. All the cases
followed typhoid.

The ages of these patients were much below
those of the former series, as nine of them were
from fifteen to twenty-five and six were over twenty-
five, the oldest being thirty-nine. There were 13
males to three females, a larger proportion of males
than in the earlier table. Two arose during the
third, fourth, and fifth weeks, two two months and
one in the fifteenth week after the fever, three weeks
after a relapse. Three were only discovered at the
post-mortem. Of seven treated properly by incision
and drainage none died. Of six, in which no mention
is made of an incision, all died.

1 66

TYPHOID HEM A TO MA TA. 1 67

The following case is the only one I have person-
ally seen.

Case XXI. Abscess of the abdominal wall and
pelvis after typhoid fever.

D. C., age twenty-seven, was admitted to St.
Agnes' Hospital June 29, 1891. On March 7, 1891,
he had been taken sick with typhoid fever and was
in bed until April 27th. On May 29th he again fell
ill with what was pronounced a relapse. About
June 2Oth he suffered considerable pain in the
lower abdomen. This was soon followed by swell-
ing, which increased quite rapidly. On admission,
nine days afterward, a swelling 9 cm. long was
found just above the pubes, apparently in the right
rectus. It was quite tender. His temperature was
102. Unfortunately, I did not examine it by the
rectum, and therefore can not state the condition
of the pelvis. As the skin was in a very bad con-
dition from the constant application of iodin, I
applied an antiseptic fomentation to the part, both to
relieve his pain and to remove the shreds of skin,
as there seemed to be no urgency in his case. July
4th I made an incision into the abscess, and found
that it not only occupied the muscle, but also ex-
tended into the lower abdomen and pelvis, reaching
to the bladder and the rectum. It had not, however,
ruptured into the peritoneal cavity, but had pushed
the peritoneum before it. Over a pint of pus was
evacuated and the cavity was then drained with a
rubber drainage-tube. In a little over twenty-four
hours the temperature fell to normal, and in twelve
days he went home.

It is gratifying that recovery followed in spite of
the extensive mischief wrought before operation.
This is partly due, probably, to the late period at
which it arose. I have ventured to place it here

1 68 SURGERY OF TYPHOID FEVER.

under the head of hematoma, though it may have
been an abscess in the abdominal wall and not have
originated in a hematoma properly so-called. Its
position, however, strongly suggested hematoma.
Unfortunately, no facilities existed at the hospital at
that time for a bacteriological examination. The
bacillus of Eberth, however, has been found in the
pus of a similar abscess by Raymond and Strauss. 1

1 Pein, These de Paris, 1891, 58.

CHAPTER VIII.
CEREBRAL COMPLICATIONS OF TYPHOID FEVER.

I HAVE already alluded to three cases of obstruc-
tion of the Sylvian artery (Gangrene, p. 77). All
three were on the left side, and were probably
thrombotic rather than embolic in origin. In one of
them, a case of ambulant typhoid, 1 there was tuber-
cular meningitis in a woman six and one-half months
pregnant, and it may be that the Sylvian obstruction
was not of typhoid origin at all. Osier 2 has pub-
lished an excellent paper upon hemiplegia in typhoid
fever. Haines 3 has also reported a case.

The other cases of cerebral complications are
19 in number, 4 of abscess and 15 4 of meningitis.
One of the cases of abscess, an " abscess of the men-
inges" (see below), perhaps should be classed as a
meningitis. In the 15 cases of meningitis, both the
dura and the pia were attacked indifferently, and
the exudate was sometimes serous, sometimes sero-
purulent, but in at least 6 of the cases was puru-
lent. In two (Ohlmacher, vide infra] there were
also 1 20 c.c. and two ounces of blood clot.

It is noteworthy that a bacteriological examina-
tion was made in all 15, and that without ex-
ception the bacillus of Eberth was found in 1 2,

1 Huguenin, Correspondenzbl. schweiz. Aerzte, 1879, 449.

2 Jour. Nervous and Mental Diseases, May, 1896.

3 Bull. Johns Hopkins Hosp., 1896. 4 Besides the case on p. 152, footnote.

169

1 70 SURGERY OF TYPHOID FEVER.

it is expressly stated, " in pure culture." Wolff 1
has collected 174 cases of meningitis in which a
bacteriological examination was made and bacteria
were found in all but 1.15 per cent. In 2.87 per
cent, the bacillus of Eberth was found. In one of
Ohlmacher's cases a mixed streptococcus and typhoid
infection was found. In two cases 2 the patients
died so shortly after the cerebral symptoms began
that, as the author of one 3 points out, there was not
time enough for other bacteria to have set up the
meningitis and then to have disappeared.

Two of the cases 4 are referred to on page 47 as
asserted cases of typhoid infection without the char-
acteristic typhoid lesions in the intestine.

In no one of the four cases of abscess was a bac-
teriological examination made, a most unfortunate
omission. All of them occurred during or after 1884,
and the bacillus was then well known. Of these
four cases a resume is given at the end of this
chapter.

Two of the 3 Sylvian cases died and every one of
the other 19. The dates of onset are significant.
Of the whole 19 cases, i of the Sylvian and 5 of
the meningeal cases arose in the third week; the
other 2 Sylvian cases arose, one "in the course"
and the other on the twenty-third day, two days
beyond the third week. Three arose in the first
week and one in the seventh week. Four of the
meningeal cases were discovered at the post-mortem.

1 Berlin, klin. Wochen., 1897, No. 10.

2 Kamen, Internal, klin. Rundschau, 1890, Nos. 3 and 4 ; Fernet, Bull.
Soc. Med. des Hop., 1891., 361.

3 Kamen, loc. cit. 4 Balp and Adenot.

CEREBRAL COMPLICATIONS. 171

Practically, therefore, of these 16 cases 7, and possi-
bly more, arose in the third week, when the fever
would be at its height.

Of the 4 cases of abscess, i arose " in the course "
of the fever, and the 3 others on the fifty-sixth,
fifty-seventh, and ninety-eighth days, two to three
months after the fever.

Sex. Of the 19 cases, 12 were males and 7
females.

Age:

Under twenty there were, 6 cases.

From twenty to thirty there were, ... 8 "

Thirty-one, i case.

Thirty-three, i "

Forty-four, i "

Fifty-seven, i "

Soldier (an adult), i "

19 cases.

The subjoined resumes of three cases of typhoid
meningitis by Ohlmacher are the most recent and
the most carefully investigated cases that have come
under my notice. It will be observed that one was
due to a mixed infection, but in two a pure culture of
the typhoid bacilli was obtained. In one in which
suppuration occurred a distinct endarteritis was
found (Plate II). This fact is not only important
in its bearing on the pathology of typhoid meningitis
which has reached the suppurative stage, but it is
possible that it may throw some additional light on
the production of the form of gangrene alluded to
on pages 63 and 70. It is true that in such gangrene
there is no suppuration so far as we know, but it at
least suggests the need for more accurate investiga-

I ?2 SURGERY OF TYPHOID FEVER.

tion to determine whether it is not possible that en-
darteritis may occur in the extremities, especially in
the legs, and thus lead to gangrene.

Case XXII. 1 Man, age twenty-five, died on
the seventeenth day after admission, in the fourth
week. At the necropsy typical typhoid ulcers cor-
responding to the fourth week were found in the
ileum, with swollen mesenteric glands. When the
head was opened he found meningitis and 120 c.c. of
blood on the right side, with edema and a cloudy pia
with yellowish flakes. The typhoid bacilli were
found in the spleen, mesenteric glands, bronchial
glands, and in the pia in the region of the hemor-
rhage.

Case XXIII. 2 Man, age forty-six, died in the
fourth week. The spleen was swollen to twice its nor-
mal size and was quite soft. In the brain was found
a leptomeningitis, with 40 c.c. of turbid fluid in the
distended lateral ventricles. The typhoid bacilli were
found in the lung, the spleen, the mesenteric and
bronchial glands, and the pia. " Countless myri-
ads " were found, on microscopical section of the
brain, in the pia, arachnoid, and in the meningeal

1 Ohlmacher, Jour. Amer. Med. Assoc. , Aug. 28, 1897, p. 419.

2 Ohlmacher, loc. cit.

SUPPURATIVE TYPHOID LEPTOMENINGITIS. (Explanation of Plate II.)

Fig. i. Portions of two cerebral gyri with intervening sulcus and meningeal cov-
ering; meningeal membrane filled with inflammatory exudate. Small branch of
middle cerebral artery seen in cross-section, showing endarteritis. Photographed
with Leitz obj. 2, oc. i.

Fig. 2. Portion of arachnoid membrane from same section as Fig. i, showing num-
erous typhoid bacilli. Drawn from a photograph with Leitz obj. f s , oc. i.

Fig. 3. From same series of sections as Fig. i. Branch of middle cerebral artery
showing acute endarteritis. Note the inner bounding membrane (endothelium) and
the numerous small cells between it and the intima. Some of the small cells are also
seen within the endothelial lining. Photographed with Leitz obj. 7, oc. 4.

Fig. 4. From another series of sections of the cerebrum in same case. Branch of
middle cerebral artery showing complete obliteration of lumen by endarteritis. Same
power as Fig. 3.

Fig. s- Same section as Fig. i. Minute arteriqle of middle cerebral artery, show-
ing endarteritis. The endothelium is raised well into the lumen. There is moderate
sub-endothelial cellular proliferation ; a few cells lie within the lumen. Leitz obj. T j,
oc. 4.

[Reproduced from A. P. Ohlmacher's paper (Jour. Amer. Med. Assoc., Aug. 28,
1897) by the kind permission of the author and editor.]

PLATE II.

CEREBRAL COMPLICATIONS. 1/3

exudate. Extensive obliterating endarteritis was
present.

Plate II is taken from Dr. Ohlmacher's paper,
with his kind permission, and shows admirably the
meningeal exudate, and especially the endarteritis,
as seen in the preceding case.

Case XXIV. 1 A woman, age twenty-four, who
died at the end of the second week, having had tonic
spasm of the flexor muscles, especially marked on the
left side, preceding death. The necropsy showed
three spots of ulceration in Peyer's patches. There
was beginning left-sided broncho-pneumonia. On the
right side of the brain there was acute pachymen-
ingitis with about two ounces of clotted blood and a
catarrhal leptomeningitis. In the blood from the
heart were found cultures of the streptococcus. [It
is surprising, in view of this, that there was no infec-
tive endocarditis.] In the spleen and mesenteric
glands and in the blood of the heart he found pure
typhoid bacilli. In the subdural space and in the
pia he found the streptococcus and typhoid bacillus
as a mixed infection. The streptococcus infection
probably reached the brain by way of the lungs.

These three cases are particularly interesting by
reason of the very careful microscopical and bacterio-
logical examination which was made.

In the bacteriological examination a reference to
his paper will show that he used all the more modern
tests for differentiating the typhoid and the colon
bacilli from each other, and the identification of the
typhoid bacillus in the brain seems to be undoubted.

The microscopical examination is quite as interest-
ing. In Case XXIII he found an " exquisite and

1 Ohlmacher, Cleveland Med. Gaz., May, 1897, 409.

174 SURGERY OF TYPHOID FEVER.

wide-spread acute endarteritis affecting the smaller
arteries of the pia in both the anterior cerebral and
the cerebellar regions ; in other words, an endar-
teritis involving at least the branches of the middle
cerebral and anterior cerebellar arteries. The pro-
cess affects both the medium-sized and the smaller
arterial branches, and varies from a partial to a com-
plete obliteration. Serial sections from one of the
larger vessels shows the advance from a partial to a
complete obliterating endarteritis (Plate II). In the
more minute twigs the change most frequently results
in complete obliteration, and the newly-formed tissue
fills the lumen of the vessel. The study thus far
made of this condition seems to point to the con-
clusion that the endothelium of the intima is raised
from its bed and forced into the lumen of the vessel
by a sub-endothelial exudate ; at least, a distinct
membrane with fusiform nuclei can be found in the
vessels in which the obliteration is not complete,
bounding the new cells internally ; and where the
occlusion is complete a central core of cells, with
laterally compressed nuclei, seems to be the same
membrane forced into a compact mass. Two dis-
tinct kinds of small cells, both poor in protoplasm,
are to be found in the endo-arterial exudate, one with
nuclei composed of compact deeply staining chro-
matin, and engaged in one or another of the stages
of indirect fragmentation ; while the others, com-
paratively less numerous, are slightly larger and
possess single nuclei with the chromatin more dif-
fused. These small cells do not differ in structure
from the pus cells of the general extravascular
meningeal exudate, and are united by delicate proto-
plasmic fibers which seem to bind the cells together
by a delicate reticulum, though they are often sepa-
rated some distance from each other."

No bacilli were found in the arteries, though they
were "abundant about the arteries, even to the ex-

CEREBRAL COMPLICATIONS. 1/5

tent of invading the perivascular lymph space, but
they seem to be effectually barred by the muscular
media."

The symptoms of cerebral involvement, especially
of meningitis, are often overlooked. They are
masked by the general stupor, and are supposed to
be only connected with the usual delirium of typhoid.
That only 15 cases of typhoid meningitis were found
in such an extensive tabulation is remarkable. I
am strongly disposed to think that such cases have
been frequently overlooked by reason of the fact
that the head is not very often opened in typhoid
necropsies unless the cerebral symptoms have been
very prominent. Even in cases without marked
cerebral symptoms, examination of the brain, I be-
lieve, will show meningitis and infection by the bacilli
of typhoid to be far more frequent than has been
supposed heretofore.

Whether anything can be done by the surgeon to
relieve such a complication is very doubtful, in my
mind. Trephining would be useless, as the infection
is too wide-spread. If I am right in this view, surgery
has nothing to offer in such cases.

In abscess of the brain the symptoms are more
pronounced, and may indicate both the nature of the
lesion and occasionally even its location. When a
hemiplegia or a monoplegia occurs, while it may be
due to thrombosis, it should also raise the question
of the possibility of abscess. If the eye symptoms
point to this complication (optic neuritis), it would be
confirmatory. But in cerebral abscess this is often
wanting. The fever accompanying the disease itself

1/6 SURGERY OF TYPHOID FEVER.

would cause a rise of temperature, which generally
is absent in ordinary cerebral abscess, and this will
obscure the diagnosis. The same may be said of
headache, which so constantly accompanies typhoid,
especially of the cerebral type. Cerebral vomiting
also would be ascertained with difficulty. On the
whole, therefore, the diagnosis is difficult, and may
be impossible.

Even if a fairly positive diagnosis can be made it
is doubtful whether trephining would offer any loop-
hole of escape from death. Yet, on the other hand,
every such case so far has died, and at least no
worse result could follow an attempt to relieve such
a hopeless condition. Only of late have surgeons
had the boldness to interfere in cases of biliary and
intestinal perforation, and with at least fair results.
Possibly the same may be true in the future, if we
attempt to rescue also the cases of cerebral abscess.
I should be inclined, at least, to try. Fortunately,
as our tables show, such a complication is exceed-
ingly rare.

I append a resume of the cases of abscess of the
brain, at least for our information and as food for
reflection.

I also add an unusual case of thrombosis of the
intracranial veins without involvement of the sinuses
but with three small abscesses (?) of the brain.

Case XXV. Holscher 1 simply alludes to one fatal
case of abscess of the frontal lobe of the brain in a
patient aged twenty-four.

Case XXVI. Josserand 2 reports a case of a
young girl of twenty who died of suppurative menin-

1 Munch, med. Wochen. , 1891, No. 4. 2 Lyon Med., 1894, vol. Ixxvi, 97.

CEREBRAL COMPLICATIONS. 177

gitis in typhoid fever. She had moderate aphonia and
right monoplegia ; death followed forty-eight hours
after the cerebral symptoms began". At the ne-
cropsy recent meningitis was found over the left
lobe. It had its origin in an abscess as large as an
orange at the base of the second frontal and the
ascending frontal and parietal convolutions. It had
depressed the cerebral substance without altering
the convolutions, which were perfectly recognizable.
The patient had a slight excoriation over the sac-
rum, only involving the epidermis and without sup-
puration. No bacteriological examination appears
to have been made.

Case XXVII. Deschamps ' reports the case of a
man, age nineteen, who entered the hospital Decem-
ber 4, 1893, with ordinary typhoid fever. On the
3ist he had a relapse. By February he had entirely
recovered, excepting for a persistent diarrhea. The
temperature had become normal. On the I4th of
February a pleurisy with effusion was observed. The
patient began to grow weaker and showed signs of
tuberculosis at the left apex. On the 28th of Feb-
ruary he complained of severe pain in the right ear
and the right face, with difficulty in deglutition, and
facial neuralgia was diagnosticated. There was
nothing abnormal in the throat. By the 22d of
February his temperature had become normal.
On March ist, about the ninety-eighth day, it rose
to 39.3 C. On the 2d, though it had fallen to
37.2, a paresis of the right hand manifested itself.
There was no paresis of the left arm. There was
no disturbance of sensibility. The facial neuralgia
persisted, and the patient for several days had bilious
vomiting. He died on March 4th. The necropsy
showed a serous pleurisy of the left side ; tuber-
culosis of the left apex ; a normal heart, liver, kid-
ney, and spleen ; congested, cicatrized, and thickened

1 Progrs Med., 1884, vol. xii, 950.

1/8 SURGERY OF TYPHOID FEVER.

Payer's patches in the intestine. There was no men-
ingitis, but an abscess of the brain was found on
the right side at the posterior portion of the first
temporal convolution. It did not communicate with
the ventricles in the left hemisphere ; there was no
lesion of the ear on the right side.

Case XXVIII. Huchard and Tissier x report the
case of a man, age fifty-seven, who suffered with all
the classical symptoms of typhoid fever. He had a
slight trace of albumin in the urine ; his hebetude was
very pronounced, but was more apparent than real on
account of his typhoid deafness. He entered the
hospital April 21, 1884, about twelve days after his
illness began. He was obliged to remain in the
hospital for six weeks on account of his slow conva-
lescence, but without any complication that was per-
ceptible until the 5th of June (fifty-seventh day) when,
after an elevation of- temperature, complete aphasia
set in, with paralysis of the right side of the face.
On the next day the arm was paralyzed ; on the
second day the leg of the right side was paralyzed ;
the paralysis in botlj being not quite complete. Sen-
sation was diminished. The patient did not complain
of his head, had not vomited, had no albuminuria,
no valvular lesion. His belly was distended and
the diarrhea had not ceased. On the 7th of June
speech partially returned and his paresis dimin-
ished. On the contrary, his intellectual state became
much worse. His torpor was excessive, so that he
could scarcely be roused by any question. He died
on the iith of June. The necropsy showed that
the heart was normal ; the intestinal lesions of
typhoid were marked. At the middle and upper
portion of the left hemisphere a localized meningitis
existed, which had resulted in an abscess of the
meninges, 12 by 5 cm. The convolutions under-
neath the abscess were flattened out. The portion

1 Progrds Med., 1885, vol. xiii, 440.

CEREBRAL COMPLICATIONS. 179

of brain involved was the frontal and parietal lobes,
especially the ascending frontal and parietal and
the second and third frontal convolutions near the
fissure of Rolando and the two parietal lobes. The
contents of the abscess were between 50 and 60
gm. of green, creamy pus. There was no evidence
of ecchymosis or infiltration. The abscess existed
between the dura and the arachnoid. There was no
suppuration in the petrous bone.

Case XXIX. Dr. A. B. Richardson l relates an
interesting case of marantic thrombosis of the intra-
cranial veins following typhoid fever, without throm-
bosis of the sinuses. The patient was a man aged
forty-three, who had had two injuries, one on the
right side of his head twelve years before, the
other on the left side of his head three months
before, but without any cerebral symptoms except
more or less headache. Toward the end of the
third week defervescence took place. Just at that
time, however, he began to complain of intense pain
in the left temporal region, with, later, subnormal
temperature and collapse, contraction of the pupils,
somnolence, delirium, and convulsive movements in
the left arm and leg and right face, and, later, on
the right side of the body. Operation was con-
sidered, but decided against in view of the too dif-
fuse and uncertain symptoms. The case was
diagnosticated as probably one of acute meningitis.
The eye grounds showed only general engorgement,
more pronounced on the left side. He died at the
end of about a week.

The necropsy showed no signs of meningitis, but
the principal veins on the surface of the cortex were
distended with hard clots ; one of particularly large
size lay along the fissure of Rolando. In the first
temporal convolution of the left side was an area
the size of a hickory-nut, which broke open, dis-

1 Jour. Nerv. and Ment. Dis., July, 1897, p. 404.

180 SURGERY OF TYPHOID FEVER.

charging a small amount of pus and broken-down
brain tissue and blood coagula as the brain was
removed. On the right side of the brain, just in
front of the Rolandic fissure at its middle and upper
third, was another area of a similar character though
less advanced. In the right occipital lobe was another
area, but not yet softened. The sinuses were en-
tirely free. Unfortunately, no bacteriological exami-
nation or microscopical examination seems to have
been made. Whether the collapse was the cause
or the result of the thrombosis is uncertain.

CHAPTER IX.
OTITIS MEDIA IN TYPHOID FEVER.

DR. WESTCOTT has collected 3 1 cases, of which 24
are reported by a single observer. 1 Since the table
was completed Hengst 2 has added 28 cases out of
1228 cases of typhoid collected from the practice of a
large number of physicians an average of about 2.5
per cent. Very likely many observed cases have
not been deemed important enough to record.
Only one case of mastoid disease was observed
(Hengst) in all the 59 cases.

The usual cause is obviously a pyogenic infection
from the throat. The diplococcus of pneumonia
has also been found. In two bacteriological ex-

animations 3 the bacillus of Eberth was not found,
but its presence has been shown by Destree and
Vincent (p. 26). The infection, however, would be
more likely to be pyogenic, access to the middle ear
being obtained through the Eustachian tube. Cold
draughts or cold water in the ear from bathing the
patient may, as Hengst believes, occasionally cause
the trouble, but I would hardly attribute much im-
portance to them as compared with the infection from
the air-passages.

The disease is a complication rather than a sequel.

1 Sorel, Soc. Med. des H6p., 3d series, vi, 1889, 224.

2 N. Y. Med. Jour., June 6, 1896.

3 Dunin, Deutsch. Arch. f. klin. Med., 1886, xxxix, 369.

181

1 82 SURGERY OF TYPHOID FEVER.

It arises usually in the second to the fourth week,
when the patient is at his lowest ebb. The mouth
and naso-pharynx are filled with mucus, which the
patient is too weak or too indifferent to expectorate,
and the same region is not seldom also the seat of
ulcers which add pus to the mucus. Though, as Sorel
points out, this complication usually accompanies
mostly grave and prolonged cases, yet not a single
death is recorded among the 59.

The symptoms and treatment call for no special
remarks.

CHAPTER X.
TYPHOID PAROTITIS.

IT is a noteworthy fact that in the later and larger
series of cases Dr. Westcott only tabulated 50 cases
of parotitis as against 378 in the Toner Lecture.
I must, therefore, refer the reader to the Toner
Lecture for the chief facts in relation to parotitis.

The difference in the numbers is easily explained
when it is noticed that in the earlier series 362
followed typhus, a far more septic disorder than ty-
phoid, and only 26 followed typhoid. In the pres-
ent table all but one followed typhoid. The death-
rate in the cases in which the result is stated is
nearly 30 per cent., for of 28 cases, 8 died. Twenty
of the 28 in which the sex is named were males.
Of 25 cases the average age was nineteen years, an
earlier age than the former series, and nine of them
were children under fifteen. Suppuration was much
more frequent in the present series, for of 34 cases,
29 suppurated and only 5 did not. In 12 cases the
parotitis was bilateral, of which 7 suppurated on
both sides.

The cause of the parotitis is undoubtedly gener-
ally a secondary infection by the pyogenic bacteria,
which find many open ports of entry in the fissures
of the lips, abrasions in the mouth, and a direct path
by the duct of the parotid. In at least two cases, '

1 Janowski, Centralbl. Bakteriol. und Parasitenk., 1895, xvii, 685 ; Leh-
mann, Centralbl. klin. Med., Aug., 1891, 649.

183

1 84 SURGERY OF TYPHOID FEVER.

however, the bacillus of Eberth was found. In the
last case it was associated with the staphylococcus, but
in Janowski's case the typhoid bacillus existed alone.
The patient was a man of twenty, who died in the
second or third month of the fever. The suppura-
tive faculty of the bacillus and its late ravages are
thus once more demonstrated.

Doubtless, very many cases of parotitis have es-
caped notice in the histories, which would give the
more salient points and omit a detail such as this.
In very many cases, also, the titles have not named
parotitis as a complication, and thus they have not
been tabulated.

The treatment is the usual one for such compli-
cations abortive, if possible by ice, iodin, ichthyol,
etc. ; but if suppuration occur, a free antiseptic in-
cision and drainage.

The following case of continued sweating in the
parotid region after a typhoid parotid abscess I
owe to the courtesy of Prof. Osier. While not
strictly surgical, it is sufficiently rare and curious to
be made a matter of record.

Case XXX. " B. F. A., age twenty-six, applied
to the Johns Hopkins Hospital January 18, 1896,
complaining of sweating over a limited area on the
right side of the face and forehead. The patient
had typhoid fever in September, 1890. During
convalescence an abscess formed in the right parotid
region, and was opened. Three or four months
after the healing of the wound the patient noticed
profuse sweating over the right side of the face and
temple when eating, and he has been troubled with
it ever since. When seen the patient was a healthy-
looking, active man. There was a scar of the inci-

TYPHOID PAROTITIS.

I8 5

sion at the angle of the jaw two cm. in length. It
was a little thickened and indurated, and slightly
sensitive on pressure. Simple movement of the
jaw, as in the act of mastication, produced no sweat-
ing. The chewing of food, more particularly on the
right side, caused profuse sweating. The application
of an electrical stimulus or of acid on the right side
of the tongue caused it. The condition was the

Fig. 2. Area of Sweating in Case XXX.

source of a good deal of discomfort, as when eating
his meals he had to mop the side of the face every few
minutes. The area over which the sweating oc-
curred (not strictly ' parotid ' however) is shown in
the diagram (Fig. 2). There was no facial paralysis
and no disturbance of sensation.

" Of similar cases reported in the literature, a num-
ber of them have followed from the same cause ;
others after injuries in the parotid region."

CHAPTER XI.
TYPHOID AFFECTIONS OF THE THYROID GLAND.

THE presence of the typhoid bacillus in the thyroid
gland has been affirmed by a number of authors
(see p. 28). That the pyogenic bacteria should also
be present would not be surprising ; but in the ten
tabulated cases in which the thyroid was involved, in
only one ' was the staphylococcus albus found, and
then not alone, but mingled with Eberth's bacillus.
In three others 2 the typhoid bacillus was found alone.
In the last case, while there can be no question that
the suppuration in the old goiter was due to the ty-
phoid bacillus, it may possibly be a question whether
the patient had really typhoid fever. The thyroid
abscess began on the second day. No typhoid bacilli
were found in the stools. If it was not a case of
typhoid fever, then it would seem to be analogous
to the cases referred to on page 43 of typhoid in-
fection without the usual intestinal lesions of typhoid
fever.

It may be merely accidental, but it is at least
noteworthy, that of the ten cases in my table, in
four suppuration occurred in thyroids already dis-
eased i. e., in old goiters. This may have been a

1 Spirig, Correspondenzbl. f. schweiz. Aerzte, Feb. 15, 1891.

2 Colzi, Lo Sperimentale, 1891, No. 2 ; Dupraz, Arch, de Med. Exp. et
d'Anat. Pathol., Jan. I, 1892, 76; Kummer and Tavel, Rev. de Chir., June,

1891, p. 507.

1 86

THE THYROID GLAND. 187

predisposing cause. The infection may readily
reach the gland through the blood, even when this
gland is normal ; but when it is in the condition of
cystic goiter, this is still more readily conceivable.
Colzi, in his case, attributed it to hemorrhages into
the cystic cavities caused by the constant cough,
and that then infection of the blood clots easily
occurred through the blood current. In all but one
of the ten, suppuration occurred. In seven the
attack began in convalescence i. e., after the third
week ; in two as late as the seventh or eighth week.
Five were males as against two females. Two were
"young" presumably, therefore, under twenty;
two between twenty and thirty ; three were over
thirty. Six recovered, and one, who had also an
abscess of the spleen, died.

Several of Liming' s cases of the laryngeal com-
plications of typhoid had also old goiters. They
are tabulated in the next chapter and not here.

Treatment. When suppuration has taken place,
the only treatment, of course, is to open the abscess
under careful aseptic precautions if the gland be
normal ; but if the case be one of old goiter, it may
be better to extirpate the suppurating half, as was
done by Kummer. This would only be done, of
course, in convalescence. During the fever, only
temporizing methods should be employed.

CHAPTER XII.
TYPHOID AFFECTIONS OF THE LARYNX.

THE larynx and the joints are the two sites of
frequent surgical complications of typhoid upon the
pathology of which the discovery of the bacillus of
Eberth has had practically no influence. In Chapter
IV I have related the results of bacteriological ex-
amination in typhoid arthritis. In not a single case
has the bacillus been found in the joints, nor am I
aware of a single observation which has revealed
its presence in the larynx. Possibly such a case
may exist, but if so it has not been found in the
pains-taking search of Dr. Westcott.

The present chapter, therefore, will be little more
than an enlargement in the way of statistics of the
corresponding chapter in my Toner Lecture, to
which, in the Appendix, the reader must be referred,
together with the development of such additional
facts as the larger number of cases will furnish.

But one attempt has been made since my lecture
in 1876 to gather together the material needful for
the consideration of the subject. 1 In 1876 I collected
169 cases. In 1884 Liining, who had evidently not
seen my lecture, collected 213 cases. Dr. West-
cott has not collated the two series, as it would
have been an unnecessary and tedious task. Pre-
sumably they are very nearly identical, excepting

1 Liining, Archiv f. klin. Chirurgie, 1884, xxx, 225.

1 88

TYPHOID AFFECTIONS OF THE LARYNX. 189

the 14 original cases reported by Liining and the 30
cases in excess of my first series. Dr. Westcott has,
however, collected 38 cases since Liining's paper,
which, with Liining's 14 original ones, added to the
169 of my first series, make 221. The following re-
marks are based, therefore, upon these 221 cases.
I shall also quote, as occasion demands, some tables
and remarks by Liining, whose paper is not only
very full and detailed, but of the greatest interest
and importance both to the surgeon and the laryn-
gologist.

Liining's description of the symptoms is so
graphic, and so useful in calling attention to the un-
expectedness and the dangers of such cases, that
I can not do better than to quote it in full (p. 286):

" The fact that the patient, at the time when the
lesions in the larynx are so wide-spread that they
ought to be recognized clinically, lies in typhoid
apathy, and often makes no complaint of his suffer-
ing, is a great hindrance to the clinician. All the
more is it his duty not to allow even slight com-
plaints, especially if they arouse even a suspicion of
any laryngeal complication, to pass unnoticed. . . .
In the histories will be found the oft-recurring re-
marks, 'The patient was doing well,' or 'he was
slightly hoarse,' ' complained slightly of dysphagia,'
etc. . . . Physician and patient together rejoice
over the daily progress toward convalescence ; of
the still slight but persistent trouble in the throat
scarcely a word is said, until all at once an exposure
to cold, a little walk, is then usually blamed for it
the hoarseness increases, and swallowing becomes
markedly painful. The picture now quickly alters.
Soon, often within a few hours, come dyspnea and
suffocative attacks. Sometimes even during the

190 SURGERY OF TYPHOID FEVER.

very first day the anxious scene of laryngeal steno-
sis sets in, with stridor, inspiratory depression of the
neck and chest wall the unrest of despair, a struggle
with death. The face becomes livid ; the respiration
becomes rapid, wearisome ; the auxiliary muscles of
respiration are all called into play ; sometimes the
respirations are prolonged and noisy. The patient
'can find no rest ; the dyspnea even prevents the tak-
ing of nourishment ; the expectoration of the increas-
ing mucus becomes imperfect ; soon attacks of suf-
focation recur. Either a tracheotomy must now be
done immediately, or the patient, if he is weak, may
choke to death, even in the first attack. More com-
monly, however, the attack subsides, and a slight im-
provement with a short sleep will ensue. Expectora-
tion of bloody mucus, masses of pus, and, in some
cases, even of pieces of cartilage, diminish the symp-
toms, and show at the same time that the real cause
of the dyspnea is not a catarrhal edema or dropsical
swelling but a destructive ulceration, even of the
cartilages. Often, also, there is severe fever. Thus
pass on, it may be even days and weeks, easy
breathing alternating with the suffocative attacks.
The alternative is only a finally fatal attack of
suffocation or a late palliative tracheotomy with all
its uncertainty. ... If one will read the cases
of death from suffocation without operation gathered
in Table B (52 cases, 49 deaths), he will find that,
almost without exception, suffocation occurred early
and quickly, before either physician or patient had
even thought of tracheotomy.

"This is the picture in cases of perichondritis. If
the patient is in the stage of typhoid stupor, when
the ulceration is accompanied with acute suppura-
tion and swelling which may lead to destruction of
the cartilages, the initial symptoms of the threaten-
ing danger may escape us entirely in spite of care-
ful observation. ... In these cases the objec-

TYPHOID AFFECTIONS OF THE LARYNX. 191

tive signs of laryngeal stenosis, on which we usually
depend, are much less marked ; stridor, movements
of the larynx, inspiratory depression, action of the
auxiliary inspiratory muscles in short, everything
by which, in the healthy, we make the diagnosis
of narrowing of the air-passages is, in the vita
minima of the weakened patient, far less outspoken,
and easily deceives us as to the degree of the
danger of suffocation. The striking suffocative
attacks, with arrest of respiration, so alarming even
to the lay observer, are less noticeable, since the
struggle of the patient with the mechanical obstruc-
tion quickly fails or is quickly abandoned. The
condition passes into a death agony, with edema of
the lungs, without the stenosis seeming to have
reached a threatening degree. . . . And thus one
sees, often with astonishment, in the reports of the
necropsies, how often the stenosis and destruction
of the cartilages occurs, as it were, 'without even
any symptoms. '

A vivid picture like this may well give both the
physician and the surgeon food for thought. In
America, however, as in England, it would seem
that cases of perichondritis are less frequent than in
Germany. The influence of nationality was not
alluded to in my Toner Lecture, nor was the nation-
ality of the cases in the second series tabulated.
Liming, however, has done so in his 199 cases from
surgical literature, and found that of the 147 cases
subjected to tracheotomy, 117 were from Germany
(including Switzerland), 16 from France, and only
8 from England. Of the 52 not tracheotomized, 37
were French, 1 1 German, and 4 English.

Two other points not mentioned in my former
paper are the occurrence of emphysema and the

192 SURGERY OF TYPHOID FEVER.

extension of the suppuration to the mediastinum.
Both are evidences of the gravity of the affection.

Thus, Wilks ' records the case of a child of twelve
who on the twelfth day developed general emphy-
sema, due to a perforating ulcer on the posterior wall
of the larynx. Durham 2 records a similar case in
a boy of ten, and Chomel 3 a third in a man of twenty,
from an ulcer which perforated the thyroid cartilage.

In one of Liining's cases (IX) an abscess existed
in which no trace of the arytenoids could be found
and the cricoid was undergoing necrosis. The an-
terior mediastinum was infiltrated with pus. In
another case 4 a similar abscess existed around the
bare thyroid cartilage, and both the anterior and pos-
terior mediastina were involved.

Following now the order of my Toner Lecture, to
which the reader is referred for a fuller discussion
of each point, I will give the revised statistics of the
two tables combined.

The total number of cases collected is 221, of
which at least 89, and probably many more, certainly
involved the cartilages.

Age. Of 146 cases there were :

Under fifteen, 12

Fifteen to twenty-five, 87

Over twenty-five, 47

146

showing that childhood is remarkably exempt from
laryngeal complications.

1 Med. Times and Gaz. , 1862, ii, 276.

2 Holmes' Syst. Surgery, 2d ed. , iv, 571. 3 These de Paris, 1877.
4 Retslay, Ueber Perichondritis Laryngea, Berlin. Diss., 1870, No. 10.

TYPHOID AFFECTIONS OF THE LARYNX. 193

The corresponding table of Liining, including his
own 14 cases, gives :

AGE. MALES. FEMALES. TOTAL.

Under ten, .... 4 2 6 ")

Ten to fifteen, ... 7 5 12 j

Fifteen to twenty, .30 n 41 )

Twenty totwenty-five, 56 . 12 68 j

Twenty-five to thirty, 25 3 28^

Thirty to thirty-five, 3 2 5 L 38

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 Liining's table, as above, there were :

Males, . 129

Females, 36

165
Site of the Stenosis. This was :

Supraglottic, 50

Infraglottic, 36

In the glottis, 18

104

This would seem to bear out the view of Liining
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, 30 "

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, for of 75 cases 71 died
a mortality of almost 95 per cent. Of the four
recoveries, two x recovered without operation and
two 2 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, 3
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. Soc. Trans., 2d ed.,
ii, 407 ; and Schififers, Annales Soc. Med. Chir. de Liege, in Jour. Amer.
Med. Assoc., 1884, 70.

2 Tiirck and Liming, Case II, p. 223.

3 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. 195

Cartilage 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 Liining's table the result is analogous :

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 not operated on. 21 recovered and
77 died a mortality of 78.6 per cent.

Of 99 cases operated on, 44 recovered and 55
died a mortality of pnly 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 Liining'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. 197

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
evidently 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 Results. Llining 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 obliged 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 Ltining'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. 1 Boulay and Mendel 2 have reported 17 cases,
and Bernoud 3 reports another case.

1 Ueber Lahmungen der Kehlkopfmuskeln beim Unterleibs und Fleck-
typhus. Sammlung klin. Vortrage, Neue Folge, No. 182, 1897.

2 Des Paralysies Laryngees dans la Fievre Typholde, 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 which the pyo-
genic power of the typhoid bacillus was proved was
in the pleural cavity. In 1885 Rendu and de
Gennes, 1 and in 1887 A. Fraenkel, 2 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 bacteriological 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 3 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, 4 in an-
other gangrene of the lung and abscess of the
spleen, 5 and in a third 6 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 France Med., 1885, ii, 1809.

4 Ramsey, Annals of Surgery, Jan., 1890, 39.

5 Griesinger, Infectionskrankh.

6 Barr, Liverpool Med.-Chir. Jour., 1893, xiii, 346.

I 99

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 drainage, 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 l 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 2 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 3 was in a man of

1 Weintraud, Berlin, klin. Wochen., 1893, xxx, 345.

2 Zeller, La France Med., 1881 ; and Le Clerc, La France Med., 1881, 54.

3 Driguet, quoted by Michon, Contrib. a 1'Etude des Suppur. dans la
P'ievre Typhoide, These de Lyon, 1890.

THE PLEURA, LUNGS, AND HEART. 2OI

thirty-six, who died on the thirtieth day, and was
likewise 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. 1

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 original 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 lonof 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 drinking 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 pro bang, measuring be-
tween five and six millimeters.

" On the 3oth 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 i3th 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 33
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

206 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 hemorrhage from the stom-
ach; perforation is also a possibility; both due to
typhoid ulceration. Pepper 1 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 orperforation." Nocase 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, 2 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

Fig. 3. Drawing of the pyloric end of the stomach in a case of enteric
fever: a, Acute perforating ulcers with clean bases; t>, 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

208 SURGERY OF TYPHOID FEVER.

the ulcers originated in disease of the solitary 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 XXXIV (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 largest 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."

Hemorrhage 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 Pathologic and Therapie,
in the section on the 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 difficult 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 large num-
ber of recoveries, even after severe hemorrhages
from the bowels, would warrant our concluding that
the expectant and symptomatic medical treatment is
certainly the best.
14

210 SURGERY OF TYPHOID FEVER.

Case XXXV (Osier). " John M., age forty (hos-
pital No. 1683), was admitted August 2 1 , 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,
3Oth, and 3ist 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 delirium. 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 more rapid, but these two
hemorrhages did not appear to have any injurious
influence. His temperature gradually fell, and was
normal on the 3ist. 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
nth, the following:

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 3ist. 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, 1 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, 2 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 3 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, 4 and in the same
year Bontecou s 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. to, p. 106.

212

INTESTINAL PERFORA TION. 2 1 3

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, 1 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 2 found that peritonitis from,
intestinal perforation took place in 1.2 per cent, of
3686 Hamburg cases in 188687. This accords with
the statement of Liebermeister, 3 who found intestinal
perforation in 1.3 per cent, of over 2000 Basle cases
between 1865 an d 1872. Holscher 4 found perfora-
tion in 6 per cent, of 2000 cases. Murchison 5 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.

1 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, 11, i, 161.

4 Munch, 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. CASES. PER CENT.

One to ten years, 7 3.6

Ten to twenty years, 46 23.8

Twenty to thirty years, .... 77 39.8

Thirty to forty years, .... 45 23.3

Forty to fifty years, 14 7.2

Fifty to sixty years, 2 i.o

Sixty to seventy years, . . . . i 0.5

192

Date of Occurrence of the Perforation. Fitz's
table is, again, as follows :

WEEK. CASES. PER CENT.

First, 4

Second, 32 16.5

Third, 48 24.8

Fourth, 42 21.7

Fifth, 27 14.0

Sixth, 21 13.4

Seventh, 5

Eighth, 3

Ninth, 2

Tenth, 4

Eleventh, 3 . .

Twelfth, i

Sixteenth, i

The Seat of the Perforation (Fitz). In 167 cases.

SEAT. CASES. PER CENT.

Ileum, 136 81.4

Large intestine, 20 12.9

Vermiform appendix, .... 5 . .

Meckel's diverticulum, ... 4 . .

Jejunum, 2

INTESTINAL PERFORATION. 21$

Hawkins, 1 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, 2 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 2 /$ 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 fistulse 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 Perforations. 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 1 and Hoffman 2 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 1 34 cases
(Fitz) :

Died on the first day, 37.3 per cent.

" on the second day, .... 29.5 "

" in the first week, 83.4 "

" in the second week, .... 9 cases

" in the third week, .... 4 "

" in thirty days, i case

" in thirty-eight days, . . . i "

We should naturally expect that perforation would
be more frequent in proportion to the gravity of the

1 Ueber d. Typhus- u. d. Typh.-Epid. d. Jahr. 1857 ; Friedrich, Die Para-
centese d. Unterleibs b. Darmperf. 5m Abdominal ty ph., 1867.

2 Untersuch. u. d. path. anat. Verand. d. Organe beim abdominaltyph. ,
1869.

3 Plates IV and V are from specimens in the Museum of the Pennsylvania
Hospital, which I was kindly allowed to have photographed.

PLATE IV.

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.)

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.)

INTES TINA L PER FOR A TION. 2 1 7

disease, but Fitz states that 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 Perforation. 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
clulness ; 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, 1 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 (leucocytosis) with the
fever, even without any complication. Four cases

1 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
1 1,000, 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 perforation,

8300.

(^) 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.
(V) One week later, 10,100.
Case II. (a) One week before onset, 4800.
(<) At time of onset, 16,200.

Otitis Media. . Case I. (a~) At entrance, 5300.

(^) Mastoid abscess, 16,400.
Case II. (a) At entrance, 8400.

(/) Two weeks later, after opening
drum membrane (sero-puru-
lent discharge), 11,200.
Case III. (#) At entrance, 7320.
(^) 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.

1 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 intestinal 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, 1 in his three cases, made cover slides and
cultures which showed pure colon bacilli.

1 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 1
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, 2
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 include (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-five 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, 1 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. 1 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, 2 since the diagnosis is extremely
doubtful.

4. Price's second case, 3 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 4 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, 5 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 suffi-
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. 6

1 Abdominal Surgery, 3d ed., 1890, 751. 2 Lancet, 1890, i, 961.

3 Med. and Surg. Reporter, Nov. 7, 1896, 577.

4 Price refers to it in his paper.

5 Brit. Med. Jour., 1897, i, 13. 6 Rev.de Chir., 1897, 169.

INIESTINAL PERFORATION. 22$

2. The 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 Finneyand 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 surgeon, 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 that the second twelve hours
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. 22J

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
operation is stated shows us the great danger of
delay. This is stated in 60 cases as follows:

CASES. RECOVERED.

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

60 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 opera-
tion is not done within about twenty-four 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 sigmoid 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 this 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 artificial anus in the ileum I
have found in cases other than typhoid to be objec-
tionable, since the intestinal juices are very irritating
to the skin.

A continuous suture is decidedly not the best.
The tissues of the bowel are very frail and may
readily tear out, and, if the suture be continuous 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 tissue, but also because they shorten the
operation, since there is but one knot to be tied for
every two sutures. Whether one, two, 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
51 and 60 subsequent perforations destroyed life in

230 SURGERY OF TYPHOID FEVER.

cases which were apparently recovering, and in case
62 had life been prolonged a little 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 supra], 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 1 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 good here. Moreover, I think well of

1 Johns Hopkins Hosp. Bull., July, 1897.

IN TES TINA L PER FOR A TIO N. 231

packing 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 agglutinated 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 the 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-sanguine surgeon : " 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 prima 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."

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RFORATION IN T 1
OPKRATION.

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1.I-5 'il

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Death % an ho
osis confirmed

ovg

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Examination
L-cted showed
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al or connect

CT; js o re /^

Death several

Death 11 hour
udden, after str
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ence the delay

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Personal c
munication.

I n tercolor
Quarterly Jour
1895, Feb.

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.
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-
pendingperforation sutured and
brought near abdominal wound.
A fistula occurred here, but
closed in 10 days.
No perforation found, but much
excoriation and injection over
base of otie 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.

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Appendix normal, but adher-
ent to a coil of ileum 4 in. above
valve. On separating, a perfora-
tion found. Sero-pus about this
area when abdomen was opened.
Running Lembert sutures of fine
silk. Appendix removed. Wound
partly packed with iodoform
gauze.
A puddle of filthy fluid found
about the perforations, and
omentum and appendix in-
volved in adhesions.

General angry peritonitis,
filthy bowel contents and in-
flammatory products. Thor-
ough irrigation and drainage.
Stitched multiple bowel fistulae.
Feces oozing out. Localized
peritonitis. Edges of perfora-
tion excised and sutured with
continuous suture.

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REMARKS.

Death 36 hours after. Au-
topsy : Gut near sutured ulcer
deeply congested. At lower
end of sutures necrosis had ex-
tended to peritoneum, but not
perforated.
Death 10 days after. Two
new perforations near the first
had occurred.

Death 40 days after. On 24th
day a second perforation, visi-
i ble through incision. Almost
complete absence of repara-
tive power noticeable ; wound
gaping after stitches removed.
On 28th day a third perforation,
with considerable loss of blood.
At autopsy closure of first per-
foration was complete.
Died in 12 hours.

o
o

Died on 45th day from pelvic
peritonitis from two other per-
forations on the 28th and 351)1
davs.

[This case and the two imme-

diately following were oper-
ated upon by Armstrong's col-
leagues.]

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W
6 bi

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3(1 day. Wassi-i/ed
after a bath. Had
pneumonia at time

n yth day after,
lections. Autopsy
tonitis from 5 other
laque of sphacelus

usually well adapt-
tive treatment, and
be compared with
.tion occurred dur-

Probably perfora-
me and been closed

V .
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hours after opera-
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24 hours.

13 hours.

16 hours.

: 1 1

29 hours.

re " 2 3

3
C
~
<

48 hours.

Twelve inches of bowel re-
sected. Cavity dried. Tam-
ponade. Abdominal wound not
sutured.

Excision and stitches. Tam-
ponade. Abdominal wound not
closed.

lent collection, fecal odor. Egg-
shaped excision. L ember t-
Czerny sutures. Gauze pack-
ing.
Peritonitis. Ichor and fecal
matter in cavity. Perforation
excised.

Edges healthy. Two rows
silk Lembert sutures. Saline
irrigation. Glass drain.
Much free pus and feces. Two
rows Lembert sutures. Saline

irrigation. Drain.
Suture. Two other suspicious
spots sutured.

Incision over appendix. Pint
of yellow fluid with fecal odor,
ed with lymph. Two rows Lem-
k. Hot saline flushing, 4 glass
iform gauze.
Sutures tried, but abandoned
on account of thickened wall,
utures, and narrowing of lumen,
(duced into bowel for drainage,
ssed through the intestinal wall,
ittu, and wound packed around

Edges trimmed. Three rows
sutures. Saline irrigation and
saline transfusion. Gauze drain.

5'7-S

to g

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CU *"

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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 1 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 Munch, 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 1841. 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 2 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 4 reports the first recorded case,
I believe, of hepatic abscess from typhoid, in which it
arose after an abscess of the parotid. Romberg 5
refers to two others arising, one from an abscess
of the fourth finger, and the second from a thenar

abscess. Another case is reported by Chvostek, 6 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.

4 Recherches Anat. Path, et Therap. sur. la Fievre Typhoide, 1841, I2th
ed.,p. 118. 5 Berlin, klin. Wochen., 1890, 192.

6 Allgem. Wien. med. Zeit , 1866, No 37.

246 SURGERY OF TYPHOID FEVER.

Burder r has reported a similar case. In these cases
the abscesses are multiple.

Solitary abscesses are more common, but even
these are very rare. Langenbuch 2 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, 3 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 ^JOTF///(Delaire 4 ). 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
through the lung. 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 Ualfte, 238.
3 Loc. fit. 4 Gaz. des Hop., 1869, No. in, 437.

THE LIVER AND THE GALL-BLADDER, 247

Case XXXIX. Sidlo l reports the following
case : A girl ten years old became ill with typhoid
fever at the end of February, 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 portae. Buckling 2 found throm-

1 Der Militar Arzt, Wien, 1875, No. 23, p. 20.

2 Falle v. Leber Al.-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, 1 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. 2 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, 3 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-
plicatiotis 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, 1 and another presented by him to
the International Medical Congress in Rome, in 1894.
Another important publication is that of Dupre. 2
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 3 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 4 first
demonstrated the presence of the typhoid bacillus
in a suppurative cholecystitis in 1890, and followed

1 Ueber Cholecystitis Typhosa, Prager med. Wochen., 1893, No. 22.

2 Les Infections Biliaires, These de Paris, 1891.
3 Cholecystitis Typhosa, These de Paris, 1876.

4 Contribution a 1 Etude Bacteriologique des Voies Biliaires. Mem. de la
Societe de Biologic, 1890, La Semaine Med., 1890, No. 58.

250 SURGERY OF TYPHOID FEVER.

up the subject in a second paper in the same jour-
nal ' in 1893. The bacillus of . typhoid has been
fourjd not only during or immediately after the fever,
but also at periods long after the fever. Thus,
Dupre 2 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, 3 in a simi-
lar case, found them eight months after the fever.
Von Dungern 4 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 August, 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,
1 889, 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, sne na -d an attack of periostitis of the
lower jaw, which got well after the discharge of a

1 Cholecystite I'urulente Provoquee par le Bacille d'Eberth, Mem. de la
Societe de Biologic, 1893, p. 956.

- Loc. fit. 3 Traite de Med. i, 764.

4 Munch, med. Wochen., 1897, No. 26, 699.

THK LIVER AND THE GALLBLADDER. 251

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
clown 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 Widal 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 bacilli
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 1 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 l 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 2 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 in 100 cases of gall-stones removed at
necropsies, found living or dead bacteria in the gall-

1 Loc. cit. 2 Gaz. Hebd., Nov. 26, 1896, 1137.

3 Origine Microbienne de la Lithiaise 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 2 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, 3
out of 42 cases, found bacteria present in 24.
These were most commonly the staphylococcus and
the colon bacillus.

Flexner 4 has stated that of 14 cases of typhoid in
which the contents of the gall-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. cle Biol., June 16, 1894. 2 Bull. Med., Jan. 22, 1896.

3 Arch, de Med. Experim., 1891. * Osier, loc. cit., p. 385.

THE LIVER AND THE GALL-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
organ.

"In Case II there were abundant typhoid bacilli
in the gall-bladder, but none could be obtained from
the intestine.

"In Case III we found pure cultures of the typhoid
bacillus in gall-bladder, duodenum, 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 excreted from 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 gall-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. 1 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. 1 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, supra),
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, 1 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

1 Diseases of the Gall-bladder and Bile Ducts, Brit. Med. Jour., March
13, 1897.

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 gall-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 XLIL Salzmann 1 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. During
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. Wurttemburg. Arztlich. Vereins, 1870, xl, 84.

260 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 XLIII (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 I9th 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 2Oth 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 ar| d at the time of the tapping of the gall-
bladder was 1 06. 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 1 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 ist an

1 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 symptoms 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 GALL-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, n, 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 16 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 gall-bladder are less irritating than those of
the intestine.

I append a resume of each of the four cases ot
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,
was first seen by Mr. Monier-Williams, September
1 8, 1894, her illness having begun on September
ijth. 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 region of the ascending 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 3Oth, 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 3ist, the patient was
much worse, with decided distention of the abdomen
and signs of recurrent peritonitis in the right
hypochondrium. On the 3ist 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-
ing ulcer near the neck of the gall-bladder had now
quite 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 in
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 XLVI (Alexieef 1 ). "A girl, age five, was
taken, November 5th, with parotitis, which suppurated
on the left side. By the 2Qth 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 egg. 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 2Oth.
Diarrhea. The urine by this time had begun to
contain a trace of albumin. On the nights of the
2oth and 22d the patient became much worse, com-
plaining of great abdominal pain. Finally she be-
came greatly excited ; jumped out of bed ; did not

1 Jour. Dietskaya Meditzina, 1896, No. 4, in the Amer. Jour, of the
Med. Sciences, Oct., 1897, p. 466.

THE LIVER AND THE GALL-BLADDER. 26%

recognize those about her ; and became very feeble
and collapsed. Temperature, 36.6 C. ; pulse un-
countable. Tinct. valer. aeth. 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 3ist
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 3ist,
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 Qth,
however, a relapse occurred, from which she recov-
ered by the 2ist. During all this time the discharge
in the healing wound had gone on satisfactorily.
The discharge 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
1 7th, but by March 26th she was entirely well.
Careful cultures from the pus showed pure typhoid
bacilli.

Case XLVII (Osier 1 ). "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 22d 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 2ist, 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 dragging 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. 271

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 igth, and has remained well ever since.' '

Case XLVIII (Osier 1 ). "November 5, 1894, he
saw a woman, age thirty-seven, at the end of the third
week of a very 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 2ist she had a severe
chill; on the 27th the temperature rose to nearly
105, and she had nausea and vomiting. The abdo-

1 Loc. cit., p. 390.

2/2 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 2ist.' '

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273

CHAPTER XVII.
TYPHOID AFFECTIONS OF THE SPLEEN.

AMONG the most constant places in which the
typhoid bacilli 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 T the abscess ruptured, produc-
ing a fatal peritonitis. In two cases there was mitral
disease, one 2 from an old rheumatism; the other 3
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 4 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.

3 Vincent, Merc. Med., Feb. 17, 1892, 73.

4 Griesinger, Infect. Krankh., Virchow'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 late 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 XLfX.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-

1 Griesinger, loc. (it.

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 2 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 3 :

Case LI. The patient was a soldier, who, after

1 Ann. Soc. de Med. de Montpellier, Iv, i, 146. 2 Lancet, 1871, ii, 712.
3 Legrain, Annales des Organes Genito-Urinaires, 1889, vii, 291.

2/8

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 analogous
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, 1 did not find a single case involv-
ing the testicle. In 1844, Velpeau, 1 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, 2 but has now been repeatedly found both in
orchitis and epididymitis, and not only in the pus, but
in the tissues. Gasser, 3 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 4 of epididymitis, at the
necropsy the suppuration was found to be intersti-

1 Diet. En Trente Vol., Art. Testicule. 2 D6hu, loc. dt., p. 82.

3 Archiv de Med. et de Pharm. Milit., 1895, No. 3, 228.

4 Arch. Gen., 1892, clxix, 43.

280 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 2 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 i. 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, 3 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, 4 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

1 Correspondenzbl. schweiz. Aerzte, 1887, 590.
'* Fein, These de Paris, 1890, 18.

3 Bouchut, Mai. des Nouveaux Nes, 1867.

4 Hull. 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
likely 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 n "
Over twenty-five there were 10 "

2 3 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 16 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 sloughing was so exten-
sive that practically the entire testicle was destroyed.

The mortality was small ; only one case certainly
died, 1 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 ; 2 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 LIL Thus, Anger 3 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. 2 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 LIII. 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 seventy 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 x 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 anteflexed, 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 2 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,
1 897. Two years before he saw her she had suffered

1 Munch, med. Wochen., 1896, No. 21, 498.

2 Centralbl. f. Gynekologie, 1897, No. 37, p. 1109.

THE SEXUAL ORGANS. 285

from chlorosis, during- which 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, 1897. 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 finger 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 1 records a case of pyosalpinx, which, unfor-
tunately, like that of Anger which occurred in 1865,
has no bacteriological proof of its typhoid cnrigin, 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
abortion at the fifth month, at the beginning of defer-
vescence, the mother, a multigravida, 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 2 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 Heviatocele. In addition to these

1 Berlin, klin. Wochen., 1895, No. 25.

2 Presse Med., March 24, 1894.

288 SURGERY OF TYPHOID FEVER.

cases, Guyot ' has collected seven cases of peri-
uterine hematocele of typhoid origin, which, with
another by Trousseau 2 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 bacteriological 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 fievre typhoide, These de Paris, 1879.

2 Clin. med. 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

1 L'Erysipele de la Face dans le cours de la Fievre Typhoide.

SPECIFIC MIXED INFECTIONS. 291

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, 1 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 2yth she developed
facial erysipelas. By June 25th the erysipelas and
typhoid had both subsided, but she was transferred
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 10, 1891, 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 2 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, n 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, 1 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 1 probably developed infection
through a blister; two 2 were attributed to a possi-
ble abrasion of hemorrhoids by a syringe (?); one 3
followed eight days after plugging of the nares for
uncontrollable hemorrhage ; one 4 followed the bite
of a horse on the finger six weeks before ; and one 5
occurred in a cavalryman who fell out of a window
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 w r ere 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-

1 Simoneau, Jour, de Med. de 1'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, 1.878, i, 44.

5 Belhomme, Arch, de Med. et Pharra. 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 2 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 thigh 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.

History. 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 1 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 2
contended that this inflammation could be cured by
"bark or quinin." In 1846 Dr. Jacob 3 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, 4 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, 5 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, 1828, v, 468-478.

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.,'i845, v, 729-773.

296

OCULAR COMPLICATIONS. 297

cence ; 31 within the following month ; 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, 1 and again by
Wilkes and Dubois. 2

In 1870 post-febrile ophthalmitis received consid-
eration from M. Charteris, 3 who investigated the
cases of relapsing fever which occurred in Glasgow
in 1870, and which, both from the ocular and gen-
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 4 examined 767 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 mentions typhus
abdominalis.

Classification of the Ocular Complications and
Sequela 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.

3 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 Freq^lency 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, 2 occurs with sufficient frequency to
accord it more attention than it has thus far received.

1 L'Union Med., 1877, 3d series, xxiii, 937-941.

2 August Hoelscher (Munch, 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, 1 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 may be 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.

1 Die Beziehungen des Sehorgans und seiner Erkrankungen zu den
iibrigen Krankheiten des Korpers und seiner Organe, Wiesbaden, 1893,
P- 395-

300 SURGERY OF TYPHOID FEVER.

Cases of this character are reported by Knies, 1
Hoelscher, 2 Galezowski, 3 Adolph Alt, 4 and a number
of other observers. The following case histories
illustrating- types of this affection are appended :

Case L VIII. Hypopyon Keratitis with Iritis
Occurring in the Fourth 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 with 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

treatment had been begun, which rapidly yielded to
the same measures.

Case LIX. Ulceration of the Cornea Followed
by Rapid Sloughing of this Structure, Occurring 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 Qth, 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, beginning in a
small point of infiltration near its lower margin. In

1 Loc. cit. 2 Loc. cit. 3 Loc. fit.
4 Mecl. Fortnightly, 3, 4, 1893, p. 47.

OCULAR COMPLICATIONS. 301

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, 1 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 n, 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 negligent 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, 1 who quotes
Knies, in the somnolent or comatose stage of severe
and fatal cases of typhoid fever, a rare complication
is a true xerophthalmia, or xerosis cornets. 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 ioclin, 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.

The 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, 1 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.

1 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 Occurring at the Be-
ginning of the Third Week of Typhoid Fever and
Resulting in Phthisis Bulbi. Notes furnished by Dr.
C. W. Hall, of Kewanee, 111. A woman, age thirty,
was taken ill with typhoid fever on October 29, 1895.
During 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-
roiditis 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-
trition of the lens is interfered with and cataract may
result. Without such antecedent inflammation,
opacity of the crystalline lens has been attributed to
the nutritional 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 2 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-

1 Gaz. des. Hop., 1879, p. 417.

2 Rec. d'Ophtal., 1887, 3, s., ix, 195-200.
20

*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 Allbutt, and in our
own country by Augustus P. Clarke 2 and J. A.
White. 3 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.

3 Trans. Ophth. 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 2 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. Hi, 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-typhoidal 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. 1

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 2 and
by Nothnagel, 3 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

1 Archives of Ophthalmology, New York, 1884, xiii, 397-399.

2 Berl. klin. Wochen., 1868.

3 Deutsch. Archiv f. klin. Med., 1872, ix, 470.

310 SURGERY OF TYPHOID FEVER.

Hersing an annular defect in the visual field. J.
Stewart 1 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, 2 and Munier 3 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 upon 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., 1894-95, xxiii, 752-758.

2 Detroit Rev. Med. and Phar., 1873, viii, 533-541.

3 These de Paris, 1874.

OCULAR COMPLICATIONS. 311

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 l and Snell. 2

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 give 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.

3 Congres 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. 1 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 change in the walls of the blood vessels in con-
nection with the general lowering 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 2 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 pe