with hemorrhage into the muscle), one case of a distended urinary bladder. The symptoms of intestinal perforation, sudden abdominal pain, tenderness and rigidity, together with distention, vomiting and rapid pulse, are also symptoms of a peritonitis. Certain causes of peritonitis will be mistaken for typhoid perforation. 5 16 Gairdners' Glasgow cases, five in number, are of this latter kind. There is no doubt that an impending perforation exists in many cases as illustrated in Case XXIV of the Shattuck, Warren, Cobb, 1st series; Case II, B. C. H. series; Scappacci, M. G. H. series, and Ayer, M. G. H., 2d series. Murchison mentions as a cause of peritonitis To the third group of cases of mistaken diag- during typhoid, softened splenic infarcts, abnoses belong certain of the lesions causing scesses in the bladder wall, abscess of the liver. peritonitis, viz., cholecystitis and perforation Mention is made in Scott's series of one case of the gall bladder. Erdmann's paper has of a rectal ulcer and one case of pericolitis, misnoted a personal case and three cases from litera- taken for a typhoid perforation. Cases of appenture, which, added to Keen's paper, makes a dicitis are occasionally operated upon for typhoid total of 34 cases of perforation of the gall-bladder. perforation. Seven operations were done in these 34 cases; I would especially call attention to a personal five complete operations, with one death. All of experience, in the following case: 17 the unoperated cases died. Killiani recently reported a case with two acute abdominal pain; rupture of an old pyosalpinx; Adult female. Typhoid fever; end of the third week perforations of the gut and a perforation of the rupture occasioned by an acute infection of the pyosalgall bladder during the fourth week of the dis-pinx by the typhoid bacillus. Diffuse peritonitis. SalThe patient lived twenty-one days after pingectomy; the abdominal cavity irrigated and operation and died of gangrene of the lungs and drained; the abdominal fluid contained a pure culture of the typhoid bacillus. Recovery. ease. empyema. Allyn, of Philadelphia, reported in 1901 a typhoid case which died three days after operation, in the third week of the disease. No lesion was found at operation. At autopsy, however, there was discovered an opening in the gall bladder communicating with a small opening in the hepatic flexure of the colon. Willis reports a perforated gall bladder during typhoid fever, in which two weeks after a cholecystostomy the patient died of peritonitis. A cholecystectomy might have terminated differ ently. 9 A. C. S., thirty-eight years old, married. A patient of Dr. Stowe, of Medford Hillside. Massachusetts General Hospital No. 137,446. She has always been well excepting for children's diseases. About four weeks ago she was taken ill with malaise, cramps in the stomach and bowel and diarrhea. She went to bed May 15. She entered the hospital May 20. The abdomen was full, moderately distended, tympanitic, and the abdominal muscles were somewhat rigid. The spleen was not palpable. The temperature was 102.2° F. Pulse, 102. Respiration, 32. Hemoglobin, 80%, white blood count, 9,900. May 22 May 23, Widal reaction positive. several rose spots were noted. Appearance, typhoidal. Ovarian cyst infections are recorded during the active period of typhoid fever. One case by June 5, no distention, temperature nearly normal, Sudeck and two cases by Lewis, Harte and very comfortable. June 8, at half past six in the mornLeConte appear recorded. Five infections of ing, she had a severe abdominal pain. This pain was dermoid cysts of the ovary are recorded, which most intense in the lower part of the abdomen. The were operated upon from three to eight months pain appeared just after a natural movement of the subsequently to the typhoid fever. Such are bowel. Immediately following this attack of pain the cases of Werth,10 Pitha " and Wallgren.12 the abdomen was held rather rigidly, and was moderRotation and strangulation of Meckel's diver-ately tender in the lower part. The pain was followed ticulum is reported by Sailer and Frazier 13 to shifting dullness was noted in the flanks. The rigidity by a chill, and the temperature rose to 103.6° F. Slight have occurred in a young adult male, during the of the abdominal muscles had increased. The white acute course of typhoid fever operated upon count rose from 9,000 to 18,000. An hour after the last as if for a perforation of the gut. chill the temperature rose to 104°. At twelve o'clock, noon, the temperature was 105° and the pulse 130. 11 Case XXI, Shattuck, Warren and Cobb, series 1, and the case of Körte, of Berlin, are instances of a rupture of infected mesenteric glands during the course of acute typhoid fever. In each of these cases a pure culture of the typhoid bacillus was secured from the peritoneal cavity at the time of operation. Vaginal examination discovered a fullness and increased resistance in the left cul-de-sac and a suggestion of bogginess. Operation at this time by a median incision below the umbilicus disclosed free, thick purifecal odor to the fluid, nor was there any gas in the abform fluid throughout the abdomen. There was no domen. The appendix was normal. The ileum was Femoral and iliac thrombosis in three of Scott's examined for several feet above the cecum and no perseries cause confusion in diagnosis. Thayer "foration was found. The pelvis, where the pus was records two such instances in Baltimore. most abundant, was explored and a mass was found 15 The Of very great interest are the cases mentioned to the left of the uterus which proved to be a pyosalby Finney, in which perforation of the intes- pinx, and corresponded to the tumor felt upon vaginal tine during the course of typhoid occurred with-examination. The salpingitis was a chronic one. out demonstrable typhoid bacillus, and also of tured allowing the escape of the contents of the sac wall of the sac was thick and edematous and had rupinterest are those cases in which a fatal peritonitis into the abdominal cavity. A salpingectomy was may develop a discoverable perforation. The done leaving the left ovary. The abdominal cavity Munich autopsies record 2.2% of such cases. was flushed with salt solution. A gauze wick and rubber tubes were placed in the pelvis. Excepting pital in the last ten years, and the analysis of these for a rise in temperature upon the ninth of the month, cases may be of interest to Dr. Harte and the about nine days after the operation, convalescence members present. was uninterrupted. The rise of temperature was thought at the time to be indicative of a slight relapse from the Boston Society for Medical ImproveIn the early part of the year 1900 a committee of the typhoid infection. The wick to the pus cavity was entirely removed upon the morning of the four-ment, consisting of Dr. George B. Shattuck, Dr. teenth, and the gradual rise in the temperature from John Collins Warren and myself, made a careful the fourteenth to the nineteenth would suggest that study of all the cases of perforation in typhoid retained puriform material might have been the cause between the years 1895 and 1900 at the Massaof the temperature. chusetts General Hospital, the Boston City Hospital, the Children's Hospital and St. Elizabeth's Hospital. It was my privilege to read the report of this committee at a meeting of the society. with a general round-cell infiltration. Diagnosis, of Dr. Harte's paper, I have studied all the cases Since I was asked to take part in the discussion chronic salpingitis.-W. F. WHITNEY, M.D Pathological report: A large pus tube which had ruptured in the course of typhoid fever. The walls of the tube were covered with exudation and upon microscopical examination showed a fibrous structure The bacteriological report, by Dr. Oscar Richardson, of perforation in typhoid at the Massachusetts from the Clinico-Pathological Laboratory of the hospi- General Hospital, both those operated upon and tal, is as follows: The culture showed about fifty small those not operated upon, between the years 1896 to medium sized, round, grayish-white, glazed colonies and 1906. My chief purpose in doing so was to of a bacillus like the typhoid bacillus. Sub-cultures see whether the new series of cases, the majority showed the typical growths of the bacillus of typhoid of which occurred in the years after the report of fever. Widal reaction was immediately positive with the Improvement Society was published, would blood from a known case of typhoid fever in dilution of 1-10. The bacillus is regarded as being the bacillus of typhoid fever. give any new information as to diagnosis and treatment, or change in any way the conclusions made in this previous report. A case of pyosalpinx is referred to by Wilson, Of the twenty cases operated upon at the Masaccording to Fitz, and one reported by Mabit 18 sachusetts General Hospital between 1896 and (1893). In neither of these latter two cases 1906, eight cases were included in the report of was a bacteriological examination made. These the Improvement Society; the other twelve are are the only cases of pyosalpinx complicating new cases. The important conclusions of the typhoid fever I can find recorded. paper read in 1900 were as follows: certain tyDoubtless some relapses in typhoid cases are phoids are so sick that perforation and spreading due to recent infections of the gall bladder, to peritoneal infection cannot be diagnosed until impending perforations of the gut or to infections widespread and of fatal extent. A number of of old pus sacs and ovarian cysts. typhoids may have sudden perforation with free. The surgeon, before operating upon a suspected extravasation; in these the symptoms are fultyphoid perforation, should examine the pelvis minant, but at first in some cases may be localof female patients and should consider, as pos-ized to a certain extent; in these cases operation sibly present, the lesions thus far recorded as must be done at once, for general peritoneal incomplicating the diagnosis. 5 Ann. of Surg., 1903, vol. 37. Surg. complications and sequels of typhoid fever, 1898. 7 Ann. of Surg., Jan., 1907, p. 34. 8 Münch. med. Wochenschr., 1896. Trans. of Coll. of Physicians, Philadelphia, June, 1902. 10 Münch. med. Wochenschr., 1893. 11 Cent. für Gynäkol., 1897. 12 Arch. für Gynäkol., 1899. 13 Univ. Penn. Reports, Nov., 1903. 14 Johns Hopkins Hosp. Rep., vol. 8. 15 Ibid., 1900. 16 Glasgow Med. Jour., vol. xlvi, p. 114, Feb., 1897. 17 BOSTON MED. AND SURG. JOUR., July 20, 1905. 18 Nouvelles Archiv, d'Obstet. et de la Gynecol., 1893. PERFORATING TYPHOID ULCERS.* fection can become past relief in from one to five hours. In the majority of mild typhoids, beginning peritoneal infection, whether from actual perforation or necrosis of the intestinal wall, is marked by less severe warning symptoms, localized abdominal pain, tenderness, muscle spasm, with or without leucocytosis; the severe symptoms following mean general peritonitis. These warning symptoms demand serious consideration and study, but in many cases are not rightly understood or not acted upon. Complaint of abdominal pain in a typhoid should also lead to a suspicion of beginning peritoneal infection. Frequent leucocyte counts are needed in every case, and an hourly count is recommended in the presence of abdominal pain. Pain associated with localized tenderness, muscle spasm and a rising white blood count points in most cases to an operation, in all cases to a surgical consultation. BY FARRAR COBB, M.D., BOSTON, Surgeon to Out-patients, Massachusetts General Hospital. I HAVE been very much interested in Dr. In the light of my recent study I see no reason Harte's complete and thorough paper, and what to change the conclusions of seven years ago, I have to say can add little, if anything, to what with the following exception: leucocytosis, if he has said and can only serve to emphasize his present, may give valuable corroborative eviconclusions. I have studied, however, the cases dence, but operation should be done where there operated upon at the Massachusetts General Hos-is pain and localized tenderness and muscle spasm, * Read at the meeting of the Surgical Section, Suffolk District Whether or not there is leucocytosis. The presMedical Society, in conjunction with Boston Medical Library, March ence of leucocytosis, especially the demonstration 13, 1907. ANALYSIS OF TWENTY CASES OF TYPHOID PER- of a wave of leucocytosis, is a valuable aid; the symptoms,-abdominal pain and vomiting. Eight absence is of no significance. The estimation of cases had sudden free perforation with severe the percentage of polynuclear cells, as advocated fulminating symptoms without warning. These by Gibson, may in future be of decided value. It cases were operated upon from two to eight hours certainly should be obtained in all cases. after the complaint of pain, an average of six hours. Two of these cases recovered, one of which was a case of my own. On the other hand, definite warning or premonitory symptoms and in ten cases, or the majority of the mild cases, signs, complaint of abdominal pain, localized tenderness and muscle spasm, with or without leucocytosis, were noted from eight to sixty hours before operation was done; on an average of over twenty-eight hours before operation was done MASSACHUSETTS GENERAL HOSPITAL FROM 1896 TO 1906. In addition there were three cases operated on under a mistaken diagnosis. Two of the twenty cases were operated upon by myself. Six cases recovered, 30%. This percentage of recoveries is considerably larger than in the series reported in symptoms and signs were noted, which undoubt1900. In that series, even if one case that died of hemorrhage on the fifth day after operation were called a recovery, the percentage of recoveries would be only 19%; without this case only three cases out of twenty-one recovered, or 14.3%. In the present series, if the case that lived eleven days and died of intestinal obstruction were called a recovery from typhoid perforation, there would be seven recoveries out of twenty operations, or 35% edly meant beginning peritoneal infection. In fifteen cases the surgeon, when called, found general rigidity and tenderness, with or without rising pulse and temperature and leucocytosis, and operated because of these. In five cases operation was decided on because of localized tenderness and spasm. In one of these five cases tenderness and muscle spasm were on the left, in four cases on the right side. Leucocytosis. - In seven cases no white blood Sex and age. All the cases were males and all count was made. An isolated count was made in white persons. Thirteen cases were under thirty eight other cases at or just preceding operation. years of age, three cases under twelve years. Only One case had high leucocytosis, 24,000; this case two cases were over forty years. There were two recovered. One case had 16,000 and one had boys nine years old and one man sixty years old. | 14,000. All but two of these cases were cases The ages of the cases that recovered are as follows: of advanced general peritonitis. The most adtwo boys nine years old, two young adults nine-vanced cases had the lowest count, 2,200 and teen years old, a man forty and one forty-five 4,300. It was stated in the paper of 1900 that a years old. That is to say, two thirds of the cases that survived operation were boys and very young adults. Character of the disease. Three of the cases were very sick typhoids, and in each it is fair to state that perforation or spreading peritoneal infection could not have been diagnosed until already fatal in extent. The other seventeen cases were mild typhoids; three of them were ambulatory cases. single leucocyte count might be of little value as a diagnostic aid. I am of the opinion at the present time that a single count soon after severe symptoms have set in may or may not be of any value, and I also firmly believe that a low leucocyte count in any case should have no influence in preventing or postponing operation; that operation should be decided upon because of the abdominal pain and tenderness and the feeling of the abdominal muscles to the palpating hand. Time of perforation. The only important I think that in certain cases frequent and early thing in regard to these figures is to substantiate leucocyte counts soon after the first symptoms. the fact that most perforations occur in the third appear may show a rising wave of leucocytosis, week, but that it is not too early to expect it in the which will strongly bear out the diagnosis of persecond week or too late in the fifth week. One of foration made because of other physical signs and the cases in the medical wards that was not oper- symptoms. Three operated cases and one unated upon occurred in a relapse. In six cases per-operated case illustrate this wave of leucocytosis foration took place at the last of the second week well. In one case four hourly counts showed a or the beginning of the third; in seven cases at rise from 6,800 to 14,000. In another case three the middle or end of the third week; in three cases hourly counts, from 4,200 to 10,000. In the at the first of the fifth week, and in four cases dur-case which was not operated upon three leucocyte ing the fourth week. These figures are necessarily counts in seven hours showed a rise from 11,000 approximate, because of the necessity of fixing to 26,000. In no case was the relative proportion the beginning of the typhoid in many cases by of polynuclear cells studied. the history given by the patient on entering the hospital. Intestinal hemorrhage. In two cases the records note intestinal hemorrhage for at least two or three days before operation. Kind of onset: symptoms of perforation. - One case was a very sick delirious typhoid, in which Temperature and pulse. — In the majority of a diagnosis of perforation could not have been cases the temperature was recorded as rising. In made and in which operation was done for ad-only five cases was there a drop in temperature at vanced general peritonitis. One case was an the onset of severe symptoms and in only two did advanced general peritonitis brought into the the temperature fall to normal or below. In all the accident room twenty-four hours after the first cases the pulse increased rapidly in rate. A chill was noted at the onset of severe symptoms in the cause of death being largely due to shock of only two cases. Vomiting was recorded in eight operation. The remaining seven cases died within forty-eight hours of general peritonitis. cases. Peritonitis. Widespread general peritonitis This study has emphasized the conclusion that was found at operation in all but seven cases. in many cases the warning or earliest symptoms In these seven cases there was some turbid fluid and and signs of typhoid perforation, which mark the injection of the intestines localized to the neigh- period when operation could be done with the borhood of the perforation. In thirteen cases greatest chance of saving life, are not recognized there was no record of cultures taken. In the as sufficiently important by many physicians and seven cases in which cultures were recorded the surgeons. The most important thing that the organism found was the colon bacillus. No discussion of this subject could bring about would attempt was made to isolate the bacillus typhosus be to make men realize that if operation is delayed by cover slip method. until the signs and symptoms of severe general Site and character of the perforation.-In nineteen peritonitis are present, the result of the operacases the site of the perforation was in the ileum. tion will usually be fatal, and to realize that in In one case it was said to be high up in the jejunum. the majority of cases perforation or localized In one case the perforation was in the ileum four peritoneal infection through necrotic areas of the feet from the cecum; in most of the cases it was peritoneum is a somewhat gradual process and under twelve inches from the cecum. The size is that there are definite typical, often localized, given, varying from a pin-head to a quarter of an signs and symptoms, and when these appear operainch in diameter. In two cases necrotic gangren- tion should be done without delay; that comous patches without gross perforation were the plaint of abdominal pain by a mild typhoid cause of the peritoneal infection. One of these almost always means a beginning infection. cases died, the other recovered. followed by ether. In three cases gas and ether were THE SO-CALLED used. In sixteen cases ether alone was used. Incision. The cases were about equally divided between incision through the right rectus muscle and median incision. Search for additional perforations. Deliberate search for additional perforations was recorded as made in six cases. In only one case was a second perforation found. A second perforation was the cause of death in one of the cases, as found postmortem. On one of the cases time was taken to invert six thin areas of intestinal wall after the actual perforation had been treated. Method of closure of perforation. In two cases a purse-string suture of silk was used. One of these cases recovered. In seventeen of the cases the perforation was closed with single or double rows of silk sutures. In one case which came to autopsy the question was raised whether the cause of death was not largely due to intestinal obstruction, because of excessive inversion of the intestinal wall by two rows of stitches. In one case it is interesting to note that no attempt was made to suture the perforation, but a Mixter glass tube was tied in. This was the case in which six thin areas of intestinal wall were inverted. This case resulted fatally. Irrigation and drainage. Only one case was sewed up tight; this case died. Drainage was used in nineteen cases. In the majority of instances cigarette drains were used, but in two or three cases rubber or glass tubes were used in addition. In four cases no irrigation was done; one of these cases recovered. "OCHSNER MUSCLE" OF THE DUODENUM. BY WALTER M. BOOTHBY, A.M., M.D., BOSTON, From the Anatomical Department of the Harvard Medical School. IN 1905, before the American Surgical Association, Ochsner called attention to what he considered an hitherto undescribed sphincter of the duodenum, situated at from 2 to 4 cm. below the entrance of the common duct. Again, in July, 1907, through the American Journal of Medical Sciences, he published 'some further observations. A careful study of his two articles led me to believe that there was still legitimate doubt as to the existence of any such sphincter muscles as he described, and for the purpose of definitely proving or disproving its existence, I undertook the following investigation: (1) Through the courtesy of Professor Dwight, of the Harvard Medical School, I was given opportunity to examine intestines of the subjects of the first and fourth year classes of anatomy. I examined twenty-five in all. In none could I demonstrate macroscopically the existence of any sphincter muscle; by palpation thickenings of the wall could be demonstrated, but in every instance this thickening could be accounted for by the irregularities of the mucous membrane. (2) Six duodena were carefully removed and hardened in 60% alcohol. The serous covering was carefully dissected off. By this method it was seen that the number of the muscle fibers, both longitudinal and circular, varied slightly in places, but no increase of fibers sufficient to be deserving of especial designation as a sphincter muscle was noted. Further, in the whole study of the thickness of the muscle wall, due allowance must be made for the degree of contraction or expansion of the longitudinal fibers at different points, causing variations in thickening of circular fibers at the time of death. (3) For the purpose of more accurate estima SECT. 5. 6. SECT. 7. tion of the thickness of the muscle layers, I had 9. At different places: 4.6, 4.2, 3.0, At different places: 3.0, 3.6, 3.0, At different places: 5.7, 5.2, 6.0, SECT. 10. At different places: 5.0, 3.6, 4.8, 3.6, 4.7, 4.8, 5.2, 5.5, CONCLUSION. = 4.7 from which sections were made and stained with methylene blue and eosin. This gave a cross section of the circular and longitudinal section of the longitudinal muscular fibers throughout the circular layer) presents certain irregularities The musculature of the duodenum (especially the whole extent of the duodenum from just above in its thickness; these irregularities are slight as the pylorus to one inch below its termination. In these sections no general uniform increase compared with the average thickness of the musin number of the circular muscle fibers could be cle, and, compared to a true sphincter, the pylorus, are insignificant. In short, I found no grouping demonstrated such as would constitute a perma- of circular fibers in the duodenum which could be nent sphincter muscle. As will be seen by reconsidered an ferring to detailed measurements of two of these, though undoubtedly there are moderate variaanatomical sphincter muscle, which I give below, there is more or less irregular- tions in the thickness. Keports of Societies. MAINE MEDICAL ASSOCIATION. ity in the thickness; this irregularity is slight as compared with the average thickness of the duodenum and insignificant in comparison with the true sphincter at the pylorus. I have made a few sections lower down in the intestinal tract, which show this same fractional variation. The second duodenum detailed below is of special THE fifty-fifth annual meeting of the Maine Medical interest. Dr. F. B. Lund was present at the Association was held in Lewiston, June 12 and 13. autopsy. He remarked, while operating on the The meetings of the Association have been held annupatient some four weeks before, that the duo- ally in Portland for many years, with the exception of denum was markedly distended and at the time a meeting held in Bangor, about ten years ago, but the spoke of the possibility of the "Ochsner muscle" attendance was large and the sessions well conducted. The papers read, while fewer in number than has been causing a constriction; as will be seen the thick-customary, were of rather unusual merit and interest, ness though irregular forms no sphincter muscle. with discussions that were free and at times bordered on sharpness. Duodenum No. 1. Units.* = = 2.0 = 2.4 = 2.8 SECT. 1. SECT. 2. SECT. 3. = 2.6 SECT. 4. At different places: 2.5, 2.5, 2.5, SECT. 5. SECT. 6. At different places: 2.6, 2.8, 2.6, At different places: 3.0, 2.9, 3.2, At different places: 2.0, 2.3, 2.2, The morning session of the first day was called to order by the president, Dr. C. E. Williams, of Auburn. Prayer was offered by the Rev. I. C. Fostin, of Trinity Church, Lewiston. The treasurer, DR. A. S. GILSON, of Portland, read his report, which was referred to an auditing committee. It was voted that the reading of the secretary's report be omitted. DR. WALTER E. TOBIE, of Portland, was appointed official reporter. It was voted to receive and publish in the Transactions, the reports of visitors to the Medical School of Maine, visitors to the Maine Insane Hospital and 2.8 visitors to the Eastern Maine Insane Hospital. DR. JOHN A. DONOVAN, of Lewiston, presented a = 2.8 paper on = 2.5 2.6 Units. = 35.0 5.4 average = SECT. 2. At different places, 4.0, 5.0, 7.0, SECT. 3. At different places: 3.5, 3.8, SECT. 4. At different places: 4.3, 4.1, 3.3, 3.8 3.8 * For measurement an ocular mem. was used, therefore thickness could not be expressed in mm. INGUINAL HERNIA, which was read by DR. JOHN STURGIS, of Auburn. Dr. Donovan emphasized the following important facts: That hernia operations to-day are not as difficult as formerly, since the patient comes to operation earlier. That high ligation of the sac is an important step and that transplanting the cord adds relatively little to the value of the Bassini operation, except in obese individuals, with large herniæ. DR. EDWIN F. PIERCE, of Lewiston, read a paper on VENTRAL HERNIA, in which he reported three cases which he believed died of post-operative intestinal paresis. In these cases a vertical incision was employed upward from |