OTOLOGICAL SOCIETY OF THE UNITED KINGDOM
1902
The Lancet
Published accounts of cases seemed to show that the later the stage of the disease the greater were the chances of recovery. In the recorded cases perforation occurred on the fourteenth and forty-second days of the disease in the successful ones and on the twenty-first and twenty-third days in those which were fatal. As regards the fatal results in two of his cases he considered that the period of operation (thirtieth and thirty-eighth hour) was the main factor and in the remaining one the
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... e form of the primary disease. Mr. A. A. BOWLBY, C.M.G., read a paper entitled "A Second Case of successful Operation for Perforation in Typhoid Fever." The patient was a boy, aged 10 years, who was admitted into St. Bartholomew's Hospital under the care of Dr. Norman Moore cn Sept. 1st, 1900. The temperature came down to normal on the thirteenth day but on the twenty-first day the patient had a severe relapse. On the thirty-fourth day, while passing urine, he was seized with sudden severe pain in the abdomen, followed by collapse. Two hours after the symptoms of perforation the abdomen was opened in the middle line and a perforated ulcer less than two feet from the ileo-caeoal valve was closed by Lembert's sutures. He remained very ill for some time and subsequently had epileptiform attacks but ultimately made a gocd recovery. Mr. Bowlby referred to a similar case which he had recorded five years ago (in conjunction with Sir Lauder Brunton) in vol. lxxx. of the Transactions of the Royal Medical and Cbirurgical Society. In both of these cases the perforation had occurred after the primary attack of fever was practically over, but in many cases the symptoms of perforation were latent, the patient being nearly or quite unconscious and the abdomen tympanitic before perforation occurred. Surgeons were entirely dependent upon physicians for the opportunity of operating upon cases of perforation in typhoid fever and for the diagnosis of the conditions. It was of great importance in all cases where perforation was suspected that a surgeon should be called in as promptly as possible. Dr. NORMAN MOORE adverted to the great difficulty of being certain that perforation had taken place. The case recorded by Mr. Bowlby (which had been under his, Dr. Norman Moore's, care) presented very clear evidences of perforation. He (Dr. Norman Moore) happened to be going round the ward when the boy's symptoms suddenly supervened and he was therefore operated on within an hour or two of the perforation. One of Mr. Waring's cases illustrated the difficulty of distinguishing the attacks of "colic which were apt to occur in enteric fever and be mistaken for perforation. Any sudden alteration in the condition of the patient was suspicious and he insisted upon the necessity of observing the patient for several hours.-Dr. DE HAVILLAND HALL also referred to the difficulty of definitely deciding the presence of perforation and described the case of a youth, aged 16 years, who was suddenly attacked by vomiting. There were widespread tympanites and loss of liver dulness. At the necropsy it was found that one ulcer had given way but there were several others on the point of rupture.-Dr. E. W. GOODALL concurred that the difficulty was to decide whether perforation had taken place and he raised the question whether they would be justified in having recourse to laparotomy when there was only a suspicion of perforation. He advocated incision in the middle line because the perforation might not be in the usual spot, and, moreover, other complications, such as the rupture of a mesenteric gland or the gall-bladder, might be met with. Their experience at the Metropolitan Asylums Board hospitals had not been favourable. He mentioned that 16 cases had been published with only one recovery, and this was one in which the peritonitis was localised, while in the others it was general. He thought that opium should be avoided until the question of operation had been decided.-Dr. C. OWEN FOWLER reminded the society that in 1883 or 1884 the late Dr. Mahomed had suggested that operation should be adopted in some of these cases. The prognosis of laparotomy rested almost entirely on the stage of the illness at which perforation took place. In the early stages the ulcers were so numerous that death would most likely ensue in any case, and the adoption of surgical measures at this stage would only bring the operation into disrepute. Perforation at a later stage was quite a different matter and here the prospects were good.-Sir RICHARD DOUGLAS PowELL, Bart., pointed out that in many of these cases there was more than one perforation. He agreed that perforation occurred most frequently after the third week, at which time all the ulcers likely to perforate were pretty much in the same stage. If in a case with a high temperature there was a sudden fall, with pain and distension of the abdomen, los of liver dulness and collapse, running pulse, sweating, and cold extremities, there could be little doubt as to the diagnosis, although no one sign would be sufficient. He pointed out that the operation would often relieve the patient by abating the extreme abdominal distension which was causing reflex paralysis of the heart. He referred to a case which he had seen in consultation with Dr. Thomas Sayer of a man who had been ailing for a month, although he continued to get about. One day he was suddenly found with a high temperature and on the third day he had severe pain in the lower abdomen with symptoms of collapse, unattended by any abdominal distension. Soon afterwards he died and post mortem they found a large perforation in the ileum and two other minute perforations, so that operation would have been useless.-Dr. A. E. RUSSELL said that at St. Thomas's Hospital they had had three cases of successful laparotomy for perforation in typhoid fever. The first was in a patient suffering from a second relapse ; the second in a man, aged 21 years, in a first relapse. Absence of liver dulness with a retracted abdomen was a significant sign of perforation.-Dr. SIDNEY P. PHILLIPS regarded laparotomy as a very reasonable method of treating perforation in enteric fever. The late Sir William Jenner had recorded one case and he (Dr. Phillips) had met with one case of perforation which bad recovered and which was subsequently verified by post-mcrtem examination, but cases of recovery were, he believed, extremely rare. More attention should be paid to the means of diagnosis. One difficulty in the diagnosis was that perforation sometimes gave rise practically to no symptoms at all, and, on the other hand, symptoms suggesting perforation might be brought about by quite other causes. He referred to a case related before the Royal Medical and Chirurgical Society in which all the symptoms of perforation were present, yet en operation no perforation was discovered, the patient recovering nevertheless. He pointed out that perforation might be preceded by pain in the abdomen or by hoemorrhage, and assistance might be derived from the bell sound over the whole of the abdomen as showing the presence of free air. He did not think they would be justified in operating on mere suspicion, although much would depend on who suspected the perforation. It was new to him that perforation was apt to occur in so late a stage of typhoid fever as in some of the cases brought forward, and it would be interesting to know what had been their diet.-Mr. F. C. WALLIS said a friend had told him that at Freiburg they were in the habit, in suspected cases of perforation, of flushing out the peritoneum with normal saline solution.-Dr. H. J. CURTIS advocated laparotomy under local anaesthesia and drainage with gauze packing in suspected cases of perforation.-Mr. BOWLBY, in reply, thought that where there was reasonable probability of perforation they ought to operate. The majority of those in whom perforation occurred were in a condition to support the operation, which, after all, was by no means a severe one.-Mr. WARING, in reply, said that he had seen a case in which perforation was supposed to have occurred turn out to be one of appendicitis, while in another case a lad who was suffering from abdominal symptoms, attributed to his having been run over, proved to be suffering from typhoid fever.
doi:10.1016/s0140-6736(00)43627-5
fatcat:5l4vxoac4vbyzkrw5r4u7ja65m