THE 
PROPRIETY OF SURGICAL INTERFERENCE 
IN 
PERFORATING TYPHOID ULCER. 
BY 
J. EWING MEARS, M.D 
OF PHILADELPHIA. THE 
PROPRIETY OF SURGICAL INTERFERENCE 
IN 
PERFORATING TYPHOID ULCER. 
BY 
]. EWING MEARS, M.D., 
of philadelphtaT 
REPRINTED FROM THE 
TRANSACTIONS OF THE AMERICAN SURGICAL ASSOCIATION, 
SEPTEMBER 18, IQ, AND 20, 1888. 
PHILADELPHIA: 
WM. J. DORNAN, PRINTER. 
1888. THE PROPRIETY OF SURGICAL INTERFERENCE IN 
PERFORATING TYPHOID ULCER. 
By J. EWING MEARS, M.D., 
OF PHILADELPHIA. 
The successful results which have so signally attended sur- 
gical operations upon the abdominal cavity and its contained 
organs, with the steady progress which has characterized the 
improvements in operative procedure, as well as the gratifying 
and positive addition to diagnostitial knowledge, would seem to 
remove from discussion the question of the propriety of employ- 
ing surgical measures in any condition involving the cavity 
or the organs within it. The present state of our knowledge 
and our largely accumulated experience have enabled us, how- 
ever, to define with a degree of exactness the limits of surgical 
interference in certain affections in some of the organs. The 
elaborate experimental researches of Senn have proven that 
complete extirpation of the pancreas is invariably followed by 
death, while partial excision of the organ for injury or disease, 
amenable to treatment of this character, is a feasible and justi- 
fiable surgical procedure. 
The critical analysis by Gross of the statistics of operations 
upon the spleen and the kidneys has made it possible to define 
clearly the limit of operation in affections of these organs. 
Thus, I venture to believe that we may approach the discussion 
of operative surgery in perforating typhoid ulcer, with the feel- 
ing that here we may be compelled to define a limit to the 
employment of surgical measures, not without regret at our 
inability to overcome the barriers which oppose success, but 
with a desire to maintain always the good repute of surgical 
science and art. 4 
HEARS, 
In studying this subject it is of supreme importance that a 
clear distinction should be made, and kept constantly in view, 
between the widely different conditions which precede and 
follow perforation in typhoid ulcer and in ulcerations of the 
intestinal tract due to other causes. A hasty conclusion might 
be arrived at thus : In both, peritonitis ensues, and, hence, the 
object of surgical interference is to arrest the action of the 
exciting cause, due to admission of the intestinal contents— 
and to treat the existing inflammation by irrigations and anti- 
septic applications. In one—simple perforating ulcer—expe- 
rience has proven this treatment to be effective. Should it not 
be equally as effective in the other form? 
While it is not within the scope of this paper to discuss at 
length the morbid anatomy and pathological lesions which are 
present in typhoid fever, it is necessary, in order to obtain a 
clear understanding of the conditions which, to a greater or less 
degree, complicate surgical procedures to bring them into view. 
Briefly, they may be divided into two classes—as those which 
are peculiar to the disease and always present, varying in char- 
acter according to the severity of the attack, and those which 
are not peculiar to it, but are of more or less frequent occur- 
rence. The former involve the agminate and solitary glands of 
the intestines, the mesenteric glands, the spleen, and other lym- 
phatic structures of the body, and in the first of these occur the 
inflammatory lesion leading, in some cases, to intestinal perfora- 
tion, with which condition the surgeon is called upon to deal. 
The lesions of the second class may be regarded as results of the 
general process, and consist of parenchymatous degenerations of 
various organs and tissues, as the brain, heart, arteries, blood, 
muscles, etc. The effect upon these organs is most marked in 
cases in which the pyrexia is of high grade and of long duration. 
The degenerative changes which take place in the muscular 
structures implicate as well the heart fibres, rendering this organ 
soft and flabby. Disorganization of the blood is a well-estab- 
lished lesion with the occurrence of endoarteritis in a proportion 
of cases. The liver and kidneys present changes in many 
instances, whilst, in some, diphtheritic inflammation of the PERFORATING TYPHOID ULCER, 
5 
mucous membranes of the pharynx and larynx has occurred. 
In severe and protracted cases the infective process invades all 
organs and tissues of the body. 
In contrast to these conditions let us consider those under 
which operations upon the abdomen are most frequently per- 
formed. In traumatisms, the general condition of the patient 
may be regarded as good—the injury being received in such a 
state of health as belongs to the individual; up to the time of 
operation the effects are expended upon organs and tissues in a 
comparative state of health. In inflammatory conditions, while 
the general system may be profoundly impressed, the lesion 
may be regarded as local in its nature, frequently confined to 
the organ immediately involved, and, when extending beyond 
it, expending the effects upon structures in a state of health. 
In diseases of a chronic character—including some forms of 
carcinomatous affections and conditions giving rise to functional 
disturbance of organs—the system has accommodated itself to 
the impression made by the morbid affection and degenerative 
changes which may occur are not usually general in character. 
The symptoms which indicate perforation of the intestine in 
typhoid fever are, as a rule, so well defined as to make the diag- 
nosis quite easy. They may be briefly stated to be sudden 
acute pain in the right iliac region accompanied by symptoms 
of collapse; in some cases marked decline of temperature soon 
follows the symptoms which denote the existence of peritoneal 
inflammation. Prostration increases and death ensues on the 
second or third day; rarely does it occur during the stage of 
collapse. Still more rarely the fatal result may be postponed 
two or three weeks after the first symptom of perforation has 
appeared. Instances are recorded in which recovery has taken 
place after perforation, adhesions occurring between the edges 
of the ulcer and the mesentery, an adjacent coil of intestine, or 
the abdominal wall. 
Perforation may occur in the active progress of the disease or 
in the stage of convalescence. When it takes place in the early 
stages of the disease it may be regarded as the result of the 
extension of the ulcerative process to the peritoneal coat of the 6 
HEARS, 
intestine. The ingestion, at too early a period, of solid food or 
of indigestible food, is the most frequent cause of perforation 
during the stage of convalescence. Distention of the intestine 
by gas, feces, or enemata, as well as sudden and violent move- 
ments of the body, may cause perforation in this period of the 
disease. 
The history of surgical interference in perforating typhoid 
ulcer may be briefly told, as up to this period a careful search of 
current medical literature reveals but four cases, in all of which 
a fatal result occurred. In chronological order of the cases in 
which laparotomy has been performed, that of Professor Kuss- 
maul, of Strasburg, reported by Professor Liicke in the Deutsche 
Zeitschrift far Chirurgie, B. xxv. 1886-87, takes precedence. In 
a paper upon the “ Abdominal Complications of Typhoid Fever,” 
Medical News, November, 1887, Dr. T. S. K. Morton transcribes 
the following report of the case: 
“ A woman, aged twenty-eight years, was admitted to the Strasburg 
Obstetrical Clinic, on September 22, 1885, and very shortly afterward 
confined normally. The puerperium was tardy and she gradually 
developed a typhoid condition. This became so marked on October 
14th as to justify a positive diagnosis of typhoid fever. All went well 
until the night of the 22d of October, when she was suddenly taken 
with agonizing pain in the abdomen and symptoms of collapse. In 
ten minutes she was seized with continuous chills, was cold, pale, and 
bathed with cold perspiration, pulse 180 and small, much vomiting; 
pain upon palpation of the abdomen and tenesmus were present. The 
patient was, a few hours later, transferred to the surgical clinic with 
the accompanying diagnosis of perforated typhoid ulcer. 
“Professor Kussraaul saw the case almost immediately and determined 
upon abdominal section. Upon commencing the operation the 
patient’s condition showed cold extremities, pulse small and weak, 
belly moderately distended and painful, great shock. Precautions 
were, warm room, legs carefully wrapped, rigid antisepsis. An inci- 
sion was then carried from the umbilicus to the symphysis pubis. The 
incised tissues were found oedematous, and upon opening the perito- 
neum much dark, flaky, feculent fluid escaped. The intestines were 
pasted together and covered with fibrinous exudate. The coils of the 
small intestine were carefully drawn out, examined, and covered with PERFORATING TYPHOID ULCER. 
7 
hot moist towels. They were found quite adherent to one another. 
One small perforation was found about a foot and a half above the 
ileo-caecal valve. From it flowed yellow feculent material. The 
caecum and vermiform appendix were negative. Mesenteric glands 
enlarged. That portion of the gut, including the perforation, was 
excised and stitched with Lembert sutures, the peritoneal cavity 
cleansed thoroughly with salicylic solution and sponging, a large drain 
placed in position, and the abdominal wound closed. The patient 
died in eleven hours, without reacting from shock. 
“Necropsy proved the presence of broncho-pneumonia and hypo- 
static congestions, foul pus in Douglas’s cul-de-sac, and fibrinous exudate 
everywhere in the peritoneum, while the drain tube was totally 
obstructed by a kink. The belly wound was in excellent condition. 
The site of resection was found to be nineteen inches above the ileo- 
caecal valve, while on either side of the intestinal incision circular 
necrosis and inflammation were well advanced.” 
Dr. Morton briefly reports the second case, communicated to 
him by Mr. T. H. Bartleet, of Birmingham, England, who per- 
formed laparotomy in a case of perforating typhoid ulcer, in 
Noyember, 1886. On opening the abdomen in this case great 
fecal extravasation was discovered. “An unsuccessful hurried 
search was made for the bowel opening, the cavity irrigated, a 
drain put in, and the parietal incision closed. The patient died 
during the second day after the operation.” 
The third case is that of Dr. R. B. Bontecou, of Troy, N. Y., 
reported in the Journal of the American Medical Association, 
January 28, 1888. 
“Patient, set. twenty-five, admitted to Infirmary October 11, 1887, 
with a temperature of 102°. On the 15th, the temperature rose to 
104°, and patient complained of nausea and right iliac pain. The 16th, 
the pain increased and tympany appeared. On the 17th, the day of 
operation, the temperature was 104°—hiccough and vomiting of prune- 
fuice matter—bowels constipated and tympanitic, pain in the abdomen 
still present; cold, clammy perspiration—peritonitis from intestinal 
perforation diagnosticated. 
“On opening the abdomen a considerable quantity of flaky, dark- 
colored serum escaped. The appendix was found to be perforated 
near its base, and was ligatured and removed. On further search an 8 
HEARS, 
oval perforation in the ileum about ten inches from the colon and about 
one line in its longest diameter was found. The intestine was appar- 
ently sound in the vicinity and elsewhere, but deeply injected and 
rather dusky in color. The portion of intestine including the perfo- 
ration was turned in longitudinally and the peritoneal surfaces were 
sutured by Lembert sutures, the abdominal cavity cleaned with a weak 
bichloride solution and the wound closed. No other perforations 
could be found. The man expired before he had recovered from the 
anaesthetic. 
“ With regard to the operation, Dr. Bontecou remarked that he was 
led to perform it on general principles, as the only thing to be done 
where intestinal perforation is recognized, appreciating the fact that it 
is a mortal accident and that with the light and aid of antiseptics he 
had faith and hope to save some case of the kind. The operation, he 
stated, could not impair the condition, and if the accident is recog- 
nized soon after its occurrence there is a chance of success.” 
In The Medical News of December 24, 1887, Dr. T. G. Morton 
reported the fourth case in which laparotomy was performed on 
November 14, 1887, for the relief of perforating typhoid ulcer. 
“This case is described as of that form commonly called a walking 
case, the patient having been scarcely in bed at any time until the last 
day and a half previous to his sudden death. It was at the end of the 
third week of the disease and his temperature had, for several days, 
been scarcely above the normal. The day before the operation he felt 
very well, ate a hearty meal of meat, etc., and in a few hours was 
seized with excruciating pain in the right lower portion of the abdo- 
men, followed by a violent chill and elevation of temperature, pulse 
and respiration rate. The abdomen became tympanitic and the pain 
more diffuse. The patient was of splendid physical frame, and at the 
beginning of his illness had weighed 190 pounds. Lapandomy was 
performed twenty hours after perforation, the temperature being at that 
time Pulse *56, and respiration about 45. On opening the 
abdomen, yellowish serum, in which floated flakes of purulent lymph, 
gas and feculent matter escaped. The small intestine was turned out 
and examined from the caecum upward. About three feet above the 
ileo-caecal valve a perforation, about three-eighths of an inch in diame- 
ter, occupying the lower end of a large ulcerated Peyer’s patch, was 
discovered. This lesion was repaired by turning the whole area of 
ulceration into the lumen of the bowel by means of eight Lembert PERFORATING TYPHOID ULCER. 
9 
sutures, paying no attention to the ulcer and bowel-tissue between the 
line of sutures. A necrotic-looking ulcer, situated a short distance 
above the caecum, which presented in a portion of its area a gray 
aspect, as if of sphacelus, but without perforation, was treated in the 
same manner by the introduction of six Lembert sutures. No other 
lesions were discovered upon further search of the intestines, etc., 
although ulcerations extended to quite a high point of the small gut. 
The whole intestine was greatly distended with gas and difficult to 
manipulate—it was congested to a dusky-red hue throughout, while in 
various sized patches, here and there, the peritoneal covering of the gut 
was in a state of arterial hyperaemia with occasional recent ecchymoses. 
The cavity of the abdomen was cleansed with hot water, sponged dry, 
and the intestines, which had been covered with towels wrung out in hot 
water frequently changed, were, with some difficulty returned, a glass 
drain carried to the bottom of the pelvic cavity, and the wound closed. 
After recovery from the anaesthetic, the pulse, temperature, and respi- 
ration remained very high, and six hours after the operation the patient 
suddenly sank into a collapsed condition, and in an hour died. 
Examination of the abdomen was made twenty-four hours after death 
and showed some of the coils of the upper portion of the intestines 
slightly adherent to each other by recent, healthy looking lymph. 
Others were congested to a bright pink color. There were no subperi- 
toneal ecchymoses upon the intestines, but, here and there, upon the 
mesentery, near the intestinal attachment, were to be seen such extra- 
vasations. None was of a greater extent than a half-inch in diameter. 
In the deeper tissues of the intestine, however, ecchymotic spots were 
present at quite a number of points—one larger than a quarter of an inch 
in diameter. Typhoid ulcers extended to a distance of probably eight 
feet above the caecum-—those nearest it being most marked and, with 
one or two exceptions, furthest advanced. Those which had been 
treated by suturing were in excellent condition. No additional perfo- 
rations were discovered, and the intestine when distended even forcibly 
with water did not leak or give way at any point. There was marked 
enlargement of the mesenteric glandular system. The peritoneum was 
perfectly clear, and free from extraneous matter, purulent lymph, or 
blood—about two ounces of clear serum had collected in the pelvic 
cavity since taking out the drain tube, which had been done a few 
minutes after death. The edges of the abdonvnal incision were glued 
together.” HEARS, 
The reports of the above cases have been transcribed in detail 
with some fear of extending this paper beyond proper limits, 
but with the feeling that an analysis of them will aid in arriving 
at correct conclusions with respect to the question under dis- 
cussion. The first and the fourth cases—the former that of Prof. 
Kussmaul, the latter that of Dr. T. G. Morton—may be taken as 
typical cases illustrating the two classes into which attacks of 
the disease may be divided. In the first one the disease pre- 
sented symptoms in an intense degree and perforation occurred 
at an early period, when the infective process was at its greatest 
height, and the vital forces at the lowest point. In the second 
case the disease was of a mild character from the first—a so- 
called “walking” case—the patient scarcely in bed during the 
attack, and the temperature scarcely above the normal. The 
perforation occurred at the end of the third week—in the period 
of defervescence—as the result of the irritation produced by the 
ingestion of improper food. Notwithstanding the marked differ- 
ence in the character of the cases it will be observed that the 
shock consequent upon the perforation was in each equally 
prompt and profound. In Prof. Kussmaul’s case laparotomy 
was performed within a few hours after the occurrence of per- 
foration, the bowel resected, the cavity cleansed of its contami- 
nating contents, drain introduced, and the wound closed. 
Death without reaction from shock ensued in eleven hours. 
The autopsy showed, beside the usual typhoid lesions, that the 
reparative process in the intestinal operation wound was defec- 
tive—circular necrosis and inflammation being well advanced. 
Laparotomy was performed in Dr. Morton’s case twenty hours 
after perforation, two ulcers, one non-perforating, were repaired 
by Lembert sutures, the peritoneal cavity thoroughly cleansed, 
drainage secured, and abdominal incision closed. Six hours 
after operation the patient “ sank into a collapsed condition ” 
and died. The tests which were applied showed that the opera- 
tive procedures had been efficient. 
Both operations were performed under strict antiseptic methods 
and every precaution taken to reduce the shock of operation. 
The full report made of the autopsy in Dr. Morton’s case shows 
that despite the apparently mild character of the attack, as PERFORATING TYPHOID ULCER. 
evinced by the symptoms, the specific lesions of the disease were 
very prominent and distinctly defined—typhoid ulceration ex- 
tending to a distance of probably eight feet above the csecum, 
and marked enlargement of the mesenteric glandular system 
being present. Seemingly the patient did not withstand the 
shock of operation as well as the patient of Prof Kussmaul, 
whose condition was more unfavorable and who was submitted 
to a more prolonged operation, that of resection of the intestine. 
In connection with the records of the above cases it will be 
of interest to refer to the case reported by Dr. J. C. Wilson, in 
the Medical Times of December 11, 1886, in which recovery 
followed an attack of peritonitis in enteric fever. 
“In this case the patient, a girl set. twelve years, was seized, on Sep- 
tember 13, 1886, one month following the beginning of the febrile 
attack in the stage of defervescence, with severe abdominal pain, 
accompanied by a chill, nausea and vomiting, and marked pulse and 
temperature elevation—the condition supervened upon the ingestion 
of food of a slightly solid character. Dr. Keen was summoned in 
consultation with a view to the performance of laparotomy should the 
necessity arise. The absence of any signs of collapse after the chill 
rendered the diagnosis of perforation doubtful, and the patient was 
placed upon a full opium treatment with counter-irritant applications 
to the surface of the abdomen. In nine days convalescence was re- 
established with tenderness in front of the border of the ileum and local 
dulness upon percussion.” 
In commenting upon this case, Dr. Wilson states that while 
it is impossible to say with certainty what the lesion has been 
in cases which recover, a consideration of knowledge derived 
from clinical and post-mortem examinations warrants us in 
dividing cases of peritonitis occurring in typhoid fever into 
two perfectly well characterized groups. The case reported 
illustrates the first class—cases of mild enteric fever in which 
peritonitis is the result of extension of the inflammation from 
the mucous to the serous surface without direct penetrating 
lesion of the wall of the intestine producing a local peritonitis 
In these cases, under favorable conditions, adhesions occur 
between the inflamed surface and adjacent structures, and per 12 
M EARS , 
foration is averted by the patch thus put upon the weakened 
bowel. Even when perforation has occurred, adhesions of this 
character have prevented fecal extravasation to any considerable 
extent, and recovery may follow the attack of peritonitis which 
takes place. Such were the conditions believed to exist in the 
case reported, and in selected cases of this group he urged 
earnestly the institution of operative measures for the relief of 
the existing peritonitis and perforation, when present, as had 
been done by Prof. Kussmaul the year before, in a case much 
less favorable in character. Upon this point he says ; “ Granted 
that the chance of a successful issue is 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 of the 
surgeon’s knife; that the lesions of the gut may be very exten- 
sive ; that the vital forces are at the lowest ebb. No one yet has 
hesitated to perform tracheotomy in the laryngeal complications 
of enteric fever, which require it to save life, for these reasons.” 
The free quotation from Dr. Wilson’s paper has been made in 
order to emphasize certain points before referred to, and to 
direct attention to the wide difference which must necessarily 
exist in the effects produced by the operations of tracheotomy 
and laparotomy in the complications of typhoid fever. Speaking 
surgically, the two operations cannot be compared in their 
effects, and the performance of the former cannot be urged as an 
argument in favor of the employment of the latter. The 
character and extent of the tissues involved make it impossible 
to institute a comparison, and above, an effort has been made to 
show that, in the different forms of peritonitis and in gunshot 
wounds of the abdomen, to which reference is also made, the 
systemic conditions differ so markedly from those which are 
present in typhoid fever, as to render comparison impossible. 
Successful operation in the former cannot give promise of the 
same result in the latter. 
For statistical purposes the value of the deductions made from 
the study of the very limited number of cases presented may 
be questioned. Lacking numbers of cases, we have been, how- 
ever, fortunate in being able to study one case of each type of PERFORATING TYPHOID ULCER. 
13 
the disease and presenting two different methods of operation, 
one by suture and one by resection. What conclusions are we 
prepared to draw from this study? To what must we attribute 
the fatal results in the two cases reviewed ? The operations 
were, in each, performed by surgeons of experience, under strict 
antiseptic methods and within a reasonably short period after 
the occurrence of perforation; the autopsy did not show that 
the interval, which had occurred between the time at which 
perforation took place and the performance of laparotomy, had 
added any complications. The prolonged exposure of the cavity 
caused by the methods of operation employed must be con- 
sidered as harmful, and may-have contributed to the fatal result. 
Experience has taught that although prolonged exposure is 
objectionable in any condition for which laparotomy is performed, 
it may not, in itself, be regarded as fatal. Clearly we must go 
further and find the failure of success in the systemic condition, 
in the degenerated and devitalized conditions of the organs and 
tissues caused by the infective process in active progress, utterly 
deprived of the power to resist the shock of operation, or in the 
condition of these structures beginning to recover from the 
effects of the poison in milder form, extremely sensitive to any 
rude impressions, and wanting in tone and power of resistance. 
It is in the latter condition, alone, that the surgeon may hope 
to achieve success by surgical interference, and then only when 
such methods are adopted as will reduce to the lowest point the 
shock of operation. 
The following propositions, with accompanying suggestions, 
are submitted in the hope that the experience of the future may 
prove that the limits of surgical art can be so extended as to 
include in the list of justifiable and successful operations, lapar- 
otomy in certain forms of perforating typhoid ulcer. 
I. Surgical interference is not justifiable and should not be 
instituted in cases of typhoid fever in which perforation occurs 
when the infective process is at its height. This conclusion is 
based upon our knowledge of the morbid conditions peculiar to 
and present in the disease, and the effects produced by them 
upon the general system. 14 
PERFORATING TYPHOID ULCER. 
2. In mild cases of the disease, in which the pyrexia has not 
been of high grade and in which perforation occurs at the end 
of the third week, or later, when the stage of convalescence is 
fully pronounced, laparotomy may be performed. Surgical 
interference in cases of this character is advocated with the hope 
that if the method of operation suggested by Liicke—laparotomy 
with the creation of an artificial anus—be adhered to, success 
may be accomplished. 
3. Rapidity in operation will be an essential factor in the 
achievement of success, through which prolonged exposure of 
the cavity will be avoided and shock greatly lessened. Median 
incision having been made, the hand should be passed to the 
position of the ileo-caecal junction, the ileum seized, drawn into 
the wound, and examined as it is slipped through the hand, 
which should remain in the cavity. The perforation being found, 
the portion of intestine including it should be quickly sutured 
to the edges of the abdominal incision, the sutures being intro- 
duced at sufficient distances from the ulcer edges to insure 
inclusion of healthy tissues. Hot antiseptic solutions should be 
then poured, in sufficient quantity, into the cavity, a glass drain- 
age tube carried to the floor of the pelvic cavity, and the wound 
closed. Prolonged “ toilette ”of the peritoneal cavity, as it is 
generally understood, should not be made while the cavity is 
open. Irrigations through the drain tube should be made as soon 
as the cavity is closed, and should be repeated at such intervals as 
the surgeon may deem proper. So extremely rare is the occur- 
rence of double or multiple perforation that, after the discovery 
of one opening, further search of a critical and prolonged char- 
acter may be safely omitted. As, in the cases in which opera- 
tion is deemed advisable, the perforation is not due to the 
extension, “per se” of the ulcerative action, but to what may, 
almost always, be designated as a mechanical cause, the absolute 
quietude of the patient, which must be enforced, as well as the 
rest secured to the intestine by the operation for production of 
artificial anus, whereby the free escape of the feculent contents 
and gas is facilitated, will contribute largely to the prevention 
of further perforations. Should the patient survive, relief from 
the artificial anus can be obtained by operation.