Rosenthal (Wiener med. Presse, Nos. 12, 18, 21, '92).
Series of twenty-six cases of enter ectomy divided into three classes: 1. Those operated on by simple suture, 9 in number, of which 5 died, yielding a mortality of 55.5 per cent. 2. Those op erated on by the Murphy button, 5 in number, of which 1 died, giving a rate of mortality of 20 per cent.; 2 had had fistulae and a retarded convalescence, and in 1 the button had not passed while the patient was under observation. 3. Those in which a decalcified-bone support in the shape of a button or some similar con trivance was employed to support the sutures, of which there were 12 cases with 1 death, giving a rate of mortality of 8.3 per cent. Mayo Robson (Brit. Med. Jour., Apr. 4, '96).
Case of a feeble woman, aged 76, who suffered from strangulated ventral her nia. In this case it was found necessary to excise 5 feet of small intestine, after which an end-to-end anastomosis was made. Time patient made a satis factory recovery, the wound healing without trouble. Subsequent to the operation there was some slight diar rhea, which was easily controlled. It is preferable to remove a strangulated portion of bowel, the vitality of which is questionable, rather than to return it with the possibility of subse quent local complications. A. E. Barker (Lancet, Apr. 27, 1901).
Operations for Perforating Ulcers of the Intestine.—Irlceration of the intes tine, which leads to perforation demand ing operation, may arise as a conse quence of typhoid fever; the presence of foreign bodies, particularly in the colon; or from a typical round duodenal ulcer. Tuberculosis and malignant disease may also ulcerate and give rise to perforation.
Perforation in typhoid fever is prob ably the most common form of intestinal perforating ulcer. It is said to occur in 6.5S per cent. of all cases; it is much more frequent among men than among women, and is comparatively rare in children. The lower portion of the ileum is most commonly affected; but the large intestine and (rarely) the ap pendix, jejunum, and Meckel's diverticu lum may also be perforated. The per foration is usually single, and, if it re sults from the ulceration of a solitary follicle, it is generally small and round. Perforation of a Peyer patch is apt to be larger, with a considerable thinned area surrounding. There seems to be no definite relation between the severity of the disease and perforation. About a fourth of the number of cases occur in the course of a mild attack, and others occur during walking typhoid. The symptomatology is fully discussed under TYPHOID FEVER.
Indications for Operation. — Ninety per cent. of all patients die without operation, and, unless the condition of the patient is absolutely hopeless, an attempt should be made in every case. Healing usually follows as well as if the patient were not suffering from the fever, and a number of patients have re covered after repeated operations. The
earlier the operation can be done, after the immediate shock of the perforation, provided there has been any, the better the chances of recovery. Every hour counts, since the infection of the peri toneum rapidly becomes more diffuse and intense.
- Surgical intervention otters practically the only hope in cases of perforation occurring in typhoid fever. There are two varieties of perforation,—appendic ular and those occurring in the free bowel; and these present different courses and prognoses. Many cases show a preperforative stage in which some cases call for a laparotomy in anticipation of a complete perforation with extravasation. Leucocytosis is not an infallible sign of perforation. When the diagnosis is made, operation is indi cated, whatever the condition of the pa tient. Even exploratory incision is more than justified. Harvey W. Cushing (Johns Hopkins Bull., Nov., 'OS).
Operation.—Incision is best made in the right semilunar line or through the rectos muscle. If there is any doubt as to the diagnosis, a small exploratory in cision may be made under cocaine, which is enlarged if the perforation is found. The perforation should be sought first in the ileum and in the adjacent emeum and appendix, and secondly in the sig moid flexure and higher up in the small intestine. The perforation should be sutured without paring the edges, using lIalsted's mattress-suture, and, if a sec ond row of sutures is thought necessary, continuous suture saves time. In case of a large perforation the suture should be placed transversely to the long axis of the intestine if possible, in order to avoid constricting the lumen of the gut. Resection of the intestine has been per formed successfully in several cases in which extensive damage was found. Other perforations or points of impend ing perforation should be sought and sutured: deaths have followed from a second perforation or luemorrhage in several cases in which this precaution was neglected. The cleansing of the peritoneal cavity is the subject of next greatest importance, and should be car ried out with the greatest thoroughness. "Whether it shall be done by flushing or wiping, or both, must be decided by the operator at the time of the operation. Drainage is necessary in most cases, but if the peritonitis is not of long standing and the abdominal cavity can be satis factorily cleansed, the abdominal cavity may be filled with salt solution and closed. Cushing has recently advocated the use of cocaine infiltration instead of general anaesthesia. This is unquestionably a step in advance, for, in the weakened condition of the patient, general anwsthesia is not borne well.