was more extensive than any previous during the day, she found that the temperature was normal. He took a few long breaths and dropped off into a quiet, natural sleep with respirations and pulse nearly normal. At midnight, when awakened for nourishment, he was perfectly rational.

At my visit the next morning I was amazed to find his pulse, respiration and temperature normal, believing that we had been mistaken in the physical signs found the night before. A examination of his back, however, showed the pneumonic area still present. Bronchophony could be heard for a week, though the dulness and bronchial breathing persisted for only a few days. He had a rapid convalescence and was up and around in a few days; this was contrary to my advice, but he felt so well that his mother was unable to keep him in bed. About two weeks later he had a slight attack of indigestion lasting about three days, from which he completely recovered.

The only treatment used in this case was ice to the head to control the nervous symptoms. As much fresh air as the nurse could comfortably stand was kept in the room all the time.

Dr. Claytor said that it was not so surprising as might at first appear that in Dr. Johnson's case roughened breathing was found on the side opposite to that in which the consolidation later appeared. The harsh breathing was only relatively harsh, because early in the pneumonic process, before consolidation occurs, the partial loss of function in the affected part results in diminished breath sounds over that region, and on the opposite side the compensatory increased function and the comparative loudness of the breath sounds closely simulate harsh breathing. With pneumonia symptoms, then, an area of very quiet breathing should excite suspicion.

Dr. G. W. Wood said that he was glad that Dr. Johnson had the courage to report this case of pneumonia; a number of similar cases had come under Dr. Wood's care and he had been frequently embarrassed by making the diagnosis of pneumonia, and then having the children get well in a few days. Most of his cases were associated with symptoms of malaria, and he thought perhaps they were not cases of true pneumonia, but instances of the internal congestions so frequent in malaria or the rapid termination might be due to the greater elasticity of blood vessels in children or to some greater antitoxic quality of the blood.

Dr. Chappell said that he was of the opinion that Dr. Johnson's case should not be called a case of one-day pneumonia, but a case of pneumonia in which the crisis occurred in one day.

He believed that the pneumonia must have persisted after the crisis.

Dr. Acker was inclined to doubt the accuracy of the diagnosis. He had seen cases of grip-pneumonia in which the crisis occurred in one day, but never had he seen the crisis so early in true croupous pneumonia.

Dr. J. D. Thomas said that criticism of the diagnosis was to be expected, as certainly such cases must be very rare. He therefore congratulated Dr. Johnson for presenting the history of the case, and expressed the opinion that the conclusions were probably correct and that the condition had been well made out. Though no one holds that the pathological conditions in the lung clear up coincidently with the crisis, the crisis may be held as marking the termination of the disease, since the dangerous symptoms abate with it and the patient's convalescence begins.

Dr. Louise Tayler-Jones related the history of a child of three years who came under her care about a year ago. The child had been taken ill, with a sudden rise of temperature and quick breathing. On the 2d day, a small spot of consolidation appeared in the lower part of the back, left side. Two days later the temperature was normal, and in five or six days from the onset the consolidation disappeared. Last summer, in Boston, she saw five cases of lobar pneumonia in children in which the symptoms disappeared on the third or fourth day of the disease. more recent case was that of a child, taken ill, with a temperature of 106.8 and respirations mounting to 80. On the second day there were signs of consolidation throughout the lower right side. Three days later the temperature and respiration were

normal.

A

In Dr. Rotch's clinic it was fairly common to see children with signs of lobar pneumonia apparently recover in three or four days, though physical signs remained a few days longer.

Dr. Loren Johnson, in closing the discussion, said that many cases occur with signs of pneumonia, as for example grip-pneumonia, which quickly recover with disappearance of the signs. But his case was not of this sort, the physical signs were distinctly those of lobar pneumonia. In most cases of grip-pneumonia the physical signs are vague and scattered; but in his case there was abundant evidence of the consolidation of an entire lobe, and morever he could obtain no history of any exposure of the child to grip infection.

With reference to Dr. Chappell's criticism, Dr. Johnson said that while the physical signs persisted for several days after the crisis, there was nothing in that fact to militate against its being a one-day pneumonia, for it is well known that in all cases of lobar pneumonia the physical signs of consolidation do not disappear with the crisis; and further he could not make his title so extensive as to completely describe the case.

He said that he quite expected to have his diagnosis assailed, and for that reason he had been careful to have it confirmed by a competent consultant. Even Dr. Osler says that he has never seen a case of lobar pneumonia in which the crisis occurred before the third day.

THE SURGICAL TREATMENT OF TYPHOID FEVER,
WITH ESPECIAL REFERENCE TO PERFORATION
OF THE BOWEL AND HEMORRHAGE.*

BY GEORGE TULLY VAUGHAN, M. D.
Washington, D. C.

The first recorded operation for perforation of the intestine in typhoid fever was done by the late lamented von Mikulicz, twenty-one years ago, and up to the present time it is possibly safe to say that not more than one thousand operations of this kind have been performed.

The best article on this subject and the most complete, is that of Harte and Ashhurst of Philadelphia, published in the Transactions of the American Surgical Association for 1903, in which is published a table of all patients operated on up to 1903, namely, 362, collected from operators in various parts of the world. Dividing the twenty years which have elapsed since the first operation into lustra of five years each, and comparing the results in each lustrum, they show a remarkable reduction in the mortality, namely, from 90 per cent. to 69.2 per cent. In the first lustrum 10 patients were operated on with 9 deaths; in the second lustrum 16 cases were operated on with 14 deaths; in the third lustrum 100 cases were operated on with 72 deaths; while in the fourth lustrum, ending with the year 1903, 166 were operated on with 115 deaths.

Frequency. The frequency of perforation is variously estimated by different authorities from 1.3 to 11 per cent. of all cases of typhoid fever. In 10,802 cases there were 321 perforations, in round numbers about 3 per cent.

Causes of perforation.-The primary cause of perforation is, of course, the sloughing incident to ulceration of Peyer's patches. There are also certain predisposing causes, as sex, perforation being four times as frequent in the male as in the female. Stage of

* Read before the Medical Society, January 24, 1906.

even

the disease, the large majority occur during the third week of the disease, then comes the second, then the fourth week, then the fifth, then the sixth and first weeks, in which perforation seems about equally frequent; then later periods, into convalescence. Severity of the disease, here opinion is divided. Harte and Ashhurst believe it is more apt to occur in the severer forms of the disease. Judging from my own experience and observation perforation occurs as frequently in mild as in severe cases. Naturally one would expect perforation to occur more frequently in those cases in which the ulceration is most severe, but the degree of local lesion bears little relation to the general symptoms. Nor does the number of ulcers seem to bear any relation to the probability of perforation, which is frequently seen in cases with a very small number of ulcers.

The immediate cause of perforation is often difficult to ascertain. At other times it may be attributed to a sudden motion in bed, to vomiting, to straining at stool, to contraction of the muscles caused by the cold bath, according to Harte and Ashhurst, to excessive tympany, distention from other causes, and peristaltic action from purgatives. In two of my cases perforation occurred soon after the administration of purgatives, in the one case magnesium sulphate and in the other castor oil. In another case perforation occurred after imprudent eating.

Symptoms. Many symptoms are given but the diagnosis is usually made on very few. In doubtful cases all the information which it is possible to obtain is needed to clear up the diagnosis. Pain, tenderness, rigidity of abdominal muscles, hemorrhage from the bowels, chill, vomiting, sweating, and changes in the countenance, temperature, pulse, leucocytes, dulness, tympany and stools-all may occur as symptoms. Pain, tenderness, rigidity and symptoms of shock, such as anxious or greyish countenance and rapid pulse, are the most reliable symptoms, and when coming on suddenly and all present, establish the diagnosis beyond a reasonable doubt.

Pain is sometimes absent or slight in apathetic patients, but even in these, tenderness can usually be discovered on palpation. At other times the pain may be as severe as in biliary or renal colic. In one of my patients, Case IX, such was the case and it lasted eight hours, with slight intermissions. There are all degrees

between these two extremes.

It is usually in the right inferior

quadrant of the abdomen but may be diffused all over the abdomen. The pain is described as sharp, stabbing, cutting, burning, aching, or as a cramp, usually constant but with waves of greater intensity at intervals.

Tenderness is probably the symptom most commonly present, but it is often present in the absence of perforation. It is usually most marked in the right iliac fossa, but after peritonitis has set in may exist all over the abdomen.

Rigidity is not reliable, but when present is of great value, especially if limited to the right side.

The change in countenance is of great value, but is not always present. It varies from an expression of uneasiness or anxiety to one with hollow eyes, pinched nose and lurid countenance.

The pulse nearly always increases in rapidity. In cases attend. ed with much shock the pulse becomes rapid, 120 to 160, weak and thready. With little or no shock, the pulse may not increase more than ten beats to the minute, until peritonitis sets in. Sweating usually occurs with the pain, especially if severe, or follows soon after.

Temperature. While in many patients the temperature falls, the most certain thing about it is its rise after perforation. If there is much shock, the temperature falls from one to six degrees Fahrenheit and then, unless the patient dies in collapse, it rises again beyond the point from which it fell. The temperature fluctuates so much in typhoid fever that a fall of one or two degrees is of no significance unless attended by other more reliable symptoms. Even a drop of several degrees may mean a hemorrhage and not a perforation.

The value of leucocytosis as a symptom of perforation is still a mooted question. Its presence is sometimes of value as corroborative evidence while its absence should not mislead one to conclude that no perforation is present.

Hemorrhage from the bowels occurs in quite a large percentage of perforations. B. W. Goodall, in a study of 96 cases of perforation, found that hemorrhage preceded perforation in 20.8 per cent. Of course hemorrhage also occurs in many cases that do not perforate. Probably a careful examination of the stools would show the presence of blood in the majority of cases previous to perforation.