The surgical treatment of intestinal perforation in typhoid fever / by Donald Armour.

  • Armour, Donald, 1869-1933.
Date:
[1903]
Catalogue details

Licence: In copyright

Credit: The surgical treatment of intestinal perforation in typhoid fever / by Donald Armour. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    so altered or obscured by other conditions that perforation may not even be suspected. The signs upon which most dependence is to be placed are sudden acute pain in the abdomen, with symptoms of collapse, accompanied by an abrupt fall in the temperature, it may be of several degrees. Vomiting is not infrequently present. Various special sym- ptoms have been, from time to time, made much of by writers upon this subject—e.g., the obliteration of liver dulness, the gurgling sound on respiration, hiccough, move- able dulness in the flanks, &c. These, like McBurney’s point in appendicitis, are very good signs when present” (Finney). Cushing^’ calls attention to a “ pre-perforative stage,” and defines it as “the whole period included between the first involvement of the serosa with the customary formation of adhesions at that point, until these adhesions, which may for a time constitute the floor of the ulcer after the serosa has given way, have themselves become broken down and general extravasation has taken place. This period, as in perforating appendicitis, may last a longer or shorter time and is associated with pain and tenderness and a possible rise in leucocytosis owing to the localised peritonitis.” Were it possible to recognise such a ‘ ‘ pre-perforative stage ” in cases of typhoid fever it is the period in which an operation should be undertaken. For obviously one would then be operating to prevent general septic peritonitis and not for its relief, as is tbe usual procedure in cases of typhoid perfora- tion. It is doubtful, however, whether this stage can be recognised with sufficient clearness to be a positive indication for operation. But if recognised it would certainly justify an exploratory incision under local anesthesia, a procedure which has been frequently shown to have no untoward effect on the course of the disease. Unfortunately, the analysis of Shattuck’s cases shows that the formation of protecting adhesions in perforation or threatened perforation of the ileum is exceedingly rare. And Monad and van Verts state that adhesions, however slight, almost never occur when the perforation is in the ileum; and, moreover, that peritoneal infection is not always a rapid fulminating affair, but may occur slowly from migration of the bacteria through the necrosed and damaged intestinal coats. Intestinal ulcers certainly may have a pre-perforative stage—i.e., a stage of local peritoneal infec- Log. cit., supra. 18 Revue de Obirurgie, 1897.