Reprinted from the Cincinnati Lancet-Clinic, April 6, 1895. 
TYPHOID ULCER; PERFORATION (?); OPERATION; DEATH. 
•? •••• CEREBRAL CYST; OPERATION; RECOVERY.1 
By B. MERRILL RICKETTS, Ph.B., M.D., 
CINCINNATI. 
There are perhaps as many deaths as 
the result of typhoid fever as that of 
any other acute disease, excepting tuber- 
culosis; while the deaths are not always 
the result of ulcer perforation, the 
greater number, I believe, are due to 
peritonitis, with or without perforation. 
The enfeebled condition at the time 
when the perforation is most likely to 
occur is no doubt one of the greatest 
factors in allowing these cases to die 
without surgical relief. But now that 
drainage of the peritoneal cavity has 
been established in so many conditions, 
we are led to believe that it may suc- 
cessfully be done, even when indicated 
in typhoid fever of any degree, for 
surely recovery cannot be expected 
without it in cases of perforation, or 
where the peritonitis is the result of 
extension of typhoid inflammation. 
One of the most misleading con- 
ditions is the absence of temperature- 
many physicians being misled by a 
temperature not more than one or two 
degrees above normal. 
Now that we have the report of 
nineteen cases operated upon with four 
recoveries, it seems that the operation is 
proven to be a rational one, and that 
the greatest step in advancing the treat- 
ment of this condition has been made. 
There does not seem to be any ques- 
tion as to the time to operate, so far as 
has yet been determined. The abdomen 
should be opened as soon after per- 
foration as possible, or as soon as peri- 
tonitis, with or without pus, is dis- 
covered, whether or not the patient has 
rallied from the shock, for no time 
should be lost in washing out the ab- 
dominal cavity and closing the perfor- 
ation in any way that may be neces- 
sary. 
Attention should at once be given to 
the collapsed condition of the patient, 
the injection of warm salt water into 
the rectum, the irrigation of the ab- 
domen with warm salt water or per- 
oxide of hydrogen, the use of nitrate of 
strychnia, digitalis, nitro-glycerine, and, 
as Abbe suggests, " very warm saline 
infusion into the vein, of at least one 
pint." 
The reports of Van Hook and Abbe 
are as follows {Medical Record, page 2, 
January 5, 1895): 
1884. Mikulicz, four cases, one re- 
covery, though, unfortunately, the diag- 
nosis is doubtful. 
1885. Lucke, one case, resection, 
death. 
1886. Escher, one case, recovery, 
but the case is regarded by Louis as one 
of appendicitis. 
1886. Greig Smith, one case, doubt- 
ful diagnosis, death. 
1886. Bartlett, one case, death. 
1887. Bontecue, one case, death. 
1887. Morton, one case, death. 
1889. Bontecue, one case, death. 
1889. Senn, volvulus and perfora- 
tion, one case, death. 
1889. Hahn, two cases, death. 
1890. Kimura, one case, death. 
1890. Taylor, one case, recovered. 
1891. Van Hook, three cases, two 
dead, one recovered. 
1894. Caley and Bland Sutton, one 
case, fatal. 
1894. H. Allington, one case, fatal. 
1894. Netschagaw, Medical News, 
December 1, 1894, page 609, one case, 
recovery. 
1894. Abbe, one case, recovery. 
1894. Alexandroff, one case, death. 
1894. Dandridge, one case, re- 
covery. 
1895. Ricketts, one case, death. 
It is not necessary that a perforation 
should be found to verify the diagnosis 
of typhoid fever, especially when the 
i Read before the Tri-State Medical Society, St. Louis, April 2 to 4, 1895. 2 
Typhoid Ulcer; Death. Brain Cyst; Recovery. 
appendix is found intact, and all the 
symptoms have verified the diagnosis. 
I fully agree with Van Hook and 
Abbe that the diagnosis may be doubt- 
ful where the appendix is involved or 
cannot be found, but where the patient 
has been in competent hands, and has 
had the usual symptoms of typhoid, and 
a sudden collapse occurs from the fif- 
teenth to the thirtieth day from the 
onset of the disease, I see no reason 
why doubt should exist as to the pro- 
priety of operative interference. 
CASE I. 
On January 5, 1895, at 5 P-M-, I was 
called by Dr. J. T. Knox to see a man, 
aged thirty-five, stout and robust, who 
had been suffering with typhoid fever 
for about three weeks. 
Seventy-two hours previous, while 
at stool in an erect posture, he felt 
something tear in the right iliac fossa, 
immediately followed by collapse. He 
was placed in bed and the attending 
physician sent for; he at once suspected 
perforation, and set about with the 
usual remedies to relieve the shock, 
which was partially overcome. The 
temperature remained about ioo°, and 
the pain was severe, the abdomen be- 
coming distended, with tenderness in 
the right side. 
Forty-eight hours afterward,his con- 
dition being about the same, it was 
with great difficulty that anything could 
be kept in the stomach. 
His pulse at the time of my visit 
was 120 and his temperature ioo°. He 
was conscious, fully realizing the gravity 
of his condition. 
I advised the immediate opening of 
the abdomen. This being consented to 
by all concerned, I made an operation 
at 6 p.m., in the presence of Drs. Knox 
and Robinson, and my students, Wall- 
ingford and Laughlin, chloroform being 
used as the anesthetic. 
An incision made through a thick 
abdominal wall in the right iliac region, 
brought me down upon a greatly dis- 
tended and highly congested perito- 
neum. Upon perforating it the gas 
and pus escaped in large quantities, 
and bespattered myself and assistants. 
An incision in the peritoneum, four 
inches long* enabled me to thoroughly 
examine about fifteen inches of the in- 
testinal tract, both above and below the 
ileo-cecal valve. The omentum and in- 
testines were matted together in a sur- 
prising manner. 
The wall of the intestine about the 
valve was very much thickened, con- 
gested and distended. The intestines 
were eroded here and there. It was 
necessary to separate all of these ad- 
hesions with my fingers. Now and 
then a cavity, formed by the omentum 
and wall of the intestine, would be 
opened, from which a pint or more of 
the most offensive pus would escape. 
Several of these pockets were opened 
so as to give free drainage of the entire 
peritoneal cavity-surely not less than 
two quarts of pus escaping. The ap- 
pendix was delivered, and, being in a 
normal condition, was removed, that no 
question as to its being involved might 
arise. This could not be done, however, 
until the adhesions surrounding it were 
broken up. 
I was not able to detect a perfora- 
tion of any size. This, perhaps, may 
have been due to the poor light from oil 
lamps which were furnished us. How- 
ever, there can be no question in my 
mind, or that of the attending physi- 
cian, as to the identity of the disease. 
The abdominal cavity was washed 
out with warm water, and the walls 
brought together with silk-worm gut, 
leaving gauze in the lower end of the 
wound for drainage. 
During the operation, warm water 
and whisky were thrown into the rec- 
tum at frequent intervals; nitrate of 
strichnia, nitro-glycerine, and digitalis 
were given subcutaneously; he was 
wrapped in blankets and placed in bed, 
and heat applied. While his condition 
improved materially and he regained 
consciousness, being able to swallow a 
little warm water and whisky occasion- 
ally, he began to fail five hours later, 
and dissolution took place at the end of 
the eleventh hour. 
Dr. Knox is free to admit that the 
operation should have been made 
seventy-two hours earlier, at the time 
that the supposed perforation took 
place. Typhoid Ulcer; Death. Brain Cyst; Recovery. 
3 
CASE 11. 
During the second week of April, 
1892, I was called in consultation with 
Dr. Dickenson to see a white boy, born 
on June 14, 1877, suffering with epi- 
lepsy, and whose family history was 
negative. 
He collided, at the age of four, 
while on a sled, with a street-car, in- 
juring the left frontal region. The scalp 
was cut for about two inches, all the 
tissues being divided down to the bone. 
He was unconscious for a few hours. 
At the age of seven one of the 
wheels of a wagon passed over the 
posterior portion of his head, the wheel 
having a three-inch tire. The face was 
buried in the mud so that no serious 
injury was occasioned. During the 
same year he fell eighteen feet from a 
barn loft, striking his head upon a 
broom handle. 
At the age of eight years he received 
a blow upon the right side of the head 
by the kick of a horse. This, however, 
owing to his close proximity with the 
leg of the horse, was not serious. 
There was nothing more eventful in 
this boy's history until the age of 
twelve, other than that he was one of 
the brightest boys of his class. He 
passed the intermediate grade at this 
age, and was admitted to the high 
school. During this time, on a bright, 
clear day he told his mother that it was 
raining, which was not the case. He 
said he could hear the rain drops falling 
on the veranda. This sound shows a 
lesion in the temporal region. His ex- 
pression changed materially, and he 
would stand like a statue. 
These attacks occurred frequently 
during the following year. He was 
as apt to turn the head to one side as to 
the other, but never has, from begin- 
ning, fallen to the ground in one of 
these attacks. 
He became dull and indolent, taking 
no interest in anything whatever, the 
attacks all the time increasing in fre- 
quency and severity. 
Dr. F. W. Langdon was called in 
consultation, and it was decided, after 
going over the history of the case and 
considering the symptoms manifested, 
that the bone over the left psycho- 
motor area, over which the large cica- 
trix was located, should be removed. 
On the 20th day of April, 1892, I 
trephined in this locality, the convul- 
sions during the preceding two weeks 
having been very frequent and severe, 
especially while recumbent at night. 
The dura was divided longitudinally 
with the opening of the cranium, and 
the area thoroughly examined. There 
was nothing unusual except a slight 
adhesion to the inner table of the 
cranium, directly beneath the point of 
injury received at the age of four years. 
The dura was sutured with cat-gut and 
the cutaneo-periosteal flap sutured with 
silk-worm gut without replacing the 
bone fragments. His condition for two 
years was greatly improved, the first 
eight months being uneventful; slight 
attacks would be noticed, but at long 
intervals. He was, as usual, placed 
under the influence of bromide of potas- 
sium, without any material benefit. He 
did fairly well until the summer of 
1894, when it was noticed that his 
mental condition was deteriorating and 
his memory bad, and associated with a 
high degree of despondency. He be- 
came less interested in things about him, 
brooding over his condition and wish- 
ing he was dead. 
He would occasionally be seized 
with one of these convulsions, which 
would last but a few minutes, he having 
no recollection of them. On the 22nd 
day of November, 1894, while on his 
couch, he was seized with one of the 
most severe convulsions he had ever 
had. This was followed in thirty or 
forty minutes by another of equal 
severity. His face was flushed and 
there was loss of memory, with no in- 
clination to converse with members of 
his family. The left thumb was drawn 
into the palm, while the convulsive 
movements of the face were upon the 
right side. It was hard to determine in 
which of the lower extremities the con- 
vulsive movements were most active. 
A consultation was again had by Dr. 
Dickenson with Drs. Hoppe, Langdon 
and myself. It was decided to operate 
upon the right side, the symptoms indi- 
cating the lesion to be in that locality. 4 
Typhoid Ulcer; Death. Brain. Cyst; Recovery. 
■ . On the 26th day of November, in 
the presence of these gentlemen and 
my student Laughlin, the right psycho- 
motor area was opened in the 'same 
manner as the previous one. A large 
opening was made in the brain, reveal- 
ing an ecchymosed condition of the 
dura about the size of a silver dime. 
The dura was at this point very much 
thickened. The introduction of the 
spatula between the dura and the brain 
substance caused a milky fluid, in color 
and consistency, to the amount of about 
half a drachm, to flow from beneath 
this lesion. The brain substance seemed 
to be softened and degenerated, and also 
discolored. There was some question 
as to just where the fluid came from, but 
the concensus of opinion was that it was 
from this area. Whether or not there 
was a membrane remains a question. 
I explored the brain with a small 
narrow spatula in various directions 
without revealing anything unusual. 
The dura was sutured with cat-gut 
and the cutaneous flap containing the 
periosteum replaced and sutured with 
silk-worm gut, a few pieces of silk- 
worm gut being left in the lower mar- 
gin of the incision for drainage. 
The patient again made a rapid re- 
covery; his mental condition has im- 
proved, he is interested in the events of 
the day, anxious to return to school, 
assists his father in his business, can be 
trusted with any responsibility, buys 
and sells wares in which they are inter- 
ested, and is a different boy from every 
point of view. 
He is mischievous, ambitious, and 
bright, and has had but one attack, 
slight in its nature, since the last opera- 
tion on November 26, 1894. 
In conclusion, I would say, concern- 
ing typhoid ulcer: 
1. That of all conditions in which 
mechanical devices should not be used, 
it is this. 
2. A small perforation should be 
treated by a simple suture, as any other 
perforation. 
3. If the ulceration is extensive, a 
resection should be resorted to, and the 
anastomosis made according to Maun- 
sell. 
4. Manipulation of the intestines 
should be avoided, except to free the 
cavity of pus or fecal matter; also to 
prevent ? rupturing an already impaired 
intestinal wall. a : 
... 5. An opening should be left at the 
lowest point in the abdominal incision 
for drainage. r . .7 ■- . 
6. Nothing but gauze should be left 
in the cavity for drainage. 
7. Glass, rubber and all other hard 
substances should be discarded in drain- 
ing the cavity. 
8. The pulse and temperature cannot 
be relied upon in determining the 
presence of pus in the abdominal cavity. 
9/ The abdomen should be opened 
immediately after perforation or as soon 
as fluid is detected within it. 
10. Remedies for shock should be 
given with the greatest of caution. 
11. The tearing sensation is not 
always due to perforation, it many 
times being the result of omental or in- 
testinal adhesions giving away as the 
result of pent up fluid or the change ot 
position of the abdominal viscera. 
12. Prolonged excessive abdominal 
distention is sufficient cause for opening 
the abdominal cavity in this, as in any 
other pathological condition. 
13. The incision should be made 
directly over the ileo-cecal valve, and 
not in the median line. There are 
always more or less adhesions attending 
typhoid inflammation, in consequence 
of which it would be with the greatest 
danger of producing further injury to 
the gut by attempting to bring the 
diseased area into the incision. 
14. The intestines should never be 
taken from the abdominal cavity to be 
examined for typhoid perforation. 
Concerning Case II, I would say: 
1. That the focal symptoms, together 
with the cicatrix, prompted the first 
operation. 
2. That there was nothing whatever 
other than focal symptoms which led to 
the second operation. 
3. It remains to be seen as to 
whether or not the pathological condi- 
tion found was the sole cause of the re- 
currence of the attacks. 
■' 4. That the end has justified the 
means in either operation remains a 
question.; 1 . • . >