Operation for Typhoid Perforation.-Dr. Hugh M. Taylor, (Va. Med. Semi-Monthly) reports a case in which repair of the intestines was done after perforation by a typhoid ulcer with successful results. The case was that of an interesting little boy who had been sick with typhoid fever for six weeks; was then convalescent two weeks; fever again for ten days; and convalescence again apparently assured. The father reported that the child had slept well all night, but awoke about 6:30 with a sharp pain in his abdomen which lasted only a few minutes and was followed by a natural fecal action. A dose of syrup of figs was at once followed by vomiting, the vomiting being repeated several times. There was another short attack lasting only a few minutes, after which the child insisted that he was all right and had no pain. While perforation was suspected the child was not sick enough apparently to justify such a suspicion. He expressed himself as being without pain, and his untroubled countenance confirmed this assertion. There were no evidences of shock, and those who saw him at the outset of the sharp attack could not say that even then he presented any of the symptoms of shock. His pulse was now 115, and his sublingual temperature 101° F. Respiration was not noticeably increased, and his morale was exceptionally good; there was, however, some appreciable rigidity of the abdominal muscles. An absence of fever for several days,. the sudden onset of pain and vomiting, a recurrence of fever, and rapid pulse, plus the abdominal rigidity, was the group of symptoms which made me fear a perforation.

The author recited the symptoms thus minutely to impress the fact that perforation may occur with only minor manifestations, or, in fact, with no symptoms at all. The child was taken to the hospital at which time the pulse had reached 140 while the temperature was only 100.5° F. The operation was done fifteen hours after the first onset of the symptoms the incision being made over the cecal region, thus giving access to the appendix as well as to the lower end of the ileum, in the last eighteen inches of which a large majority of typhoid perforations are known to occur.

On incising the peritoneum, a quantity of sero-purulent fluid escaped from the peritoneal sac, but no gas. The cæcum was quickly delivered, and not more than twelve inches of the small bowel was examined before the punched-out, pencil-sized hole in the ileum was discovered. There was but little if any appreciable inflammatory change about the intestinal lesion; in fact, it looked as if a cobbler's punch had been driven into a healthy bowel and a circular section punched out. To close the opening with deep mattress and Lembert sutures was the work of a few minutes. In ten minutes from the time the section was begun, the abdomen was opened, the lesion found, and sutured. This fact as to the time consumed is not mentioned to extol rapid work, for not infrequently rapidity of operating is at the expense of thoroughness. We would, however, impress the idea that the technique

of dealing with typhoid perforations may be very simple and quickly completed. Upon first thought, it looks like desperate surgery to subject to celiotomy the cadaverous looking patient, ill with typhoid fever for weeks, with the added prospect of prolonged anæsthesia, extensive evisceration, etc., to find the suture the bowel opening, but knowing the usual site of the lesion, near the ileo-cæcal junction, we have, in all instances, a starting point from which to begin our search.

In addition to the free discharge of sero-pulent fluid from the peritoneal cavity, a number of flakes of lymph were discovered, and not more than half an ounce of greenish looking fecal fluid was found puddled near the perforation. Suppurative peritonitis was obviously quite general. No effort at walling had been made. No one who saw this clean cut perforation, with not the slightest trace of adjacent plastic peritonitis, could fail to be impressed with the idea that death was inevitable without surgical intervention. Twenty minutes more was consumed in eviscerating the patient, in wiping the intestines, in thoroughly irrigating with hot saline solution the abdominal cavity, and in placing multiple gauze drainage. In thirtyseven minutes from the beginning of the operation, the patient was removed from the table to his bed. Let me here remark that twenty minutes of this time could probably have been saved if the patient had been operated upon in the morning. At that time, it would probably have been best merely to have sponged off the soiled area, and drainage might have been dispensed with.

It has now been four weeks since the operation was performed. Convalescence has been uneventful, and recovery is assured. Statistics should now read, 61 operations, 14 recoveries.

Removal of Seven Hundred and Five Pebbles from the Bowel of a Child. -Dr. Eugene Argo, (Ala. Med. and Surg. Age) reports the following remarkable case :

I was called to see Charley McCarty September 12, age six, male; found him suffering with pain, griping and tenesmus, with frequent desire to stool and passing nothing but a muco-sanguinous discharge, with some elevation of temperature. On further inquiry I found history of dirt eating which his peculiar sallow appearance would readily reveal. His father had kept him guarded, and in the house for some weeks to break him of his liking for dirt. Finally one afternoon he went at large, and I suppose clay not being very accessible, and the pebbles being in great abundance, he proceeded to satisfy his peculiar appetite by filling his stomach with these little rocks. On examining his bowels, I found the abdomen apparently full of these pebbles. They had lodged in the rectum until a complete impaction had come about. Manipulation over the abdomen would remind me very much of grit in a chicken gizzard. I introduced my finger into the rectum for the purpose of clearing it, but the pain was so great and the contraction of the sphincter was such that I resorted to chloroform anæsthesia. After removing a lot of the pebbles with an ordinary pair of forceps, I gave an enema of castor oil, and cleared the lower portion of the rectum with my finger. Finding still more "rocks" higher in the bowel, I gave a number of enemas of warm water and soap. With massage, enemas, oil and endurance, I finally removed in number seven hundred and five pebbles.

In charge of W. H. WAKEfield, M. D., Charlotte, N. C.

New Instruments for Excision of Tonsils.

It is conceded by all physicians of large experience in the treatment of throat and nose diseases that enlarged tonsils and adenoids should be removed surgically, and the market is flooded with instruments for that purpose.

The following paper is reproduced from the Journal of Am. Med. Ass’n. as it advises a mode of procedure in the removal of tonsils that is, perhaps the best. [I use the instruments in my practice and am pleased with them. -ED.]

The author, W. H. Peters, B. S., M. D., Lafayette, Ind., says:

As to the anatomy and pathology of the tonsil, I will only say that the normal throat has nothing of the kind in it. And as to treatment, nothing but complete removal of the diseased glandular mass gives the desired relief.

Many plans are in use to accomplish this. The guillotine will slice off the tonsil, and in children, if the claws which complicate it are removed and suitable forceps used in their place, the guillotine is fairly satisfactory, but hemorrhage is free.

Though not dangerous in chrildren, this hemorrhage is troublesome, because it interferes with the simultaneous removal of the pharyngeal tonsil, which is almost invariably present.

In the adult, however, this hemorrhage is a serious matter and has been fatal in many cases. To avoid this, Barnett and other authors recommend that a snare be used-the growth being cut through gradually-several hours being consumed in the operation. The method is worthy of the Inquisition.

The galvano-cautery loop I must condemn by using Burnett's own words: "We may resort to the cautery in suitable cases, which are certainly exceptional, with a feeling of security and with the expectation of getting a thorough and satisfactory result."

My personal experience with the cautery loop has been confined to a single case, in which acute otitis media resulted on the fourth day.

Other authors have devised an array of scissors, cutting forceps and knives which do the work well, but the operation is a bloody one, requiring general anæsthesia and an hour's time to complete it.

Igni puncture is too tedious, months being required and a bad cicatrical stump remaining.

The guillotine, then, with its limited usefulness; the ordinary snares, with the prolonged torture and shock, certainly indicate a demand for something different.

Here let me say that the tonsil must be completely removed; that tonsils which absolutely demand removal are often deeply imbedded or diffused over a surface of an inch and a half by two inches in size. In tonsils of the kind named, the guillotine and cautery snare are useless.

In 1888 I devised a tonsil snare which was finally perfected in 1890, and has been in almost daily use ever since, with such satisfactory results that I beg to present it to you.

The instruments I show you belong together. In small children, chloroform is used. In children over ten years of age and in adults it is unnecesIn children, the fenestrated tip recommended by Dr. Vedder, of Pitts

sary.

burg, is always used, and the suggestion he makes to form the wire loop around a piece of hard wood is valuable.

The operation is performed as follows:

In infants, the child under cloroform; the patient lies upon a couch, with his head toward an artificial light four feet away; my assistant kneels at the patient's head and I stoop over the patient at the side. The instrument has been prepared as you see-two extra fenestrated tips being held in reserve. Here let me say that the screw adjustment in this instrument is never under any circumstances used except to regulate the size of the loop before operating. The patient's tongue is held down by myself or my assistant, as the case may require. If the tonsil is prominent, no forceps are used, and I hold the tongue depressor myself. If not prominent, the forceps are passed through the loop, the tonsil seized, the traction made, and with a single stroke the tonsil severed.

The other tonsil is removed at the same time. The operation up to this time is bloodless, and now the index finger explores the naso-pharynx for adenoid trouble. If present, and it usually is, the mass is removed by Gottein's

This operation has taken less than a minute, and the child is rolled to the edge of the couch, with his face immediately over the opening of a fountain cuspidor. (This latter is of my own design. It takes care of any vomited matters, etc., though vomiting is very rare.)

In adults a 25 per cent. solution of cocaine is applied around the tonsil and in its crypts, and the tonsil is seized, drawn through the loop and severed by a single stroke.

In some tonsils, one in six, perhaps, some dissecting is necessary, and this requires only two or three rapid strokes of the knife.

The patient himself, even among children, holds the tongue down with a tongue depressor while the operation is being performed.

In many cases of diffused tonsils a second or third application of the

snare, without the patient leaving the chair, is necessary.

As a rule, the hemorrhage does not exceed a few drops. Only in one case has it been sharp-in that of Miss Hattie K., 14 years old, living at

Rensselaer, Indiana, Dr. Burkley being present. In that case the tonsils were enormous, and there was a sharp gush of blood, about two ounces in all, but it stopped kindly, and in no way alarmed the child or rendered me uneasy. She returned a week later and had the second one removed-the same phenomenon recurring.

I have never seen a drop of secondary hemorrhage from any tonsil. The snare handle should be made of machinery or soft steel-not tool steel-and of the full size shown. A worthless imitation of this snare is on the market in Chicago. It is too light to be of value. The forceps are easily aseptible and have a wide range of usefulness.

Bosworth's special tonsil snare is altogether too weak, as he himself admits. The snare I show will easily remove any tonsil instantaneously, no matter how hard it may be.

I use No. 10 piano wire, as No. 5 is too light; I have broken it. The No. 10 wire can be obtained from Wm. H. Armstrong & Co., Indianapolis, Ind., who make these instruments.

This operation, the instant ecrasement of the tonsil with cold snare, is original with me, I think, and the instruments employed certainly are original. I use these instruments in the removal of lingual tonsils. Never use a wire the second time.

AFTER TREATMENT.

In children there is little or no pain following and no treatment necessary. In adults-no matter how the tonsils are removed-there will be pain following the operation, except in such individuals as are by nature insensitive. The pain is less in ordinary enlargements where the gland can be wholly removed at a single stroke; but in every case there is a raw surface which will be irritated by swallowing. The patient is ordered to gargle the throat with hot water, to avoid sour and salted foods, and to eat chiefly crackers and milk and medium-boiled eggs, for twenty-four hours.