weaker and died at the end of the eleventh day, of blood poisoning. With this case ended my diphtheria cases and I think the last in the neighborhood were in this family. I have only described my worst cases, there were several milder where the membrane was confined to tonsils and faucial membrane, the disease lasting from three to seven days.

In all I had fifteen cases and two deaths. This does not include a single case but what had actual diphtheritic membrane extending at least over tonsils and faucial membrane. My treatment was Marchands hydrogen per. ox. used as a spray every two hours, and hydrorg. bi. chlor. from 0 to 20 grain every two hours. Brandy I gave freely. Every patient was fed on pineapple juice, fumes from burning sulphur filled the sick chamber, and occasionally had a patient inhale the steam from slacking lime. The treatment was nearly the same in every case but the two remedies which were depended on and the ones which saved the lives of my patients were the peroxide of hydrogen and the bichloride of mercury. The peroxide to destroy the germs and keep them from multiplying, but of more importance still is the bichloride to eliminate the poison from the system.

I regard the bichloride the sheet anchor in the treatment of malignant diphtheria. It certainly modifies the course of the disease, protects the kidneys and in many cases prevents membranous development. In my fifteen cases and two deaths the membrane extended to the larynx in only one case (the ten year old boy), while in the three cases and five deaths of the other school in the same epidemic (and sometimes in the same house), where the bichloride was not used, the membrane extended to the larynx in all but two (and in one of these cases the bichloride was used at my suggestion and used freely). The quantity of bichloride given would average from 4 to 1⁄2 grain in twenty-four hours for the first three to five days, or till the membrane began to loosen; from that time the dose was gradually diminished, but never discontinued till all trace of the disease had disappeared. There was no diarrhoea resulting from its use, the bowels generally moving once or twice each day. Had no suppression of the urine, which fact was attributed to the use of mercury. I think the disease was prevented in some that were actually exposed. Aged from six to fourteen years they were given the bichloride, and in the course of a week or ten days from date of exposure they all had all the symptoms of the disease except the membrane; they would recover in two to four days. I had a routine habit of giving it to every one that had been exposed or was afraid of taking the disease; would give 20 gr. tablet trit. after each meal to all over twelve years of age; to those younger would give from one to two tablets each day, and in many cases this medicine was taken regularly for two weeks. Although the bichloride was used freely by about seventy different persons, large and small, there was not a single case of ptyalism resulting from its use.

In conclusion allow me to say. It is not all in the remedies used; some credit must be given to the faithfulness in using it. A great list of diseases can be treated on the expectant plan. Not so with the disease under consideration. This is one of the acute life destroying diseases in which proper medication and diligence on the part of physician and friends. will certainly be rewarded with success. There are older and more experienced minds than mine here to

day, and I trust they will all agree with me that to cure a case of malignant diphtheria requires faithful, systematic treatment. Be sure you have the best remedy or combination of remedies, use them thoroughly, keep the patient under the influence of them till you have the disease under control or till death is certain.

vests.

Peritonitis.*

BY X. O. WErder, M. D., PITTSBURGH, PA.

While peritonitis, as a disease, was well known to physicians of all ages, a full knowledge of its pathology and an intelligent method of treatment is clearly the work of modern investigators. Its etiology, particularly, was very little understood until the phenomenal advances in abdominal surgery cleared the darkness and threw light into the mysteries hidden in the abdominal cavity. Hand in hand with the surgeon worked the pathologist, and their combined efforts brought about a revolution of our views of the disease and its treatment. In no branch of medicine has such wonderful progress been made as in that pertaining to the peritoneum and the organs it inIt is true this progress has benefited surgery much more than medicine; so it appears that peritonitis, at least many of its forms, is rapidly becoming a surgical disease. The diagnosis of peritonitis does not satisfy the progressive mind of the modern physician; he has learned the importance of striving to arrive at its cause and seat which, though contained in that large cavity invested by peritoneal membrane, may belong to any of the many organs located there. Peritonitis is, therefore, a general name for many diseases, differing not only in their symptoms, pathology and etiology, but frequently also in their treatment. They are only alike inasmuch as they are all accom panied by inflammation of the lining membrane of the diseased organs, the investing peritoneum.

To enter into detailed description of all these forms of peritonitis would be a task impossible to me without transgressing the limits of my time. I therefore decided to confine my remarks to two large groups of this disease which are by far the most frequent and important, the one affecting with particular predilection the male sex, especially the younger portion of I refer it; the other is exclusively a female disease. to perityphlitis or, more correctly, appendicitis and pelvic peritonitis.

Formerly most inflammatory conditions in the right iliac fossa were regarded as a typhlitis or perityphlitis, the former being a catarrhal inflammation of the mucous membrane of the cæcum, the latter an extension of this inflammation to its surrounding peritoneal covering and especially of the retro-peritoneal connective tissue of the cæcum, which was frequently accompanied by abscess formation in this retro-peritoneal tissue caused generally by perforation of the cæcum through its posterior wall. These collections of pus were, therefore, thought to be outside of the peritoneal cavity. Disease of the appendix was much less connected with inflammation in the right illiac fossa. Within the last few years our views have experienced a decided change, principally influenced through the experience gained by the numerous abdominal sections made for this disease. Inflammation of the cæcum or peri-typhlitis is now regarded as * Read before the Allegheny Med. Soc., Nov. 17, 1891.

very rare, at least on the primary lesion, while appendicitis is extremely common. McBurney says that in a hundred cases of inflammation in the iliocæcal region, ninety-nine are cases of appendicitis.

An appendicitis may be a simple catarrhal inflammation of the mucous membrane of the appendix vermiformis, causing few or no symptoms, excepting, perhaps, some slight tenderness over the region, which may be easily overlooked, accompanied by more or less disturbance of the digestive organs and often some febrile symptoms. The appendix in such cases generally contains small fecal concretions which act as irritants to the mucous surface and are accused of bringing on the inflammatory trouble, though in eight cases operated on by Lewis A. Stimson in only one were there concretions of sufficient size to be justly blamed for the existing condition. Foreign bodies, such as cherry pits, grape seeds, etc., are much rarer the cause than was usually supposed, and according to Jacobi it is probable that "few, if any foreign bodies enter the process unless the latter has previously lost its elasticity and contractility by an inflammatory change." This catarrhal inflammation may be followed by a complete resolution and permanent cure, but in many cases frequent relapses occur. The appendix may not be able to rid itself of these irritating fecal concretions, or the previous inflammation may have left a stricture at its cæcal orifice followed by retention of its own secretion which may give rise to renewed attacks of inflammation, especially if excited by some traumatic influence. This may not confine itself to the mucous membrane, but extend to the submucous tissues and serous coat. Lymph is thrown out over its neighboring structure and adhesions are formed encapsulating the original seat of disease, the appendix, and surrounding it by a barrier intended by nature to protect the general peritoneal cavity, should ulceration and perforation result in the appendix.

An abscess now forming would, contrary to olden teachings, be intra-peritoneal, though not communicating with the general peritoneal cavity; loops of intestines glued together may form the abscess wall and prevent general septic peritonitis and death. The mass often felt in the right iliac fossa is nothing else than this exudation surrounding the diseased appendix which may have become organized into a distinct abscess wall. When inflammation and perforation come on suddenly and before nature has time to protect the general peritoneal cavity by such a provisional lymph-barrier, a violent septic peritonitis is the result, with death in two or three days. The autopsy of such a case I witnessed three or four months ago. The subject was a young, vigorous man who was taken severely sick with peritonitis and died at the end of the third day. The whole abdominal cavity was in the condition of septic inflammation; the appendix was perforated and sloughing, containing a cherry pit, and the cæcum almost gangrenous and also perforated. In such cases there generally have been previous attacks of appendicitis, though in this instance no history of such could be obtained.

If an abscess has formed the pus may find its way under the abdominal walls or into the retroperitoneal tissues, or it may rupture into the general peritoneal cavity, or into an intestine. Within three months I have seen two cases with rupture into the bowel. In one, a boy of sixteen years, the only

thing he complained of when he consulted me was inability to walk on account of stiffness and contraction of the flexor muscles of the thigh. An examination revealed a deeply seated mass in the right iliac fossa, tender on pressure. As this mass in spite of rest and appropriate treatment, increased in size it was decided to operate. On the morning of the day set for operation he had a number of stools containing evidences of pus, and the mass had almost disappeared. The other case had two attacks of appendicitis within three months; during the second of which the abscess ruptured into the bowel. In both this accident was followed by rapid recovery.

The disease may produce no symptoms outside of those of an ordinary indigestion, so long as it is confined to the mucous surface of the appendix. Severe symptoms point to a more violent inflam. mation not confined to the appendix alone. Such cases may be ushered in by vomiting, and sometimes purging accompanied with severe pains, particularly in the ilio-cæcal region; the pulse is accelerated, temperature often high, face anxious. On pressure we find tenderness over the seat of the disease, the abdominal muscles over the region are tense and rigid. Tympanites may supervene. These symptoms may continue three or four days and then gradually subside. In many cases a tumor can be felt in the region of the appendix. If these symptoms continue unabated beyond the third or fourth day, especially if tympanites increase, the pains remain severe, the pulse becomes accelerated, the temperature rises to 102° or 103°, perforation and formation of abscess may be looked for. Cases beginning with violent symptoms, intense pain, severe vomiting, marked tympanites, great tenderness in the ilio-cæcal region which papidly spreads over the whole abdomen, rapid pulse, are of the gravest nature and denote perforation into the general peritoneal cavity. A pulse of over 120 with rapid breathing, slight cyanosis, are extremely bad prognostic symptoms, as they are the expression of toxic effect on the action of the heart.

Frequently appendicitis does not have a typical course and its diagnosis may be very difficult. The pain may be referred to other parts of the abdomen, the cæcum being such a movable organ, that displacement and change of position is not infrequent. Then again it may be disguised by other symptoms or complications, such as strangulation or obstruction of the bowels. Ransohoff reports twelve cases in which appendicitis ran its course without any other symptoms than those of internal strangulation of the bowel. Hartly also reports two cases in which an operation was performed for internal strangulation which proved to be intestinal obstruction from adhesions to the wall of an abscess formed by a gangrenous appendix. It would therefore be well in all obscure acute cases of abdominal troubles to keep in mind how frequently appendicitis bears a causative relation to many of these acute affections of the peritoneum. In obscure cases "McBurney's point" may be of some diagnostic value. In McBurney's experience in every case "the seat of greatest pain, determined by the pressure of one finger, has been exactly between an inch and a half and two inches from the anterior superior spinous process of the ilium on a straight line drawn from the process to the umbilicus. This point indicates the base of the appendix where

it arises from the cæcum, but does not demonstrate that its chief point of disease is there."

The large majority of cases of appendicitis recover. Statistics in regard to the mortality of the disease. differ greatly, however. It is a remarkable fact that German statistics show a much more favorable prognosis than those of America. Dr. Fred. Lange, of New York, thinks that either appendicitis in America is more fatal than in Germany or else the very severe cases in that country do not go to the hospitals, from which such statistics are derived. He says "Americans eat much, particularly concentrated food, masticate very little and suffer from constipation," and are, therefore, particularly liable to this disease. Renvers treated at the university clinic in Berlin, within four years, fifty-four cases, of which three died. It is also stated that out of 2,000 cases of inflammatory conditions in the right iliac fossa in the German army, 96 per cent recovered without operation. Nothnagel treated at his clinic in Vienna from 1882 to 1890, 65 cases, 55 men and 10 women, two-thirds of them between the ages of 11 and 30 years, with a mortality of three. Matterstock, however, gives out of 177 cases 30 per cent mortality, of 70 children under 15 years, 70 per cent. Fitz in the "Transactions of the Association of American Physicians," states that he observed 72 cases, of which 74 per cent recovered and 26 per cent died.

Simple cases of catarrhal appendicitis usually make a speedy recovery under treatment by absolute rest in bed, restricted diet, laxatives, particularly calomel or the salines, morphine, hypodermatically if absolutely required for pain, hot fomentations and possibly leeches. It is the severe forms that give the physician greatest anxiety and tax his skill to the utmost. The greatest difficulty is to decide when to interfere surgically. Unfortunately the symptoms are only too often unreliable guides; often when the symptoms indicate the necessity for operation the patient has already passed beyond the hope of relief.

Lewis A. Stimson says: "We have no means of distinguishing those cases which will go on to the formation of an abscess without accident from those in which evolution will be gravely interrupted." He, therefore, recommends early laparotomy (within the first three days) as it enables us to avert the process by the removal of the cause, and regards it as less dangerous than the expectant treatment. McBurney states: "The pathological condition of the appendix as compared with the symptoms in my own cases most positively show that one cannot with accuracy determine from the symptoms the extent and severity of the disease." Mynter says: "That we are utterly unable to judge correctly from the symptoms alone of the extent and severity of the appendix lesions and for this reason alone abdominal section must be the safest method of treatment."

I believe that the advice of Thos. S. R. Morton, who in connection with his father, Thos. G. Morton, has devoted considerable attention to this disease, and whose experience in the surgical treatment of this disease has been quite extensive, is not only good but sufficiently conservative to meet the approval of the nonoperative physician. It is, "to operate not later than the third day of the disease, if the patient up to that time has failed to markedly improve, under rest, restricted diet, purgation and topical applications. Especially should this rule be adhered to in cases where we have failed to move the bowels

they are apt to be of the fatal cases. Further than this we should invariably operate as soon as the presence of pus is assured; when peritonitis is developing and spreading; when signs of sudden rupture of an abscess into the peritoneal cavity appear, and when septicemia from septic absorption is taking place. In children operation must often be done earlier than in adults, as in them the malady is more speedy in development, more fatal in tendency and shows greater proclivity to involve the general peritoneal cavity." (Thos. S. R. Morton, Philadelphia County Society, Sept. 28th, '91.)

Pelvic peritonitis is the most common form of peritoneal inflammation in the female. It is most frequently localized with a tendency to remain so, and follows an essentially chronic course, with occasional acute exacerbations. More so even than appendicitis is it characterized by frequent relapses. One-third of all gynecological cases are victims of this disease. Bande found residue of circumscribed peritonitis in more than half of all female cadavers, Winkel in more than 33 per cent, A. Martin in 122 out of 287 cases of tubal disease.

The cause of pelvic peritonitis, or perimetritis as it is also called, in a large majority of cases, is diseased tubes. This is a fact which has only been learned quite recently. Most inflammatory conditions in the pelvis were thought to originate in the cellular tissue and from there sometimes to invade the peritoneum; cellulitis was, therefore, the primary and most important disease. Not later than six years ago, Emmet, in the last edition of his work on Diseases of Women, says: "I shall employ the term "cellulitis" in expressing the most common condition of pelvic inflammation in connection with nonpuerperal diseases of women. Pelvic peritonitis will not be treated of as a distinct lesion, but as an accident, rendering the case of cellulitis more grave in character from this complication."

The first description of the true pathology of pelvic inflammation was given us by Bernutz and Goupil over thirty years ago, who, by a careful examination of ninety-nine cases, both during life and in the postmortem room, pointed out very clearly that it was not the cellular tissue which was involved in this inflammation, but the peritoneum and that the cause of it originated in the fallopian tubes. Their teaching, however, was entirely ignored until operative surgery has opened up the peritoneal cavity to daily explorations and found the conditions exactly as described by these investigators. The masses and indurations generally found in the pelvis by bimanual examinations and spoken of as exudations in the pelvic cellular tissue can be removed by the surgeon from the peritoneal cavity; they do not involve the cellular tissue to any extent, but consist of ovaries and tubes folded upon themselves, matted together by exudation and adherent to the posterior surface of the broad ligament of the uterus. Frequently we find also intestines and omentum or an appendix as a part of the tumor. Polk, in 1886, in a paper on the "study of sixteen cases, of the so-called pelvic inflammation, known as 'pelvic cellulitis,'" states that abdominal section was made in all these cases and the lesions found were salpingitis, periovaritis and pelvic peritonitis. In two of ten cases there was slight oedematous swelling of the cellular tissue in the broad ligaments, just beneath the spot, at which an inflamed tube had rested; in the remainder the most careful examination failed to de

tect the slightest induration or swelling in any part of the cellular tissue that lay about the uterus or between the layers of the broad ligaments."

Dr. N. C. Coe (Exaggerated Importance of Minor Pelvic Inflammations) says: "Of half a dozen fatal cases of hysterotrachelorrhaphy and incision of the cervix in which I enjoyed the rare opportunity of studying carefully the sequence, in every instance the cause of death was acute diffuse peritonitis." In regard to the more chronic cases to which circumscribed areas of inflammatory exudations were found, he states that "peritonitis is certainly the most prominent element in most of these cases, so far as the postmortem appearances afford any light," and again" By far the greatest number of these indurations are situated high up in the broad ligaments and consist of cicatricial masses, mostly confined to the peritoneum of tubes and ovaries surrounded by old adhesions or occasionally an imprisoned knuckle of intestine. confess that I have rarely (perhaps half a dozen times) found such thickening in the cadaver which could be inferred to a pure and straightforward cellulitis, and this, too, when I have recognized by the vaginal touch (before and after death) what seemed to be an induration, a distinct band extending outward from a deep. laceration of the cervix or a condition of tension in or above one lateral cul-de-sac, which did not exist on the opposite side."

I

Joseph Price, who has been in the abdominal cavity oftener than any other American surgeon, says: "The operative gynæcologist does not find any pelvic cellulitis." Lawson Tait is equally emphatic on this subject.

Having established that cellulitis is a rare disease, at least outside of the puerperium, and that what we used to regard as such is in reality, in the large majority of cases, a pelvic peritonitis from the outset. We will now briefly inquire into the etiology of the latter. A diseased tube is usually the focus from which the peritoneal infection starts. Disease of the appendages may have preceded the attack of peritonitis for weeks or months, when a leaky tube may precipitate a peritonitis, that is, the secretion pent up in the tube may discharge through the abdominal orifice of the tube into the peritoneal cavity as the result of hyperdistention, trauma, violent exertion, etc. Or the tubal disease may arise acutely and extend at once to the peritoneum, the most common causes in producing inflammation of the uterine adnexa puerperal infection, gonorrhoea, extension of an endometritis to the tubal mucous membrane, a catching cold, especially during menstruation, etc. skillful intrauterine treatment, minor operations about the cervix, such as Emmet's operation, dilatation, etc., especially if done without the strictest antiseptic. precautions, are frequently followed by salpingitis and subsequently peritonitis; the introduction of an unclean sound, especially if it produce a lesion to the mucous or muscular surface of the uterus, frequently results in pelvic inflammation. The symptoms of pelvic peritonitis vary considerably in intensity, while often so mild as to escape our attention, its onset may, especially if due to a leaky pus tube, be so sudden, severe and violent as to resemble a peritonitis following perforation. The disease is usually ushered in by a chill, fever, more or less severe pains in the lower part of the abdomen, back and thighs, irritability of the bladder, sometimes rectal tenesmus. The hypogastric region is tender on pressure and vag

Un

Within forty-eight

inal examination very painful. hours a swelling may be noticed on bimanual examination, which in a few days may reach to the umbilicus. It is at first soft, baggy, almost fluctuating, but gradually becomes firmer until it often appears as hard as a board.

Under rest, opiates to relieve suffering, hot fomentations and after the febrile symptoms have subsided, the iodides internally and tonics, and the local applicatien of iodine over the abdomen and to the vaginal vault, hot douches, glycerine tampons, iodoform, ichthyol, etc., the exudation gradually decreases until after a few weeks or months it has become imperceptible. The patient's appetite has improved, her pains have lessened or disappeared entirely, she is gaining flesh and regards herself as cured. The inflammation however, does not always run such a smooth course. Instead of ending in resolution it may go on to suppuration. Abscesses form and may discharge through vagina, rectum, bladder, abdominal walls, or intestines. They may then heal spontaneously, very rapidly or they may continue to discharge indefinitely, until the patient dies from exhaustion or sepsis, unless surgical measures are adopted. Even if the disease ends in resolution, this does not always mean cure, on the contrary it is often followed by a life of misery and suffering. When the patient returns to her ordinary duties she finds that she is unable to fulfill them. She has aching in her back, abdominal pains, increased on slight exertion, disturbance of her gastric functions and other reflex symptoms. Her menses are more profuse than formerly and more painful, marital relations are accompanied with suffering or may have become utterly unbearable in that, she presents the picture only too familiar to every physician practicing in gynæcology. Examination reveals extreme tenderness over one or both uterine adnexa; perhaps some thickening in the region of tube and ovary; or you may find large masses in the region of tube and ovary and filling up Douglas' point. In other words, while all active peritoneal inflammation may have subsided, the focus of the disease, the diseased appendages, have remained and wait only a favorable opportunity to light up another acute pelvic peritonitis. I have seen three and four such attacks within one year. Such cases will probably go on from bad to worse until these diseased appendages are removed.

For the sake of convenience the results of pelvic inflammation may be tabulated in five groups.

1. Complete resolution and recovery. Such cases are restored to perfect health and are able to bear children.

2. Adhesions about ovaries and tubes which, however, do not affect the general health of the patient, but are frequently associated with sterility.

Recovery with a catarrhal salpingitis and possibly oöphoritis which under proper, but often prolonged treatment, improve and often get perfectly well.

4. Includes cases of old and obstinate forms of salpingitis, hydrosalpinx and oöphoritis, who pass from one physician to another, or from one quack to another and are doomed to permanent invalidism unless relieved by the removal of the diseased organs.

5th and last are principally the victims of grave puerperal infection or gonorrhoea, suffering from pyosalpinx and ovarian abscess, which are certainly threatening their lives and are only curable by laparotomy.