ANNUAL ADDRESS DELIVERED BEKOKE THE Jibuti, NOVEMBER 1 2, IS 72, BY JOSEPH LEWI, M.D., PRESIDENT or THE SOCIETY'. KENT AK A COMMUNK ATION TO THE: NE:W TURK STATE: MEDICAL SOCIETY. BY RESOLUTION OE' THE ALBANY COUNTY MEDICAL SOCIETY. ALBANY, N. Y.: . JUKI, MUNSKFiL. 1 H 7 8 . ANNUAL ADDRESS DELIVERED BEFORE TUE NOVEMBER 12, 1872, r / BY JOSEPH Lyrtl, M.D., PRESIDENT 0FJ<1e SOCIETY. HUNT AS A COMMUNICATION TO THE NEW YORK STATE MEDICAL, SOCIETY, BY RESOLUTION Or TIIK ALBANY COUNTY MEDICAL SOCIETY. ALBANY, N. Y.: JOEL MUNSELL. 1 873. ADDRESS. idiopathic peritonitis. % Gentlemen of the Society: The variety of cases of peritonitis, as well as the many different causes by which this malady is contracted, make it very laborious for authors to dwell in detail on each; and while the student is allowed to profit in general knowledge by reading the lengthy articles about peritonitis, he does not derive the necessary information for the manage- ment of his cases. And very naturally so. In most of the cases, peritonitis is the result of a traumatic injury, and the surgical as well as the medical treatment must depend upon the extent of the injury done to the peritoneum and adjoining parts. In other in- stances, peritonitis is due to effusion of the con- tents of an abscess into the cavity of the abdomen, or it is the result of a strangulated hernia, in all of which cases the treatment of the peritonitis will be subordinate to the general surgical treatment. Peritonitis propagated from inflammations of other adjoining organs—stomach, liver, spleen, intestine—are considered and treated as secondary. 4 To puerperal peritonitis authors devote deserv- edly particular attention, on account of the fre- quency of cases, of the virulence of its character, and the great mortality from it at certain times in certain localities. The above named kinds of peri- tonitis are especially favored by the different authors of the present time with minute descrip- tion of the nature, the symptoms, and the treat- ment of the same, leaving for the idiopathic, or, as some call it the rheumatic peritonitis, only a little space, under the idea that this malady, contracted by a cold, is very rare and hardly ever attacks persons in general good health. Although this last mentioned kind of peritonitis is not so frequent as inflammation of other serous membranes, especially the pleura, I venture to maintain that peritonitis, especially in childhood, say from two to fifteen years of age, is of more fre- quent occurrence than pericarditis, and, from causes to be stated, more fatal than pleurisy. I will also state here that a twenty-six years’ prac- tice has taught me that this malady presents to a young practitioner more difficulties in forming a diagnosis and adopting a mode of treatment, and more embarrassment in giving satisfaction as to the prognosis, than any other inflammation. I therefore propose to say in this address a few words on idiopathic peritonitis. Sometimes there are no premonitory symptoms; but in most of the cases a chill, slight or violent, will compel the otherwise well-appearing individ- ual to retire from his avocation. After six or twelve hours the inflammation will, in very dis- tinct cases, manifest itself by an intense fever, fre- quency of the pulse, high temperature, and a more or less violent pain in one or the other side of the abdomen, which side or spot will be very sensitive to the touch, so much so that the pressure of the bed-covers will be intolerable; the patient lying immovably on his back, his lower extremities drawn up. The patient talks little, and in a low tone. After a shorter or longer period the abdo- men becomes bloated and filled with gas, which crowds against the diaphragm to such an extent that the lungs are compressed and impeded in their action. Respiration becomes difficult and frequent. Constipation and vomiting most gener- ally accompany these symptoms of acute peritonitis. In fatal cases all these symptoms increase in inten- sity, the abdomen becomes hard and tympanitic, the lungs and heart become so compressed that the respiration is very laborious, and the agony of the patient is terrible. At last he becomes apa- thetic and delirious, the pulse grows smaller and more frequent, the skin is covered with a cold sweat, and the patient dies. In a great many cases the disease does not reach such a desperate height. The symptoms having culminated, the intolerable pains and difficulty of breathing grow gradually less and less severe, and the patient recovers after the lapse of a few days or weeks. And in some instances, even after the mal- ady has assumed all the bad features described above, it makes a retrograde movement; the symptoms come to a stand-still, absorption of the infiltrated blood takes place, or an abscess forms, the contents of which either discharge through the walls of the abdomen by nature’s effort or by sur- gical interference, or they penetrate into the adjoin- ing rectum or bladder, whence they are expelled with the faeces or urine,—and the patient may recover entirely, or may be troubled temporarily, or for the remainder of his life, with the results of this extraordinary termination of the disease. So far the regular process of cases of idiopathic peritonitis, as described by most authors and known to all practitioners. The management of such cases of peritonitis was, as late as twenty-five years ago, strongly antiphlo- gistic. Blood-letting by venesection and the appli- cation of leeches, mercurial preparations internally and externally, scanty nourishment, and the mild- est of drinks in the inflammatory stage, absorbents internally and blisters externally in the stage of exudation,— such has been the treatment pre- scribed by the authors of former times. This plan has now been almost universally abandoned as irrational and pernicious, and, although it has been demonstrated that by promoting the peristal- tic motion of the bowels the symptoms of inflamma- tion will become aggravated, and the inflammation extend, and that the loss of blood (by venesection or leeches) will add so much to the general de- bility resulting from the disease itself, as to de- stroy the energy of the constitution of the patient so essential to reaction, and although we must admit that vast numbers of the human race have suffered an untimely death by this course, my long experience and close observation compel me to say here that there are exceptional cases of peritonitis where the application of leeches, and even venesec- tion, is not only permitted, but imperatively de- manded to save life in some instances, and to bring on a speedier recovery in others. If a person ex- traordinary in development and plethoric in ap- pearance is, after exposure, etc., seized with all the above-described abdominal symptoms to such a de- gree as to bring within twenty-four hours his pulse to 120 or 130, the temperature to 103°, and the res- piration to 40 or 50; if delirum and a cyanotic ap- pearance of the face should accompany these symp- toms, a practitioner is, in my opinion, not only justified, but morally obliged to resort to blood- letting. I have seen in a large number of cases the most beneficial results from it. The circulation and respiration improved so much that the inflammation took its natural course and was in time conquered by less heroic means; and it is to be presumed that in a majority of these cases the violent onset would have destroyed the patient before the disease had fairly developed, and before any other measure could have made any impression on the system thus disturbed. But, with the exception of blood-letting in such exceptional cases, and counter-irritants in the later stages of the disease, all the appliances belonging to the antiphlogistic and depleting mode of treat- ment ought to be relinquished for all time to come. In a great many, and, as my experience tells me, in a majority of cases of idiopathic peritonitis, the course is irregular, and therefore not easily to be distinguished from other complaints of the abdo- men ; and if the practitioner does not take heed, and is over-hasty in farming a diagnosis, the patient’s life may be endangered, and with it the reputation of the physician. In such cases the patient becomes indisposed and morose, loses his appetite, and complains occasion- ally of a dull, annoying pain in the abdomen. Aversion to all kinds of solid food, and an inclina- tion to vomit, satisfy him or his neighbor that his “stomach is out of order,” and a “good, strong physic” is taken on his own judgment, or on the advice of somebody. The remedy so taken gen- erally distresses the patient more or less; he tries, and after awhile succeeds in throwing up the same, with whatever eatables were contained in the stomach, with a good portion of bile. After being relieved of the distress, but exhausted from the exertion of vomiting, the patient imagines that he feels better; but soon after he complains again about the pain all over the abdomen ; and at this stage only, even in better classes of society, the physician is sent for. The patient explains to the doctor that “ he is not sick ; that his stomach was only out of order for the last few days; that he was constipated ; that the physic he took seems not to have been strong enough for his constitu- tion ; that he vomited the medicine as well as bile, and that a strong laxative to remove the bile would probably be the best for his case.” The physician examines the patient, and ascer- tains that there is a circumscribed space on the abdomen painful to the touch; that there is no expansion of the abdomen, no tympanites, no fever; all the symptoms of the digestive organs correspond to the narrative of the patient, and he is very apt to act according to the suggestion of his patient, and to aggravate the case most de- cidedly. If the proper course is adopted, the patient will have the benefit of temporary relief under all circumstances, and, if it turns out to be a mild case, may recover within a few days. If it is a bad case, the symptoms will develop in the course of a day or two, so as not to leave any doubt in the mind of the physician about the nature of the disease and the necessary remedies, and then it will be time to adopt a mode of treat- ment in accordance with the suggestions of the modern authors. However difficult it may be in the primitive stage of all such cases of semi-acute peritonitis to make a correct diagnosis, and how- ever often the practitioner may become guilty of misconception and the introduction of improper treatment through the interference of the ignorant patient, it is far more difficult to avoid mistakes in similar cases of children under six years of age. Compared with other disturbances of the abdom- inal part of the body, peritonitis is of such rare occurrence that the parents or guardians, in most cases, resort either to laxatives in the form of cas- tor oil or rhubarb, or to very drastic vermifuges, and before the physician is called all the mischief is done and the case is desperate. The slight local pain has changed into a violent, excruciating one all over the abdomen. The physic given has not evacuated the bowels, but has caused them to swell up and to be sensitive to the touch. Insatiable thirst, high fever, and a tendency to vomit, are the results of the harmless medicine given yester- day. The physician, if not ripe in experience, is liable to misconception, where the history of the case is given to him by a talkative mother, who prejudices his opinion of the case; and where the general as well as the local symtoms of the inflam- mation are so indistinct as described above, he is the more liable to make a mistake as the patient is not sensible enough to describe his condition, correct the misstatements about the course and duration of his complaint, and, in his peevish con- dition, not inclined to answer questions. Misled in this primitive stage of the disease, and induced to administer purgatives, the physician will only find out his mistake when it is too late to correct it, and when, in consequence of his injudicious interference, the symptoms have assumed such a character as to make the prognosis very unfavor- able. To .avoid the commission of such mistakes in similar cases, I would advise all young and inex- perienced practitioners to take the utmost pains in making the examination; to be reserved in ex- pressing a decided opinion at their first and second call; to adopt an expectant course, and to use only such palliative remedies as will be beneficial to the patient; and to avoid all measures that could in any event have a tendency to promote the peristaltic motion of the bowels or to irritate the serous membranes of the abdomen. Warm applications in the form of wet flannel or poultices, small doses of opiates in the form of Dover’s powder or a solution of morphia, mild drinks, a horizontal position, and positive rest, will, in most of the cases, accomplish a cure and speedy recovery. In some cases the disease may assume a chronic course and require absorbents, counter- irritants, and tonics; in other instances the above described semi-acute inflammation may after a few days develop into a very violent acute inflamma- tion, and require a more heroic treatment. But, under all circumstances, even if the diag- nosis should turn out to be incorrect, and the patient should suffer from cholic or worm-fever, or the painful spot should develop into a muscular abscess, no harm will have been done and no aggra- vation of the symptoms caused by the mode of treat- ment adopted. In all cases of suspected peritonitis where the symptoms are not distinct and conclusive, the phy- 12 sician should call to mind all the diseases that could be mistaken for peritonitis. Catamenial colic, uterine colic, hysterical pain in females; pains from indigestion, bilious colic, nervous colic, inflam- mation of the duodenum, of the stomach, or of the liver, enteritis, retention of urine, worms, and wind- colic, present in some instances symptoms similar to those described in semi-acute peritonitis. The physician may ascertain the nature of the disturb- ance by closely examining whether his female patient is at or near the period of menstruation, or whether she is pregnant; he may also be able to determine in a great many of these obscure cases that the tenderness and pain indicating perito- nitis are dependent upon the irregular functions of some disordered digestive organ, or the presence of worms or gas in the intestines, and proceed ener- getically to relieve the patient at once; but if there remains a shadow of doubt in his mind about the existence of an inflammatory process in the perito- neum, he must content himself with the admini- stration of such remedies and appliances as to relieve the patient of pain and distress, to give him the necessary rest and comfort, and to keep his strength and vigor intact for the expected struggle. Now, gentlemen, let me congratulate you on the happy termination of another year of the Society’s existence and prosperity; let me thank you in the highest terms for the support given me, for the numerous attendance at the meetings, for the inter- esting contributions and instructive debates, as well 13 a8 for the peace and harmony maintained during the last year’s administration. Allow me, gentle- men, also to draw your attention to the memory of one who has been associated with this Society for more than half a century, who has been a use- ful and efficient member of this as well as the State Medical Society, and who departed this life, after having labored faithfully in the profession that he loved so well for more than fifty years, ripe in years and honored by the profession as well as the community. I allude to our brother the late Dr. Peter Van Olinda; and, while we deplore his loss, it is a matter of congratulation that this is the only loss by death our Society, numbering one hundred and fifteen members, has sustained; and he almost an octogenarian. You have this year admitted fifteen new members,—the largest number during one year since the existence of the Society.