“Opium at first decidedly influenced the condition; the patient took daily 0.5 to 1.8, and since yesterday morphin subcutaneously 0.02 at a dose.”

[Of course, anyone acquainted with opium knows that it loses its effect, but it never fails to do its damage.  The daily intake of 7-3/4 grains to 27.5 grains must lead to trouble.]

“Ice bags were not well borne, and Priesslitz compresses were used continuously.  The intake of food was reduced to almost nothing.”

[Not one teaspoonful of food should have been given; under such treatment this case would have been very comfortable.  Foods and drugs were the cause of the discomfort.]

“With a sharply circumscribed perityphlitic abscess there could be no doubt of the diagnosis of diffuse peritonitis nor of the indication for operation on account of the long continuance of the severe symptoms.  But neither this proposition nor that of an exploratory laparotomy, the result of which might have induced the patient to yield, was accepted.”

[It is an evidence of professional officiousness to say positively that there was a “sharply circumscribed perityphlitic abscess.”  How was it possible with meteorism as described, to say that there was a sharply circumscribed perityphlitic abscess?  It was tacitly assuming a diagnostic skill that must test the strength of every American physician’s credulity to the utmost.  The long continuance of the severe symptoms was no fault of the disease.  The worst case should be made comfortable in three days.

Just why diagnosing a perityphlitic abscess should have cleared the diagnostic atmosphere to such an extent as to justify one in declaring that, since the discovery of the abscess there could be no doubt of diffuse peritonitis, is hard to understand.  According to my training in the worth of differential diagnosis, I should look upon such a diagnosis as most excellent proof that the peritoneum was still intact, and, if the case were handled carefully, its intestine sacredness would remain free from the vandalizing influence of toxic infection.

I am not inclined to accept the diagnosis, for within twenty-four hours the abscess broke into the cecum, and if the case had advanced to perityphlitic abscess, the pus would have burrowed downward towards the groin and would not have terminated as early as it did.  My reason for so believing is that we always have a typhlitic or appendicular abscess at first; which naturally opens into the bowel, but if the abscess be interfered with—­handled roughly enough to rupture the pyogenic membrane—­the pus is forced into the subperitoneal tissue where it may gather and become encysted, but this is exceedingly doubtful.  When the pyogenic cyst is once broken the pus becomes diffused, and as it has no retaining membrane it burrows in all directions, and more or less of it is absorbed, causing pyomia.

The parts may be handled to such an extent that the abscess will be forced to develop low down toward the groin, so low that the natural outlet, through the intestine, will be impracticable; under such circumstances an outside opening with drainage is the only choice in the matter of treatment.