“Somewhat less rapidly than this, but nevertheless in the course of a few hours, another change took place, a favorable turn following the rupture of pus into the intestine.  Here we were dealing with a well known and familiar phenomenon; if this occurs in the peritoneum the effects are particularly well marked; similarly as in the case of a phlegmon which rapidly disappears with the discharge of pus even although the inflammation extend beyond the pus focus, the symptoms of diffuse peritonitis promptly disappeared after the rupture.  Very likely, as has already been stated, the symptoms of diffuse peritonitis in the first stages of the disease are to be referred to a chemical inflammation of the serosa, i. e., one due to toxins and without the ingress of bacteria; and it must be remembered that the clinical picture of this chemical peritonitis cannot be differentiated from that of the severe bacterial form.  With the rupture of the abscess, the entrance of poisons into the free peritoneal cavity, and their resorption by the extensive peritoneal surfaces, as well as the vomiting and the intestinal paralysis, ceased.  The taking of nourishment again be came possible.

“The point of rupture formed adhesions, the natural drainage of the peritoneal ichorous focus ceased, perhaps a new influx of inflammatory material from the perforated appendix also took; place.  There was a fresh relapse of the local peritonitis which extended beyond the boundaries of the limiting adhesions, and permitted the invasion by bacteria of the free abdominal cavity.  This, time the severe toxic picture of collapse immediately followed, and with marked decrease in cardiac strength led to death.

“Doubtless the patient might have been saved in the first stages of the disease by the evacuation of the abscess; the incision would at first have acted similarly to spontaneous rupture into the intestine, but the relapse would have been prevented by permanent drainage, and a radical cure might have been brought about by the immediate or subsequent removal of the appendix.

“Opium, no doubt, had a favorable effect upon the affection.  By relieving intestinal irritability, and by bringing about a mild degree of narcosis, the patient was kept quiet and this materially assisted in limiting the severe perityphlitic suppuration in the first stage of the disease.”

[All of which is positively not true, as I have witnessed for years.]

“If, as it unfortunately happened, the point of rupture had not immediately closed again, if it had remained open until suppuration ceased and contraction and healing of the perforated appendix had taken place, opium would have been regarded as instrumental in saving the patient, and unquestionably, at least to some extent, justly so.  Among other factors in the treatment, the relief to the intestine by the suspension of nourishment was of paramount importance.  The subcutaneous saline infusion had an obvious but, naturally, only a transitory effect.”