The doctor is in error when he gives the name of “Acute, Diffuse Peritonitis.”  The case could not have been peritoneal perforation at the start, for the symptoms do not justify the diagnosis.  A perforation causing diffuse peritonitis so early would have a higher pulse and temperature, and death would have followed within a few hours.

I can believe that there might have been an ulcer extending to the peritoneal covering, and this set up local peritonitis; but there was not at any time before the fatal relapse, a toxic inflammation within the peritoneal cavity; hence there was not diffuse peritonitis, and there could not have been without complete perforation which would have ended the case in death very soon.

In this case the point of infection was walled in, as all such cases are, with exudates and whether the appendix was primarily affected or not doesn’t matter; it was within this enclosure and found to be ruptured, which is common; but its rupture was of no consequence because the escaped contents were in the abscess cavity that finally emptied into the cecum, the natural outlet in all these cases if they are left to nature and not officiously fingered—­thumbed and punched to death.

The distinction drawn by this author between toxic and bacterial peritonitis is, to my mind, a distinction without a difference.

In this case the tympanites following the obstruction was due to the fact that the gas in the bowels was retained for a few days because of the completeness of the obstruction, and would have passed off in three days had it not been for the paralyzing effect of the opium; hence the distention that came from gas was succeeded by the distention peculiar to opium and caused the doctor to believe that he had a case of diffuse peritonitis when, in fact, he had a case of gas distention due to morphine paralysis.  The morphine directly and indirectly weakened the heart.  The distention of the bowels was a constant interference.  The pulse at the start was fine at 112, but in six days it had increased to 140 and finally reached 160.

CHAPTER VIII

The following case comes to my mind, for some of the initial symptoms are similar to those of the case just described:  M. B., age 42, farmer, was taken sick with the usual symptoms of appendicitis as near as I could get the history from his wife, who was his nurse.  He lived twenty miles from Denver.  When he was taken sick he called a local physician who treated him for bilious diarrhea. The drugs used, as near as the wife could remember, were small doses of calomel followed with salts to correct the I liver, morphine for pain, and bismuth and pepsin for digestion and diarrhea, and quinine to break the fever; also hot applications on the bowels.

The pain was so great that morphine had been given quite freely.  At the end of one week the sick man, being no better, declared that he would go to Denver and consult another physician.  When he told his physician what his intentions were, the doctor advised him not to attempt the trip himself, for he was too sick, but to send for the physician.  The sick man was willful and forceful, and he was also afraid of the cost; and, being a plucky fellow, he declared that he could go just as well as not and that he would and he did.