Now we will go over Dr. Vierordt’s case in connection with mine and see if his case of diffuse peritonitis is not about as near like my case as it is possible to have two cases.

His patient was a merchant 31 years old, mine a farmer 42 years old.  There is a difference in these two men, caused by their occupations.  The merchant could not have made the trip to my office as did the farmer, for several reasons:  First, merchants are pampered; they are not used to discomfort; they are not used to waiting upon themselves as country men are.  When they are sick they send for the doctor; the farmer goes to the doctor.  The merchant has learned the habit of spending his money and the farmer has learned the habit of saving his, and perhaps that one statement is enough for the discerning.

The merchant was too sick to make such a trip and he knew it.  The farmer was too sick to make the trip and he didn’t know it.  This is the vital difference between these two cases.

The merchant was tympanitic from the first day of his prostration, which is not usual.  On the fourth day his temperature was 104 degree F., pulse 120 to 136, mind clear but anxious.  His lesser symptoms were about like the farmer’s, with the exception that the merchant had been given more narcotics and presented more of the dorsal decubitus than the farmer.  Laymen, the plain everyday meaning of dorsal decubitus is lying on the back.  In low forms of disease it is looked upon as an unfavorable symptom.  Where much morphine has been given it denotes prostration peculiar to the drug.  My patient was on his back for several days, because it is impossible for a patient to stay on either side while suffering from severe tympanites.

On the sixth day the merchant’s pulse was 140 and the temperature 101.3 degree F., which proves, if nothing else does, that he did not have diffuse peritonitis, for it is impossible for a patient to have acute, diffuse peritonitis, be drugged and fed, and go through the daily physical examinations such as he was put through, and on the day before the abscess breaks into the bowels show a temperature of 101.3 degree F. The pulse counts for nothing in such a case as this; I did not look upon the farmer’s pulse as indicative of any serious state, for I knew the opium had caused it.  If the pulse of either the merchant or the farmer had been due to peritonitis death would have ended either one before his abscess had broken.  In fact diffuse peritonitis comes from perforation with discharge of the abscess contents into the peritoneal cavity, and it always spells death.

When vomiting recurs, or continues after the third day, there is malpractice, or there is a serious complication, or there is a mistaken diagnosis.

It is well to get this one fact well in mind, namely, appendicular and typhlitic abscesses are not accompanied with complete obstruction; hence, when the symptoms are so profound as to point to absolute obstruction, no delay should be made in having the abdomen opened and the obstruction, whatever it is, should be removed at once.