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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.
"Diagnosis: Acute diffuse appendicular peritonitis, probably also perforation; circumscribed perityphlitic abscess." "Operation was considered but not performed. Removal to the hospital for the purpose of an operation was absolutely declined by the patient." "I saw him upon the following day, the fourth of the disease."
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.
Especially is this true when it is a positive fact that all typhlitic and appendicular abscesses will open into the bowels if allowed to do so. In this ease I reasoned as follows: This must be a case of abscess, for the signs of obstruction are not those of complete obstruction, such as are seen in hernias, volvulus, constricting bands and many other causes not necessary to mention.
"A, ileo-colic artery; B and F, posterior cecal artery; C, appendicular artery; E, appendicular artery for free end; H, artery for basal end of appendix; 1, ascending or right colon; 2, external sacculus of the cecum; 3, appendix; 6, ileum; D, arteries on the dorsal surface of the ileum." Byron Robinson. The reader will see how very much like a blind pouch the cecum is, 2.
If the attack is an acute one, use the "Cascade" every third hour until relieved. This injection should be retained at least half an hour longer if necessary. If this does not break loose the obstruction, resume the use of the "Cascade." Hot fomentations over the appendicular region are valuable. Give no medicine, it can do no good, but may do infinite mischief.
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