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"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."
"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."
"Moreover, the bacterial finding of streptococci and cold bacilli in the perityphlitic abscess is typical, and the limitation of the diffuse peritonitis to areas below the omentum is also instructive. This simultaneously prevented the invasion of organisms producing inflammation into the serous surfaces above." "This strong man, aged 31, had previously regarded himself as perfectly well.
This fact is pointed out by the prompt retrogression of the diffuse peritoneal symptoms after rupture of the abscess; the diffuse peritonitis of this stage might then be designated a nonbacterial 'chemical' inflammation, according to the terminology now in vogue; finally, it was positively a bacterial infection, although the postmortem finding of bacteria in the distant folds of the peritoneum is not proof of this; we know that during the terminal agony or after death these may wander a long distance from the perityphlitic focus."
The point of rupture, however, then closed, and partly perhaps to the action of fresh infectious and toxic material, perhaps only to the perforation of the appendix, may be ascribed the exacerbation of the peritonitis, that is, a renewed attack which caused the death of the patient." Please note particularly: The appendix was found in a pus cavity a perityphlitic abscess.
"The pulse from the onset was comparatively frequent, regular and somewhat tense. In regard to the dejecta, the two passages at the onset of the disease pointed to increased peristalsis; this was of short duration, soon changing to the opposite condition, and until the rupture of the perityphlitic abscess absolute constipation existed."
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.
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.
If the child is fed, and the tumor manipulated subjected to unnecessary examinations the abscess may be made to burrow down toward the groin, which should be avoided for it is a very undesirable complication. The first abscess is typhlitic, the second is perityphlitic.
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.
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