In this case opium and morphine were given; this was very bad treatment, for these drugs always produce nausea and vomiting, exactly what was not desired because of the evil effect the retching had on the forming abscess. It is true that these cases frequently vomit the first three days after the obstruction, but there is practically no danger from retching that early in the disease. Again, the opium masked the case dreadfully; for it produced vomiting at that stage of the case when there should have been no trouble with the stomach at all, and induced a tympanites that was mistaken for the same state brought on by peritonitis. In this case the doctor was in a mental mist from the beginning to the end; notwithstanding he was so confident that he knew all about his patient, that he has given the case a careful summing up so that it may be put with the medical classics. 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