The pulse was 130, temperature 102 degree F., in the forenoon; he had been troubled with nausea a great deal, but with the exception of one or two vomiting spells, the first and second day, the nausea did not often cause retching. The mouth and lips were dry, tongue coated, bad taste in mouth and breath very offensive.
The reason there had not been more vomiting in this case was because there was diarrhea at first and not quite so much locked up fecal matter as common. The bowels had been relieved of the usual accumulation more than is common to the majority of such diseases before the swelling and fixation had become established.
There is a small percentage of people who are not quite so irritable as others; in these the contraction, constriction or fixation—the embargo laid on these parts by nature in her conservative effort at preventing movement—is not established quite so early, and the efforts on the part of doctors to force a movement are more successful in cleaning out a part of the accumulation; or there may come a diarrhea from the putrefactive poisoning which is causing the infection of the cecum or appendix and leading to abscess, and this causes a partial cleaning out before fixation is established; in these cases there is never so much vomiting nor nausea, neither do they suffer so much pain for there is not the usual accumulation in the alimentary canal to excite the peristaltic movement.
The history that the patient and his wife gave me from memory was that the urine had been scant, and at times painful to pass. There had been from the start severe pain in the lower bowels, but neither the patient nor his wife could remember if there had been more pain on right, lower frontal region than anywhere else; they both declared that the pain was all through the bowels and that there was much bearing down like unto the pain of a diarrhea.
Breathing was shallow, of course; it never is otherwise in severe abdominal distention.
I scarcely touched the abdomen, for I knew I dare not press, in percussing, enough to distinguish any sound except the tympanitic. It has never been my custom to allow my curiosity to run away with my judgment, and cause me to make needless examinations.
All examinations are needless when, it matters not what the diagnosis can or must be, the treatment will be the same. All possible bowel troubles which present the same general symptoms of the disease I am here describing, must receive a like general treatment. This being true, it matters not what the difference is, there cannot be a variation requiring a bimanual examination to differentiate it that will justify the risk. All examinations are needless and criminal when there is a possibility of rupturing an abscess. 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. If there were complete obstruction there would be increasing nausea and vomiting, ending in collapse and death. This tympanites cannot be from peritonitis for perforation would be necessary to cause it and nothing would stop the progress after it had once started except to open the cavity wash and drain. Hence this cannot be peritonitis, for there has been no operation and the patient still lives. It can be distention from the effects of morphine, but there must be more than morphine paralysis, for there is a temperature of 102 degree to 103 degree F., and there has been, so the wife says, a temperature of 104 degree F. The pulse rate being 130 does not indicate fever nor exhaustion, and is not in keeping with the temperature nor physical strength, hence the rapidity must be partly due to pressure on the diaphragm from the gas distention and partly from the paralyzing effect that opium has on the heart.
The professional reader will see that I have by my analysis eliminated much of the formidableness that the physical appearance gives to this case, but I would not have you believe that this man was not a desperately sick man even if I have accounted for the dangerous symptoms. The fact is, if the pronounced symptoms had been what they appeared to be, the man would have been saved his trip to me, for he would have been dead.
The farmer had learned from experience that the less he put in his stomach the better he felt; hence, for a day or two before he left his home to consult me, he had refused food and drugs and had taken very little water.