may ensue, or collapse may suddenly occur, recovery or death following.

If appendicitis alone exists there may be no interference with the passage of the intestinal contents, and the evidences of a tumor in the iliac fossa are wanting, unless the appendix have undergone great distention. In ulcerative appendicitis, perforation not rarely results, giving rise to a general or localized purulent peritonitis. This event may be announced by sudden pain, shock, chill and rise of temperature, followed by the development of a fluctuating tumor indicative of abscess; or the condition may develop insidiously and be difficult of recognition. Sometimes, after initial shock and pain, deceptive improvement is manifested. Surgical exploration may be a diagnostic necessity. Attacks of typhlitis are prone to be repeated.

Perityphlitis.

What are the symptoms of perity phlitis?

Perityphlitis, or inflammation of the tissues surrounding the cecum and its appendix, usually occurs in the course of typhlitis or of appendicitis. The fibrous structures and the peritoneum are involved alone or in association. If perforation takes place, an abscess may form, or general peritonitis result, or both complications may be present. As a rule, the pus is shut off from the general peritoneal cavity by a capsule. The symptoms vary with the pathologic association. To those of the primary condition are added an acute exacerbation of pain and tenderness, as well as of the general symptoms, perhaps preceded by a chill. The pain is deep-seated and is increased by flexing the right thigh upon the abdomen. Sometimes the patient is unable to lift the right leg. He usually lies upon the right side, with the thigh semiflexed. If an abscess forms, there may be repeated rigors and a fluctuating tumor in the right iliac fossa. The tumor is not superficial and sausage-shaped like that of cecitis, but is deep-seated and irregular. A pericecal abscess may sometimes be detected by rectal exploration. If peritonitis develop, death may ensue, from septicemia or gradual exhaustion, or suddenly, with manifestations of collapse.

With what conditions may appendicitis or perityphlitis be confounded?

Inflammations of the cecum and its appendix or inflammation and abscess of the surrounding tissue have been mistaken for typhoid fever, and for "idiopathic peritonitis."

The mistake is more likely to be made when the inflammation of the appendix has been slow and the symptoms indistinct, until perhaps perforation occurs, causing a limited abscess or a general septic peritonitis. Deep-seated but limited abscess may for a time be concealed from other than surgical exploration, and through septic poisoning give rise to the "typhoid state." Before localizing symptoms, such as induration, or the presence of a fluctuating tumor in the iliac fossa, render the case clear, the occurrence of one or more rigors, the absence of distinctive characteristic symptoms of typhoid fever, the course of the temperature, and sometimes the location of the tenderness, should prevent mistake. The location of the pain and tenderness, however, may be misleading, as the appendix varies greatly in its position; and appendicitis has even been known to simulate hepatic disease. Sometimes only an exploratory incision can settle the diagnosis.

The exploring needle or aspirator should never be used. How are perityphlitis and typhlitis to be distinguished from a lumbar abscess?

Destructive disease of a lumbar vertebra is usually followed by suppuration, the pus following in the course of the psoas muscle and seeking exit below Poupart's ligament. A collection of pus forming in this way differs from typhlitis or perityphlitis by the absence of symptoms of intestinal derangement. The situation of the tumor is different in each case. In the one case, examination will reveal a deformity of the spinal column, with pain and tenderness in the lumbar region. The symptoms are slow and progressive. They may be associated with visceral tuberculosis.

How are typhlitis and perityphlitis in a woman to be distinguished from an abscess of the right ovary?

An abscess of the right ovary is situated nearer the middle line than is the swelling of typhlitis or perityphlitis. With typhlitis

or perityphlitis is associated gastro-intestinal derangement; with abscess of the ovary, uterine and menstrual derangement. Vaginal and rectal examination may clear up any doubt.

How are typhlitis and perityphlitis to be distinguished from carcinoma of the cecum?

The symptoms of typhlitis and perityphlitis are likely to appear suddenly; those of carcinoma insidiously and progressively. Typhlitis and perityphlitis are affections of comparatively brief duration; carcinoma of the cecum will probably continue for a number of months after its detection. The inflammatory processes are usually attended with fever; carcinoma is not. When typhlitis or perityphlitis has existed for some time, fluctuation-indicative of the occurrence of suppuration -can be detected in the tumor; the carcinomatous new-growth retains its original density. Perityphlitis or typhlitis may be attended with emaciation and sallowness of skin, but not with the cachexia of carcinoma. When the cecum is the seat of carcinoma, like new-growths are usually found in other parts of the body.

Intestinal Obstruction,

What are the symptoms of intestinal obstruction?

The lumen of the bowel may be obliterated by an accumulation of feces, by a large gall-stone, by an intestinal calculus (enterolith) or other foreign body, by organic narrowing of the bowel, by stricture or neoplasm, by a twist or volvulus, by external constriction and by strangulated hernia, internal or external.

The condition may arise in a subject of habitual constipation or of hernia. It may follow a violent physical effort. due to acute enteritis. From the onset, or after a variable It may be period during which no stool has been passed, abdominal pain and rumbling set in. Vomiting ensues; at first of the contents of the stomach, then of yellowish-green fluid and mucus ; finally the vomiting becomes stercoraceous. The apparent constipation does not submit to ordinary measures. The abdomen becomes distended. The expression of the face is drawn and

anxious, the pulse small, rapid and feeble, the surface cold and clammy, and if the condition be not relieved by medicine or operative intervention, death is the inevitable result.

When the obstruction is not complete, as in some cases of fecal impaction, there may be more or less frequent passages of liquid matters somewhat fecal, which the patient will describe as diarrhea. Inspection of the stools, and the evidences given by palpation and percussion, of the presence of a hard mass in the course of the bowel, usually in the transverse or descending colon, will prevent error. The nature of the obstruction in any case is to be determined principally by physical examination. In cases of strangulated hernia the knowledge of the existence of hernia may assist the diagnosis. In the absence of such history, examination must none the less be made, if only to exclude that condition from among the possibilities in the case.

Intussusception.

What are the symptoms of invagination or intussusception of the bowel?

Under certain circumstances, not definitely recognized, one portion of the bowel becomes invaginated in another portion. The small intestine or the large intestine, respectively, may be alone involved; but most commonly the small intestine enters the large at the ileo-cecal orifice. The occurrence of the accident is announced by a sudden attack of pain, repeated in paroxysms, followed by the presence of a sausage-shaped tumor in the abdomen, and stools of a dysenteric character. Sometimes no fecal matter is passed, and there are frequent discharges of blood-stained mucus. The pain is intense, and the child (for the affection is most common in children) often draws up its legs close to the belly. Pressure and manipulation relieve the pain, and quiet the excruciating cries of agony. In the course of a variable period of time, blood is passed by the bowel, the pain becomes continuous and vomiting occurs, with the symptoms of intestinal obstruction. The invaginated bowel may be accessible to rectal examination; it may even protrude from the anus; it may slough and be detached, and recovery ensue; or it may occasion stenosis of the bowel. Intussuscep

tion is more common in children than in adults, and in boys than in girls.

How are intussusception and obstruction of the bowel to be differentiated?

Intussusception is the more common in children; obstruction, in adults. The symptoms of intussusception appear abruptly; those of obstruction are often abrupt in onset, though sometimes of long standing. A sausage-shaped tumor is characteristic of intussusception; certain varieties of obstruction are attended with abdominal tumors of irregular shape. Constipation is not so absolute in intussusception as in obstruction; and stercoraceous vomiting is less common in the former than in the latter. A discharge of blood and the protrusion of a portion of bowel from the anus are diagnostic of intussusception. Digital exploration of the rectum will often assist in discrimination.

How are typhlitis and intussusception of the bowel to be differentiated?

Both typhlitis and intussusception may present a sausageshaped tumor in the right iliac fossa and be attended with severe pain and the evidences of intestinal obstruction; but intussusception, unlike typhlitis, is sudden in onset, is uncommon in adults, is usually afebrile, is likely to be attended with ineffectual or bloody stools, and perhaps to be accompanied by protrusion of the bowel at the anus. The tumor of intussusception is not necessarily confined to the right iliac fossa.

Carcinoma of the Intestine.

What are the clinical manifestations of carcinoma of the intestine?

Carcinoma of the intestine is most commonly situated in the rectum, the sigmoid flexure, the cecum, the vermiform appendix or the duodenum. When in the duodenum, the papilla of the pancreatic duct and common bile-duct is usually involved and jaundice is apt to result. When other parts of the bowel are involved, in addition to the pain and constitutional phenomena occasioned by the malignant growth, symptoms of partial intes