DIFFERENTIAL POINTS.-In renal colic and twists of the ureter the pain radiates into the groin and testicle, and there is hæmaturia or hæmoglobinuria. Pain in the groin and testicle is sometimes observed in appendicitis. The urine should be examined for small calculi.

Indigestion and Enterocolitis.-No circumscribed tenderness. No rigidity. No tumor. No tenderness of the appendix on palpation.

Intestinal Obstruction.-Palpation of the appendix is negative.

Acute Cholecystitis or Hepatic Abscess.-Tenderness on pressure from below the margin of the ribs upward. No tenderness of the appendix on palpation.

Gallstone Colic.-Pain radiates to the back on the right side, and the appendix is free on palpation.

Salpingitis, oophoritis, and ectopic gestation are recognized by bimanual palpation of the pelvic organs, and the latter is denoted by menstrual irregularities.

Perinephritic abscess on the right side may arise from appendicitis, but is usually a complication following an operation for appendicitis. If it is independent of appendicitis, the appendix is not tender on touch.

Tuberculous peritonitis is a slow process; palpation of the appendix may be impossible.

Mucous colic gives its own characteristic symptoms, and the appendix is found to be free on palpation.

Coritis. In young children appendicitis has been mistaken for hip joint disease. As the appendix can readily be palpated in children, the differential diagnosis is not difficult.

Acute rheumatic myositis of the rectus abdominis muscle simulates appendicitis.

Typhoid fever is usually associated with right iliac tenderness. The Widal serum test will settle the diagnosis in most cases. In typhoid fever the onset is slow and roseola is generally observed. Seibert, of New York, has reported two cases of typhoid fever combined with appendicitis.

Influenza, pleurisy, pneumonia, malarial disease, herpes zoster of the twelfth intercostal nerve, and other infections which frequently begin with severe gastrointestinal symptoms cannot be mistaken for appendicitis by any one who has learned to palpate the appendix.

The prognosis is uncertain. Mild cases end in recovery, as do localized abscesses after an operation. Severe septic peritonitis cases will often prove fatal with or without an operation. We are unable to judge of the clinical severity of a case before an operation, and we are unable to give a reliable prognosis, and physician and surgeon therefore should co-operate in the management of a case.

Treatment.-GENERAL INDICATIONS FOR OPERATION:

1. In cases of diffuse perforative appendicitis an immediate operation is indicated. Exceptionally patients get well without an operation.

2. In cases of acute appendicitis the patients always need careful observation. If the pulse has the tendency to stay high, the indication for an operation is given.

3. In mild cases, when the patients are doing well, wait for the subsidence of symptoms and operate in the interval.

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After the

4. In case of doubt, the operation is better than waiting. first attack from which the patient recovers without an immediate operation the appendix should be removed. The appendix, once inflamed, must be looked upon as a diseased organ which is very apt to give repeated and more serious, even fatal trouble in the future. Chronic appendicitis is to be diagnosticated, not on subjective symptoms, but on objective signs. Unless, in cases of suspected chronic appendicitis, the surgeon can recognize by palpation the thickened appendix and limit tenderness on pressure to the diseased organ, he will not be justified in operating. One broad rule governing the question of operative interference in appendicitis should be, not to operate in chronic cases unless you can feel the diseased appendix, nor in acute cases unless by palpation you can recognize either the diseased appendix or the presence of a tumor. Anæsthesia may be necessary, in exceptional instances, to decide the question.

The gravest complications following appendicitis are septic peritonitis and septic thrombosis of the portal vein. The latter is almost invariably fatal and may be recognized by fever, chills, sweating, rapid action of the heart, and local tenderness.

NON-OPERATIVE TREATMENT.-If in a given case of appendicitis an immediate operation is not decided upon, the management is symptomatic, as follows: Rest in bed, an ice bag or hot water bag to the abdomen, liquid diet, a small enema of warm soap water or oil each day or castor oil internally, and, to aid digestion, 5 to 10 drops of dilute hydrochloric acid, to be given in water after each feeding. It is not wise to mask the clinical picture by giving morphine or opium. When pus formation is evident, and an operation has been decided upon, the patient can be made comfortable by morphine subcutaneously. When the pain is quite severe and the pulse and temperature are not high, and it has been decided not to operate during the first attack, an injection of morphine may also be indicated.

BENIGN AND MALIGNANT NEOPLASMS OF THE INTESTINE Diagnosis. The diagnosis of carcinoma rests on the following points: The age of the patient, usually over fifty years, a palpable tumor, progressive anæmia and cachexia, signs of obstruction or disturbed bowel action, colicky pain and vomiting, the presence of blood, pus, and shreds in the stools, secondary deposits in the liver, lungs, and mammæ, and such other symptoms as may be inferred when the kidney or ureters are involved or perforation, fistulæ, and general peritonitis are present.

DIFFERENTIAL POINTS.-Carcinoma of the rectum may be mistaken for chronic dysentery or non-malignant stricture, and vice versa. A tumor due to fæcal impaction can be indented. Cysts and tuberculosis of the peritonæum or mesentery may simulate a cancerous tumor. Movable kidney and chronic appendicitis have been taken for cancer of the intestine. Cancer of the pancreas, of the pylorus, and of the gall bladder may simulate cancer of the intestine. Benign tumors have been observed and mistaken for cancer of the intestine. In all such obscure conditions the proper procedure is exploratory laparotomy with immediate extirpation and intestinal anastomosis if feasible. If the case is found to be "inoperable " x ray treatment is indicated.

INTESTINAL OBSTRUCTION, ACUTE AND CHRONIC

Symptoms. The cardinal symptoms of intestinal obstruction are acute and severe pain (sometimes absent), no movement or passage of flatus from the bowels, vomiting (gastric, bilious, or fæcal), tympanitic distention of the abdomen, usually no fever, prostration and collapse in the terminal stage.

THE SITE OF THE OBSTRUCTION.-If the obstruction is high up, there is less abdominal distention than in obstruction of the colon; if in the lower bowel, there may be tenesmus and the passage of bloody mucus. Abdominal palpation and bimanual palpation externally and through rectum or vagina may reveal a tumor or swelling. On various occasions the writer has been able to detect the site of the obstruction by noting where the tympanitic percussion sound of distended intestine merged into dulness over a collapsed area of intestine.

Invagination, or intussusception, of the intestine may be ileocæcal, ileocolic, or colicorectal. In infants and young adults the onset is more or less acute, with tenesmus, mucus, and blood. Occasionally a sausageshaped tumor can be felt.

Differential Points.-Volvulus, or twist of an intestine, is usually located in the large intestine or the sigmoid flexure, and gives no distinctive symptoms apart from those already enumerated.

Facal obstruction is usually chronic, with a history of constipation. Indentible fæcal masses can sometimes be felt.

Strangulation is usually through adhesions and narrow natural slits (foramen of Winslow, diaphragmatic hernia, and incarcerated hernia). A palpable tumor is rare in cases of strangulation.

Gallstone obstruction of the intestine is usually intermittent.

Stricture of the intestine from ulceration is seldom recognized before opening the abdomen, unless it is situated in the anal region.

Stricture of the intestine from a malignant or benign tumor cannot be recognized in a tympanitic abdomen.

Paresis of the intestine and obstruction sometimes follow abdominal section or peritonitis, and has been observed in neurotic constipated children. On auscultation the intestinal sounds are absent. Other rare causes of obstruction can only be conjectured.

In enteritis and diffuse peritonitis with obstruction there is generally a rise of temperature.

In hepatic colic and obstruction the pain is localized and characteristic, and jaundice is often present.

In renal colic and obstruction the urine shows hæmaturia or hæmoglobinuria.

Treatment. The treatment of bowel obstruction is by high enemata and inflation, in the dorsal or knee-elbow or inverted position, by means of soap water (soft rectal tube); oil with the soft rectal tube; air with the soft catheter, bicycle pump, or hand bellows, or carbonic acid gas (inverted siphon).

The best guide to the amount which has been introduced is tension of the abdominal walls. A thorough trial should occupy fifteen to thirty

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minutes, and it may be repeated in an hour. It may be done under narcosis. Gentle manipulation through the abdominal wall is permissible.

If after two or three trials there is no improvement, an operation should not be delayed for more than three or four hours. In cases not acute, where several days have passed without symptoms of strangulation, laparotomy may be delayed longer and further attempts at reduction are proper. The writer has observed paretic and pronounced obstipation in a girl of nine years, lasting eleven days, with complete recovery. In ileus injections of atropine sulphate may be tried.

Cathartics are contraindicated as soon as the diagnosis of complete obstruction is made. Opium or morphine may be administered, to quiet pain.

HÆMORRHAGE FROM THE INTESTINES

Causes. Hæmorrhage from the intestines may result from a variety of causes, such as dysentery, typhoid ulcer, malignant disease, the hæmorrhagic diathesis, acute and chronic, congestion in the portal circulation, a foreign body, simple ulcer, tuberculous or syphilitic ulcer, aneurysm, hæmorrhoids, vicarious menstruation, hæmorrhage from above the intestine, and swallowed blood. In bleeding from the intestines all these possibilities must be borne in mind, an exact diagnosis being arrived at by exclusion.

Treatment. Rest, fluid diet, opium and acetate of lead internally, an ice bag to the abdomen, strychnine, and suprarenal extract. Hæmorrhage of the lower intestine may be controlled to a certain extent by means of clysmata of cold water, 1 quart; or alum water, 3ij ad Oij; or tannin in water, 3j ad Oij; or by means of a tampon or the actual cautery.

REMARKS ON STRANGULATED HERNIA AND TAXIS

Definition. An incarcerated hernia is one in which the bowel contents cannot escape, but in which the blood circulation is not cut off. A strangulated hernia is one in which the constriction is sufficient to shut off the circulation of the blood.

Symptoms. The symptoms are the logical result of the conditions producing them and are sufficiently characteristic to allow us to form a diagnosis by a discrimination between functional constipation and abdominal shock with obstruction.

Pain. This comes suddenly, is severe, is at first localized, and becomes general over the abdomen. Sudden cessation of local pain without reduction of the hernia is a grave indication of gangrene.

Obstipation is pronounced throughout, but the lower bowel may empty itself, after which there will be no passage of gas or fæces.

Tympanites will increase until relief is offered.

Vomiting is early and persistent and eventually becomes stercoraceous. The pulse is accelerated and becomes irregular, small, and thready. The temperature may be subnormal in shock and collapse, and may be elevated from systemic intoxication.

The local symptoms are those of inflammation-swelling, heat, redness, pain, and tenderness. The face is pinched, drawn, and anxious.

Treatment. The treatment for strangulated hernia is by operation. Before we cut down upon the strangulating structures it may be justifiable

FIG. 111.-REPRESENTS A PROPERLY APPLIED TRUSS FOR THE RETENSION
OF DOUBLE INGUINAL HERNIA.

The frame is of German silver covered by hard rubber, with pads of the latter substance.

to place the patient in a position which may favor spontaneous reduction and apply an ice poultice to the seat of the trouble, and to employ gentle taxis with or without anesthesia, with the hope of reducing the hernia. Failing in this after one or two trials, the use of the knife is indicated. To wait for fæcal vomiting or until the patient is exhausted is inexcusable.

Clinical Varieties.-Inguinal hernia (complete or incomplete), femoral hernia, umbilical hernia, ventral hernia, congenital hernia, diaphragmatic and other internal hernias.

Regarding the question, "Does hernia exist?" it may be safely stated that reducible tumors in the region where hernias are found are generally hernia.

Dr. W. B. Degarmo's definition of a good truss: A well fitting truss is one which retains the protruding viscera within the abdomen and has its springs so shaped to the body that it will remain constantly in place no matter what position the body assumes.

INTESTINAL PARASITES

Common Forms. The cylindrical worm (Ascaris lumbricoides), the thread worm (Oxyuris vermicularis), the tapeworm (Tania saginata or mediocanellata, the beef tapeworm, sucking disks without hooklets; Tania solium, pork tapeworm. The head has hooklets).