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Errors in Diagnosis in Conditions Resembling Appendicitis

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ERRORS IN DIAGNOSIS IN CONDITIONS RESEMBLING APPENDICITIS.

All who are accustomed to deal surgically with intra- abdominal inflammations appreciate the frequency with which errors in diagnosis are made. I think all will agree that in the majority of instances these errors have been in mistaking atypical forms of appendicitis for other conditions. At any rate, most of the communications which have recently been made on this subject have dealt with errors of this kind, and much thereby has been added to our knowledge of the differ ential diagnosis in conditions resembling appendicitis, particu larly with reference to inflammatory diseases of the female pelvic organs and of the gall-bladder.

As we frequently learn more from a careful consideration of our errors than from a study of the cases in which our diag nosis is found to be correct, I have decided to present for your consideration this evening a series of instructive mistakes.

During the past eighteen months the writer has, on eleven occasions, made the mistake of regarding as appendicitis con ditions which, upon operation or autopsy, have been shown to be other and unsuspected pathological processes. As a study of these cases has proved far more instructive to the writer than the much larger number of fairly typical cases observed during this period, and, as some of the conditions encountered are comparatively rare, the cases will be briefly reported, in the hope of gleaning from the discussion certain facts which may enable us to avoid such errors in the future.

The cases may be classified as follows : in two the symp toms were found to be due to renal calculus; in four, to dis eases of the uterine appendages; in one, to sarcoma ileum; in one to cholecystitis; in one, to acute suppurative pancreatitis, and in two, to general sepsis.

With the exception of the two renal cases, all were ob served by the writer during practically the entire course of the illness. Six were operated upon during a supposed acute attack of appendicitis; four were kept under observation until the acute attack had subsided and were operated upon during the interval ; while in one, a fulminating no operation was performed, the condition being determined by autopsy.

I.-A. B., aged twenty-one. Native of Bermuda. Family and previous personal history negative. In the autumn of 1899, he experienced sudden attacks of acute abdominal pain, generally referred to the right lumbar and iliac regions. These attacks at times would be of short duration, occasioning him but temporary inconvenience, at other times they would last for days and be accompanied by nausea, vomiting, and local tenderness. He was examined by a competent surgeon at his home, who, after observation of the symptoms, made the diagnosis of renal calculus and proposed an exploratory operation. Early in is000 this was done ; the kidney exposed, thoroughly palpated, pro nounced in normal condition, replaced, and the wound closed.

Complete relief for a period of several weeks followed the operation. After quitting the hospital, however, the symptoms returned, and after unsuccessful medical treatment for a short period he came to New York and entered the Roosevelt Hospital. At this time the pain was almost constantly present, and it was located just above and to the inner side of McBurney's point. It was characterized by acute exacerbations, when vomiting would occur. There was no vesical irritation. The temperature and pulse were normal. Urine clear, acid, no albumen, sugar, pus, or blood.

Examination of abdomen showed no muscular rigidity, no tumor, no distention. An area of acute tenderness, about one inch above and to the inner side of McBurney's point, was noted. Kidneys not palpable. Gall-bladder region free from evidences of disease. Rectal examination negative.

The negative result of the renal exploration, the location of the pain and tenderness, together with the vomiting, led to a diagnosis of chronic appendicitis, with the probable presence of a concretion. Intermuscular operation early in June. Appendix found acutely flexed, but apparently normal in other respects. Gall-bladder and kidney region palpated, with negative result. Wound closed. Immediate relief followed, and the patient left the hospital in two weeks.

A few weeks later he again returned, suffering more than ever, this time referring the pain to a point one inch to the right of the umbilicus. The pain was continuous, but was increased at intervals. The vomiting occurred several times a day and was very exhausting, the violent retching lasting often for several hours. No bladder irritability, no tenderness over the kidney region. The urine at this time contained a few red blood-cells, but was otherwise normal. A cystoscopic examination was then undertaken and an attempt made to catheterize the right ureter, which failed. The cystoscopic examination was negative. A few days later, under chloroform anwsthesia, the kidney and upper third of the ureter were exposed by a lumbar incision, and a calculus found at the junction of the pelvis and ureter. This was removed through a small incision and the wound in the ureter united with silk. Primary union, excepting for the drain age opening. No urinary leakage. Complete relief followed. The patient left the hospital in about four weeks. A letter re cently received reports him in perfect health.

IL—A. V., a girl aged thirteen. Ever since early childhood, patient has complained of abdominal pain, located chiefly in the right side. This was occasionally accompanied by fever and general malaise. The pain was paroxysmal, occurring at long intervals at first. Later, the attacks became more fre quent, and were accompanied by vomiting. For a period of about one year the attacks occurred nearly every day. Two years ago she was admitted to the Roosevelt Hospital and her appen dix removed. Six months later, there being no improvement.

the abdomen was again opened and the gall-bladder region ex plored, with negative result. Two weeks later the right kidney was exposed and anchored to the quadratus muscle. A certain measure of relief followed this operation, although albumen, pus, and casts appeared in the urine, and have since remained. She left the hospital on February 22, was re-admitted on March 4, with a return of the same symptoms. She was kept under obser vation for several weeks, during which the attacks of pain would occur at intervals of six to twenty days. During the attacks there would be a moderate elevation of temperature, nausea, and vomiting; tenderness over the right side of the abdomen and flank ; no muscular rigidity. These attacks would continue for four or five days. Urine, cloudy ; specific gravity, 1026; I per cent. albumen ; free pus and casts.

On June ii, under chloroform, the bladder was examined with a Pryor cystoscope and the right ureter catheterized. Ex amination of the urine, from the right ureter, showed io per cent. albumen and a very large amount of pus, with a few red blood-cells and casts.

On July 13, the kidney was exposed by a lumbar incision and palpated. Nothing abnormal was felt. A cortical incision into the pelvis was then made, and a calculus the size of a small bean was found and removed. The renal wound was packed and the lum bar wound partly sutured. Recovery uneventful. No return of pain. On her discharge from the hospital, the urine contained but a trace of albumen and a small amount of pus.

III. R. W., aged sixty, was admitted to the service Iii. R. W., aged sixty, was admitted to the service of Dr. Lilienthal, at Mount Sinai Hospital, at midnight, early in January last, suffering from acute abdominal pain, nausea, gen eral tenderness, muscular rigidity, vomiting, fever, and a rapid, feeble pulse. There was a history of several previous attacks. The onset was that of an acute appendicitis, pain in the right iliac region, nausea, and moderate fever for three or four days. The symptoms had then increased rapidly in severity and were thought to be due to a perforation, with beginning general peritonitis. On examination, the abdomen was found to be moderately dis tended. General muscular rigidity was found, but more marked on the right side. Rectal examination, rigidity, and tenderness on the right side, but no mass. Under chloroform, a large mass was felt to the right of the median line, just above the pubis.

Incision along the right border of the rectus muscle. When the peritoneum was opened, a moderate amount of free fluid escaped ; a large black, almost gangrenous cyst was found attached to the right broad ligament by a pedicle, which was twisted two and a half times to the right. This was easily re moved, the abdomen closed with a cigarette drain. Recovery uneventful.

IV. In May last I was called to see T. W., a young woman, aged twenty-four, who for three days had been suffering from right-sided abdominal pain, nausea, fever, and general malaise. Two years ago she had a similar attack, which kept her in bed for two or three weeks, the diagnosis at that time being acute appendicitis.

On examination, the abdomen was found to be slightly dis tended, with marked muscular rigidity and tenderness in the right iliac region. There was exquisite tenderness over McBur ney's point. No mass could be felt. Vaginal examination nega tive. Urine negative. There was no history of menstrual irregu larity, or of inflammatory disease of the pelvic organs. Pulse, 'co; temperature, me F. She was admitted to the Private Patient Pavilion of Roosevelt Hospital, a cathartic given, and an ice-bag applied to the right inguinal region.

The following day the pain was relieved, after which the temperature promptly fell to normal. She was discharged at the end of a week, with the understanding that she was to return in two weeks for an interval operation. Abdominal examination at this time was negative, excepting for a slight tenderness in the appendix region.

She returned to the hospital in about eight days, suffering from another acute attack, and was seen by my colleague, Dr. Blake. The temperature and pulse at that time were elevated, the pain severe, the tenderness general. The question of an immediate operation was seriously considered, as the symptoms seemed to indicate a more acute process than in the last attack. The same treatment was pursued as in the former instance, and at the end of hours a decided amelioration was noted. The im provement continued, and at the end of nine days the temperature had fallen to normal, the pain had subsided, and the muscular rigidity had disappeared.

On June 2, under chloroform anaesthesia, an ovoid tumor was felt, which was distinctly movable, and the possibility of a strangulated ovarian cyst was considered. The abdomen was opened by the intermuscular method and a cyst was found, about three inches in diameter, attached by a short pedicle to the omen tum. This was removed. The right Fallopian tube and ovary were then drawn into the wound and three or four minute cysts were discovered, each attached by a long pedicle to the broad ligament, immediately above the ovary. On close inspection, a ruptured pedicle was found, arising from the same region, which had doubtless been the stem of the larger cyst, which, after spon taneous separation by torsion, had probably become attached by inflammatory adhesions to the omentum. After removal of the smaller cysts, the abdomen was closed. Recovery was uneventful.

V. H. H., female, aged thirty-six, was sent to the Roosevelt Hospital with a diagnosis of acute appendicitis. On admission, the temperature was 101.4° F.; pulse, 112. She com plained of severe pain in the right inguinal region, with nausea, vomiting, and rigidity of the right half of the abdominal wall. Bowels free. By vaginal examination, tenderness, but no mass was felt in the right half of the pelvis. Urine negative.

The following day she was much more comfortable, and it was decided to wait until the interval for an intermuscular opera tion. The attack quickly subsided, and she was discharged at her own request. Ten days later she was re-admitted, giving a history of constant pain since resuming her household duties. At the end of three or four days the pain had become localized and so severe as to necessitate her going to bed. On admission, marked tenderness existed, and what was thought to be a thick ened appendix could be palpated in the right iliac region. Mod erate muscular spasm. Temperature, 98.6° F.; pulse, 9o. Vagi nal examination negative. Under chloroform anxsthesia, the abdomen was opened over the appendix region. An apparently healthy appendix was found, and not disturbed. In examining the pelvic viscera, an oblong, thin-walled, translucent cyst was found attached to the uterus and right pelvic wall, which, upon close inspection, was found to be a very much dilated Fallopian tube. This was apparently twisted at its uterine extremity. The cyst and ovary were removed, the abdomen closed, and the pa tient placed in bed. The convalescence was normal.

VI was that of a young married woman, about thirty years of age, who had experienced a severe attack of general abdominal pain, accompanied by high fever, vomiting, and nausea, with tenderness over the lower right side. Duration, twenty four hours. This was diagnosticated appendicitis by her attend ing physician, who sent her to the Roosevelt Hospital. On admis sion, it was evident that the attack was subsiding, and it was thought best to postpone operation until the interval.

The temperature on admission was mo° F.; pulse, 116. Examination revealed marked tenderness in the ileoczecal region, with a moderate spasm of the lower half of the right rectus mus cle. Vaginal examination revealed only slight tenderness of the pelvic roof, uterus movable, no induration. The absence of any pelvic disease was also verified by a member of the gynxcological staff of the hospital. There was, however, a history of vaginal discharge.

Treatment : rest in bed, a mild cathartic, and an ice-bag to appendix region. After two or three days the muscular rigidity disappeared, and it was thought that a slightly tender appendix could be palpated.

About five days after her admission there occurred a sudden rise in temperature to I04.2° F., with a corresponding elevation of the pulse. This was accomplished by a reappearance of the pain, with more or less general abdominal tenderness, slight muscular rigidity, and distention. These symptoms rapidly in creased in severity, and she soon presented the appearance of grave illness. Examination of the chest was negative. Urine negative. There was a well-marked leucocytosis.

She was immediately prepared for operation, the supposi tion being that a perforation of the appendix had occurred or the rupture of an abscess, with a resulting general peritonitis. On opening the abdomen, no evidence of inflammation was found. The appendix was absolutely normal in appearance, and pre sented no evidence of previous inflammation. The region of the gall-bladder and right kidney were examined, also the pelvic vis cera, but nothing was found to account for the symptoms. The abdomen was closed with a small drain of gauze. Her symptoms were apparently not influenced by the operation. She continued to complain of general abdominal pain, and had a high continued fever for several days, at the end of which well-marked signs of a circumscribed pneumonia were discovered in the right lung. With this there continued some nausea, occasional vomiting, and a moderate amount of distention. The bowels were moved, however, without difficulty, and after four or five days the pain became localized on the left side, over the middle third of the descending colon. This soon disappeared with the fever and other symptoms, and in ten days she was thoroughly convalescent. After a week or more of entire freedom from pain and other symptoms, a gradual rise in temperature was again noted. This was accompanied by a feeling of discomfort in the left inguinal region, just above Poupart's ligament. A day or two later a small, tender mass was felt, which, by bimanual palpation, was found to be located high in the pelvic cavity. The symptoms not yielding to expectant treatment, two days later an exploratory laparotomy was made, an abscess found immediately beneath the anterior abdominal wall ; but its relation to the uterus, or broad ligament, could not be determined without breaking down firm adhesions. After evacuating the pus, the cavity was swabbed with peroxide of hydrogen, a cigarette drain in troduced, and the abdominal wall sutured. The convalescence was uneventful.

VII. A young woman, twenty-three years of age, Vii. A young woman, twenty-three years of age, single, was sent to the Roosevelt Hospital during an attack of acute abdominal pain. She gave a history of a sharp attack of colic two years before, situated in the right iliac region, which was not accompanied by vomiting, fever, or constipation, and which did not necessitate her remaining in bed. Similar attacks were experienced every two or three weeks for a year or more, in which the pain was always localized in the right iliac region. These attacks were of short duration and occasioned her but slight inconvenience. One year ago she had a severe attack which was accompanied by vomiting, and necessitated her remain ing in bed for several days. Between these attacks there was al ways a certain amount of soreness in the right iliac region, which was especially marked on exertion. On June 15 she experienced a very acute attack of pain in the region of the appendix, which was accompanied with fever, chills, and persistent vomiting. The symptoms gradually increased in severity for six days, when she was admitted to the hospital. On admission, her pulse was ioo ; temperature, 99.8° F. Complains of moderate pain and frequent vomiting. On examination, tenderness and muscular rigidity were noted over the entire right half of the abdomen. The ten derness, however, was more marked over McBurney's point. No tumor was found. The urine was cloudy ; specific gravity, 1036; acid. No albumen, sugar, pus, or blood.

As she was apparently convalescent from the attack, and as her menstruation appeared, operation was postponed for several days. During this period the abdomen was frequently palpated and the tenderness generally felt low down, which, with the character of the previous attacks, and absence of jaundice and gall-bladder tumor, led us to regard the condition as one of chronic relapsing appendicitis. Under chloroform anxsthesia, nothing abnormal could be felt in any part of the abdomen.

The appendix was exposed by a small intermuscular incision and found to be normal. The gall-bladder was next examined and found to bear the evidences of recent inflammation. It was opened, and twenty-seven large and small stones found and re moved. There was a moderate inflammatory thickening of the walls. The viscus was attached to the abdominal wall by three oi four catgut sutures and drained by means of a rubber drain tube, introduced and fixed by three rows of purse-string sutures. The result was satisfactory, the wound healed kindly, and after removal of the tube there was practically no leakage.

VIII. E. G., male, aged fifty-three, was admitted to Viii. E. G., male, aged fifty-three, was admitted to Roosevelt Hospital in August last. The patient had complained of a digestive disorder for many years. Seven years ago he ex perienced an attack of severe abdominal pain which was accom panied by fever and was regarded as an acute peritonitis. From this he fully recovered. Five days before his admission, he com plained of general abdominal pain, which gradually increased and was accompanied by vomiting, fever, and general malaise. Free catharsis produced no relief. His symptoms grew worse. A progressive distention of the abdomen ensued. He had sweats, and became extremely weak and prostrated. On admission his temperature was 104.2° F.; pulse, mo, but weak and thready ; respiration, 36 and shallow. The abdomen was greatly dis tended, tenderness was everywhere present. No mass, no jaun dice, no fluid wave, liver percussion normal. Heart and lungs negative. Rectal examination negative. Urine negative. Bowels constipated.

He was seen by the writer about midnight, and, as his condi tion seemed extremely critical, he was immediately prepared for operation.

As the clinical picture was one of a general peritonitis, the absence of signs of gall-bladder disease, or the symptoms of a perforative lesion of other portions of the alimentary tract, led us to a diagnosis by exclusion of a perforated appendix.

Under chloroform anwsthesia, the abdomen was opened. There was no general peritonitis. The appendix region was thoroughly explored and found to be normal. The gall-bladder region was next examined and nothing of an inflammatory na ture detected. As the intestines were greatly distended, an ob struction was looked for, but not found. All of this was done quickly, as the pulse was becoming rapidly weaker, and the most vigorous stimulation was being employed, including a hot saline infusion.

The region of the pancreas was next palpated, through the walls of the stomach and omental tissue, and pronounced nega tive by two examiners. There was, however, noticed a large number of small white spots, generally distributed throughout the greater omentum, the largest being about one-sixteenth of an inch in diameter. One of these was removed for examination, after which the abdomen was quickly closed, with generous gauze drainage.

The patient did not rally and died the following day. A report received from the hospital pathologist stated that the small white nodule was of the nature of a fat necrosis, and the autopsy revealed the pancreas to be the seat of a number of small circum scribed abscesses. The case was, therefore, one of acute sup purative pancreatitis.

IX. A man, aged forty-two, was admitted to the ser vice of Dr. Lilienthal, at Mount Sinai Hospital, in January last, suffering severe abdominal pain. He stated that up to fourteen days before admission he had been apparently well. He then noticed an acute pain in the lower abdomen, with tenderness over the right iliac region. This pain increased in severity, was ac companied by fever, nausea. vesical irritability, and general weak ness, necessitating his giving up his work and going to bed. On admission his temperature was to 1.4° F. ; pulse, 98. The ab domen was flat. There was perhaps a slight muscular rigidity present in the lower right quadrant, and on palpation a large ten der mass, about the size of an infant's head, could be distinctly felt, occupying a position in the right iliac and hypogastric re gions, and extending beyond the median line to the left. This was not movable, and gave the impression of fluid surrounded by thick, dense walls. By rectal examination, the mass was felt, occupying nearly the entire pelvic cavity, and very tender. The bowels were free. There was no jaundice. Urine pale, acid; specific gravity, IO26; albumen, and casts. A hasty examination of the blood revealed a marked leucocytosis. Supposing that we had to do with a large appendicular abscess, he was immediately prepared for operation. Under chloroform anmsthesia, the ab domen was opened by a large incision situated just to the right of the median line. This exposed at once an enormous tumor, growing from the small intestine, which almost entirely filled the pelvic cavity and extended upward half-way to the umbilicus. It was adherent to the parietal peritoneum of the abdominal and pelvic walls, to the cmcum, ileum, appendix, sigmoid, rectum, and bladder. Severe hmmorrhage followed the separation of these adhesions. The tumor, together with about six inches of small intestine, was removed, and the intestinal tube united by a Mur phy button. The tumor was soft, and during the manipulations was ruptured, allowing a certain amount of granular detritus— from a softened area situated in its centre—to fall into the pelvic cavity. This was removed, but, as there was no reason to regard this material to be other than sterile, as it apparently came from the centre of a solid tumor, great care was not exercised in sub sequent disinfection. The patient left the table in good condi tion.

For three days the pulse and temperature remained below ioo. There was, however, more or less constant vomiting and a pro gressive asthenia. He died without further elevation of the temperature or pulse, and without abdominal distention. Autopsy showed a localized peritonitis. Examination of the tumor re vealed the fact that it was a soft sarcoma growing from the in testinal wall, and that there was a minute perforation of the mucous membrane, which conveyed infection to the centre of the mass, thus accounting for the leucocytosis, and also for the peri toneal infection.

X. A young man, aged twenty, was admitted to the service of Dr. Lilienthal, of the Mount Sinai Hospital, in January, Is000, with a diagnosis of general peritonitis. He stated that until four days before he had been perfectly well. He then had ex perienced severe paroxysmal pain in the abdomen, which he later referred to the right lower quadrant. He became weak and faint and was obliged to remain in bed. There had been no vomiting. During the last twenty-four hours the symptoms had changed. The pain had, in large measure, disappeared, but the abdomen had enlarged and become exquisitely tender, and was hard. Tem perature on entrance, F.; pulse, to8. A hasty blood ex amination showed a marked leucocytosis.

The abdomen was greatly distended and of a board-like rigidity, which practically prevented any satisfactory palpation. Tenderness was, however, everywhere present. The respiration was shallow. The countenance expressed grave illness. The diagnosis of a general peritonitis following a perforative appen dicitis was concurred in by all present, and an operation im mediately undertaken. On opening the peritoneal cavity, with the exception of a very slight congestion of the vessels of the bowels and a well-marked distention, nothing abnormal was seen. The appendix was normal, the region of the gall-bladder, kidney, spleen, and stomach were free from adhesions or other abnormalities. Several very much enlarged lymph glands were, however, found on the right side of the pelvis, along the course of the internal iliac vessels.

The abdomen was closed with a small cigarette drain, after which a rectal examination was made. This revealeld evidences of an acute follicular prostatitis, with a chain of en larged glands leading upward from the prostate. From the urethra was expressed an abundant purulent discharge con taining gonococci.

The course of the disease was apparently not modified by the operation, the fever and abdominal symptoms continuing for several days. Under urethral irrigation and local measures ad dressed to the prostatitis, however, the conditions began to im prove, the abdominal symptoms diminishing first, the other evi dences of sepsis later. He was discharged well in about three weeks.

February, 1899, I was called to see H. 0., male, aged twenty-four years, who was convalescent from a lobar pneumonia. He had been critically ill for about two weeks, but for the past five or six days had been free from temperature, and was thought to be rapidly recovering.

A few hours before he was seen by the writer, he had com plained of pain in the right inguinal region, had experienced slight nausea, and was generally ill. His temperature was ioo° F., pulse something over wo. An examination of the abdomen revealed only a slight muscular spasm over the ileocxcal region and marked tenderness. As he had had several sharp attacks of supposed appendicitis during the past four or five years, and the question of the removal of the appendix had been seriously con sidered, a diagnosis of appendicitis was at once communicated to his friends ; but, owing to his condition, only expectant treat ment advised.

In a few hours the temperature had risen to 103° F., and the pulse to 120. There was well-marked muscular rigidity over the entire right half of the abdomen. The patient was mildly de lirious. At the suggestion of his attending physician, Dr. Evan Evans, Dr. Janeway was called in consultation. When seen by Dr. Janeway his temperature had risen to 104°, and tenderness was present over the entire abdomen, but was more acute over the region of tne gall-bladder. The diagnosis of a rapidly spreading peritonitis was concurred in by all, but whether due to appendix or gall-bladder was not clear. In view of his condition, no opera tive interference was deemed advisable.

The following morning, he was seen in consultation by Dr. W. T. Bull. At that time he presented every symptom and sign of a septic general peritonitis. Temperature, 105° F.; pulse, 140. The abdomen was greatly distended and of board-like rigidity. Tenderness was everywhere present. The patient was delirious. The urine was scanty and albuminous.

Examination of the lungs revealed only the evidences of a resolving pneumonia. His condition precluded any idea of an operation. His symptoms gradually grew worse. The tempera ture rose to 106°, the pulse to tho. His delirium deepened into coma, and he died the following night. It was noted that for several hours before his death the abdominal distention and mus cular rigidity had entirely disappeared.

On autopsy, the abdomen was found to be entirely free from the evidences of inflammation. There was a resolving pneu monia of the lower lobe of the right lung, a meningeal con gestion, and other evidences of a severe general sepsis.

Cultures made from the blood taken from the right heart and spleen showed a pure culture of the pneumococcus, which, as a result of animal inoculations, was found to be of extreme viru lence.

In this we evidently had to do with a primary pneumo coccus infection of the lung, after the subsidence of which a new infection occurred ; this time the blood being the culture medium, a pneumococcus septimmia.

These cases present no new lessons. They, however, illus trate facts which are known to us all, but are often overlooked, and which may be briefly summarized as follows : Cases I and II show that renal calculi may produce pain, simulating that produced by lesions of the appendix or the biliary passages, and are often unaccompanied by classical signs, such as hxmaturia, vesical irritation, and tenderness in the lumbar region. They prove, also, that even by inspection and palpation of a kidney, through a lumbar incision, • small stones may occasionally be overlooked.

Cases III and IV illustrate the well-known fact that cysts of the right ovary or parovarium, when strangulated by a twisted pedicle, may often present symptoms which closely simulate an acute appendicitis.

Case V, that a twisted hydrosalpinx (certainly a rare condition) may simulate the same disease.

Case VII would seem to emphasize the well-known fact that cholecystitis and appendicitis are often extremely hard to differentiate.

Case VIII teaches that the negative results of palpation of the region of the pancreas, through the walls of the stomach or tissues of the omentum, by no means exclude an acute suppurative process in that organ that the presence of small white areas of fat necrosis generally distributed over the peritoneal surfaces should immediately direct our attention to the pancreas, and also that the local condition, or the general sepsis caused by this lesion, may give rise to symptoms and signs strongly simulating those produced by a general infec tion of the greater peritoneal sac.

Case IX illustrates the fact already emphasized by Libman that a rapidly growing sarcoma of the small intestine is often mistaken for acute appendicitis, and that in the early stage of their development these growths produce no obstruction, and often give rise to no discomfort.

Cases VI, X, and XI illustrate in a most striking manner that severe general sepsis, from infected foci entirely removed from the abdominal cavity, may often give rise to symptoms and signs identical with those produced by a local or general peritonitis. .

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