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vomiting (particularly if the patient is taking enemas), abdominal ten- 
derness, etc., may indicate appendicial involvement, but the history of the 
case, careful palpation and percussion, lessened or absent rigidity of the 
abdominal muscles, the area. and diffuseness of the tenderness and the 
location and character of the tumor mass, make the diagnosis fairly easy 
in the majority of instances. This is the class of cases where frequent 
and needless appendicectomies are done by some physicians with more 
surgical ambition than judgment. Having performed the autopsies on a 
few of these, examined the removed appendices in several, and later treated 
the condition of the bowel in a number of others, I can not condemn 
this practice too severely. ‘The operation in this class of cases is not only 
useless but dangerous, because of the delay which it causes in the treat- 
ment of the condition of the bowel. 
Cases which may be classified under the second, third, and fourth 
headings very closely resemble, in clinical symptoms, the class just de- 
scribed and two or more of the conditions are, in fact, often combined. 
It is not possible to diagnose amoebic disease of the lower ileum with 
certainty. Acute, localized peritonitis and other adhesions about the 
cecum frequently oecur, particularly in severe infections and are usually 
quite painful. The omentum is often plastered about the cecum and 
adjacent structures and, when the bowel is empty and there is not too 
much tenderness, the condition should be recognized by the experienced 
examiner. Periceecal amcebic abscesses are usually recognized by the same 
manifestations as are those from other causes; they have a strong tendency 
to spread into the surrounding tissues. 
Gaseous distention and even fecal accumulations in the caecum are 
frequently met with in patients taking enemas and often give rise 
to a painful condition. The symptoms may be relieved by an active 
cathartic, which should also be used before a final diagnosis of other con- 
ditions in the region of the cecum is attempted. Severe symptoms are 
often permanently relieved by one or two doses of salts. 
Acute, catarrhal appendicitis may, of course, occur during the time 
a patient is suffering from intestinal ameebiasis. ‘This complication, 
curiously enough, is comparatively rare, but when it is the case the symp- 
tomatology and treatment are the same as in appendicitis occurring in an 
otherwise healthy person. ; 
Chronic recurrent appendicitis is no more or no less frequent in this 
disease than in other classes of patients. Recurrences in appendices where 
ameebic infection is present are sometimes due to close association with 
the diseased cecum. An amoebic infection is sometimes engrafted upon 
such an appendix, but this is of very rare occurrence and the diagnosis 
is then not only difficult but often impossible. 
Primary appendicitis is the most frequent type of amoebic infection of 
the appendix. Its clinical manifestations, when there is an occlusion, 
closely resemble acute appendicitis from other causes. ‘These infections 
