576 AFFECTIONS OF THE INTESTINAL CANAL. 



as a result of advanced perityphlitis, and who can give only a very 

 incomplete history of his disease, the two affections cannot be dis- 

 tinguished. 



Although the peritonitis and perityphlitis in ulceration of the 

 processus vermiformis are in most cases caused by its perforation 

 and escape of its contents, these diseases may nevertheless run the 

 above-described favorable course. This is most frequently the 

 case when the perforation takes place gradually, so that the in- 

 testine becomes attached to the surrounding parts, and the rest 

 of the peritonaeum is thus protected from injury by the escaping 

 contents. Finally, firm adhesions may form ; the pus and escaped 

 masses may be incapsulated in a dense tissue, or they may perforate 

 outwardly, while the point of perforation in the processus vermi- 

 formis is closed by a dense cicatricial tissue, so that no further 

 escape takes place. >. 



[Peritonitis limited to the lower right part of the abdomen, or 

 starting from that part, especially in males, may arouse the suspi- 

 cion of primary disease of the caecum or vermiform appendix. In- 

 flammation of the latter is mostly due to the presence of a foreign 

 body, such as a concrement of inspissated mucus, small fecal masses 

 hardened by chalky salts, seeds of fruits, or round worms. In a 

 girl aged ten years a tooth was found which had been swallowed 

 four years previously. Whether the final cause of their arrest in 

 the vermiform appendix is the presence of the so-called GerlacKs 

 valve (a fold of mucous membrane sometimes forming a cover to 

 the entrance of the appendix), or relaxation of the muscles from 

 precedent catarrh, or a combination of causes, is doubtful. The 

 especial frequency of this inflammation and ulceration of the caecum 

 and appendix in the later years of childhood and youth, and among 

 males (who have about eighty per cent, of cases), is noteworthy. 



When the fever is not high and the peritonaeum is only mod- 

 erately inflamed, typhlitis usually recedes, but it is apt to leave 

 a tendency to recur; on the other hand, peritonitis starting from 

 disease of the appendix vermiformis is more apt to prove fatal, as 

 it is frequently due to perforation.] 



Severe inflammations and ulcerations of the intestines at other 

 points than those above mentioned are much more rare ; their most 

 frequent seats, however, are in the transverse colon and sigmoid 

 flexure. The symptoms are similar to those of typhlitis, and con- 

 sist in obstinate constipation, pain in a circumscribed spot in the 

 abdomen, and the occurrence of the characteristic tumor. They 

 very rarely induce general peritonitis, as it is much easier to re- 



