. The diagnosis and treatment of diseases of women. 410. Diagram showing various positions in which the Appendix vermiformismay lie, with the caecum in tne usual place. {KeWy—Diseases of the Appendix.) In cases where the caecum varies from theusual position, the appendix may be stillfarther from its normal position, as indicated inFig. 411. In a case of appendicitis there maybe a point of pain and tenderness elsewhere inthe abdomen, in addition to that in the appen-dix region. Then immediately arises the ques-tion, Do any of these additional areas of ten-derness represent an additional lesion
. The diagnosis and treatment of diseases of women. 410. Diagram showing various positions in which the Appendix vermiformismay lie, with the caecum in tne usual place. {KeWy—Diseases of the Appendix.) In cases where the caecum varies from theusual position, the appendix may be stillfarther from its normal position, as indicated inFig. 411. In a case of appendicitis there maybe a point of pain and tenderness elsewhere inthe abdomen, in addition to that in the appen-dix region. Then immediately arises the ques-tion, Do any of these additional areas of ten-derness represent an additional lesion or is thepain and tenderness simply reflex from the in-flamed appendix? My friend. Dr. LeonidasKirby,of Harrison, Arkansas, recently calledmy attention to the following method ofidentifying the reflex areas of tenderness. Withthe patients knees drawn up to relax the ab-dominal muscles as in regular abdominal pal-pation, note the areas of tenderness. Thenmake steady pressure exactly over the appen-dix to cause decided pain and, while. Fig. 411. D agram showing variouspositions whichtheCaecum and Appendixmay occupy, in cases where the caecum isdisplaced. (Kelly—Diseases of the Ap-pendix.) MASSES FROM INTESTINAL TRACT 273 maintaining this pressure over the appendix, palpate with the other hand the areaswh ch are tender. When the tenderness in the other areas is reflex, it disappearsas long as the pressure over the appendix is maintained, to reappear as soon as thepressure over the appendix ceases. Dr. Kirby has found this simple expedientvery helpful in a considerable number of doubtful cases. 13. Fecal Mass, in caecum and extending along the ascending colon. 14. Tumor of Caecum. This is usually malignant. It presents chronic irrita-tion in the caecal region, generally leading to a diagnosis of chronic appendicitis. There are exacerbations of trouble at times, due apparently to irritation in thecaecum from retained fecal material. In some cases there is a swelling
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