abscess and sinus had been laid open, a small piece of bone, of triangular shape, and with sharp angles, was discharged, and recovery very quickly took place. Death occurring from a different cause not long after, it was found that the appendix vermif. was lying in the inguinal canal; it was enlarged to three times its usual size, its coats much thickened, and its apex opaque, contracted, and adherent to the bottom of the canal. In the second case, there was a swelling of the scrotum caused by the hernial protrusion of omentum enveloping the appendix vermif. Abscesses and sinuses formed in the part, healthy pus was at first discharged, afterwards sanious and offensive matter; the quantity of discharge was profuse, but varied in quantity, and was frequently of a pale orange color. Death occurred from exhaustion, and it was found that the appendix, healthy in structure all the way down to near its blind extremity, was ulcerated at about half an inch from this point, and that a communication existed between its interior and the sinuses of the scrotum. More often inflammation, excited in the vermiform appendix by the presence of hard bodies, extends to the peritoneum, and either at once induces general peritonitis, or gives rise to adhesions, which even if gangrene of the part and perforation occur, may prevent the fatal result for some time. Rokitansky mentions, a curious accident of a different kind which sometimes befalls the appendix. Its canal gets blocked up at a certain part by a foreign body without ulceration taking place. In consequence of this, the mucous secretion accumulates in the closed receptacle, which it distends into a kind of dropsical pouch lined by a thin, serous-like membrane.

The defective state of development of the rectum already alluded to as atresia ani is of various degrees, consisting either in simple closure of the anus by the integument being continued across it, or in the rectum terminating in a blind pouch at a greater or less distance from the anus. Sometimes the canal extends for an inch or two upwards from the anus, and then terminates. It is important to remark that when the deficiency in the rectum is considerable, the pelvis is also imperfectly developed, especially in its antero-posterior diameter.

Lacerations of the rectum and anus occasionally take place, all the coats sometimes being torn through, as after a severe labor when the perineum has quite given way, or only the mucous lining being injured, as sometimes happens after the passage of concretions, or hardened feces. The rectum may be excessively distended by fecal accumulations, especially in persons of lax fibre and low nervous power, or when paraplegia exists. Sometimes its channel is much narrowed by the pressure of surrounding organs, when displaced or diseased; a retroverted uterus, an enlarged prostate, a vesical calculus, or a pessary in the vagina, may all have this effect. Rokitansky asserts that hypertrophy of the sphincter ani may give rise to obstinate constipation, and even to ileus, and that it frequently induces excoriation of the mucous membrane, the so-called fissure of the rectum. We think the converse is generally, if not always, the case, that excoriation or cracking of the mucous membrane, by the irritation which it excites, becomes the cause of excessive action and consequent hypertrophy of the sphincter. This is the opinion also of Sir B. Brodie, who says that "the contraction of

the sphincter appears at first merely spasmodic; but in proportion as this muscle is called into action it increases in bulk; and after the affection has continued for some time, it becomes considerably larger." Fissures may be situated at various points, as described by Dupuytren; some, which are below the sphincter, and scarcely involve any texture but the skin, occasion only pruritus. Those which are above the sphineter give to the finger the sensation of a knotty hard cord, and during the act of defecation give rise to indescribable tenesmus. They are commonly produced by the ulceration of internal piles, and mark their situation on the cylinder of feces by a streak of puriform, sometimes bloody mucus. Fissures situated on a level with the sphincter are the worst, being attended with such agonizing pain during defecation, that patients have been known nearly to starve themselves to avoid the recurrence of the action as much as possible. The appearance of these ulcers is that of a narrow fissure, "the bottom of which is red, and the margin somewhat swollen and callous." "Catarrh and blennorrhoea," says Rokitansky, "accompanied by hypertrophy of the coats, which frequently gives rise to plicated and polypous excrescences of the mucous membrane, are very frequent affections of the rectum." Dr. Copland describes rectal polypi as varying from the size of a pea to that of an egg, having a broad or a very narrow pedicle, situated high up or low down, presenting generally a mucous aspect, a pale-reddish hue, and a smooth or lobulated surface. A small growth of this kind, which we had the opportunity of examining through the kindness of Mr. I. B. Brown, had a short pedicle, was of the size of a pea, rather highly vascular, of lobulated aspect. It consisted entirely of Lieberkühn follicles, and of

Fig. 225.
+

Piles, after excision, showing the dilated veins, of which they are in a great measure composed.

low folds or ridges covered with well-marked columnar epithelium, and mingled with only a small quantity of fibroid tissue. Hæmorrhoids depend essentially on a dilated condition of the veins of the rectal mucous membrane, and are quite analogous to the varices of the legs, which are so common. They are named internal, or external, according as they are situated above or below the sphincter. Although all take their origin in dilatation of the hæmorrhoidal veins, yet in their subsequent progress they come to present different appearances, which we proceed to notice. The first variety, sometimes termed mariscæ, are described by Dr. Copland as "fleshy tubercles, of a brownish or palered color, situate within the anus, or descending from the rectum. They have a somewhat solid or spongy feel; and when divided they present a compact, or porous and bloody surface. As the blood oozes from the cut surfaces, they become pale and flaccid." Whether internal or external, they often contain a central cavity filled with fluid, or coagulated blood, of a dark color. "More frequently, there is no regular

cavity, the substance of the tumor being as if infiltrated with blood, which becomes coagulated and dark; but this appearance is not owing to extravasation, but rather to a dilatation of a number of small vessels which traverse the tissue in the direction of the axis of the rectum; as, upon dividing the part longitudinally, numerous dark streaks are seen in its substance, while a section made transversely shows only small roundish specks." These tumors elongate, assuming a conical form with bases larger than their necks. Sometimes blood is exhaled from their surface, sometimes only a serous fluid, and sometimes, when they are external, they are quite dry. At first, they generally disappear in two, three, or four days; but return again at an uncertain, or at a regular period, and increase in size, becoming firmer in texture. "After some blood is evacuated from them, or after the determination of blood to the parts has ceased, they collapse, leaving small pendulous flaps of skin, which ultimately disappear if the tumors have been small; but if they have been large, these flaps continue conspicuous, and give a projecting and irregular margin to the anus." Having been strangulated by the sphincter, or repeatedly engorged with blood, or chronically inflamed, these tumors become more permanent and solid. "The permanent state of the tumors is owing partly to the development of capillary vessels, and partly to the effused blood and lymph becoming organized; this latter circumstance especially giving rise to the excrescences, or irregular mass of tumors found around the anus in those subject to hæmorrhoids." The second variety of hæmorrhoidal tumors includes such as are formed by a pure dilatation, or varicose state of the veins of the part. Dr. Copland, from whom we continue to quote, describes them "as not so disposed to enlarge at particular periods, and as more permanent, and less painful, than" the first variety. "They are commonly of a dark or bluish color, and soft and elastic to the touch." They are easily emptied by compression, but quickly fill again. "They are round and broad at the base, and often distributed in irregular or ill-defined clusters," which extend often for some way up the rectum, sometimes even as far as the colon. "M. Begin observes that, in most cases, the dilated, superficial, submucous, or subcutaneous veins are only the smaller part of those

Fig. 226.

A slightly lobulated tumor divided in its middle, and the cut surfaces exposed. It was passed per anum. It seems to have been formed by exudation taking place around varicose dilatations of the veins. The cavities seem to have resulted from the dilatation of mucous follicles.

surrounding the rectum. Sometimes the lower part of this intestine appears as if plunged in the middle of a network of dilated and engorged veins, forming a thick vascular ring, the incision or puncture of which may give rise to dangerous hemorrhages." If, in consequence of in

flammation on the congestion of the varicose vessels, exudations of plastic matter take place around or in the substance of these tumors, they become more solid, and more or less similar to those of the first variety. Sometimes the products of inflammation are deposited within the dilated vessel, which induces its obliteration, and the atrophy of the tumor. Perhaps in some cases the reverse takes place, a vein within an originally solid tumor may become considerably dilated. In short, the varieties met with seem chiefly to depend on the predominance of vascular dilatation, or surrounding plastic exudation. A third variety of hæmorrhoidal tumors are described as of an erectile character. They are soft and spongy, and of a purplish color, and give rise to considerable losses of blood. Dr. Colles found in one case "blood vessels of the size of crowquills, running for some way down the intestine, then dividing each into numerous ramifications, and each forming, by the interlacing of its numerous branches, one of these erectile or vascular tumors. The trunks and branches of these vessels were covered only by the lining membrane of the intestine." Some hæmorrhoidal tumors appear to result from the effusion and coagulation of blood in the surrounding tissue. The reality of this occurrence is denied by Rokitansky, but we quite acquiesce in the remarks of Mr. H. Lee,' that it is by no means easy to determine whether the delicate, smooth, and shining membrane lining the cavities in which the coagula are contained, is the lining membrane of the venous system, or one of new formation derived from the blood itself. He also notices the effect of hæmorrhoidal tumors on the mucous membrane around them, which is raised and forced down along with them when they are protruded beyond the sphincter, so that at last it becomes permanently relaxed and "baggy." The female sex, sedentary occupations, and constipation, are enumerated as the chief cause of hæmorrhoids, to which we should add a plethoric habit, and a lax condition of fibre. It does not appear at all proved that cirrhosis of the liver, or obstructive disease of the heart, has any marked influence in the production of piles, as one would naturally expect. The mucous membrane thinned over an hæmorrhoidal tumor is prone to ulcerate, and the resulting sore, according to Rokitansky, is characterized by its seat in the vicinity of the sphincters, its irregular shape, its indented and sinuous flabby margin of mucous membrane, and the ridges of similar tissue that surround or pass over it. These ulcers may continue to burrow into the surrounding areolar tissue, and give rise there to abscess, and ultimately to fistula in ano. This, however, more often results from inflammation being set up in the deeper-seated tissues, the areolar and adipose, but still in the vicinity of the bowel, which advances to suppuration, and in most cases makes its way first outwardly through the integument surrounding the anus, and afterwards. establishes a communication with the cavity of the rectum by a small aperture situated very constantly at the distance of an inch, or an inch and a quarter, from the anus. It does not clearly appear why fistula in ano should occur so often as it does in persons prone to pulmonary tuberculosis, and still less why its existence should be preservative, at

Medical Gazette, August, 1848.

least in not a few cases, against the invasion of the dread malady. Cancerous disease attacks the rectum in most of the forms mentioned as affecting the whole intestine; the only one which it seems desirable. especially to notice, is that which gives rise to the annular structure. This occurs almost exclusively at the upper portion of the rectum, especially at the junction of the sigmoid flexure; the strictured part is sometimes unattached, more often firmly agglutinated to the promontory of the sacrum, but is, nevertheless, pushed down by the feculent accumulations above, so as to be within reach of examination by the finger.

VII. ABNORMAL CONDITIONS OF THE INTESTINAL
CONTENTS.

The secretion of an excessive quantity of gas from the lining membrane of the intestinal canal constitutes the most ordinary form of Tympanitis. It often occurs in inflammatory affections of the canal, which induce more or less paralysis of the coats, in consequence of which the gas is not expelled, but goes on accumulating. The gas in the stomach of an executed criminal was found by Magendie and Chevreul to consist of atmospheric air with a part of its oxygen replaced by carbonic acid, and some hydrogen. In cancerous strictures of the pylorus, and in chronic catarrhal states, the gas contains but little oxygen, much carbonic acid, probably also hydrogen, and carburetted hydrogen, and constantly also sulphuretted hydrogen. In the small intestines of criminals, Magendie and Chevreul found an abundance of hydrogen and carbonic acid, no oxygen, and a varying quantity of nitrogen. Marchand found in the gaseous contents of the large intestines carbonic acid, nitrogen, hydrogen, carburetted hydrogen, and a small proportion in one case of sulphuretted hydrogen. That these gases are secreted by the mucous lining, and do not proceed from decomposition of the ingesta, is considered improbable by Lehmann. We cannot, however, coincide in his opinion, at least to the exclusion of the first-mentioned way of production, if for no other reasons, on account of the experiment performed by Frerichs, which he himself details, that a portion of intestine emptied of its contents, and isolated from the rest of the canal by two ligatures, always became full of gas after being left some time. Mucus in any appreciable quantity can scarcely be said to exist in perfectly healthy intestines; but it is secreted abundantly, as we have seen, under catarrhal irritation. Rokitansky applies to it the following epithets in various cases; it is either milky white, yellowish, and purulent, or glutinous, transparent, vitreous, spawny. He also states "that there can be no doubt that a peculiar gelatinous constitution of the mucus is the nidus of intestinal entozoa, and the cause of helminthiasis." Under irritation of an acute character small membranous patches of mucus are often passed; we have seen these in a case of dysentery constituting the whole of the scanty evacuation. Between these and the fibrinous tubular formation before noticed, there is no very essential difference, and both are to be distinguished from certain membranous substances which occasionally appear in the evacuations, and may cause