These changes of position1 vary according to the point of adhesion, and assume very different forms. They are of importance, as they sometimes offer impediments to the propulsion of the contents of the intestine; but this is not in a ratio with the extent or degree of adhesion, but bears a direct relation to the degree of dislocation produced in one or more coils of intestine. We are now alluding to the adhesions produced by cellular or fibro-cellular tissue, the remains of an entirely extinct exudative process, since we find that similar adhesions, when accompanied by heterologous formations, and especially by peritoneal tuberculosis, rarely produce constipation, but almost invariably give rise to diarrhoea.

We therefore speak of the following forms: a. Partial circumscribed adhesions of the intestine, with the abdominal parietes, with a second, less movable portion of the tube, with the mesentery, with the internal female sexual organs, etc, causing an angular inflection of the intestine. The inflection will be the more considerable, the more the adhesion is limited, and the more remote the latter is from the normal position of the intestine.

When occurring at the colon, the dislocation may be induced by direct adhesions of the less attached portions, or indirectly by the adhesions of the omentum, especially when the latter is shortened, or when it lies in the sac of an inguinal or femoral hernia.

b. Extensive adhesions among the coils or the mesenteries, that often affect the entire small intestine, in such a manner as to twist and bend them, and to produce external valvular duplicatures of the intestinal coats at the projecting angles. This form of adhesion is not unfre-quentlj developed in intestinal segments which have long been included in large hernial sacs, in which case it is limited in extent. A remarkable instance of this was offered in a case of fatal constipation, where a portion of the ileum, twenty-four inches in length, was found inclosed in a cartilaginous sheath of peritoneum of four inches.

1 Oestr. Jahrb. xviii. 1.

4. Solutions Of Continuity

These are the effect of penetrating injuries produced by cutting instruments or firearms, or they may be the result of concussions affecting the entire trunk, as in the case of a fall from a considerable height, or a small portion of the abdomen only, as from compression, in being driven over, etc, in either instance giving rise to rupture or laceration of the intestine; or they may be the consequence of ulcerative processes that proceed from without inwards, or vice-versa, in the shape of perforating intestinal ulcer.

The danger of these lesions bears a direct relation to their extent, and in the last case, also to the rapidity with which the morbid state is developed.

We must finally adduce those perforations of the intestine which are the combined result of mechanical injury, and of an ulcerative process brought on by foreign bodies that have been introduced into the canal; the putrefaction of the intestine, in consequence of sloughing gangrene at or near the spot; and the spontaneous and incurable ruptures of the intestine which follow its excessive distension above a stricture, and are commonly accompanied by circumscribed sloughing of the mucous membrane, or which are the consequence of complete softening of the coats.

Unless the injury affects the coats of the intestine in a very slanting direction, we find that in wounds produced by cutting or stabbing, sloughing or ulceration, the mucous membrane projects over the peritoneal surface in the shape of a tumid fold. In the case of ulcerative perforation, this will not take place until the destruction of the external and internal plates coincide.

In those cases in which a fatal termination is not induced by an escape of fecal matter into the abdominal cavity, giving rise to general peritonitis, nature adopts the following process:

After a mechanical injury has been inflicted, we find that in the vicinity of the orifice, plastic exudation immediately agglutinates the perforated coil to an adjoining surface, which temporarily closes up the hole; in ulcerative processes the perforation is generally anticipated by the inflammatory action of the peritoneum throwing out a guard of lymph.

This agglutination, when following injuries to the intestines that occupy the umbilical region, rarely unites them with the abdominal parietes, except by the intervention of the omentum, which protrudes into the opening of the abdominal walls; it commonly unites them to a neighboring coil. The small intestine that lies in the inguinal region, the colon, a portion of intestine included in a hernial sac, are in close proximity to parietal regions allowing agglutination, and we there find the lymph converted into cellular tissue.

The opening in the intestine communicates with the external surface of the body by means of the agglutinating medium. After ulcerative or gangrenous perforation has occurred, the extravasated intestinal contents give rise to and maintain inflammation and ulceration; and thus perforation of the abdominal parietes or of the adjoining intestinal coil is induced. In the first two cases an abnormal opening of the intestine outwards is formed, which, according to its size, and in proportion as it suffices for the discharge of feculent matter, receives the name of fistula stercorals or anus artificialis. In the latter case an abnormal communication is established between two portions of intestine (fistula bimucosa), and then we have a condition which presents a variety of complications.

These results may not take place; the minute intestinal orifice which results from ulcerative or gangrenous perforations, not sufficing to induce the secondary destruction of the adjoining abdominal or intestinal parietes, the agglutinating tissue is converted into a rounded extended cord, into which the perforated intestine sends a funnel-shaped prolongation of its mucous membrane, and the intestine itself is thus less firmly attached. Continued traction gradually closes up this funnel-shaped cavity, the cord becomes solid, and the mucous membrane cicatrizes over it, generally leaving a pouch at the spot. At a later period the cord may become detached, and it then shrivels up into a cellulo-fibrous nodule lying above the cicatrix of the mucous membrane.

The cure of fistula stercoralis is established in a similar manner. The intestinal opening communicates by means of a layer of organized lymph, with the external surface of the abdomen. The exudation gradually becomes distended so as to form a hollow cord, which, to a certain extent, is lined by the mucous membrane of the perforated intestine; continued traction lengthens out the cord, its channel diminishes at the same time and finally closes. The immediate consequence is the healing up of the external fistulous opening, and in the same manner cicatrization of the intestinal orifice may be effected.