THE TRIPPER'S LEAVINGS
541 inflammatory changes in the appendix. Partly these bodies accomplish this by blocking the outlet and favouring the accumulation of mucus within the appendix. The increased tension thus produced in itself assists the passage of microbes into and through the mucous membrane and the other coats of the appendix, but it also damages the mucous membrane and thus lessens its resisting power. Further by inflicting injury on the lining membrane of the appendix these bodies assist in producing
... citis. Before discussing the nature of these appendical bodies it is well to make clear the fact that the presence of one of these bodies is by no means essential to the production of an attack of appendicitis; in very many cases no included body is found in the appendix and even when it is there it is not rarely probable that it has not assisted in the causation of the appendicitis. Moroever, it is ,clear from our present knowledge that, though the stenosis which prevents the escape of an appendical body may be the result of the irritation produced by that body, a stenosis may occur from any attack of appendicitis, due to any cause whatever, and without the presence of an appendical body. In the present issue of THE LANCET are three papers bearing on the subject of the nature of the bodies found in the appendix. When the diseases of this organ first attracted the attention of the medical public it was believed that the majority of these bodies were " foreign bodies " in the sense that they were thought to have been taken in by the mouth. Many of them were of the size and shape of cherry stones, others resembled apple pips, and even when examined more carefully the stratification which was seen was thought to support the theory that they were seeds. Microscopic and chemical examination have shown, however, that the vast majority of these "foreign bodies" are nothing more than masses of fseoal material bound together with inspissated mucus. When the appendix is healthy it is possible that small fseoal particles may enter the organ for a time ' , and then be carried out with the flow of the secretion of the appendix ; but if at any time the presence of a minute faecal mass should coincide with some predisposing factor, some temporary swelling of the mucous membrane near ' ' , , the orifice, then the imprisoned particle grows by the deposition on it of more fsecal material and is cemented with the morbid mucus poured out by the irritated walls. Not only, however, do these fascal conglomerations mimic "foreign bodies"-that is to say, substances introduced from without-but they also imitate structures formed elsewhere in the body. Sometimes, though rarely, a number of facetted " calculi " are found in an appendix; in colour, in shape, and in appearance they are almost indistinguishable from biliary calculi ; and it is certain that some of the cases in which gall-stones have been described as occurring in the appendix have been instances of facetted appendical concretions. The only valid test is the chemical, for if cholesterin and bile pigments are shown to be present the calculi may be claimed as gall-stones. Judged by this test true biliary calculi do very rarely occur in the appendix. Dr. D. T. Barry of Cork has contributed a paper to this issue of THE LANCET in which he describes a case where four small facetted stones were found in the appendix.