Original Articles.

CONTRIBUTION TO THE STUDY OF SOME OF THE DISEASES PECULIAR TO THE RIGHT ILIAC FOSSA :

Whole Volume LXVIII.

for salpigin dropsy, pyosalpinx or any of the other maladies, which may so interfere with the functions of these organs as to disturb the general economy and resist the ordinary line of medication.

Those surgeons who have had experience in the surgical treatment of the diseases of the ovaries and their

SURGICAL INTERFERENCE.

A Paper read before the Ohio State Medical Society, May 5, 1892,

BY

R. HARVEY REED, M.D., Professor of the Principles and Practice of Surgery and Clinical Surgery, Ohio Medical University; Member American Medical Association, National Association of Railway Surgeons, British Medical Association; Past-President North Central Ohio Medical Society: Surgeon Baltimore and Ohio Railroad; Honorary

Member D. Hayes Agnew Surgical Society (Phila delphia); Honorary Member Texas State Medical Society, etc., etc.

In the paper we presented before this association last year we confined our study of the diseases peculiar to the right iliac fossa to that of chronic catarrhal appendicitis, and endeavored to show you by practical experience the importance of removing the appendix vermiformis as a safeguard to the patient's health and life from the dangers that are liable to arise from a chronic catarrhal condition of this useless appendage. In addition, however, to chronic catarrhal appendicitis, this appendage may be the seat of a variety of other difficulties, which are equally as dangerous, if not more so, than the chronic inflammation of this rudimentary attachment.

Single or double oöphorectomy has long been considered an established and a justifiable operation by gynecologists the world over. Also the removal of the appendages for chronic catarrhal inflammation of the Fallopian tubes, or

beneficial results which have been derived

from the surgical assistance afforded by operations for their relief; and, notwithstanding this operation may deprive a woman of the ability to carry out the prime object for which she was created, yet few surgeons hesitate to remove these organs for her relief when the indications are such as to appear to justify it.

On the other hand, man, and even his helpmate, woman, have been subjected for lo! these many years to a variety of diseases of the appendix vermiformis, which, under many circumstances, are fully as dangerous and equally as painful as the diseases peculiar to the appendages of woman only; and, notwithstanding the removal of this useless extension of the cæcum places no embargo on the procreative power of either man or woman, yet it has been allowed to go on without surgical interference for ages, notwithstanding it has been the unquestionable means of causing the death of thousands and tens of thousands of patients.

Strange to say, however, that in the face of these facts we have surgeons, but more particularly physicians, in almost every part of our country to-day who object to surgical interference in diseases of the appendix vermiformis, and at the same time will advocate the removal of the ovaries and their appendages, and thus desex woman for dis

eases which are no more painful, and even less dangerous, than those which are liable to attack their next-door neighbor, the appendix vermiformis.

To my mind, nothing can be more paradoxical than for a surgeon or a physician to advocate the removal of the ovaries and their appendages under almost every conceivable circumstance for the relief of the many different forms of disease which may affect them, and at the same time object to the removal of the appendix vermiformis (a harmful, useless rudiment) for the relief of diseases which are equally dangerous, correspondingly painful, and comparatively as frequent.

It has always seemed strange to me that physicians and surgeons would, in the language of the commercial traveler, allow themselves to make "a run" on certain diseases, or rather diseases peculiar to certain organs, to the practical exclusion of all others, which are equally important if not fully as dangerous.

The liver has long since been the "scapegoat" for a multitude of diseases; likewise malaria has made it easy for the physician to diagnosticate a conglomeration of symptoms which he is unable to solve and render a rational solution for, and trace to any one particular cause. At the same time "idiopathic peritonitis" has taken its seat in the amen corner with "malaria," "liver complaint" and "female weakness."

We can truthfully say that volumes have been written on these subjects. In fact, for years the medical student would have been justified in arriving at the conclusion, from his study of the various text-books, that certain organs of suffering humanity were the principal seats of all diseases, to the practical exclusion of all others.

It took a Senn to demonstrate that the pancreas was not only liable to cystic degeneration, but was susceptible of successful' surgical treatment; whilst it was left for a McBurney to direct the attention of the profession to certain diseases of the vermiform appendix, which were not only, like the diseases of the pancreas, dangerous, but susceptible of successful surgical interference.

In the language of an old adage, that "it is hard to learn an old dog new tricks," we realize the difficulty of diverting certain members of the profession in every community from the time-worn ruts they have long since traveled in, and induce them to strike out in a new and to them untrodden path, especially when it is so easy for, them to jog along in the old time-worn rut and depend on opium, the customs of the past, and the grave-yard, to bury their ignorance and justify their adopted line of treatment.

We take it for granted that there is not an educated physician or surgeon at this day and age who will admit, or who can conscientiously believe in the old idiopathic theory of the origin of any disease. But, on the contrary that every disease is due to some cause, and whenever we attempt to make ourselves believe that this cause is of an idiopathic character, it is only admitting that we have not been able to discover the real cause of certain effects, and are simply trying to smooth off our ignorance and soothe our conscience, and console the patient by assuming that this difficulty has been of an iodiopathic nature.

This being the case, we are in a position to assume that every case of not only typhlitis, para-typhlitis or appendicitis is the result of a cause, but in addition to this we are satisfied that many cases of so-called idiopathic peritonitis have been the result of one or more of the diseases above mentioned, which are peculiar to the right iliac fossa.

Traumatic Influences.-That traumatic influences are frequently the cause of grave injuries of the viscera, peculiar to the right iliac fossa, is beyond any question. A direct blow over the right inguinal region may produce a rupture of the head of the cæcum, or even of the vermiform appendix, without breaking the skin or producing a solution of the continuity of the abdominal parietes, as I have seen in several instances, a good illustration of which will be found in Case No. I.

Again, I have seen cases where direct force applied externally over the right inguinal region was sufficient to produce enough of contusion, without rupture of the intestinal walls, and no visible external appearance to indicate it, to set up an inflammation of the head of the cæcum, or the appendix vermiformis; which is followed with a "sick spell" lasting any where from one to eight weeks, or longer, followed by apparent recovery; yet most of these cases are sooner or latter annoyed by recurrent attacks referred to in this region.

In this class of cases, whilst the inflammatory symptoms may not be very severe, and the patient's life not particularly threatened, yet at the same time I have seen the most aggravated conditions grow out of a very slight injury of this character, resulting from the adhesions produced by the inflammation, which had glued the vermiform appendix (which in some instances is double the normal length) to the mesenteric side of the cæcum, thus obstructing the circulation to such an extent as to produce the most marked varicosed condition of the veins supplying the cæcum and ascending colon, which is illustrated by Case No. II.

Under the head of traumatic influences effecting the right iliac fossa, resulting from intra-peritoneal injuries, may be mentioned those produced usually by lifting or jumping. For instance, I have seen cases in which a hernia involving the appendix vermiformis was produced by lifting, which necessitated operative interference for its relief and the preservation of the life of the patient. Again, I have seen cases in which acute congestion and rupture of some

of the capillary vessels supplying the vermiform appendix, was followed by the most aggravated symptoms, and was only relieved by operative interference, which is demonstrated by Case No. III, whilst Case No. IV demonstrates the result of non-operative interference.

Foreign Bodies.-Perhaps the most common cause in producing diseases of the right iliac fossa, and especially those involving the vermiform appendix, are foreign bodies. These may be received from without, such as cherry pits, grape seeds and the like, which are swallowed and eventually find their way into the vermiform appendix, and set up ulcerative inflammation, which in the course of time results in a perforation, and either general suppurative peritonitis or a circumscribed abscess, which is not always confined to the right iliac fossa, but may extend to the rectum, or may ascend as high as the liver and involve a portion of that, as has been shown by Dr. Weir, of the New York Hospital. I consider these abscesses of the most dangerous character, as they are liable to attack and destroy, by sloughing and gangrene, any portion of the ascending colon, as is demonstrated by Case No. V, or even involve the omentum to such an extent as to produce gangrene of a large portion of this natural protector of the abdominal viscera, as is clearly shown by Case No. VI.

I dare say that few operators will disagree with me when I say it is the exception, rather than the rule, to find the diseased vermiform appendix free from one or more fecal enteroliths, which, in many instances, are very hard, and at any time are liable to produce perforation by ulceration, and threaten the patient's life; which I have seen occur time and again.

At all events, these fecal concretions are, I firmly believe, formed within the vermiform appendix, and are nearly always associated with chronic catarrhal appendicitis. Yet, it is a question whether they are the cause of this chronic catarrhal condition, or whether the chronic catarrhal condition favors their formation. But whilst it is interesting scientifically for us to determine

which of the causes come first, and which is the exciting cause of this chronic condition, and which is not, yet practically it is of little consequence when you are called to the bedside of a patient whose life is threatened by one of these abominable fecal enteroliths, whether it has been caused by a catarrhal condition of the appendix, or the catarrh has been caused by it.

The Result of Disease.-That many of the affections peculiar to the right iliac fossa, are the result of disease, and not in any way associated with traumatic origin, is certainly beyond any question.

Congestion, the result of "catching cold," is a frequent cause for getting up inflammatory troubles involving the vermiform appendix, or even the head of the cæcum, and every time an acute inflammation of the vermiform appendix occurs, the patient is liable to become a sufferer from chronic catarrhal appendicitis, which we know by experience is usually followed by recurrent attacks of an acute character, which, as a rule, become more and more severe, until the patient is relieved of his malady by death or surgical interference. In fact, every time a patient has an attack of acute appendicitis, he is not only in danger of having it followed by a chronic catarrhal condition of this rudiment, but he is in imminent danger of having it followed by suppuration, which experience has led me to consider and fear as a most grave and dangerous condition - a condition from which the patient seldom makes permanent recovery, or if he does, it leaves him suffering from some sequel, the result of destructive changes of the viscera of that particular part of the abdominal cavity, the consequence of this suppuration.

My attention has recently been called to a case of tuberculosis of the vermiform appendix, which of course is perhaps just as liable to be attacked by this dreaded disease as any other portion of the abdominal viscera; but the peculiar symptoms and history of this case are of such a character as to not only be misleading, but to be convincing to my mind that the tubercular

trouble had its origin in the mesenteric portion of the vermiform appendix, which I think is clearly demonstrated by Case No. 7.

DIAGNOSIS.

In the free discussion which followed my paper on "The Surgical Treatment of Chronic Catarrhal Appendicitis," at the last meeting of this society, I notice that the great "bugbear" which seemed to scare some of our members with reference to operative interference last year, was the dif ficulty of diagnosticating the exact nature and extent of the pathological changes which had taken, or were taking place. Whilst we admit the diag nosis of the exact condition of the ver miform appendix is about as difficult and complex as it is to make a positive diagnosis as to the exact pathological conditions which may effect the uterine appendages, yet how many gynecolo gists are there nowadays who will object to an operation simply because they can not diagnosticate beforehand whether the ovaries contain a number of cysts, or but one cyst, or whether the Fallopian tube is distended with water, blood, or pus? In fact, where is the gynecologist with an extraordinary amount of practical experience, who will dare to venture a positive and explicit diagnosis as to the particular pathological condition of the uterine appendages which he proposes to remove? He will tell you very quickly that it is enough to know that the disease is incurable without an operation, and severe enough to warrant relief by an operation, and that after the operation it will be much easier for him to explain the exact pathological condition that existed than prior to an operation, with much less danger of being mistaken. In brief, all that he desires to determine from a practical standpoint is that the uterine appendages are diseased, and that the disease is of such a character as will not get well under ordinary circumstances without surgical interference, and with this amount of knowledge, nine-tenths of the gynec ologists in this country will, without any hesitancy, advise an operation.