A Contribution to the Study of Some of the 
Diseases Peculiar to the Right 
Iliac Fossa; 
WITH REFERENCE TO THEIR RELIEF BY SURGICAL 
INTERFERENCE. 
BY 
R. HARVEY REED, M. D., 
(University of Pennsylvania,) 
MANSFIELD, OHIO, 
Professor of the Principles and Practice of Surgery and Clinical 
Surgery, Ohio Medical University. 
REPRINTED FROM 
The American Gynecological Journal, Toledo, 0., 
JULY, 1892. 
THE BEE JOB ROOMS, TOLEDO, O. A CONTRIBUTION TO THE STUDY OF SOME OF THE DISEASES 
PECULIAR TO THE RIGHT ILIAC FOSSA; WITH REFERENCE 
TO THEIR RELIEF BY SURGICAL INTERFERENCE.1 
BY R. HARVEY REED, M. D. (UNIVERSITY OF PENNSYLVANIA), MANSFIELD, 
O., PROFESSOR OF THE PRINCIPLES AND PRACTICE OF SURGERY AND 
CLINICAL SURGERY, OHIO MEDICAL UNIVERSITY. 
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 vermi- 
formis 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 append- 
age 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 oophorectomy has long since been considered an 
established and a justifiable operation by gynecologists the world over; 
whilst, in the removal of the appendages for chronic catarrhal inflamma- 
tion of the Fallopian tubes, or for salpingo-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 treat- 
ment of the diseases of the ovaries and their appendages are living wit- 
nesses of the 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 
Read before the forty-seventh annual meeting- of the Ohio State Medical Society, held 
at Cincinnati, Ohio, May 4th, 5th and 6th, 1892. 2 
prime object for which she was created, yet few surgeons hesitate to 
remove these organs, for her relief, when the indications are such as 
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 caecum places no embargo on the procreative power of either 
man or woman, yet it has been allowed to go on without surgical inter- 
ference 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, in the face of these facts, we have sur- 
geons, 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 women for diseases 
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 append- 
ages, 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 harm- 
ful, 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 a certain disease, or rather diseases, peculiar to certain 
organs, to the practical exclusion of all others, which are equally im- 
portant, if not fully as dangerous. 
The liver has long since been the scape-goat for a multitude of 
diseases; likewise malaria has made it easy for the physician to diagnos- 
ticate 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 justi- 
fied 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 to successful surgical 
treatment; whilst it was left for a McBurney to direct the attention of 3 
the profession to certain diseases of the vermiform appendix, which 
were not only, like the diseases of the pancreas, dangerous, but suscept- 
ible to 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 graveyard 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 effect 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 assum- 
ing that this difficulty has been of an idiopathic nature. 
This being the case, we are in a position to assume that every case 
of not only typlditis, para-typhlitis, peri-typhlitis or appendicitis is the 
result of a cause, and, in addition to this, we are satisfied that many cases 
of so-called idiopathic peritonitis have been the results of one or more 
of the diseases above mentioned, which are peculiar to the right iliac 
fossa. 
ETIOLOGY. 
In the study of the causes that produce many of the diseases pecu- 
liar to the right iliac fossa, we may enumerate the following: 
First.-Traumatic influences: a. Direct injury, extra-peritoneal. 
b. Direct injury, intra-peritoneal. 
Second.-Foreign bodies: a. From without, b. Formed within. 
Third.-The result of disease: a. Congestion, b. Inflammation, 
acute or chronic, c. Suppuration, d. Tuberculosis. 
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 caecum, or even of the vermiform appendix, without 
breaking the skin or producing a solution of the continuity of the ab- 
dominal parietes, as I have seen in several instances; a good illustra- 
tion of which will be found in case number 1. 
Again, I have seen cases where direct force applied externally over 
the right inguinal region was sufficient to produce enough of contusion, 4 
without rupture of the intestinal walls, and no visible external appear- 
ance to indicate it, to set up an inflammation of the head of the caecum, 
or the appendix vermiformis, which is followed with a " sick spell," 
lasting anywhere from one to eight weeks, or longer, followed by appar- 
ent recovery, yet most of these cases are sooner or later annoyed by 
recurrent attacks referred to 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 pro- 
duced by the inflammation, which had glued the vermiform appendix 
(which in some instances is double the normal length) to the mesenteric 
side of the caecum, thus obstructing the circulation to such an extent 
as to produce the most marked varicosed condition of the veins supply- 
ing the caecum and ascending colon, which is illustrated by case 
number 2. 
Under the head of traumatic influences affecting 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 pro- 
duced 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 
blood vessels supplying the vermiform appendix was followed by the 
most aggravated symptoms, and was only relieved by operative inter- 
ference, which is demonstrated by case number 3, whilst case number 4 
demonstrates the result of non-operative interference. 
FOREIGN BODIES. 
Perhaps the most common cause producing diseases of the right 
iliac fossa, and especially those involving the vermiform appendix, are 
produced by foreign bodies. These may be received from without, such 
as cherry pits, grape seeds and the like, which are swallowed, and even- 
tually find their way into the vermiform appendix and set up ulcerative 
inflammation, which, in the course of time, result 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 number 5, 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 number G. 5 
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 faecal enteroliths, which, in many in- 
stances, 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 faecal 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 those abomina- 
ble faecal enteroliths, whether it has been caused by a catarrhal condi- 
tion of the appendix, or the catarrh has been caused by it; 
THE RESULT OE DISEASE. 
That many of the diseases 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 caecum, and every time an acute inflammation of 
the vermiform appendix occurs the patient is liable to become a suf- 
ferer 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 also 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 a 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 6 
portion of the vermiform appendix, which, I think, is clearly demon- 
strated by case number 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 diffiulty of diagnosticating the exact nature and extent of the path- 
ological changes which had taken or were taking place. Whilst we admit 
the diagnosis of the exact condition of the vermiform appendix is about 
as difficult and complex as it is to make a positive diagnosis as to the 
exact pathological conditions which may affect the uterine appendages, 
yet how many gynecologists are there nowadays who will object to an 
operation simply because they cannot 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 stand- 
point 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 gynecologists in this country will, without any hesitancy, 
advise an operation. 
Now let us, with the light thrown on the question of diagnosis by 
the practical gynecologist, proceed to determine the essential points 
necessary to warrant operative interference on the vermiform appendix. 
It is usually a very easy matter to determine the possibility of the 
disease of the right inguinal region, not only by the locality, but by the 
tenderness of the parts on pressure, together with the pain in this 
region of the abdominal cavity. Especially is this so in the male. In 
the female, however, it is necessary to differentiate between a patholog- 
ical condition of the right ovary and that of the appendix, or the cae- 
cum. This, however, is usually very easily done by a bimanual exam- 
ination, in which one hand is used to make pressure over the right ingui- 
nal region, while the index finger of the other is placed well up in the 
right horn of the vagina, by which manipulation it is very easy to follow out along the broad ligament and the tube until you come to the 
ovary, and then determine whether the tenderness is in the Fallopian 
tube, the ovary, or higher up in the region of the vermiform appendix. 
After practically determining that the difficulty is confined to the 
head of the caecum or its appendix, it is usually a very easy matter to 
learn from the history whether the difficulty is the result of direct extra- 
peritoneal injury or not. It is usually an easy matter to obtain from 
the patient the fact whether he, or she, has been struck or kicked over 
this region, or whether he has, as I have seen, bruised himself by push- 
ing some heavy article, by placing it against his abdomen. 
Intra-peritoneal injuries are not quite so easily determined, al- 
though they are generally connected with the history of a heavy lift or 
strain, which are immediately, or in a very few hours after, followed by 
pain in the right inguinal region, frequently extending up toward the 
umbilicus, which the patient usually refers to as "colic." This may be 
followed by vomiting and constipation, or we may have constipation 
and diarrhoea alternating, whilst the tenderness increases and a circum- 
scribed tumor can usually be detected on palpation, and, in addition to 
this, the circumscribed dullness, which usually occurs from the local- 
ized oedema, is sufficient to warrant the opinion that the difficulty is 
the result of some intra-peritoneal injury of this particular region. 
In cases where there is no history of either extra- or intra-perito- 
neal injuries, it is of no practical importance whether the morbid 
changes which are going on in the right iliac fossa are the result of 
foreign bodies, such as cherry pits, grape seeds, and the like, received 
from without, or whether it is the result of enteroliths formed within 
the vermiform appendix. I say there is practically no necessity of 
determining which of these conditions is the cause of the difficulty, 
because the results of either are practically the same, and at the same 
time there is no method known, at the present time, by which a differ- 
ential diagnosis can be made, in reference to these particular con- 
ditions. 
In pathological conditions of the right iliac fossa, resulting from 
disease, it is usually very easy to trace a congestion to a severe cold. 
The patient may have been exposed in some manner, resulting in a 
chill, followed with congestion, which may soon localize itself in the 
right iliac region, followed with pain, tenderness, and often circum- 
scribed swelling in that region. In these cases it is not unusual to 
have them ushered in with vomiting and followed with severe constipa- 
tion, which may finally give way to acute diarrhoea, followed with reso- 
lution. More frequently, however, this class of cases is apt to be fol- 
lowed with a chronic catarrhal condition of the vermiform appendix, 
in which recurrent attacks of acute inflammation are liable to occur. 
They usually become so severe in a few months or years as to make life 
a burden and a disgust, rather than a comfort and a pleasure. 
7 8 
Again, acute congestion followed with inflammation, or even chronic 
catarrhal appendicitis in any of its recurrent attacks of acute inflam- 
mation, may be followed with suppuration, which is, as a rule, easily 
diagnosticated; first, by localized tenderness and swelling, by the pecu- 
liar red tongue, by fluctuation and rigors, which sooner or later mani- 
fest themselves under these circumstances, and especially the general 
collapse, which is always manifested when there is suppuration, the 
result of perforation. Whilst we may have tenderness over the entire 
abdomen, it will be found that there are not usually present symptoms 
of general peritonitis, and that the focus of tenderness is in the region 
of the right iliac fossa, and that, as you recede from the so-called Mc- 
Burney point, the tenderness is less marked, the dullness dissolves 
into resonance, fluctuation is lost, and, last but not least, the 
circumscribed tumor, usually consisting of the abscess walls, can 
be distinctly outlined in the right iliac region, on careful exam- 
ination. 
It is much easier, and also much less important, to diagnosticate 
between suppurative appendicitis, the result of traumatic influences, or 
suppurative inflammation, the result of acute congestion, or chronic 
catarrhal appendicitis, than it is to distinguish between suppuration 
from these causes, and circumscribed effusion resulting from tuberculo- 
sis of the appendix vermiformis; especially so, when there is no family 
history of tuberculosis traceable in the patient. 
It is not necessary for us to argue the question, which has already 
been settled by different investigators, that tuberculosis is liable to occur 
in any person, whether they have a family history of hereditary tuber- 
culosis or not. In other words, tuberculosis is believed to be a disease 
which is susceptible of transmission from one person to another, and 
also that it may attack almost any portion of the human economy. 
When this dreaded disease attacks the vermiform appendix, and makes 
this its initiatory locus minoris resistentias, then we may expect to have 
an inflammatory condition with effusion. We are also liable to have 
(as is demonstrated by case number 7), the vermiform appendix 
encysted, and, when this condition of things occurs, it is quite as diffi- 
cult to diagnosticate between a cyst containing peritoneal effusion due 
to tubercular irritation and a cyst including the appendix, containing 
pus or non-tubercular effusion. 
It is exceedingly important to determine, if possible, whether the 
origin of the appendicular trouble is the result of tubercular inflamma- 
tion, or whether it is the resuit of some other exciting cause, and espe- 
cially so if the case is one of long standing, for, unless the tubercular 
focus is removed early, there is little or no use of attempting its removal 
with any hope of permanent recovery, for the reason that the disease 
will soon extend along the mesentery to other portions of the intestinal 
tract, or even the omentum or liver. 9 
To my mind there is no known method, in the absence of the 
knowledge of existing tuberculosis, by which we can determine between 
a cyst containing tubercular effusion and a cyst containing pus or non- 
tubercular effusion, excepting by aspiration, and this I would consider 
much more dangerous to the patient, for various reasons, than to make 
an exploratory incision and determine the true nature of the difficulty. 
Usually, however, it is possible to elicit a history of tuberculosis, or the 
symptoms of the patient may be of such a character as to lead to its 
detection; yet even the enlargement of the glands, due to tubercular 
influences, cannot always be relied upon as a diagnostic symptom of this 
disease, for the reason that enlargement of the glands may result from 
absorption of pus from an abscess in the right iliac region, as well as 
from an abscess in any other part of the human economy. 
PROGNOSIS. 
Experience, which has always been considered a good teacher, and 
as such has led us to be guarded in our prognosis of the diseases pecu- 
liar to the right iliac fossa, has taught me that, whilst we may have a 
perforation of the vermiform appendix followed with an abscess, which 
may open externally and finally result in resolution, with or without a 
faecal fistula, yet we often have what may start as* a mere congestion of 
the vermiform appendix, followed with inflammation, and later, chronic 
catarrhal appendicitis, followed by perforative ulceration from a faecal 
enterolith, resulting in death. 
Experience has also taught me to look upon these troubles as al- 
ways being of a dangerous and treacherous character, and, like a vol- 
cano which may rest for years in a passive and harmless condition, may 
burst forth at any time with a disastrous eruption, causing death and 
destruction to everything before it. So with the diseased vermiform 
appendix, in regard to which we feel like endorsing the language of the 
Indian, who was asked what he thought of a gun, when he said " it was 
dangerous without lock, stock or barrel." So it is with the writer, who 
looks upon the diseased vermiform appendix as always being of a dan- 
gerous character, and like the old adage that "the only good Indian is 
a dead Indian," so it is with the vermiform appendix-the only safe 
vermiform appendix is the amputated one. By this we mean to say 
that we look upon the diseased vermiform appendix as being dangerous 
at all times and liable to assume a fatal condition at any time, and 
therefore, our prognosis should always be of the most guarded character. 
TREATMENT. 
The experience of the past year has not changed the 'writer's 
opinion as to the proper and safe treatment of the diseased vermiform 
appendix, and, like money in the commercial world, which is said to be 
" the root of all evil," so the vermiform appendix may be looked upon 10 
as the "tap root" of all evils occurring in the right iliac fossa, with the 
possible exception of the ovary in woman; and, unless further light is 
thrown upon this subject to convince me that I am wrong in my con- 
clusions as to the proper method of treatment, I will reiterate in 
substance what I said in my paper last year, that the only safe and 
reliable method of treating the diseased vermiform appendix, and the 
only one that will enable you to render anything like a favorable prog- 
nosis, is the amputation of this useless, dangerous and treacherous rudi- 
ment-the inheritance we have received from our ancient ancestors. 
REPORT OF CASES. 
Case I.-William H., of Crestline, Ohio, a vigorous, healthy, 
muscular man, aged 37, was ripping lath on June 29th, 1891, and about 
3 p. m. was struck by the end of a lath, thrown by a buzz-saw, with 
great violence, over the right iliac region, producing a slight abrasion of 
the skin, considerable bruising of the muscles, followed with ecchy- 
mosis, without a rupture of either the integument or the abdominal 
walls. 
The man walked home from the shop where he was working, a dis- 
tance of several blocks, and called a local physician by the name of 
Clutter, who gave the man but little attention and went off and left him 
in the hands of a tyro. The man continued to get worse until Doctors 
Kelley and Son, of Galion, were called in counsel by the friends, who 
in turn sent for the writer, who found the man suffering from circum- 
scribed peritonitis, with severe pain over his right iliac region, counte- 
nance pinched and anxious, pulse rapid and temperature above normal, 
indicating every evidence of a rupture of the intestine, with faecal ex- 
travasation, resulting in circumscribed peritonitis; and, in harmony 
with the opinion already advanced by Doctors Kelley and Son, we 
advised an operation at the earliest possible moment, as giving the best 
chance for his recovery, notwithstanding the opposition to the same by 
the attending physician, Dr. Clutter. 
A laparotomy was performed by the writer, assisted by Doctors 
Kelley and Son, in the presence of Dr. Clutter and others, in which we 
found a rupture of the colon just above the head of the caecum, which 
was one and one-eighth inches in length, and from which large quanti- 
ties of faecal matter had escaped into the abdominal cavity, setting up a 
most violent circumscribed peritonitis, which by this time had formed 
large quantities of lymph, which was rapidly breaking down into pus. 
The abdominal cavity was thoroughly washed out with a bi' 
chloride solution, the opening in the bowel closed with a Czerny-Lembert 
suture, a drainage tube introduced and the external wound closed. Not- 
withstanding the enormous destruction to the intestinal and parietal 
peritoneum, which resulted from the faecal extravasation, followed with 
the most violent suppurative peritonitis, the man lived seventy-two 11 
hours after the operation, when death took place suddenly, probably the 
result of rupture of the intestine, due to sloughing and gangrene. 
Remarks: It is our candid opinion that had this man been 
operated on in time, as he should have been, that a valuable life would 
have been saved with but little or no trouble, but, owing to the dilatory 
methods adopted by his attending physician, who delayed and opposed 
the operation until his opinion was overruled by the friends of the 
patient, at which time (four days after the injury) the destruction occa- 
sioned by the injury had become so great as to make the prognosis 
without an operation absolutely unfavorable, and even with an opera- 
tion (which in our judgment gave the only chance of recovery) very 
uncertain. 
Case II.-Mr. Alpheus S., age about 40, of Marion, Ohio, a farmer 
by occupation, was seen by the author for the first time on March 10, 
1892, in counsel with Dr. Rhu, who gave the history of his patient 
having been struck by a wheel in the right inguinal region, some six 
months previous, and from that injury he dates his difficulty in the 
right inguinal region, which gradually grew worse and worse until he 
was confined to his bed and recovery was doubtful, when an opera- 
tion, which had been advised by Dr. Rhu, was consented to by his 
friends, and on March 13th he was operated by the writer, assisted by 
Drs. Rhu, Martin and Thomas, of Marion, and Dr. F. H. Harding, of 
Mansfield. 
On opening the abdominal cavity, the veins of the caecum were 
found in a remarkably varicosed condition, whilst the vermiform appen- 
dix, which was five inches in length, was found tightly adherent to the 
mesenteric side of the caecum and ascending colon, thus interrupting 
the circulation and producing this remarkable varicosed condition of 
the veins thus involved. The appendix was carefully dissected out of 
its abnormal position, which necessitated the tying of several small 
arteries, after which it was ligated dose to the head of the caecum and 
removed. The stump of the appendix was covered with omentum and 
the abdominal wound closed. 
The patient made a rapid recovery without any bad symptoms, 
whilst the pain was relieved almost immediately after the operation, 
and he is to-day in the enjoyment of his ordinary health. 
Remarks: Here is another case showing the result of traumatism, 
in which the circulation was so obstructed as to sooner or later set up 
such destructive inflammation as to have endangered recovery, but for 
an operation, which was not only advised by the attending physician 
and his counsel, but by the operator, and the result of the wisdom of 
this advice needs no comments beyond the report of the facts of this 
case. 
Case III.-Fred. B.,aged 25, of Shelby, Ohio, whilst lifting a heavy 
weight on July 4th, 1891, felt s miething "give way" in the right iliac 12 
region, which induced such severe pain as to make him "double up" 
for a few moments, which was followed soon after by diarrhoea. The 
same evening, however, he rode to Shelby, a distance of some two miles, 
and while there was taken with severe " cramps," and returned home as 
soon as possible. These " cramps " were followed with diarrhoea, which 
lasted all night, and the next morning, July 5th, he again rode to 
Shelby and consulted his family physician, Dr. A. F. Hyde (to whom 
I am indebted for the report of this case), who found his pulse and 
temperature slightly elevated; abdominal muscles rigid with extreme 
tenderness, as the doctor puts it, "in the southwest corner of his 
abdomen," meaning the right iliac fossa. 
Dr. Hyde promptly advised him of the serious aspect of his symp- 
toms, and put him on small doses of calomel and opium. But, not- 
withstanding, he grew rapidly worse, and July 6th tumefaction began 
to occur in the right iliac fossa, which, in a day or two, was followed by 
more favorable symptoms, which only lasted a short time, when his symp- 
toms became aggravated, his pulse weak and rapid, his temperature 
ranging from 101° to 103.5°, countenance anxious and facial expression 
pinched, with marked aggravation of all the symptoms in his case. 
On July 18th the writer was called in council with Drs. A. F. Fly de 
and M. T. Love, who had already advised operative interference. I 
made a laparotomy, found the head of the caecum inflamed, with a 
short, contracted vermiform appendix, which was removed in the ordi- 
nary manner, a drainage-tube was inserted and the external wound 
closed by three rows of sutures. The first, a fine continuous suture of 
cat-gut, closing up the peritoneum; the second, a continuous suture of 
heavier cat-gut for the muscular walls, and third, closing the integu- 
ment with deep interrupted silk sutures,- which dipped down into and 
included the second row of cat-gut sutures. 
The patient made a rapid and uninterrupted recovery, and, in a 
few weeks, was out attending to his ordinary avocations on the 
farm. 
Remarks: This case is simply another example of the importance 
of operative interference in traumatic injuries, which set up and main- 
tain a continuous, or even recurring, disturbance of the abdominal vis- 
cera in the right iliac region. 
Case IV.-1 am indebted for the report of the following interesting 
and instructive case, wich was furnished me by my friend, Dr. Auguste 
Rhu, of Marion, Ohio. 
Orley H , aged 15 years, sustained a slight injury of the right 
inguinal region, while riding a bicycle. A week later he complained of 
cholera-morbus and pain in the abdomen, from which he made a partial 
recovery, but, on August 6th, 1891, he had another attack, for which he 
was treated by his father, who was a physician, for peritonitis, who had 
called to his assistance several other local physicians. 13 
Dr. Rhu was called in on the fourth clay of this last attack; diagnosed 
the case as one of suppurative appendicitis by the McBurney method, 
and advised immediate surgical interference, which was refused. The 
result was that a post-mortem was held August 11th, 1891, which re- 
vealed a large collection of pus, surrounding a perforated appendix, 
that contained a faecal enterolith, in addition to another faecal concre- 
tion, which had escaped and was found in the abdominal cavity. 
Remarks: In this case we have a marked contrast with case num- 
ber three, of the results of non-operative interference, as compared with 
operative interference, for traumatic injuries of the right iliac fossa, and, 
except to call your attention to this one particular point, we do not 
deem further comment necessary, as the case and its results speak for 
themselves. 
Case V.-Mrs. Maud S , of Marion, Ohio, a prominent young 
married lady of that city, was taken ill about July 2d, which illness 
was marked by pain and tenderness in the right iliac fossa, which in- 
creased in severity, until it was evident to Dr. Rhu, the attending phys- 
ician (to whom I am indebted for assisting me in obtaining a report of 
this case), that suppurative appendicitis, resulting in a circumscribed 
abscess, had occurred, notwithstanding he was unable to trace her ill- 
ness to any particular cause. Whilst the Doctor was unable to determine 
satisfactorily the etiology of this case, subsequent investigations of the 
case showed a perforation of the vermiform appendix, which was un- 
doubtedly due to ulceration, caused by a foreign body, which, in all prob- 
ability, was a faecal enterolith, which had escaped and formed an 
abscess and subsequently dissolved in the pus, and thereby escaped 
detection. 
Dr. Webb J. Kelley, of Galion, was called in counsel and con- 
curred in the opinion of Dr. Rhu, that operative interference was the 
only possible chance for her recovery and, in harmony with that opinion, 
the writer was sent for on July 24th, 1891, at which time he found all 
evidence of a circumscribed abscess in the right iliac region, which un- 
doubtedly involved the vermiform appendix and the head of the 
caecum, and advised immediate operation as the last and only possible 
chance for her recovery. 
Owing to a sudden collapse, which occurred about three o'clock 
the night previous to the operation, it is the opinion of the writer that 
perforation of the ascending colon took place at that time, and it was 
with great difficulty that the attending physicians were enabled to 
secure reaction from the shock she sustained at this time. The patient 
having to a certain extent rallied from the shock at the time the writer 
saw her, it was decided by Drs. Rhu, Kelley and himself that nothing 
short of an operation could possibly save her life, and there was no 
guaranty of that doing so, owing to the delay and extensive destruction 
that had undoubtedly taken place. 14 
This, however, being explained to the family, an operation was 
decided upon and a laparotomy made by the usual oblique incision 
parallel to Poupart's ligament, which revealed that gangrene had taken 
place, and that, owing to that, a perforation had taken place in the 
ascending colon, about three inches above the head of the caecum, with 
large quantities of fecal extravasation which was mingled with the 
most offensive character of pus, of which fully a quart and a half was 
evacuated, and the circumscribed abscess cavity, which involved the 
head of the caecum and extended well down in the iliac fossa, was thor- 
oughly washed out with a jqVo bichloride solution. 
Owing to the marked pathological changes, with adhesions and 
thickening of the parts, we were unable to find the vermiform appendix, 
and, going on the advice of other operators, that when such was not 
readily found, owing to the adhesions, it was best not to break up those 
adhesions and remove it, we allowed it to remain. After closing the 
opening in the bowel by a Czerny-Lembert suture, a large drainage tube 
was placed in the abdominal wound, which was closed in the usual 
manner. 
The patient rallied from the operation, and, for a few days, promised 
fair prospects of recovery, but unfavorable symptoms returned and the 
patient died on the sixth day after the the operation. A post-mortem 
showed an abscess under the ascending colon, where the perforated ap- 
pendix had been attached, and, owing to the perforation, was keeping up 
the original cause of the whole trouble. 
Remarks: This case contains several interesting'lessons. In the 
first place, it was mistaken by some of the local physicians for a case of 
typhoid fever. I suppose this was owing to the fact that we sometimes 
get tenderness in the region of the right iliac fossa in typhoid fever, 
due to irritation of the so-called "Peyer's patches." 
In the second place, owing to this division of opinions, the case 
was delayed until operative interference gave but little chance for per- 
manent recovery. 
In the third place, when operative interference was made, the per- 
forated vermiform appendix, which could not be readily found, owing 
to the thickening and adhesions already mentioned, was allowed to 
remain, in harmony with the advice of other writers and operators, 
whose opinions and experiences we at that time considered worthy of 
imitation; but this case has clearly and distinctly shown the fallacy of 
making an operation of this character without finding and removing 
the offending vermiform appendix and evacuating every particle of pus 
and foreign material which may infest any part of the abdominal cavity. 
Case VI.-John H , of Shelby, Ohio, aged-44, a laborer, of spare 
build and ruddy complexion, had the history of having had a scrotal 
hernia on the right side, which disappeared with the use of a truss, 
when at about the age of 12 years. 15 
For several years prior to his death he suffered from occasional 
attacks of abdominal pain localized in the right iliac fossa, followed by 
a more or less persistent diarrhoea. He complained of tenderness and 
soreness in the region of the appendix vermiformis, which pain was 
always aggravated by hard labor, especially by efforts at lifting heavy 
weights (which he was accustomed to do, owing to the fact that he was 
a marble cutter), but which he thought arose " from weakness " due to 
the rupture. On February 19th, 1892, he was attacked with severe 
abdominal pain, nausea and vomiting, accompanied with constipation. 
Dr. A. F. Hyde (to whom I am indebted for assisting me in obtain- 
ing this report), saw him for the first time on the evening of February 
20th, for up to this time he was under the treatment of Dr. Ryal, a 
homoeopath of that village. His pulse was found to be 90, and temper- 
ature 99°, whilst severe tenderness was observed on palpation over the 
right iliac region. 
Dr. Hyde at once gave it as his opinion that the man was suffering 
from an attack of appendicitis, with the possibility of suppuration, but 
did not see him again until the evening of the 22d, the fourth day after 
the onset of his last attack. At this time his pulse was 120, tempera- 
ture 98°, with considerable tympanitis. Hiccoughing had set in twen- 
ty-four hours previous to this, as the natural result of septic infection, 
and gave the patient a great deal of pain and annoyance. Marked dull- 
ness was observed over the right iliac fossa, in which was diagnosticated 
an abscess, and immediate operation was advised as a last resort. In 
harmony with this opinion the writer was sent for, and saw him a few 
hours later, and confirmed the opinion of Dr. Hyde and proceeded at once 
with the operation, in which he was assisted by Drs. Hyde and Love, 
of Shelby, in the presence of Drs. Bricker, Ryal, Sawyer, Sager and 
others. 
I made the usual lateral incision and found an enormous abscess 
filled with the most fetid and offensive pus, in which was obtained an 
enormously enlarged vermiform appendix, containing a perforation 
from which a grape seed had escaped into the abdominal cavity and 
which we subsequently obtained. It also contained a large faecal enter- 
olith which had formed above the grape seed, and, from all appearances 
and the history of the case, had been a long time in forming, and un- 
doubtedly had imprisoned the grape seed all this time, which had 
finally perforated the appendix lower down and subsequently made its 
escape into the abdominal cavity. 
In addition to this, we found that a quantity of the omentum had 
become necrotic, and consequently quite a quantity of it had to be re- 
moved and will be seen accompanying the specimen. 
The ordinary toilet was made, a drainage tube inserted and the 
incision closed by the method already described. It is almost need- 
less to add that this patient died in a day or two after the operation. 16 
Remarks: This constitutes another grave-yard witness of the dan- 
ger of foreign bodies in the vermiform appendix, and the destruction 
occasioned by circumscribed suppuration due to their perforation and 
escape into the right iliac fossa. From the history of this case we have 
every reason to believe that this grape seed has been lodged in the 
vermiform appendix for many years, and had no doubt set up a chronic 
catarrhal appendicitis, which was still more aggravated by the forma- 
tion of a large and unyielding faecal concretion. 
There is no question in the writer's mind that, had this case been 
operated prior to this last attack, the life of this patient might have 
been saved; but owing to the enormous destruction resulting from long 
continued delays in operative interference, the vitality of the patient 
was so exhausted and the destruction of the abdominal viscera so ex- 
cessive that nothing short of death was left to follow (whether he was 
operated or not) as his only relief, although it is our firm opinion that 
an operation even under these circumstances gave the only chance for 
recovery. 
Case VII.-Frank H. T., aged 43, a farmer by occupation, living six 
miles north of Mansfield. I was called to see him for the first time, 
March 29th, 1892, and found him with an excellent family history, 
which in no direction could be traced to the slightest taint of hereditary 
tuberculosis. The fall previous he was taken with a dry hacking cough, 
which was soon followed with a pain in the right iliac fossa, which he 
attributed to a strain from coughing. This cough, however, only lasted 
a few weeks, when it entirely disappeared, but the pain in the right iliac 
fossa continued and extended up to the region of the liver. A short 
time later he was taken down with an acute attack of pain, which was 
referred to this same region, and for which he was treated by a homoe- 
opath, who never gave him any diagnosis of his case, but subsequently 
very frankly told him he did not understand his case and did not know 
what ailed him. He quit all treatment for a while and gradually got 
some better, so much so that he could be up and around, but the pain 
still continued, until it became so severe that he consulted another 
homoeopath, who treated him for awhile with no better success than his 
predecessor. He finally went to a notorious quack in the city, who 
claimed a " dead sure thing " on curing him, but, instead of being cured, 
he gradually grew worse, and on the date above mentioned the writer 
was called to see him. 
A careful examination revealed an exceedingly red tongue, pulse 
ranging from 85° to 95°, with temperature but little above normal, appe- 
tite poor, bowels alternating with diarrhoea and constipation, stomach 
irritable, but vomiting the exception, although occasionally occurring. 
Marked circumscribed tenderness and dullness was found over the head 
of the caecum and vermiform appendix. The tenderness, however, ex- 
tended as high as the liver, but gradually faded out as we radiated to 17 
other parts of the abdominal cavity, although there was more or less 
tenderness over a great portion of the abdomen. 
A careful examination of the lungs revealed nothing abnormal, 
either by ausculation or percussion, but all his pain was principally re- 
ferred to the right side and more particularly the right iliac region. 
With this history and these symptoms, it was my opinion that his 
trouble originated with the vermiform appendix, and the other parts of 
the abdominal cavity had become affected secondarily, and, owing to the 
extremely red tongue and occasional rigors, there was a strong probabil- 
ity of the existence of a small circumscribed abscess having formed 
around the vermiform appendix. This opinion was more firmly im- 
pressed on my mind as the case developed further; but, owing to the 
many complications which manifested themselves, I was not well satis- 
fied in my own mind as to whether an operation was advisable or 
desirable under these circumstances. I saw the case again on April 
5th and 13th; at the latter date a counsel was held with Dr. J. W. 
Craig, who confirmed my opinion that operative interference was, without 
doubt, the best treatment we could give him, for by this time a circum- 
scribed tumor with fluctuation could be distinctly outlined in the right 
iliac fossa, and which extended well back, producing marked bulging 
on the right side in the lumbar region. In addition to this, jaundice 
had made its appearance within the last day or two, leading us to believe- 
that, like Dr. Weir's case, of New York, which we have already referred 
to, the liver had become involved. 
After explaining the dangers and uncertainties connected with the 
operation, the patient finally decided to submit to an operation, and on 
April 15th, assisted by Drs. J. Harvey Craig, J. S. Hedges and F. H. 
Harding, I performed a laparotomy and removed the vermiform appen- 
dix, the mesentery of which was found to be tubercular. This rudi- 
ment was discovered to be distended with semi-solid feecal concretions,, 
and was found completely enclosed in a cyst, the size of your thumb,, 
which contained nothing but serum, in addition to the appendix. 
I also found, on examination, just before the operation, that the cir- 
cumscribed dullness, which heretofore had been confined to the right 
iliac and lumbar regions, had become more diffuse; and on opening the 
abdominal cavity, I found that the adhesions had in part given way and 
allowed the serum (which had been confined in this heretofore circum- 
scribed portion of the abdominal cavity) to in part escape into the 
general peritoneal territory. I found nearly two quarts of this serum, 
which I carefully drained out, and in addition to this I discovered that 
the tubercular trouble had extended along the mesentery of the ascend- 
ing colon and attacked the omentum, and had also attacked the liver. 
Evidently, what we found to be a circumscribed tumor was a col- 
lection of this serum, which by adhesions had been confined to the 
right iliac and lumbar regions, but which, just prior to the operation, 18 
had found its way through the walls of these adhesions into the general 
abdominal cavity; while the icterus I found was due to adhesions of 
the omentum, which produced a stenosis of the common bile duct. 
The vermiform appendix was removed, the adhesions around the 
common duct loosened up as much as possible, but we found it was 
impractical as well as impossible to remove the omentum or other por- 
tions of the abdominal viscera which were involved by the tubercular 
disease. We contented ourselves with doing what little we could for his 
relief, and, after washing out the abdominal cavity, we introduced a 
drainage tube and closed up the abdominal wound; and, whilst there 
was no possible chance for his recovery, we have the satisfaction of 
knowing that the operation gave him decided relief. The abdominal 
wound closed by first intention, and during the remaining seven days of 
the patient's life he was much more comfortable than he had been at 
any time for weeks previous to the operation. 
Remarks:-This case presents a very interesting chain of symp- 
toms, while the history and report of the case show how easy it is to 
be misled under certain circumstances as to the exact cause or causes 
which are producing the disease or diseases of the right iliac fossa, and 
which, often, only operative interference is likely to reveal the true nature 
of, which in this case was found to be tuberculosis of the mesentery, 
with associated effusion, which up to a day or two before the operation 
was circumscribed, and from which it was natural for us to draw the 
legitimate conclusion that it was pus, owing to all the symptoms of the 
septic infection which existed, and the fluctuating tumor which was 
found clearly indicated in the right iliac fossa. 
We have already called attention to the importance of making a 
clear diagnosis in this class of cases, not that an operation will hasten 
the impending death which stares the patient in the face, but because 
little benefit outside of temporary relief can be obtained in tubercular 
disease of the appendix by an operation. But if you do operate, the 
patient and his friends should be carefully guarded against expecting 
brilliant results, which under more favorable circumstances might effect 
a happier termination. 
GENERAL CONCLUSIONS. 
First.-Never adopt the rule of making operative interference the 
last resort in the treatment of disease peculiar to the right iliac 
fossa. 
Second.-The only genuine safety for a patient with a diseased ver- 
miform appendix is to have it placed in a bottle of alcohol for the 
adornment of some surgeon's pathological museum. 
Third.-Early operation in diseases of the vermiform appendix is 
the only safeguard against recurrent attacks of inflammation, perfora- 
tion, suppuration and death. 19 
Fourth.-Never wait for suppuration in attacks of acute appendici- 
tis. Such practice is just as sensible as it is to wait for stercoraceous 
vomiting and gangrene of the bowel before operating in strangulated 
hernia; for, like in strangulated hernia, procrastination is the thief that 
has stolen thousands of patients from the physician and surgeon and 
given them to the undertaker.