Hunterian Lecture ON THE INFLUENCE OF NERVE IMPULSES ON VISCERAL DISORDERS
Tiris study embraces a series of 123 cases, in which fixation, partial or "complete," was performed in 106. Since my experiments on shock I started out with the hypothesis that mesenteric inhibitory nerves could be stimulated by mechanical traction. Experimental evidence supported such a view ; and it is not surprising that visceral disorders should have been approached from this standpoint. The relief of such a strain by a normal anchorage of the bowel would clearly cure the symptoms, provided
... symptoms, provided secondary lesions were not too firmly established. Accordingly, I have during the last eight or nine years practised various operations for fixation of the csecum, ascending and transverse colon, being originally led to do so after reading a report of Wilms's paper on caecum mobile (published tnl904). In order to facilitate a detailed analysis I have divided these cases primarily into two main groups according to the situation of the chief mesenteric strain: (A) tension on the ileo-csecal and ileo-colic mesentery; (B) tension on the .transverse mesocolon. Thus, A arises in excessive mobility of the csecum and ascending colon; and B when there is marked proptosis of the transverse colon. A and B may exist together in general viceroptosis. In all these fixation operations the object has been the transference of an excessive mesenteric strain to a region which is innocuous. A. Caecopexy and Ascending Colopexy. From the first I have never performed Wilms's " pocket operation, but have always attempted to reproduce as accurately as possible the normal result of mesenteric fusion. Depending on whether the esecum alone or the caecum and, ascending colon is to be fixed, I open the peritoneum of the posterior wall and iliac fossa about in. external to the line of the mesenteric attachment, from a point just short of the brim of the pelvis as far up as necessary (Fig. 4 (A-B) and Fig. 6 (X-X')). The suture of the internal cut edge of the peritoneum to the postero-internal aspect of the cxcum is commenced at and includes the meso-caecum (in order to obviate the possibility of internal hernia). The sutures are continued downwards, the apex of the csecum being sutured to the lowest point of the peritoneal incision. From this point upwards to the upper extremity of the peritoneal incision the cut edge is sutured to the external tasnia, muscularis. All sutures should include the muscular wall of the bowel. The caecum and ascending colon are thus rendered extra-peritoneal in their posterior aspect over the required area. That such an attachment proves permanent I have twice had the opportunity of establishing ; once in a case I operated upon again a long time afterwards, and once at an autopsy after accidental death from coal-gas poisoning. Of 53 cases, no fixation was performed in 7, of which 3 were not operated upon at all, and the only one of these I can trace is relieved by corsets, but still suffers pain. Of the remaining 4 cases, 3 have been traced; 2 are cured, and the other has had a recurrence of pain. This leaves 46 cases on whom fixation of caecum or cseoum and ascending colon was performed. Of these, I have not been able to satisfy myself, either by -letter or personal interview, of the late results in 13, some of which were operated on a good many years ago. I have thus a series of 33 cases in which the end-results can be traced over a varying number of years, and in 2 of these (though I have no news of them lately) the result was entirely satisfactory for a long time after the operation. The figures for this series :-With regard to the failures I have made careful investigation and will discuss them in a moment; but it is clear that little can be learnt from the percentage of successes alone. The figures agree in the main with those given by Wilms (75 per cent. cures), but the details are instructive and deserve some elaboration. The groups of symptoms for which this operation has been performed are three. (1) Recurrent acute attacks of pain resembling acute appendicitis, but unaccompanied by any marked rise of temperature and pulserate and other constitutional evidence of acute inflammation. The attacks usually last a few hours only and clear up rapidly, leaving the patient little beyond a sore, bruised feeling locally. During the attack, a T"1 to a less extent for a few days afterwards, there is a fullness and tenderness in the right iliac fossa, which is a little guarded against deep palpation. This is due to marked distension of the caecum, which can be emptied with a definite gurgling sound. Between the attacks the existence of a distended, gurgling, and prolapsed caecum is easily demonstrated, clinically or by X rays. There is no doubt that Wilms's explanation of these attacks is true in a certain proportion but not in all. I am sure that in some they are due to limited volvulus of the caecum, the twist being external and the obstruction partial. Of this there is distinct evidence in two of my cases. (a) The caecum was found large and freely mobile, and twisted externally so that the ileo-cseoal valve was situated antero-externally. Fixation of caecum in its proper position resulted in a cure. (b) The caecum was externally rotated, the retro-csecal appendix was lying anteriorly, and the terminal ileum passed across the caecum and appendix to enter the former in its external aspect. A Lane's kink was present, somewhat remote from the ileo-caecal valve, around which, I think, the rotation had taken place. A plastic lengthening of the Lane's kink, appendicectomy, and caecopexy resulted in a cure. Lane's kink was present in four of this series and was dealt with in the manner already described; one was further complicated by an extensive Jackson'a membrane. Two were cured and two were failures, which I shall refer to later. A Lane's kink will contribute to inhibitory distension, as already shown, and is thus an additional factor in the causation of acute attacks; while these may clearly be accentuated in severity by the pull on a Jackson's membrane. Operation was undertaken in 18 instances for such acute attacks (1 resembled a gastric ulcer, and 17, acute appendicitis); the latter figure, therefore, represents 51 per cent. of the series. Of these, 88 per cent. were complete cures. Two failed to produce complete cure. In five instances symptoms were accompanied by vomiting; three were cured. (2) Chronic rig7zt-sicled dragging pain.-This is a mechanical result of the drag of an inhibited mobile caecum and ascending colon on the peritoneum, mesentery, and kidney; and it is associated with varying degrees of right renal mobility (Fig. 6 ). It is this class of case for which nephropexy was so often practised, with such poor results, in past years. When associated dyspeptic symptoms are present (3) these are attributable to the drag on the terminal ileal and ileo-colic mesentery, produced by the prolapsed caecum 'in the erect posture (Fig. 6) , and the mechanism is similar to that already referred to in the case of the Lane's kink and the controlling appendix. (See Group (3).) Reflek gastro-intestinal inhibition also occurs from the afferent sympathetic stimulus induced by the drag on the right renal pedicle. It is particularly instructive to note that, whereas in the 21 per cent. of cases where chronic dyspeptic symptoms (e.g., nausea, flatulence, and distension) were complained of, 85 per cent. were cured: when the chief symptom was a right-sided dragging pain (24 per cent.), a cure was only established in 62 per cent., two cases recurring after apparent cure. (3) Chronic dyspeptic symptoms have already been referred to, and may accompany either of the former class of case. Cures in 21 per cent. of cases were 85 per cent. This supports the view that the drag of the bowel stimulated the mesenteric nerves of the ileo-colic mesentery and (in (2) ) the renal pedicle. Further support will, I think, be obtained from X ray examination. For I have observed that in well-marked visceroptosis, where ileal stasis is associated with marked delay in the ascending colon, the peristaltic waves in the terminal ileum are very obvious in the recumbent position, but are sometimes much less evident and more difficult to follow in the erect posture. I have not, however, examined sufficiently often to be sure 011 this point. It is evident from this analysis that the largest percentage of cures from csecopexy are obtained either when acute attacks of pain (88 per cent.) or chronic dyspeptic symptoms (85 per cent.) are the prominent features. The smallest percentage of cures result when the operation is undertaken for chronic right-sided dragging pain, and the reason is apparent from a study of the failures. Failures (9 per cent.).-In two of the failures present symptoms point to the origin of these as part of a general visceroptosis. In one gastric symptoms were very well marked, and it was evidently a mistake on my part to expect the remedy of an advanced general condition by a purely local procedure like caecopexy. This patient says she is a little better. In the other case caecopexy was only performed during operation for a supposed recurrent appendicitis. Recurrences (two cases).-These are both instructive. Both complained of chronic right-sided dragging pain in the erect position as the prominent feature. In both the cseoum alone was fixed. In one case a Lane's kink was remedied, and a cure, lasting for 18 months, was followed by a relapse to the pre-operative condition. In the other a Lane's kink was remedied, and a well-marked Jackson's membrane was left untouched ; caecopexy only was performed. A cure lasted until parturition, when the old symptoms gradually returned, clearly owing to diminished support. Caecopex1J and ascending colopexy.-It is interesting to note that in this series the ascending colon was also fixed in eight cases for all groups of symptoms. One was complicated by gall-stones, which I do not think were responsible for the symptoms complained of. This operation resulted in 87'5 per cent. of cures; one (improved) has occasional attacks of indigestion. These figures, small as they are, afford a clear indication of the reason for these two recurrences and the means of avoiding them-i.e., if the prolapsed caecum is dragging on the ileal mesentery alone the resulting inhibition will cause attacks of acute distension (resembling appendicitis), associated with reflex gastric symptoms of mild or intermittent type (Fig. 3) . Here caeeopexy is sufficient, and will effect a permanent cure. Symptoms associated with right-sided dragging are an indication that the right-sided prolapse is more general and is involving the kidney ; accordingly, fixation of the ascending colon also is called for (Fig. 6 ). This inference is supported by the good results of ascending colopexy in the subsequent series, and when performed as an adjunct to other operations. Cotts<MMtMM.—This was a prominent feature in 27 per cent. of cases, and in these 77 per cent. were cured. It was not a marked symptom, or only present during acute attacks in 72 per cent., and in this series 83 per cent. were cured. It would appear that these were early cases.