New York Medical College - Fleuroscope Yearbook (Valhalla, NY)

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c 4oMMoN SENSE INASURGICAL DIAGNOSIS THIS is a machine age and machinery has become such an important part of medicine that we often wonder if the art of medicine is not lost sight of. A machine is good only when there is a rational brain behind it. The appendicitis problem is a serious one. There has been a tendency to emphasize the complications instead of recognizing the disease as an entity early. History taking is an art which is frequently passed over lightly. Osler used to say that the history is often three quarters of the diagnosis. In every appendicitis case a careful history will show the presence of abdominal pain with some form of intestinal upset. Formerly the physical examination syn- drome was emphasized, and rightly. Inspection is the first stage. With the eye on a line with the abdomen one can often detect protective tension of the abdominal wall over the site of the trouble. The breathing is often shallower in real abdominal disease. The parts lack symmetry. Palpation, starting in a Silent area with the wrist end of the hand resting firmly and the fingers gently pressing, then following around near the point of tenderness, then reversing the process again to the point of tenderness, then deep pressure, rebound and then the pinching of the skin for hvperesthesia, is the second point in the diagnosis of this disease. A rectal examination is of value in certain rare pelvic forms. Kidney palpation and the use of the stethoscope over the chest will probably eliminate two of the differential diagnostic con- ditions such as pyelitis and right sided pneumonia. When these procedures are carried out, and only after the information from these is gained, is it advisable to look to the laboratory. The blood count shows us theprogress of the- disease. We know so little about the blood count of the individual in health that it is sometimes a mistake to draw too many conclusions from it. With the positive symptoms as shown by physical examination, we have no right to delay operation. We well know that many an acutely inflamed appendix because of its peculiar anatomical location, blood and nerve supply, has not had time to cause a constitutional reaction, and we therefore know that this is the safe period in the manage- ment of this disease. Many times we have operated cases with a normal pulse, normal temperature, a so-called normal blood count, only to find on opening the appendix, many gangrenous spots starting in the mucosa and the submucosa, with frank pus in the lumen as proved by culture. Therefore we feel that common sense dictates a diagnosis of appendicitis on the history and physical signs leading to prompt operation and quick recovery. Disease of the gall bladder presents a different problem. A careful his- tory shows the incidence of indigestion, so-called, over quite a period of time, with the peculiar symptom of pain in the right upper quadrant immediately following the ingestion of food, especially fat food, accompanied with gas. This syndrome is quite different from that of ulcer. A careful physical exam- ination usually shows a tension on respiration in the right upper quadrant accompanied by some pain under the scapula. Hammer percussion at a point where two lines cross, one from the ensiform to the anterior-superior One hundred eighty-four

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SCHOOL DAYS FROSI-I There was a Freshman at Flower Who studied mnernonics by the hour But when quizzed by the Boss He found keys a total loss Now sight of M .D.'s makes him cower. SOPH A soph towards study was cool With wine and women he'd fool Exams drove him frantic And his libido gigantic At last got him kicked out of school. JUNIOR The Iuniors all go to the Met To do their service obstet With hearts aquiver They stand and deliver Offspring begot tete-a-tete. SENIOR The seniors are inclined to be cynical They shun experiences clinical Interneships they seek Which seven days a week Will bring them patients qyr1'ical. MOTHERHOOD Par la boca - Bespiro - Breathe, mother Now push - pujo - That's fine - Now Thats the way It's just a few more pushes mother And then we'll call it a full Business day Oh - here it comes. BE STILL motherl Don't Push - non puio - Oh B'gosh, its come Well, Ritgen, your text book manouever Was made for para O but not for Para tenl GEN DEI.. VERBARG One hundred eighty-three

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BY JOSEPH I-I. FORBES, M. D., F. A. C. S. PROFESSOR OF SURGERY spine, and the other from the cartilage ot the ninth rib to the umbilcus, shows tenderness. Palpation may discover an enlarged liver. The presence ot hem- orrhoids confirms the liver congestion. Ot course, in the acute stone colic, recognition of the condition is quite easy. The x-ray and all the laboratory tests may indicate the progress ot the disease, but the diagnosis can be made on the physical signs and history. Perforation of a gastric or duodenal ulcer presents a clinical picture which cannot be denied. A history obtained from the family or from the patient shows long continued indigestion, sometimes with vomiting of blood. There is a sudden onset with shock accompanied by severe pain in the epigastrium. This pain is of a burning character and travels downwards along the right gutter of the abdomen, burning as it goes. There is immediate abdominal tension not only of the walls, but of the diaphragm. This is a protective mech- anism and it is shown by a slightly cyanosed appearance of the patient due to poor oxygenation from lack of proper lung expansion. All ot us have ex- perienced the chagrin of operating these cases for acute appendicitis, for we examined the patient at the stage where the upper part of the burned tract had become numb and the acrid juices had just reached the cecum. A history and a common sense evaluation of the situation usually pre- vents this mistake. The temperature is usually subnormal and the pulse rapid but they are concomitant conditions and may occur in other catastrophes. Acute pancreatitis and mesenteric thrombosis are quite difficult but the severity of the pain and the excessive shock point the way towards immediate operation anyway. Occasionally we will be called in consultation on patients with acute abdominal pain with some upper abdominal distention. lf there is a history of angina pectoris, we have always been able to withstand the importunities of the internist and cardiologist and have resisted operation. We have never been sorry. ln these instances the history of previous disease has been the deciding factor, and common sense has taught us to keep our hands oft a practically hopeless condition. In two patients in which we were called to perform an immediate abdom- inal exploration for the so-called acute abdomen, we obtained a history of sore throat and a long continued mucous diarrhea with some blood. Exam- ination of the abdomen showed a swollen abdomen with tender points along the colon, a liver which was enlarged. Rectal examination did not show any sign of growth. They were very Weak, sick patients. Further questioning into the history showed a habit of taking some form of amidopyrine. ln this type of case the blood count is essential, and in one instance showed 800 white blood cells to the cubic millimeter, and in the other, 1200. lt is unnecessary to state that both patients went on to the usual outcome of agranulocytosis with- out the helping hand of the surgeon. Any one over forty years of age with an anemia which cannot be ex- plained by the presence of any patent disease process deserves a thorough One hundred eighty five