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

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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

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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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x-ray examination, but even in these cases a careful history will discover the slow onset of vague symptoms gradually becoming localized in the favorable points for new growth, such as the stomach, the hepatic, splenic and sigmoid flexures of the colon and rectum. Some cases have been easily diagnosed by the introduction of the gloved finger into the rectum, much to the chagrin of the attending physician. A nurse 60 years of age with a slowly increasing abdominal measurement received the benefit, so-called, of a complete gastro- intestinal x-ray series and a barium enema, with every type of laboratory ex- amination possible in a high class hospital, with no positive diagnosticpoint except in a negative way. A rectal examination revealed multiple pelvic nodules. An abdominal tap demonstrated bloody fluid. Neither of these pro- cedures were costly but both were diagnostic not only as to the region and extent of the disease, but also its operability, to say nothing of the economic waste and loss to the institution . An interesting point in the value of the history occurred many years ago. An elderly German woman presented a tumor in the region of the right upper quadrant of the abdomen. It was of slow growth with very little discomfort except by pressure. All the laboratory tests and x-rays were done with no result except to demonstrate that it did not involve the intestinal tract. One of the junior attendants on the medical side, who had that inquiring mind which is so frequently valuable in a practical way, asked the old lady if she had ever had any pet dogs. She said she had a little skye terrier of which she was very fond., He then asked her if she ever kissed this dog and she said she did. He said My diagnosis is ecchinococcus cyst of the liver, and it was. The diagnosis of surgical conditions in childhood is one that taxes the ingenuity of the clinician. lt is a great aid to obtain the history from the parents, but be sure that it is a correct one. A young girl about 10 years of age, a Porto-Rican, was admitted to the Flower-Fifth Avenue Hospital with a pain in the left side in the region of the kidney. She gave a history of being operated on in Porto Rico several months previous, as she said, for a stone. Physical examination and laboratory tests were all negative, although the genito-urinary department was not quite sure, leaving themselves a little on the fence as to whether there was really any ureteral pathology or not. The scar was present in the kidney region. We have always felt that if time per- mits, before doing any surgical procedure, it is wise to find out what the other fellow did. In this instance we wrote to the Governor of Porto Rico, who is an old friend of ours, and he reported back through their hospital that the girl had fallen and hit against a stone in the left loin, causing a severe wound. This was operated upon in their hospital. We have just been through a serious influenza epidemic. During this epidemic We were called to the hospital to see a young woman who had an operation about a year previous with the removal of the right tube for an extra-uterine pregnancy. Her health had been good, with this exception, up One hundred eighty-six