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

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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

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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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until a Week ago, when she had a bad cold of the influenzal type, followed by a diarrhoea. She never really got over this. The evening before she entered the hospital her temperature went to 103, with considerable abdominal pain and tenderness all over the abdomen, but without any nausea. The diarrhoea still continued. Physical examination showed a well nourished woman with a cold, a sore throat, and some cough. The abdomen was distended. Palpa- tion showed tender points over a good deal of the abdomen, more down the left side. Vaginal examination showed some tenderness towards the left fornix. Rectal examination showed a thickening in the cul de sac but the point of greatest tenderness ran up towards the left kidney. Palpation of the kidney itself did not give any pain. The pain shaded off towards the umbil- icus, where it lost its intensity. We felt that this was one of those rare cases of influenzal colitis with some peritoneal involvement, and we advised against operation. The attending physician had made a diagnosis of abdominal ab- scess because the temperature was 103 and the blood count was 22,000 white cells, with 93? polys. The use of colonics, diathermy and the indicated remedy, which in this case was belladonna, followed later by bryonia, finally cleared the entire condition. In these influenzal cases, we frequently find that after the chest condition has disappeared the process has gone to the abdomenp the abdomen will clear up and then there will be an involvement of the appendix with the characteristic physical signs. Then we feel justified in making a diagnosis of appendicitis and advising operation. Sometimes these influenzal conditions will gravitate towards the cul de sac postperitoneally, in the cellular tissue, and then we will have increasing signs of thickening around the rectum: finally with a large mass and fluctuation. Then we can make a diagnosis of abscess, and use the proper surgical procedure. Sometimes these influenzal conditions will form small cellular infiltrates in and around the loops of the small intestine, but they will easily respond to diathermy and remedies, and it is much safer to treat them this way. In elderly people, as the tissues lose their elasticity, diverticuli that have been in existence for some time will become filled, especially along the sig- moid and descending colon. When there is a tender spot along this region with the evidences of an increasing inflammatory area, a tentative diagnosis can be made. In this instance a previous x-ray is of great value. Of course, surgery is only indicated when the abscess is ripe for incision and drainage. Rarely do they rupture into the general peritoneal cavity. In all diagnoses, especially for surgical conditions, positive signs are of more value than negative. Our special senses are of the greatest value, and we must not neglect any of them. If this rather rambling discourse has served to direct your minds towards the use of instruments which we have always with us, the special senses, eyes, nose, fingers, ears, instead of trying to make short cuts which are often misleading and costly, I will feel that my writing has not been spent in vain. One hundred eighty seven