Sidebilder
PDF
ePub

life may not be placed in jeopardy by delay or disastrous treatment be instituted.

X. (a) Determine, if possible, the location of the initial pain; (b) enquire if the pain was at first diffuse in the central abdomen for a while; (c) later and final observe whether the pain localizes itself in the region of the affected organ (peritonitis).

XI. The location of the pain may be superficial (hyperesthesia of the skin) or deep in the muscularis (rigidity). McBurney's point is a skin hyperesthesia (from the cutaneous branches of the twelfth dorsal and first lumbar nerve-the ileo-hypogastric).

XII. The location of the sudden abdominal pain is indicated by the segment (somatic) of the spinal nerves in adjacent abdominal muscles (rigidity), skin (hyperesthesia). The diseased abdominal viacus is protected, fixed by muscular and nerve mechanism similar to the muscular protection fixation of an inflamed joint.

XIII. The topographic anatomy of the abdominal viscera should be mastered, for, it is the solid ground of nature on which rests rational diagnosis. This can be accomplished by study in the cadaver and at autopsy.

XIV. Remember the major regions of peritonitis-appendicular, pelvic and that of the gall-bladder.

XV. Remember the major regions of violent peristalsis, colic (calculus), biliary, ureteral, oviductal and pancreatic.

XVI. Call the most available and competent abdominal surgeon early in consultation. XVII. Remember that operations do not kill-it is disease that tolls the funeral bell. XVIII. Operations on the dying are unsatisfactory.

GENERAL TREATMENT OF SUDDEN ABDOMINAL PAIN.

First and foremost, should be introduced: -(a), anatomic rest which is maximum quietude of skeletal or voluntary muscles. Retire to bed not to rise for defecation or urination; (b), physiologic rest which is minimum function of viscera. Food and fluid are prohibited per mouth.

No anodynes or in minimum repeated doses until clinical history and the diagnosis is completed (maximum doses of anodynes obscures the diagnosis).

(NOTE.-The method of treatment for abdominal pain by anatomic and physiologic rest was especially advocated by the distinguished English physician, Wilkes, in 1865 (living at present), continued by the celebrated American Alonzo Clark (1807-1887) by the "opium splint" and established for

ever in 1888 by one of the greatest surgical geniuses of his age-Lawson Tait (1845-1900).

Heat (hot, moist cornmeal poultice, hot water bag, hot bath) aids to relieve pain.

No cathartics-cathartics stimulate peristalsis, increases pain and distribution of sepsis. They induce vomiting. A rectal enema (or two) may be employed-the composition. may be equal parts of molasses and milk, soap suds, glycerine, magnesium sulphate. tal injections of air.

[ocr errors]

Rec

THE REASON FOR "PATENTS."-And here it may be remarked that there is a reason for the "patent-medicine fake." Many patent and "proprietary" compounds are distinctly useful. Sometimes they fill a void in what we are wont to term "legitimate" therapeutics. Most of those that are worthy of confidence have been manufactured in the first instance, from the prescriptions of physicians. Many patent compounds have become distinct evils, whatever they may have been originally.-M. F. Cupp, American Jour. of Clinical Medicine.

CONCERNING THE DIAGNOSIS.-Joseph N. Study declares that upon the correct diagnosis depends the intelligent administration of therapeutic agents, the proper use of surgical appliances, and the all-important question of the necessity of operative surgical procedure. After reviewing the history of some of the modern aids to diagnosis, he concludes that we are justified in saying that it is unwise to declare that an individual is suffering from some disease simply because the specific bacillus is found in the body, that the Widal or diazo methods indicate typhoid fever, or that the tuberculin test indicates tuberculosis. These helpful methods of diagnosis the writer believes to be somewhat limited in value, and too much dependence should not be placed in them as a class unless they are accompanied by the clinical phenomena which are characteristic of the disease. The microscopical examination of diseased structures, secretions and exceptions has often cleared up a doubtful diagnosis. The writer concludes by saying it would perhaps be fair to say at the present time that there are many cases both of a medical and surgical nature, in which the diagnosis must be somewhat limited. The physician who would serve his patient best must use all methods for correctly interpreting disease and other abnormal conditions of the body, not relying upon any one procedure to the exclusion of others which have been proven to be meritorious.--Medical Record.

[blocks in formation]
[blocks in formation]

was seen by several more experienced than I without suspecting the correct diagnosis; the history, with the exception of the one fact which would have made the diangosis, was fairly complete and accurate as substantiated by the patient's daughter. Following is an abbreviation of the history and clinical notations:

White, male, age about 70, and a bricklayer by occupation; entered the City Hospital November 15th, 1905, with the diagnosis of debility. Habits were good; takes beer occasionally, no whiskey. Family history shows no hereditary taint, no tuberculosis, cancer or neurotic tendencies.

Previous History.-Had measles, scarlet fever and varioloid in childhood. Has had several attacks of rheumatic fever, the last one occurring a year ago. Has been subject to attacks of sore throat.

Present Trouble.-Patient says he has had an attack "just like this" before. This is corroborated by his sister, who says that about ten years ago he was taken with the same kind of sickness, and the doctors did not think he would live. His present illness began a week before the patient entered the hospital when he noticed that his throat was getting sore, swallowing was very painful, and he became very hoarse. He did not take solid food, because it gave him too much pain, but liquids he was able to take without so much discomfort, and they passed readily enough to the stomach. Two or three days after the beginning of the trouble patient says a diffuse swelling appeared at the base of his neck-he indicates the suprasternal region.

On the day he was admitted to the hospital he expectorated a small amount-patient

says about a teaspoonful-of blood and mucus. This relieved his pain considerably, and deglutition became much easier. I saw the patient for the first time the next morning. He then told me that he had just "choked up"-this is the expression he used -about half an ounce of light red blood. This I saw; it was partially clotted with a small amount of mucus not intimately mixed, which on microscopical examination. was seen to consist mainly of red blood cells in good condition with a number of nondegenerated leucocytes and a few bacteria.

On the same day patient had a very large, tar-like passage from the bowels. With the exception of this local trouble patient has no pain or discomfort, but he feels very weak. He says that during the past three months he has lost considerable weight, even as much as 25 or 30 pounds. (His sister also says that in the past half year he has lost greatly in weight and strength.)

Physical examination shows a fairly well built man of large frame, somewhat emaciated, skin loose, cheeks sunken, clavicles prominent, sallow complexion, mucous membranes very pale, only one or two teeth remain in the mouth, tongue dry and swollen, pupils equal and react. The breath has a peculiar foul, fishy odor. The swelling which the patient says is at the base of his neck is not evident. Chest is quite well formed, etc., no rales, no abnormal dullness, area of cardiac and hepatic dullness not increased. Second aortic sound is slightly accentuated. Abdomen flat, epigastric pulsation, muscles flabby, no tenderness, no palpable masses, no ascites, no visible hernia. No general glandular enlargement, no edema, arteries very markedly sclerosed. Pulse 96, respiration 24, temperature 98.4. The temperature remained about this point, or was a little subnormal during his illness. The urine shows a low specific gravity, a trace of albumin, and some casts.

The trouble is evidently about the upper part of the digestive tract. The tongue is dry, swollen and glazed, the under surface is congested and shows dark blue dilated veins; the mouth and pharynx are dry. The laryngoscope shows the lower pharynx and the

larynx dry, and containing considerable dry, stringy mucus. I could note no other abnormality.

On the morning of the 18th the patient again brought up blood to the mouth, and also had a small tarry stool; he is very weak and somewhat restless and complains of epigastric tenderness for the first time. He does not vomit. Leucocytes number 25,000, hemoglobin 30-40%. Smear shows nothing of special significance. Patient is getting nothing by mouth, is fed rectally. In account of his age and weakness, but most especially because of a possibility of renewed hemorrhage I do not feel justified in using the stomach tube for diagnosis.

November 19, 1905.-Rectal feeding, saline enemata with whiskey hypodermoclyses; nothing given by mouth except tannin. tient very weak. Small tarry stools.

Pa

November 20, 1905.-Stools show no evidence of hemorrhage today, same treatment continued, enemata not well retained.

November 21, 1905.-Small amounts of fluid by mouth with no apparent bad results, patient growing weaker.

Patient showed no improvement and died on the 23d. No new symtoms bearing on the local trouble developed. We were much at a loss for a diangosis. The history and picture were not typical to us of any special condition. After thinking over the matter pro and con, and considering ulcus, carcinoma, varicose esophageal veins, and aneurism, in view of the history of steady loss of weight, the cachexia, passage of a little fresh blood from the mouth with large tarry stools, epigastric tenderness, pain and difficulty in swallowing I ventured a diagnosis of carcinoma of the stomach involving at least to some extent the cardia, and that some large vessel had been eroded.

The post-mortem findings were startling. Besides a fatty degeneration of the heart, small white kidney, etc., the following condition existed. Opposite the cricoid cartilage a piece of sharp triangular shaped tin measuring about an inch on each side had lodged in the esophagus perforating the walls. on both sides into the posterior mediastinum, and causing a gangrenous abscess behind the esophagus, extending from the first to the fourth dorsal vertebra.

As to the reasons and justification for the diagnosis of carcinoma about the cardia I do not care to enter. No doubt I should have done like Allen Ramsay's dial, "gladly own I dinna ken.

I came across the following statement in a text-book, "The presence of a perforating foreign body, cancer, or aneurism, about the esophagus is indicated by such characteristic

symptoms that the condition is readily recognized." The present case is the only one of foreign body in the esophagus that I have seen, but knowing the great variety of objects that might enter this tube with different size, shape and other physical properties I believe that there is some exaggeration in the statement. Some might cause total obstruction with very little hemorrhage, others little hemorrhage or obstruction with considerable pain, or as in the present case considerable initial pain, excessive hemorrhage and partial obstruction.

A few points were brought home very forcibly by the case: Firstly, in all cases of hemorrhage from the upper part of the digestive tract the possibility at least of foreign body in the esophagus must be considered.

Again, an article which appeared in a recent Johns Hopkins Bulletin is recalled in which the routine use of the X-ray in all obscure cases about the thorax is advocated. This latter seems a very rational and practical suggestion, at least in hospital work. In the article reported its value is demonstrated and several very peculiar and obscure cases diagnosed, mostly aneurism. In the present case its use would have settled the diagnosis and given opportunity for surgical interfer

ence.

DISCUSSION.

Dr. William Rush.-This is an extremely rare and interesting case. I do not see how a correct diagnosis was possible without the use of the X-ray and this omission was excusable under the circumstances. This man was passing blood from the bowels and gulping up fresh blood, and you therefore, naturally, would not introduce the stomach tube or a sound for fear of doing harm. I should have been inclined to consider this a case of ulcer, rather than carcinoma, owing to the freshness of the blood and the acute beginning of the trouble. However, the treatment the man received was correct, the withdrawal of food by the mouth, and the avoidance of sounding. Possibly the introduction of a hard or a soft sound would have detected the resistance, but one would not introduce a sound in the case of a patient losing blood from the stomach or esophagus, apparently from ulcer. I have never seen an ulcer of the esophagus, but I know of a case with many features similar to those related this evening, in which the diagnosis of ulcer of the esophagus was finally made and the patient recovered under the method of treatment used by Dr. Cook in this case. case presenting such symptoms as painful swallowing, blood not vomited but gulped up, should lead us after this experience to make

A

[ocr errors][ocr errors][ocr errors]

use of the X-ray. This case is a great lesson Had I had such a case, not knowing of such an occurrence, I should have thought of an ulcer, and should have attempted to relieve the symptoms by the ulcus treatment, and of course the patient would have died.

Dr. W. E. Sauer. The proper thing to have done here would have been to examine the esophagus. The sudden onset and the difficutly in swallowing would have led to a supicion that the trouble was in the esopha-. gus. The patient could have been cocainized and an examination easily made. The fact that the pain came on suddenly and that it continued on swallowing pointed to some condition in the throat or esophagus, and if the esophagoscope had been used in the examination I think the diagnosis could have cleared up the case.

Dr. J. M. Pfeiffenberger. This reminds me of a case that occurred when I was in the

hospital. That was carcinoma of the esophagus. The patient complained much as this one did and had hemorrhages. We introduced a sound and found there was a thickening about midway between the mouth and the cardiac end of the stomach. We were able to pass the stomach tube and found there was no trouble in the stomach, so a diagnosis of carcinoma of the esophagus was made. But the patient was not in a condition for operation. He died in the hospital, and we found this thickened portion of the esophagus at post-mortem, a thickening to such an extent that it explained the feeling of fullness in the throat that the patient had complained of. It was practically the same picture that Dr. Cook's case presented. There were also the tarry stools and the vomiting of fresh blood. The breath was very offensive.

Dr. Jules M. Brady. -The recent work of Holzknecht published in the Berliner Klinische Wochenschrift, would seem to justify the use of the X-ray as a routine procedure in all obscure abdominal and thoracic conditions. It is all very well to theorize after we know the result of a case, but from the his

tory and objective examination the diagnosis

of carcinoma at the lower portion of esophagus or of the cardia, seemed very probable. The correct diagnosis could have hardly been arrived at by any other means except by the use of the X-ray. Holzknecht claims to have been able to palpate abdominal tumors which previous to the use of the rays he was unable to feel; some palpable tumors which were supposed to belong to the stomach he was able to make out had a different seat. He experimented with Sahli's desmoid test and by

means of the fluoroscope was enabled to see when the little bag which was tied with catgut opened. I observed a similar case to this one at the City Hospital, though the foreign body was in a different situation. A patient was brought to the hospital in a comatose state; he was sent to the nervous ward, of which I had charge. After observing the case twenty-four hours, not being able to arrive at a diagnosis, patient was transferred to a medical ward. Every possible condition was thought of until on digital examination of the rectum a thickened bone was found, extending across the rectum penetrating the urethra. Operation was performed, but failed to save the patient.

Dr. William S. Deutsch.-It is interesting to get as complete a history as has been given us in this case. There are a few points in which I differ from Dr. Rush: first, that the patient was very likely mistaken in having had a similar attack twenty years ago. There might have been some loosening of the piece of tin; it might have been partly dislodged and given many of the symptoms he had. It would be very rational to believe that he had swallowed this when a child. The other point in which I disagree with Dr. Rush is that the surgeon being called upon to operate for something when the internist could not make a diagnosis, would not have had to make a gastroenterostomy, but might have given the man a fistula through which he could be fed. He would not necessarily feel that because he could not find an ulcer he must make a gastrastroenterostomy, but he would have made a fistula by which the patient could have been kept comfortable and these hemorrhages avoided. A point that may be of interest to Dr. Brady is that in a recent visit to the Mayos I found they were doing much of that work there. They have made a great many experiments in the past year, especially good results have been obtained by them in X-ray work showing dilations in the esophagus.

Dr. B. H. Gradwohl.-I would ask whether the failure to make a chemical analysis of the stomach contents was due to fear of doing damage by the introduction of the tube.

[blocks in formation]

shown. It is quite common to observe certain adventitious muscle changes in making radiographs for other lesions or suspected bone affections; and such changes in the soft parts may be neither calcareous ncr osseous deposits, but merely relative thickening, due to more transient conditions, such for instance as simple congestion or the more enduring cellular hyperplasia. For the whole scheme of radio-photography is based on the principle of relative density, and there is almost no limit to the possibilities in showing contrast between substances of varying penetrability to the rays. The difficulty is in the matter of technique. The X-ray has been before the world for nearly a decade, and in spite of the fact that office instalment and hospital equipments are getting to be as common almost as any of the other essentials to an up-to-date armamentarium, there is a woeful lack of anything like the technical knowledge that is absolutely necessary in the operating of an X-ray outfit to the desired ends. I have frequently come across instances of men trying to make radiographs without paying attention to the requirement of backing the plate with some highly absorbing substance, such as sheet lead, with the result, of course, that their plate was fogged, unless, the exposure happened to be a very short one. The reason for this fogging being the responsive or retro-radioactivity of the table or chair upon which the plate happened to be placed in making the exposure. When we have learned to use to the very best advantage our apparatus, no matter how modest and meager it may be, will very much broaden the field of the X-ray and the hopes of its champions and those who see a promising future based on the accomplishments of the past, will be realized.

we

Dr. L. H. Hemplemann.-There was no attention attracted to the esophagus, and had the X-ray been used it would have been directed to the stomach, which would not have shown anything in the esophagus. Patients with thickening in the esophagus bring blood up in a different manner from those who vomit the blood, and this might have led to a consideration of the esophagus.

Had one sounded and met an obstruction at the cricoid cartilage it would have been thought that it was a hardening of the cricoid which is common in old people rather than a foreign body.

Dr. Brady. Would it not have been danBrady.-Would gerous to pass a tube down there? Might

not a perforation have resulted?

Dr. Sauer. No, not if done carefully. You could use a short tube, one with a conical

point and never lose sight of the end of the tube. In all cases of bleeding from the esophagus or trachea these tubes are introduced, but always absolutely under the direction of the eye. There is absolutely no danger.

[ocr errors]

Dr. Wells. As to the possibility of this piece of tin having been swallowed in infancy, while I see plenty of reason for totally discrediting such view in this case, I recall a case sent to me for X-ray in which I located a tin whistle lodged in the esophagus of a child about one year old, the child having presented no alarming symptoms and took its milk without difficulty. This whistle would have gone down and been passed in the expected manner because of its shape and smoothness, but had it been otherwise and of a shape to engage itself in the membranes of the gullet, it might have done so, and produced no more serious symptoms; for a time, at least, until inflammatory changes were induced, when, of course, the presence, of a serious condition must have become evi

dent.

Dr. Rush, in closing.-I did not really suppose any surgeon would operate on this stomach, but Dr. Deutsch says they would. Of course a gastrostomy would have done no good for a man bleeding to death from the esophagus. Not having in mind a foreign body the picture was of an ulous and where you suspect an ulcus the use of sounds and stomach tubes are entirely contraindicated. Of course there are instruments, such as the esophagoscope, that would have revealed the trouble, but we must consider the case as the picture was presented to Dr. Cook. the picture of a bleeding ulcer. Many cases have been caused to bleed profusely by the introduction of the tube, even fatal hemorrhage resulting. No one would think of an obstructing foreign body in such a case without such an experience as this.

It was

Dr. W. C. Mardorf said that the paper was a most interesting and instructive one, and thought Dr. Cook should be commended for his courage and frankness in reporting the case. The failures were not heard from as much as the successful cases, but in this instance the essayist showed the true scientific spirit. The speaker differed with the statement which had been made that the report was the picture of gastric ulcer. The typical form of gastric ulcer, as he conceived it, was that of a more or less chronic

condition of indigestion, with pain and tenderness over the stomach, vomiting, and the vomiting of blood. In this case the onset was sudden, with no previous digestive dis

« ForrigeFortsett »