THE RIGHT ABDOMEN and PELVIS CONSIDERED HOMOEOPATHICALLY vs SURGICALLY The title of this paper has suggested itself to me because of the many puzzling situations arising from right-sided abdominal and pelvic pain. The many and varied conditions that result from pain in this location require careful differentiation.
How many of us have been confronted by a dilemma when a patient states that he has a severe right-sided pain and then places his hand over the right abdomen ? The question immediately arises: Is this going to be a strictly surgical procedure, or one that is amenable to the proper homoeopathic remedy ?.
If all organs remained in their proper anatomical relation, the decision in arriving at the proper treatment of this individual would be less difficult, but when one considers that a gallbladder may be located anywhere from the costal border to a location well within the pelvis, and that a kidney may take a like sojourn, diagnosis both of the condition and remedy is complicated.
In acute conditions with septic temperature the properly selected homoeopathic remedy will forestall the need for surgery in ninety per cent of the instances. Yet many of these conditions, in spite of homoeopathic prescribing, develop into fulminating abscesses with resultant danger of rupture with general peritonitis and death.
RIGHT-SIDED ABDOMINAL PATHOLOGY
Right-sided abdominal pathology requires much more careful differentiation than right-sided chest troubles, where general emergencies are rare. Here, pleurisy may be readily distinguished in right hypochondriac troubles by eliciting friction rub and its location well within the costal border, its aggravation from breathing, and freedom from any rigidity of the abdomen. Sedimentation rate is not affected and seldom is there leucocytosis.
Many and varied are the conditions that may affect the organs of this portion of the body. A proper differential diagnosis of an existing condition is necessary to ascertain whether the individual condition can be cured by homoeopathic remedies.
The differential diagnoses in this region may be most confusing, though in the light of present day diagnostic methods there is much to simplify our conclusion.
Let us consider these conditions differentially, both as to diagnostic findings and remedy indicated.
1. PAIN IN THE RIGHT HYPOCHONDRIUM.
This may arise from any of the following organs:.
Liver and gallbladder.
Head of the pancreas.
Affections of the spine or chest wall.
II. PAIN REFERRED FROM THE RIGHT ILIAC FOSSA.
1. PAIN IN THE RIGHT HYPOCHONDRIUM.
The gallbladder, as previously stated, may have pain arising anywhere from the costal border to the pelvis, its characteristic pain arising in or near the epigastrium, extending into the back and under the right scapula. Yet this pain may be most confusing in the light of the presence of duodenal ulcer. Both conditions have a peculiar gnawing pain which is relieved by eating or soda, and in both conditions pain arises within two or three hours after eating.
Duodenal pain may extend through to the back, though rarely is it extended to the right scapula.
One striking differential point here lies in the fact that duodenal pain does not reach the height of severity that is found in gallbladder disease, especially when there are small stones present in the gallbladder or cystic duct.
Icteric index here becomes of valuable laboratory assistance. It is high in gallbladder disease and normal in duodenal ulcer.
Differentiation may not be possible without x-ray. Blood sedimentation becomes of valuable assistance.
Duodenal ulcer often causes deep-seated pain in the right hypochondrium; a gnawing pain, relieved by eating or soda; these pains are sometimes found also in cholecystitis and appendicitis. Differentiation may not be possible without the x-ray. Sedimentation test becomes of valuable assistance. Duodenal ulcer shown slight leucocytosis with normal sedimentation rate. Cholecystitis, on the contrary, shows marked leucocytosis and marked acceleration of sedimentation rate. Phlegmonous appendicitis shows marked leucocytosis with normal sedimentation rate. Adnexitis shows slight leucocytosis and marked acceleration of sedimentation rate.
The percentage of free HCL in the stomach contents is more persistency high in duodenal ulcer than in either appendicitis or gallstones. The presence of occult blood in the faeces would favor ulcer. Perforation or severe haemorrhages from duodenal ulcers demand immediate surgical attention unless the perforation be very limited and the small area affected completely walled off.
These conditions may also be confused with pancreatic stone, pancreatitis, or malignant disease, though this differentiation is seldom difficult owing to the fact that in acute pancreatic inflammations or calculus the pain is agonizing, extending through to the back or mostly in the median line, and is accompanied by shock, a normal icteric index, and is not affected by the intake of food or soda.
Malignant disease of the pancreas may cause pain in the right hypochondrium. A deep-seated tumor may be felt and there is often jaundice along with a distended gall-bladder. Acute pancreatitis must be differentiated from perforating ulcer, gallstones and Dietls Crises.
DIETLS CRISES AND RENAL CALCULUS.
Two other conditions of importance arising in the location are Dietls Crises and renal calculus.
Here there are sudden attacks of paroxysmal lumbar pain with nausea and vomiting. There is seldom tenderness on pressure and absence of leucocytosis or acceleration of blood sedimentation. Indications of intermittent hydronephrosis should be looked for; sudden appearing renal tumor with occasional discharge of large quantities of urine; renal attacks occur more during the day, while biliary attacks occur more during the night. Carcinoma in this location would require x-ray. Right renal colic: severe pain in the right hypochondrium or back, extending into groin with frequent urination and urinary tenesmus.
Unfortunately many abdomens have been opened following an attack of Dietls Crises (where an acute appendix had been diagnosed), when a properly fitting kidney pad, with the addition of fat deposits about a detached kidney, would in many instances have eradicated the condition.
Calculi of the common duct or right or left hepatic ducts bear the same differentiation as do those of gallbladder calculi.
Pyelitis may cause severe pain in the right hypochondrium but is usually diagnosed by urinanalysis. In both pyelitis and renal colic pains usually extend down the abdomen and through the back, thus affording differential diagnosis from gallbladder colic.
Perinephric abscess causes pain in the right hypochondrium and lumbar region, accompanied by septic temperature. Surgery is rarely needed.
Again, ovulation may be confused with appendicitis or varicocele of the broad ligament, a knowledge of which may save the patient operative procedure. The symptoms most common to ovulation are clear-cut:.
1.–Periodic intermenstrual pain, occurring half-way between the menses. (Any time between the seventh and twenty-first day.) Usually precedes the approaching menses by a definite number of days.
2.–Pain recurrent periodically.
3.–Mostly in women 30 years or younger.
4.–Temperature range usually 101 with a leucocytosis of 12,000.
5.–No abdominal rigidity.
6.–General pelvic tenderness elicited by bimanual examination, though usually more marked on one side.
7.–More pelvic than abdominal tenderness.
8.–Bloody leucorrhoea, often seen during time of pain.
Tubal pregnancies may occur anywhere along the course of the Fallopian tube and may be also ovarian. Also has been known to occur in the accessory horn of the uterus and on the fimbria ovarica. The result is the same regardless of location, namely, rupture. Rarely do the first months of an ectopic gestation pass without symptoms which will direct attention to the pelvis as the seat of trouble. Usually the patient misses a period as early concomitant symptoms of early pregnancy, but soon complains of pain in the lower abdomen; in this instance, the right abdomen.
The pain is cramp-like due to either uterine or tubal contractions, or both. There may be mild pelvic peritonitic symptoms. After a few weeks irregular bloody vaginal discharges appear, which are usually mistaken for threatened abortion. On the occasion of a jar, strain, coitus or an examination, a sudden severe pain is felt; the patient usually becomes faint or dizzy; may vomit or be nauseated; symptoms of shock may appear. The symptoms of rupture of the sac are pain on the affected side, sudden, usually excruciating, soon spreading over the lower abdomen. There is evidence of shock and internal haemorrhage.
This symptom picture gives conclusive evidence of ectopic gestation. Surgery is the only answer.
Peritonitis is the end result of many of the foregoing conditions where rupture following any infection within the abdomen or pelvis, namely; perforated gastric or duodenal ulcer, gangrenous or abscessed appendix, perforated intestine from whatever cause, ruptured pyosalphinx, twisted ovarian cyst pedicle, ruptured liver, acute haemorrhagic pancreatitis.
The picture presented here is sudden severe pain, rapid abdominal distension, great tenderness and vomiting. The patients facies is sometimes of the greatest importance in helping one diagnose between colic and peritonitis; drawn features, anxious expression. The face is much more anguished with peritonitis than with colic. Jaundice may result from the peritonitis.
Rectal and vaginal examinations should be resorted to whenever practicable. A tender, bulging, appendicular swelling may be felt; or a balloon bowel if there is obstruction; or a sense of free fluid in the pelvic pouch of the peritoneum which serves to indicate that there is something more the matter than some variety of colic. The knee-jerks and pupil reflexes should be tested in all such cases lest tabes dorsalis be the cause of gastric or other abdominal crises simulating peritonitis. Examine the gums for the blue line of plumbism.
The above symptoms may be differentiated from those of varicocele of the right broad ligament, which are as follows:.
VARICOCELE OF THE RIGHT BRAND LIGAMENT.
No periodical pain; pain severe, more or less continuous. No rigidity. No rise in temperature. Little or no pelvic tenderness. Pains fleeting. No pain elicited on pressure. No leucocytosis.
CALCIFIED MESENTERIC GLANDS.
Again calcified mesenteric glands may cloud any of the foregoing conditions, the symptoms of which are:.
1.– Pains mimic appendicitis so closely that many laparotomies have wrongly resulted.
2.– Pains usually in childhood.
3.– Quiescent tuberculous glands usually precede.
4.– Vomiting in rare conditions– especially when pain is severe.
5.– Leucocytosis normal.
6.– Temperature range normal.
7.– No rigidity.
8.– Mesentery of the ilium mostly involved.
9.– Fluoroscopic examination will usually differentiate from recurrent appendicitis.
THROMBOSIS OF MESENTERIC VEIN BRANCHES.
This is probably not very uncommon. The diagnosis of the actual thrombosis is seldom possible at the time unless there is either a pulmonary embolism or an abdominal attack followed by the passage of blood as a complication.
Many intraabdominal thrombosis remain entirely unsuspected but they are the commonest cause of the sudden deaths from pulmonary embolism which may occur about the tenth day after abdominal operations that have been apparently successful.
The pain of appendicitis is so well known that little need be said, although it may often radiate to the right hypochondrium and may be in the nature of a hungry pain. In these instances only the x-ray may be the deciding factor. The tenderness is almost invariably over Mc-Burneys Point. In differentiating from gallstones it is well to remember indicanuria is common in appendicitis and usually absent in gallstones.
The sedimentation rate here becomes a valuable index for the need of surgery: The marked leucocytosis and almost normal sedimentation indicating phlegmonous appendicitis, while marked leucocytosis and markedly accelerated sedimentation rate dispels the diagnosis of acute appendicitis. Again, slight leucocytosis and markedly accelerated sedimentation rate corroborate the diagnosis of adnexitis.
AFFECTIONS OF THE SPINE OR CHEST WALL.
Refer to osteomyelitis, periostitis, and intercostal neuritis. In these instances surgery is not required, with the possible exception of an osteomyelitis, which in my experience has responded to the properly indicated remedy.
INTERCOSTAL NEURALGIA OR NEURITIS.
Sharp. stitching pains coming on regardless of breathing; extremely sensitive to light pressure of the skin; those at the right side respond readily to treatment.
Bears a history pointing to the precedent gastric or duodenal ulcer, appendicitis, hepatic abscess, or some operation upon the lower abdomen. Onset of pain may be sudden or gradual. Patient runs a septic temperature. Use of the x-ray may be helpful in locating the abscess. There is so much danger in attempting to treat the rapid formation of pus in this region that surgery is the rule, though occasionally this may be aborted by the use of high Mercurius, Belladonna, Aconite or Bryonia.
II. PAIN REFERRED FROM THE RIGHT ILIAC FOSSA.
In consideration of referred pain in this region, the appendix, adnexa and ureter have been discussed. We now consider the uterus. appendages and ascending colon. Here, again, a variety of conditions make differential diagnosis most desirable.
TWISTED PEDICLE OF RIGHT OVARIAN CYST.
This generally produces symptoms analogous to those of strangulated hernia. The diagnosis may be established only when laparotomy is performed.
Pain usually starts in lower part of abdomen before it becomes general, often causing severe tenderness in the region of the appendix. No septic temperature is present in this condition.
This is a familiar difficulty in its differentiation from appendicitis. It is common for the patient suffering from this condition to refer to the pain not to the back or loin at all, but to the front and lower part of the abdomen, particularly over the right iliac fossa, in such a way that acute appendicitis is indicated. Not a few patients of this kind are invariably operated on for appendicitis.
This condition is most common in children and pregnant women.
(or inflammation of the right ovary).
Acute salpingitis is generally secondary to some pelvic inflammation or gonorrheal infection.
Here a vaginal smear, the differential sedimentation rate, history of infection, and the clinical course of the disease usually serve to differentiate.
Iliocaecal kink: Vomiting, ileus, abdominal distension, shock.
Adhesions around the appendix itself: Pains recurrent; pyrexia; most cases are impossible to diagnose.
Tuberculosis of the caecum: It is nearly always associated with often than formerly. It is nearly always associated with chronic phthisis. Examine sputum. X-ray findings in this region are those of a dilation of the terminal ilium and an empty ascending colon. (Bierleins Phenomenon.).
Carcinoma of the Caecum: Diagnosed entirely by x-ray findings. Impossible to differentiate from actinomycosis.
Dysentery and ulcerated colitis: Abdominal pains are usually general, or at least referred now to one, now to another part of the whole colon. Occasionally the pains may be more pronounced in the right iliac fossa than in other parts. Usually blood and mucus in the stool.
Tumour of the right iliac bone: May be osteoma or chondroma, or it may be malignant. In either case the diagnosis is arrived at by careful deep palpitation when the tumor will be felt to be firm or even of stony hardness.
Thrombosis of mesenteric veins: Acute abdominal pain followed by passage of blood and mucus. This condition is probably not uncommon but the diagnosis is seldom made.
Both surgical and homoeopathic treatment are here discussed.
Surgery of the gallbladder need only be resorted to where the condition is so long standing that there are gross structural changes, and where careful remedy selection has failed.
Even cholelithiasis may now be treated with success by the use of the acid, alkaline or neutral ash diets, as indicated, using the urine as an index. These dietetic measures, accompanied by the proper remedy, will sometimes cure apparently intractable cases.
Belladonna: Heat and sensitiveness of the liver to touch; throbbing pains; bright red face; sweats on covered parts only.
Bryonia: Inflammation of the liver; thirst for large quantities of water; coated tongue; aggravation from motion; relief from heat and pressure.
Calcarea carb: Liver is enlarged; sore to touch; intolerance of tight clothing with ascites; clay-colored stools.
Chelidonium: Fixed pain under the right shoulder blade.
China: (One of our most valued remedies). Much flatulence; jaundice; ringing in the ears; eructations give no relief; patient is weak and faint.
Digitalis: Soreness over the liver; slow or irregular pulse; clay-colored stools.
Mercurius vivus: Perspires easily; foul breath; worse lying on right side; jaundice; tongue bears imprint of teeth.
Kali bi: Pain right hypochondrium; gnawing pain relieved by eating; thick tenacious mucus, either in stool of expectoration.
Natrum carb.: Debility; worse in summer; swollen feeling; gnawing pain in stomach, relieved by eating (Graphites).
Lycopodium: Acid eructations; pain in right hypochondrium, worse 4:00 to 8:00 P.M.; brick-dust sediment in urine.
Berberis: For gallbladder colic.
Calcarea carb. has been successful in treating calculi (Chionanth, Hydr.).
Argentum nit.: Great gastric distension; frequent eructations, very loud; pain in stomach radiates to other parts of the abdomen; great craving for sweets, which disagree.
Arsenicum: Burning in stomach; restlessness; nightly aggravation (12:00 to 1:00 P.M.); exhaustion; apprehension; fear of death; vomits soon after eating.
Kali bi: Thick tenacious mucus; relieved by eating or soda; round ulcer of the stomach; pains migrate quickly.
Phosphorus: Restless, mostly the legs; craving for cold, acids and salty foods, hunger soon after eating; sour taste and eructations, water vomited as soon as gets warm in stomach.
Except in perforating ulcers of the stomach or uncontrollable gastric haemorrhage, surgery is seldom called for in gastric ulcer. The properly selected homoeopathic remedy will bring about permanent cures in by far a great majority of cases.
Where surgery is required, subtotal gastrectomy is the operation of choice.
What is said of calculi of the gallbladder also pertains to calculi of the pancreas.
Phosphorus: As described under gastric ulcer.
Carbo an.: Burning, griping pains in epigastrium; repugnance to fat food; sour eructations; weak, empty gone feeling in stomach.
Iris: Burning of whole alimentary canal; sour vomiting; vertigo followed by headache, or partial blindness followed by headache; nausea; profuse saliva.
Iodine: Ravenous hunger and thirst, yet the patient loses weight; empty eructations as if every particle of food were turned to gas; anxious, worried; enlargement of the liver; whitish, frothy, fatty stools.
Mercurius vivus: As for gastric ulcer.
Ceonanthus: Dry mouth, not relieved by water; gripping feeling as though a string were tied in a slip knot in the region of the epigastrium and suddenly drawn tight and gradually loosened; stool soft, yellow, pasty.
Is strictly surgical condition, except an occasional cure by the use of kidney pad and the increase of abdominal fat.
RENAL COLIC, CALCULI.
Phosphorus: In the pathogenesis of Phosphorus we find that it destroys bone, disorganizes the blood. It is especially useful in tall, slender persons, narrow-chested, with thin, transparent skin; great nervous, debility; very sensitive to external impressions; noise, odors, touch, electrical changes; great lowness of spirit; apprehension; loss of memory; craves cold, salty and sour; sour taste and sour eructations; water is thrown up as soon as gets warm in stomach; hematuria; turbid urine, brown with red sediment.
Mercurius cor.: Low spirit; urination frequent, painful with marked tenesmus; urine thick, acid, albuminous, containing granular, fatty and bloody casts.
Arsenicum alb.: Restless, fretful, apprehensive, worse after midnight; headache with vertigo; oedema of lids; burning on urination; urine scanty, dark, yellow, turbid.
Lachesis: Vertigo, flickering before the eyes; vision dim with flicker before eyes; aggravation during and after sleeping; frequent urination; urine copper-colored or like coffee grounds, containing high percent of albumin; patient cannot bear anything tight about body.
Cuprum ars.: Vertigo, confusion dark spots before eyes; frequent urging to urinate, burning lasting some time after urination; urine is dark red; great nausea; cramp in abdomen, fingers and toes.
Pareira brava: Sensation as if bladder were distended; pains go down thighs; constant urging with great tenesmus; pains go down thighs during efforts to urinate; can emit urine only when he goes on his knees; incontinence after urination; violent pain in glans penis; itching along urethra. (Parietaria –Renal Calculi.) Fearful dreams of being buried alive.
Lycopodium: Most often indicated for urate stones; worse right side of body or travels from right to left; intellectually keen but weak muscular development; worse 4:00 to 8:00 P.M. Craves everything warm; acid eructations (water and gas); pain in the back before urinating; ceases after flow; slow in coming; must strain; heavy urate sediments; polyuria, during night.
Argentum nit.: Great desire for sweets; splinter-like pains; melancholic; hurried; time passes slowly; tremulous; eructations very loud; incontinence of urine; urethritis with pain, burning and itching, pain as from splinter; urine scanty and dark; emission of a few drops after having finished urination; bloody urine; worse from warm and cold foods; sweets; left side; better from eructations, fresh air, cold, and pressure.
Sarsaparilla: Despondent, sensitive, easily offended, ill- humored and taciturn; urine scanty, sandy, containing mucus, bloody; severe pain at conclusion of urination; urine dribbles while sitting, child screams before and while passing urine; mostly right kidney calculi; tenesmus.
Berberis vulgaris: Rapid change of symptoms; shifting pains; thirst alternates with thirstlessness; hunger alternates with loss of appetite; old gouty constitutions; pain in regions of kidneys is most marked; useful in both gallstones and renal calculi; haematuria; burning on urination; sensation as if some urine remained after urinating; urine contains thick mucus and is bright red; mealy sediment; bubbling sore sensation in kidney regions; pain in thighs and loins on urinating, and burning pains when not urinating.
Ocimum canum: Pain from kidney into ureters with passage of red sand in urine. This remedy is one of the greatest remedies for renal colic.
Polygonum: Colic and calculi. (Polygonum persicaria.).
Juncus effuses: Great solvent for renal or gallstones.
Bryonia: Is the outstanding remedy for the first stage. Aggravation from motion; thirst for large quantities of water at long intervals; hot, dry, parched lips; constipation, stools hard and dry; relieved by lying on painful side.
Belladonna: Bright red face; dry throat; sweats on covered parts only; restless; excitable.