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.
APPENDIX.
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.
SUBDIAPHRAGMATIC ABSCESS.
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.
COLIBACILLURIA.
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.
ACUTE SALPINGITIS.
(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.
ASCENDING COLON.
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.
TREATMENT.
Both surgical and homoeopathic treatment are here discussed.
GALLBLADDER.
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.).
GASTRIC ULCER.
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.
Seattle.
Chairman, Bureau of Surgery