A PLEA FOR DIAGNOSIS IN SURGERY


Hahnemann, in an age where the scientific approach to medicine had not even begun and in which medicine was a conglomeration of theory and supposition unsupported by any relation of fact, observed in his work as a translator, the similarity between the poisonous effects of malaria and the cinchona bark, a resemblance between these effects and the symptoms suffered by those affected by the disease which they seemed to benefit.


I am coming before you this afternoon totally without others on my program. There are two reasons for this, one of which is probably my fault in that, although I had short notice, I could not persuade any of my surgeon friends to write a paper for this bureau. The other reason is probably yours because you are not interested in things surgical and your criticisms too often are those of unfriendly critics who only tolerate the surgeon as, at most, a necessary evil to be called upon only after all other measures, often too long persisted in, have failed, and then use his failure to support the alibi that nothing could have been done in any event.

Hahnemann, in an age where the scientific approach to medicine had not even begun and in which medicine was a conglomeration of theory and supposition unsupported by any relation of fact, observed in his work as a translator, the similarity between the poisonous effects of malaria and the cinchona bark, a resemblance between these effects and the symptoms suffered by those affected by the disease which they seemed to benefit.

Starting form there he began to collect data on the effect of medicinal substances on people and to give to the sick like-acting remedies. After years of experiment and observation he announced his discovery. Here is the first record of a really scientific approach to the treatment of the sick man.

This method was presented, except for minor papers, in his Organon which was brought out in a world of medical bigotry, theory and polypharmacy, and without more that 10 percent of the medical knowledge of today.

In that day there were no instruments for diagnoses, no knowledge of pathology or true physiology; surgery, except for the crudest kind of traumatic and battlefield surgery, was practically non-existent. In such an age medical treatment is some form was used for at least 95 percent of all ill people and usually, poor crutch that it was, was all they had.

Hahnemann offered much more efficient treatment with much less mumbo-jumbo and torment and with the success of his method, and I may say largely because of it, the scientific approach to medicine began and grew and medical knowledge spread. With this spread the decline of drug treatment and the extension of other agents of care became more important.

The physicians sole duty is to heal the sick person by the surest, gentlest, safest way. It is not to indulge in theories, etc. In other words, the treatment must fit the patient. The patient must not be fitted to the treatment, whether it be to homoeopathy if it is not so amenable. That diagnosis must be made; or, if it cannot be made, it must always be remembered that the safest treatment in the light of the medical evidence present must be carried out.

It seems to me that it is of utmost importance for us as homoeopathic physicians to make a diagnosis – a homoeopathic diagnosis – before undertaking the treatment of a case. This homoeopathic diagnosis, as Hahnemann pointed out, has to do not with the name of the disease but with the discovery of the exciting cause and its removal, if it is removable; and he gave examples adequate in the light of the medical knowledge of his time before instituting homoeopathic treatment. Today these examples are not enough, for there are other measures which in some cases are more effective and safer than the homoeopathic remedy.

From the surgeons standpoint it seems to me that all physicians should be not only aware of, but quick to recognize and to act upon, the signs of the surgical emergency such as severe haemorrhage, ruptures or perforations of the organs within the abdomen, intestinal obstruction from any cause, mechanical obstruction of the bile ducts and increasingly severe appendicitis, to many probably the most common.

You, as specialists in the homoeopathic treatment of sick people, are not interested in the technique of surgery or in descriptions of operations. You should be interested, in addition to the homoeopathic pre- and post-operative care where your special knowledge is often of a decisive nature, in those signs and symptoms of conditions such as I have mentioned which should lead you immediately to feel that surgery may be needed and promptly to call for consultation and advice in the interest of the safety of your patient.

I know that often under good homoeopathic treatment surgical aid will often not be necessary, but none of us are always successful and many times the crisis is present and must be met immediately when you first see the patient.

LEt me illustrate:.

About four weeks ago my nephew, who is associated with me in practice, was called about midnight to see a woman, 85 years old, who at about ten P.M. had been suddenly taken with pain in her abdomen and persistent vomiting. She had an old incisional hernia following an operation for perineal abscess 19 years before but it was not swollen or tense and the ring was not tight.

He sent her to the hospital and called me. On examination I found an old incisional hernia with some abdominal distension. She was vomiting every few moments and there was severe abdominal pain. There was no history of dietary indiscretion, no fever, pulse about 90, face showed suffering. Bowels had moved about 18 hours before. Hernia was not strangulated.

Thru the thin abdominal wall two distended loops of dilated bowel could be seen. Those loops showed spasmodic peristaltic action but did not change their position. Diagnosis – intestinal obstruction. Operated at 1:30 A.M. Bowel was obstructed where a loop of intestine had gone thru a ring formed by adhesion of a loop of bowel to itself. Obstructed intestine was swollen, somewhat reddened. The white lines of the empty arterioles of early obstruction were present. The ring was destroyed and the obstruction relieved.

Because of the prompt operation the obstructed bowel was not permanently damaged and recovery was prompt and even. You can easily imagine what a delay of even 6 or 8 hours would have meant to the condition of the bowel and the welfare of the patient. SAFETY FIRST!.

About 4 weeks ago one of our members called me and said that she had a patient who might have acute appendicitis and that if I thought so I was to take her to the hospital and operate on her. On examining the patient I found a woman in the sixties who accompanied of some pain in the lower right quadrant. Her pulse, temperature and bowels were normal. She had no nausea. There was some tenderness in lower right abdomen and also some in back. I told the patient I could not make a diagnosis of appendicitis or other surgical condition and to call her doctor again. That afternoon her son and daughter took her to the hospital to be operated.

Next day I was more certain there was no surgical condition, except possibly a stone in her ureter, and I advised X-ray of abdomen. This was negative – the appendix filled with the barium. The family was still not satisfied and wished further consultation. Another physician examined her and after rectal examination suggested a proctoscopic examination because of a fancied lump in her pelvis.

The next morning before the proctoscopic examination I saw the patient who still had some right-sided pain, and saw that during the night she had broken out with Herpes Zoster which explained all her symptoms. In spite of this the proctoscopic examination was unnecessarily done and later, at the insistence of the son and daughter, an unnecessary catheterization of the bladder was done. No surgical condition. No surgery. I am sure the son and daughter were much disgusted with me for not rushing in.

I could go on and on reciting cases. I could tell of the young woman who in spite of no pain but because of the way she held her abdomen tight, her rapid pulse, her anxious face and her two months pregnancy, was operated immediately because we felt that there was an internal haemorrhage, probably from the rupture of an extra-uterine pregnancy, and the patient was saved because of prompt action. I could tell you of the woman of 80 with gall- stone colic with beginning duct obstruction who had many attacks and who, in spite of advice, waited so long that she died during a last-hope operation; whereas had she been operated 10 years before, when I first began to advise it, would probably be alive and well today.

The point of this too-long paper, and its sole reason for appearance, so to impress upon you that you must make a diagnosis not of the name of the disease but whether this special case is, first, one which can most effectually and safely be treated with the homoeopathic remedy, or whether other help is needed, whether it is infectious for the protection of others, and if it is incurable, what is the best way to bring about the best adjustment of the sick person so that he may be carried along though his remaining life in the best possible condition as to comfort and happiness.

In conclusion let me say that surgery should not be treated as your unloved step-child, but as an unobtrusive friend who, in time of doubt or need, may pull you out of a mean jam.

WASHINGTON, D.C.

DISCUSSION.

DR. ELIZABETH WRIGHT HUBBARD: I want to thank Dr. Custis for his very salient and wise and also, as always with him, very charming paper. I will not have him say that no kind words are said about surgery here. I am also extremely interested to hear about the lady whose family wanted her to be operated on for appendicitis which turned out be shingles.

Two weeks ago I was called in a great hurry to see an old gentleman of eighty, with all sorts of heart conditions, emphysema, and asthma, and he thought he had appendicitis. He had right lower pain, no fever, but a fast pulse. I poked around and finally I said to him, “Have you been awfully nervous lately and under great strain?”.

He said, “Why, yes!”.

“You havent got a few eruptions down around your right hip?”.

“Why, you know, Doctor, I have!”.

“Do they itch?” Do they burn?”.

“No, they dont”.

But, sure enough, there was a beginning of a herpes zoster right on his right hip. A dose of Ranunculus bulbosus fixed him in short order. The first symptom of pain they thought was appendicitis and it turned out to be shingles, and here the past master found the same thing.

I want to thank him especially for the term “homoeopathic diagnosis.” I am one of the homoeopathists who insists we must have a regular diagnosis as well, if it is possible to make it, and I get into all sorts of battles with my colleagues from Boston and Connecticut about that. I want that in addition to the homoeopathic diagnosis, which can be come at in a curious way sometimes through the remedy the symptoms call for, and sometimes in other ways. It is a very important concept and one all us should bear in mind.

DR. HARVEY FARRINGTON: Mr. Chairman, you know I cannot remember these criticisms. It is true some of the old war horses that look down on surgery may have said something, and they included Hahnemann; but it seems to me that in general we Hahnemannians have taken a more rational view of things, and we perceive the fact that medicine as a whole is ours, and we add to it only our knowledge of materia medica, and the special way in which we prepare and give our medicine.

Surgery is necessary, and this short, petit paper gives us the line that we should have in mind all the time.

Now, there is another view. What is a homoeopathic diagnosis? We all know it is according to what Hahnemann taught, but cant we enlarge on that and say a true homoeopathic diagnosis includes everything in the patient? You know, we look back over the history of some of the chronic cases and occasionally there is in something that a patient has had correctly diagnosed a little clue to the remedy that may be only partially indicated by the symptoms present at the time.

We talk diagnosis all the time. Here is a man with tonsillitis. That is making a diagnosis, and Lippe once cured a man in consultation who had arthritis because several years before he had a throat that alternated sides. He cured him with Lac caninum.

I could tell you a number of case, too, that would confirm the doctors contention in regard to this – the one I mentioned last year, the old man seventy, operated on in emergency for strangulated hernia, when I was called by my friend who had him in charge, he had omentitis and a flickering heart and was almost comatose. He could talk if you roused him, but he was so sleepy, he would fall asleep while you were talking to him. He had a dry mouth.

Nux moschata was plainly indicated. At nine-thirty he got a dose of the 10M. At two oclock I got a call. “The patient is worse, cussing and swearing around here, and the nurses cant do anything to please him.”.

I said, “That is all right. He is coming to life again. His bile went down and his dander went up”.

Now, if we learn even the rudiments of diagnosis in surgical cases, it will help us out. If there were a beginning herpes zoster involving the lower right quadrant of the abdomen, there wouldnt be that tenderness of the muscles there that you find if there is appendicitis – a few little simple things like that, and as we were told in college, look out for pain in the knee, because it may be the beginning of hip disease, and one of the biggest surgeons in Chicago, to my knowledge made a mistake in that.

He had a tubercular case in a girl and even got her father to build a gymnasium on the back of the house and kept her exercising for nearly a year when he suddenly woke up to the fact that he had a case that should have been immobilized.

Many papers have been read about homoeopathy and surgery. I thought the subject was darn near worn out, but our doctor here has given us a new view of it.

DR. WILLIAM B. GRIGGS: I think it is criminal negligence to neglect good surgery when needed. I had an infant brought in to the Childrens Hospital, which had been vomiting for three weeks. It was dehydrated, eyes sunken, vomiting everything, even a teaspoonful of water; no history of stool except a little starvation stool. The doctor prescribed everything he knew for “vomiting immediately on taking liquid” – I think Arsenicum, Bismuth, Cadmium. The first think I did when I examined the childs belly was to go carefully and I felt a little lump. I watched the childs stomach and observed a reverse peristalsis. We operated for pyloric stenosis, which was present. The child was almost dead, and it took a great deal of case post- operatively to bring it along. The child should have been operated on early.

DR. A.H. GRIMMER: I think the paper is well-timed and cannot be reminded too frequently of the necessity for every physicians at least recognizing a surgical case when it is present to him, and it will help us a great deal to win the respect of those outside of our own circles. I want to thank the doctor for an excellent paper.

DR. ALLAN D. SUTHERLAND: The proper use of surgery will also win respect within our own circle.

DR. J.B. GREGG CUSTIS [Closing discussion]: As I said in the first place, I wasnt talking about elective surgery, which can be done any time, the surgery of the end product of the disease, the surgery of the descent of the uterus, which has to be done for the comfort and safety of the patients – I was just trying to talk about the necessity for the quick diagnosis of the surgical emergency, the case which is not amenable to homoeopathic treatment and is acute.

You take the surgery where the tumor becomes so large that it is practically a mechanically obstructive object, where the cyst gets so big that it is in the way, where the hernia persists – that is all necessary surgery for anybody, for any doctor, but the thing I want to bring to your attention is the necessity for a prompt diagnosis of surgical emergencies where the waste even of a short few hours may mean the difference between having a live patient and a dead one.

You take this case of intestinal obstruction in old lady, eighty-five or eighty-six, and six hours or eight hours might mean a gangrenous bowel, and a necessary intestinal anastomosis, and a person that age probably wouldnt get over the intra- abdominal haemorrhage for hours. The woman would have been dead of haemorrhage. That is the sort of thing I want particularly to call your attention to.

Now I am going to go over in discussion a few of the symptoms which make up the surgical emergency, just to refresh your memories on that subject. First I want to recite to you the acute symptoms of a few of the surgical emergencies in the abdomen particularly. The first one is haemorrhage. In an internal haemorrhage, of course, you dont see any blood. YOu see an anxious face, pallor, difficult breathing, a rapid, weak pulse. If you have time to do it, you find a lowered haemoglobin, a lowered cell volume, an increased blood sugar, and increased non-protein nitrogen. If you have time for a blood examination, it is very well to know that.

In bowel obstruction you have vomiting, pain, distention, no passage of gas, no bowel movement, and often you can see a ladder-like arrangement of the intestinal folds, unless the abdomen is so fat that you cant perceive the intestinal obstruction at all, and, if you cant, an x-ray picture will often show that ladder-like arrangement.

If you have a strangulated hernia, unless it is one of the internal hernias, you find the hard, tense lump sticking through, and I want to make a plea for very gentle and short attempts at reduction because I have seen one or two cases which had been reduced without any difficulty and the patient kept on getting worse and, on operation, a gangrenous kink of bowel was found which had been pushed back when it was too late, and the patient died, so you want to be very careful about trying to reduce a strangulated hernia – very careful.

Of course, we all know the symptoms of appendicitis, with the vomiting, the tenseness and distention, the tension of the abdomen, which is common to all intestinal-abdominal inflammatory conditions, the more or less feeling of tension.

In internal haemorrhage, especially from the ruptured extra- uterine pregnancy, you feel an abdomen almost like a board, from attempt to guard it, and examination shows a very tender cervix. Any pressure on the cervix causes very much pain, even though with no inflammation.

Inflammation of the gallbladder-it is the same as with appendicitis, though it may be higher, but they may be so close together you cant tell them apart until you get in there and look. We have seen that, and, of course, in gallbladder obstruction and obstruction of the bile ducts, you add jaundice to the other picture.

Remember also that increasing painless jaundice is likely to be cancer of the head of the pancreas or obstructing the bile duct at the ampulla of Vater.

Gregg Custis J B