CHAPTER XL (Part 3)

Remember that sudden pain in the right iliac fossa, fever, rigidity of right rectus muscle, and localized tenderness is appendicitis almost without a single exception. Remember that fecal vomiting, a very common symptom of obstruction, is never seen in appendi- citis. Remember that marked tenesmus and bloody stools in children are the signs of intussusception ' and not appendicitis. Remember that the thermometer is one of the most trustworthy guides in diagnosing appendicitis, and Murphy says he would refuse operation if no fever was present during the first thirty-six hours of the disease. Remember that the subsidence of excruciating pain is an ominous sign of gangrene, and perfora- tion is not far distant. Remember to exclude the onset of pneumonia in 38 DISEASES OF THE INTESTINES. cases of sudden colicky pain in abdomen of children by auscultating the chest. Remember that typhoid bacilli may cause appen- dicitis and many cases of perforation occur through typhoid ulcer. Never mask your symptoms with morphin; it is positively suicidal for both doctor and patient. If the patient complains of pain in emptying the blad- der or rectum, always examine per rectum for recto- vesical or rectouterine tenderness, or an inflamma- tory swelling. Tenderness at the right side of the rectum in rec- tal examination is nearly always present, although there may be none at McBurney's point. Masked Appendicitis. In this form there is no history of an acute attack, and the usual clinical picture of appendicitis is absent. 1. Dyspepsia, with belching, pain at irregular intervals following meals, persisting for a time, fol- lowed by a period of complete disappearance of all symptoms regardless of diet. 2. Diarrhea, especially early morning, with two or three loose movements, with freedom from it for balance of the day. Evacuations may be preceded by colicky pains, which the evacuations relieve. At times there is a peculiar periodicity of diarrhea, occurring at a certain morning hour. There are periods of freedom from diarrhea, just as the APPENDICITIS. 39 gastric symptoms. The stools may be normal at first, but later become slimy and contain mucus. Persistent constipation, with extreme neurosis, may occur. 3. Pain is paroxysmal, with all degrees of sever- ity. Occurs suddenly, often in the epigastric region, accompanied by nausea and vomiting, 4. Palpation over the appendicular area will usu- ally reveal tenderness and often causes nausea. The swollen appendix can be palpated through a re- laxed abdominal wall if not too thick. Remember that disease of the gallbladder, stomach, and pelvis must be excluded before mak- ing a positive diagnosis. Have the patient lie on the back and limbs straight. With the tips of the fingers over the cecum, make deep pressure. Now tell the patient to make the muscles of the right limb rigid and stiff at the knee, and raise the foot by using hip joint and lifting as against a weight. If the appendix is at all tender, he will complain of pain. Treatment. Remember that the treatment of appendicitis is always surgical, regardless of type, time, or tender- ness. The danger of perforation and general peri- tonitis occurring at any hour should always be kept in mind, and warn us against useless medication. If an operation is absolutely prohibited, then Oschner's method gives best results. Give abso- lutely nothing by mouth; use nutrient rectal ene- 40 DISEASES OF THE INTESTINES. mata. If vomiting is present, wash out the stomach. Apply an ice bag over the cecum. Use continuous seepage (page 29) of normal saline. If pain is intense, use enough morphin to make it bearable, but never entirely relieve it. Mucous Colitis. Remember that this is a neurosis, and is found in hysterical or hypochondriacal patients. They are dyspeptics, and have carried self-dieting to such ex- tremes that they become thin and anemic. The diagnostic sign is mucus — either as strips, shreds, or casts — passed at stool. Other times it is a slimy, gelatinous mass, resembling frog-spawn. Usually occurs at intervals and follows prolonged constipation. Colicky pain, usually agonizing, with tenesmus, is present. These mucous segments are often mistaken for segments of tapeworm. There is tenderness over the colon, and often a spot of great tenderness between the navel and left costal arch. Abdomen is rarely distended. Mucous casts may be found in the urine. Urticaria and boils are frequently associated with this condition. Treatment. Plenty of outdoor exercise should be given. Diet must be liberal, and consist of the ordinary foods; should be well cooked and served at regular time. Foods leaving considerable residue are good to over- come constipation. MUCOUS COLITIS — VISCEROPTOSIS. 41 Constipation is best prevented by castor oil. Give in morning on empty stomach and enough to open the bowel. Calomel or magnesium sulphate may be used, but are not so good. Pain can usually be re- lieved by hot applications to the abdomen, but at times it is so severe as to require hypodermic of morphin combined with atropin. Irrigate the colon with normal saline solution. In severe neurosis use the Weir-Mitchell method of feeding. Quiet the nervous condition with bromids. At night inject as high as possible half to a pint of warm olive or cottonseed oil. Have patient re- tain the oil all night if possible. This usually causes a copious evacuation in the morning. Continue this every night for two or three weeks, then every other night for same period, then three times a week. Arsenic and the glycerophosphates will often give excellent results. Visceroptosis. To determine the degree of displacement of the abdominal organs, accurately and easily applied sur- face markings of the normal position of the organs are essential. The following lines will be of aid : The sternoensiform line is drawn across the body at the junction of sternum and ensiform. It marks the height of the abdominal viscera. In the right nipple line, with patient in recumbent posture, hepatic dullness begins. Gastric resonance falls half an inch below it on left side; the central tendon of 42 DISEASES OF THE INTESTINES. the diaphragm half an inch below in median line. In addition, this line indicates the kind and degree of chest deformity. It crosses the fifth costal on either side in normal chest, but may cut the fifth space in emphysema because the ribs and cartilages are abnormally horizontal; or it may cut the fourth space or fourth rib if the ribs are abnormally de- pressed, as they so often are in visceroptosis. The midepigastric point is midway between the umbilicus and the sternoensiform junction. The transpyloric line passes through this point. It cuts the costal margin near the outer border of the recti and crosses the ninth costal cartilage. The pylorus is situated on this line, halfway be- tween the midepigastric point and the costal mar- gin. In ptosis it is displaced downward and toward the median line. The lesser gastric curvature is about three-fourths of an inch above and the greater curvature one and one-half inches below the midepigastric point; this point marks the lower hepatic margin as it crosses the body, while behind it the pancreas crosses the spinal column. The umbilical line is drawn through the umbilicus and touches the iliac crests. The transverse colon lies just above it, while the lower poles of the kidneys do not reach it. In ptosis both colon and kidneys fall below this line. Symptoms. A high degree of ptosis may cause no symptoms. VISCEROPTOSIS. 43 1. Circulatory disturbances are manifested by diz- ziness, fainting, flushing of the head, and palpi- tation in the upright position, but relief is obtained on lying down. 2. Grastric symptoms are anorexia, nausea, vom- iting, and eructations. 3. Nervous group includes pain or dragging sen- sation in back or loins, neuralgic pains in the head, sleeplessness, despondency, and reflex cough. 4. Intestinal — constipation is the rule, but diar- rhea is present if mucous colitis exists. Eespiration is costal, superficial, and apex beat of heart may be seen in sixth space, and visible tug on strictures at root of neck. Epigastric area sinks in, and hypogastric region protrudes in erect pos- ture. The skin is of grayish hue, and cold and clammy. Hands and feet readily become cold. The abdominal organs are displaced downward. The pancreas is palpable as a cord crossing spinal column. Treatment. Diet should be liberal, with a view of putting on fat, thus furnishing additional support to the viscera. I'orced feeding on the Weir-Mitchell plan is excel- lent, because the nervous system improves in addi- tion to the benefit derived from the fat. Mechanical support for the viscera may be ob- tained by using abdominal bandage or adhesive strips. If the binder be used, it should fit snugly, and have straps to prevent "riding the hips." If 44 DISEASES OF THE INTESTINES. adhesive, use six-inch zinc oxid, and cut them long enough to extend three-fourths around the body. Apply in recumbent posture, beginning in the hypo- gastric region. Drugs are indicated when tonics are needed. Strychnin may then be used to good advantage. Operation for replacing organs and suturing them is indicated in a few cases with neurasthenia, yet not all neurasthenics should be operated upon. Caution. When visceroptosis is discovered in a patient, it is well not to tell him, as it often forms a basis for many imaginary disorders in the neuras- thenic or hysterical.