CHAPTER XXXIX DIAGNOSIS OF SOME CASES OF CHRONIC (Part 1)

CHAPTER XXXIX DIAGNOSIS OF SOME CASES OF CHRONIC INDIGESTION Within recent years a large number of cases of chronic indigestion have been found to be due to conditions susceptible of relief or cure by surgical treatment, and it is tlierefore necessary that surgeons should be able to investigate such cases and to diagnose those conditions which can be dealt with sm-gically, and to distinguish these cases one from another ilie aroup of cases we are now to consider is not very clearly definable, but they are generally character- ized l3y abdominal discomfort or pam, sometimes by nausea or vomiting, belching of wmd or intes- tinal flatulence, constipation, and a certain degree of debility. The symptoms have been of some duration when the patient conies for advice, and he often associates them in some way with the taking of food. Included in this group of cases are— Absence of molar teeth. Chronic appendieitis. Pyorrhcea. f "^"o^'^ f '^'^l""- , ■ 1 Internal hernia. il., 1 . 1 Panereatic calcuhis. Dilated stomach. i ancieai Duodenal ulcer. Cancer of paneieas. Ileal kink.' ^"^'™F T^i Chrouic duodenal ileus. Visceral adhesions. C*cal stasis. riC2 CHRONIC INDIGESTION 563 To arrive at a diagnosis in these cases, the sur- geon should first inquire carefully into the history of the case, then note exactly the symptoms, and finally make a thorough examination of the teeth and of the abdominal organs. I. The history. — Two classes of facts in the his- tory are of special importance : (1) the mode of onset of the symptoms; (2) their duration and progress. 1. The onset of the symptoms may have been spontaneous, or without recognizable cause, or it may have followed some acute illness, or operation, or pregnancy. The symptoms may have come on abruptly, or so gradually that their beginning was unperceived. An abrupt onset indicates either an infection, or some mechanical disturbance such as the displacement or kinking of a part or the move- ment or impaction of a stone. A sequel to an acute illness is caused by permanent damage to an organ by inflammation, or by interference with its func- tion by adhesions. If the illness follows upon an operation, it is the result of adhesions, or it is caused by the direct effect of the operation ; the disturbance of pregnancy is often followed by chole- cystitis and cholelithiasis. Where the symptoms have come on without a known cause they are likely to result from an auto-infection, from some persistent violation of physiological law, or from the onset of malignant disease. 2. Duration and progress of the symptoms.— The dura- tion of the symptoms is chiefly significant as showing the greater or lesser gravity of 'the functional dis- turbance. The history of the progress of the symp- toms is more important. They may have been per- sistent and unchanged for years, indicatiTig a very chronic and less grave condition ; they may have been definitely intermittent, constituting successive 564 SUKGICAL DIAGNOSIS [chap. attacks of iUness, indicating successive infections ot exacerbations ; or there may have been some recent aggravation or change in the symptoms, mdicatmg the onset of a secondary compUcation such as car- cinoma engrafted upon a chronic ulcer, cholecystitis secondary to appendicitis, stenosis foUowmg upon ulceration or upon the impaction of a gall-stone. II. Symptomatology. 1 . Pain, (a) Its seat. —Pain is not always felt close over the seat of its cause, although this is often the case, e.g. m gastric ulcer, cholecystitis, and appendicitis; sometimes it is referred to a surface distant from the cause, e o- the right shoulder in gall-stones, aroimd the umbilicus or at the epigastrium in appendicitis. Patients are often able to state definitely that the pain is wholly above the umbilicus or wholly below that point, and, still more, that it is entirely limited to the right or to the left side of the belly. Where this is so, the cause of the pain is m the first case to be sought in the stomach, gall-bladder and bile- ducts, duodenum, or transverse colon ; m the second case, in the small intestine below the duodenum the ca3cum, appendix, right or left colon ; m the third case, in the appendix, ciBCum, ascending colon, or gall-bladder if the pain is wholly right-sided, and in the descending and sigmoid colon if wholly lelt- sided. Again, there arc many cases where the patient says the pain i,s at a particular definite spot "—the upper or lower epigastrmm, the right hypochondrium just below the ninth costal cartilage, beneath the right rectus muscle ]ust above the umbilicus, or in the region of the cnecum V. hen pam is limited to one of these small areas it usual > indicates that the cause of the pam is immediate]) beneath that part of the abdominal wall._ (b) Character of (he pf«n.-Not much importance XXXIX] CHRONIC INDIGESTION 565 is to be attached to such descriptions of pain as "burning," "stabbing," "cutting," "dragging," " gnawing," but a good deal of weight is to be put upon the use of the term " griping " or " hi.bour- like," as an indication of strong but inefltective action of involuntary muscle, as in the biliary passages, stomach, or intestine. When pain is described as " shooting," the direction in which the pain is said to shoot should always be inquired into. Thus, pain shooting from the epigastrium round the right side of the body to the lower dorsal spine — some- times also up to the right shoulder — is very charac- teristic of trouble in the gall-bladder or bile-passages ; pain in the right iliac region, shooting up towards the umbilicus or lower epigastrium, or across to the left iliac region, is often mentioned in cases of chronic appendicitis ; occasionally in this aflection the pain is described as shooting down the front of the right thigh or along the fold of the groin, but not to the pubes or along the urethra. Extension of the pain from its original site to another part may be a sig- nificant point, e.g. the extension of epigastric pain through to the back may indicate the extension of a gastiic ulcer through the stomach wall to the pancreas. (c) Onsei of the fain. — This may be gradual, sudden, or intermittent. Gradually increasing pain is felt in such cases as pyloric stenosis and gastric ulcer ; sudden pain occurs in gall-stones, in appen- dicitis, and in internal hernia ; intermittent pain in duodenal ulcer and in gastric or intestinal obstruc- tion. The time at which pain occurs is often signi- ficant— not only the time of day, but also the relation of the pain to the taking of food and the passage of wind or motion. The pain of chronic appoidicitia often comes on in the early liours of the morning 566 SURGICAL DIAGNOSIS [chap. or after exercise, and it is not iufluenced by the laking of food nor by the character of the food taken. The pain of gastric ulcer comes on at an interval after taking food, and is worse after solid than after bland fluid food. The pain of duodenal ulcer is relieved by taking food, and then comes on again two or three hours after the food ; it is worse after a mixed meal than after bland fluid food. The pain of chronic cholecystitis and of cfscal stasis conies on in the later hours of the day. The pain of gastric distension is relieved by copious belcliing or vomiting ; the pain of gastric ulcer, by the speedy vomiting of food taken; the pain of intestinal obstruction, by the free passage of flatus and fseces. 2. Nausea and vomiting. — Nausea is met with in cholecystitis, intestinal kinks, visceroptosis, and csecal stasis, and is a marked symptom in some cases of gastric cancer. Vomiting is met_ with in gastric cancer and in some cases of gastric ulcer ; copious vomiting, and vomiting of food taken a day or two before, in cases of pyloric obstruction ; occasional fa3cal vomiting, in cases of cancerous fistula between the stomach and colon. (For fecal vomiting in cases of intestinal obstruction, see Cha]). XXXVIII.) Hajmatemesis occurs in gastric ulcer and cancer and in duodenal ulcer. The association of acute spasmodic pain with belching of great volumes of wind is often seen in biUary cohc. 3. Jaundice. — When the patient gives a history of having been yellow in colom-, and reports that at the same time the motions were pale or chalky in colour and the urine very dark, it is certain that there has been obstructive jaundice, and this fact would strongly support a diagnosis of gall-stones. 4. Stools.— In many of these cases it is necessary to examine (he stools oneself, but a history of copious xxxix] CHRONIC INDIGESTION 567 meltena, with or without sudden faintness, points usually to duodenal ulcer ; a history of the passage of a little red-brown blood and mucus in the stools would rather indicate the presence of an ulcerated growth in the colon or of a chronic intussusception. A history of chronic constipation or of the constant and more or less ineffectual taking of aperients is common in many of these conditions, and is a marked symptom in visceroptosis, csecal stasis, and visceral adhesions. Occasional attacks of diarrhoea with habitual constipation occur in ileal kink. The passage of a large-sized motion, even at long intervals, shows that there is no narrowing of the lower colon or rectum; the repeated passage of tiny fa3cal pellets is often associated with the development of diverti- culitis ; the progressive diminution in size of the motions and increasing difficulty in getting _ the bowels to respond to purgatives are characteristic of a gradually increasing stenosis of the colon. 5. Rigors. — The occurrence of irregular rigors associated with a feeling of depression and with jaundice is very strongly indicative of a calculus in the common bile-duct. 6. The general condition. — Rapid wasting and in- creasing debility out of proportion to the other symptoms usually result from cancer. Considerable emaciation and great weakness may result from non-malignant conditions, such as cicatricial pyloric stenosis or hour-glass stomach when this condition has existed for years. III. Examinatiou oi the patient. 1. Teeth and gums. — Notice particularly whether there are sufficient sound molar teeth to effect proper mastication, and whether pyorrhoea is present. The signs of pyorrhoea are a red line along the free edge of the gum, recession and ulceration of the gums, the welling up of pus 5(38 SURGICAL DIAGNOSIS [chap. around the neck of a tooth when the gum is pressed, and a peculiar odour of the breath. Pyorrhosa may be present on the oral side of the teeth alone, and, since in some cases it is only identified after a very careful search, the examination must not be cursory. The absence of efEcient molar teeth is a frequent cause of pain after food, and of flatidence ; if this is the cause of the symptoms, they quickly disappear when the patient has proper dentures. Pyorrhoea may, in some cases, be a caiisative factor in gastric and duodenal idcers. 2. General form ol the abdomen. — The abdomen may be generally distended, flaccid or scaphoid, or local distension of the stomach, ca3cum, or colon may be apparent. Through the thin abdominal wall a tumour of stomach, of pancreas, of liver, of gall- bladder, or of caecum may be evident. Peristaltic waves of intestinal coiitraction may be visible ; unless there be such thinness of the abdominal wall that peristalsis of normal intestine is visible, they indi- cate hypertrophy of the intestinal musculature, and are a sign of organic intestinal obstruction, and therefore of great importance in diagnosis ; if they are not excited by the mere exposure of the abdo- men, gentle pressure of the hand is often sufficient to bring them on. They are frequently accompanied by gurgling sounds (borborygmi) and by griping pain. With the patient upright, a flattening of the epigas- trium with a bulging of the hypogastric and iliac regions betokens a general entcroptosis. 3. Respiratory mobility of the abdomen. — Get the patient to take two or three slow, full breaths, and notice whether the abdominal wall rises and falls fully and equally as it should, or whether its move- ment is less free than normal, or limited in area, and whether any viscus or tumour can be seen to xxxix] CHRONIC INDIGESTION 569 move up and down beneath it. Full and equable mobility indicates the absence of muscular rigidity, and of marked tenderness of the abdominal viscera. Local immobility is a useful indication of the pres- ence and position of a tender viscus such as an ulcer- ated duodenum or an inflamed appendix. A tumour that is seen to move under the abdominal wall during respiration is certainly connected with one of the viscera adjacent to the diaphragm — stomach, liver, gall-bladder, or spleen — and is free from serious adhesions. 4. Muscular rigidity and tenderness. — Place the hand flat upon the abdomen, then gently flex the fingers, and notice very carefully any lessening of the flac- cidity of the wall. In some cases the local rigidity is very slight yet definite, and it will be missed unless sought for with care. The fiaccidity of corre- sponding areas of the two sides, particularly of the two iliac regions, and of the upper part of each rectus muscle, should be very carefully compared. Rigidity is an indication of hypersensitiveness of the subjacent viscus, and is an important sign of appendicitis in one situation, and of duodenal ulcer in the other. Then examine with equal care for local tenderness — first with gentle pressure of the fl.at hand ; if none is elicited, firmer pressure may be made, and then a single finger-tip should be gently but steadily pressed backwards. This exam- ination should be made systematically so as not to miss out any portion of the belly ; it is especially important at the epigastrium, in the right ihac region, over the upper part of the right rectus, and belovv and beneath the right costal arch, particularly at the outer edge of the rectus muscle. To examine for tenderness of the gall-bladder, when there is no gall-bladder tumour to be felt, the finger-tips of the 570 SURaiCAL DIAaNOSIS [chap. right hand should be pressed up just below the ninth and tenth costal cartilages, and the patient should then take a full inspiration ; this will bring the gall-bladder down against the fingers, and if it is tender will occasion pain. Tenderness at the epigastrium is met with in gastric ulcer, especially along the lesser curvature, in the anterior wall, and near the pylorus. Tenderness to pressure with a finger-tip at a spot midway between the xiphoid cartilage and the navel is never absent when a gall-stone is impacted in the cystic or in the common bile-duct. Tenderness just above and a little to the right of the navel is a sign of duodenal ulcer. Tender- ness about one-third of the distance from the right anterior iliac spine to the navel, and when the hand is felt to roll over the lower edge of the caicum, is a sign of appendicitis; when this pressure causes pain°also referred to a point just above the navel, it is still more indicative of chronic appendicitis. Tenderness may be found over any abdominal tumour. 5 Tumours and iheir characters.— The reader is re- ferred for details to Chap. XXXVI. Attention m the cases we are here considering should be especially directed to determining the exact seat of any tumour, its mobility within the abdomen, its dullness or resonance on percussion, and its constancy. As to the last point, the distension of the stomach or of part of the bowel may be intermittent, and the tumour it causes may be sometimes present, some- times absent, or varying in size. Again, a distended and obstructed stomach or coil of bowel may be only recognizable when made tense by the con- traction of its muscular coat, and manipulation of the part may, by causing this contraction, make the tumour become gradually palpable. AMien tJus is recognized, its significance is great m tlic diag- XXX ix] CHRONIC INDIGESTION 571 nosis of pyloric obstruction, intestinal obstruction, and chronic intussusception. In other cases, during massage of a lump it may be felt to melt away gradually under the hand by the subsidence of muscular spasm. 6. Position, size, and mobility ol tlie abdominal viscera. — By percussion define the position and size of the stomach and liver, feel the lower edge of the liver and, if possible, the gall-bladder, and determine the degree of mobility of each kidney. By percus- sion the gaseous distension of the intestine can be determined ; it is especially important to notice any relative distension of the higher colon as compared with the lower part, as this is a sign of obstruction to the free passage of its contents. In particular the csecum may be felt distentled to form a soft mass with an ill-defined outline, manipulation of which produces well-marked gur- gling and some discomfort. 7. Examination of vomited matter. — The vomiting of a very large quantity of material is evidence of dis- tension of the stomach, which is usually dependent upon chronic pyloric obstruction. The presence in the vomit of portions of food taken many hours or even a day or two before is evidence of delay in the passage of food out of the stomach; and a yeast- like appearance and odour of the vomit, and the detection of sarcinoB ventriculi under the micro- scope, also show that there is obstruction to the passage of food from the stomach into the duode- num. The frequent presence of blood in small quantity is a common sign of gastric cancer, while occasional large ha3morrhage is met with in gastric or duodenal