CHAPTER X
VAGUE ABDOMINAL DISCOMFORTS—LOOSE KIDNEY
After the vague pains around joints so commonly called rheumatic, and which occur so frequently that probably there is no one over forty who is quite ready to confess that he has not had rheumatism, the most important source of vague discomfort is the abdominal region. This occurs particularly in people who are engaged in a sedentary occupation which prevents much exercise, keeps them indoors, and gives them abundant opportunity as a rule for introspection and dwelling upon their sensations. There are few people who live the intellectual life who have not suffered from some of this abdominal discomfort, which they presumed must mean some definite lesion, or portend some serious development, and yet, as a rule, they have lived for years afterward without any of their fears proving true.
Physicians are not spared from this source of worry and discomfort. They suffer from it even a little more than others. Their knowledge of the possibilities of serious pathological developments within the abdomen, especially after the age of forty, makes them a little more concerned as to the significance of these vague discomforts.
At least half a dozen times a year, for the last ten years, I have heard physicians say that they were sure that some organ or other within was not performing its function properly, and that there was probably some organic lesion. The thought has usually been in their minds for months, sometimes for years, and they have come to be thoroughly examined. Sometimes they rather expect to be told that they should go to a surgeon. They are usually half concealing a question as to how soon they should set about putting their affairs to rights and how serious the outlook is. As a rule, I am able to dismiss them without any further treatment than the injunction not to think so persistently about certain obscure feelings which they are allowing to occupy their consciousness. Sometimes I know they take the advice—even oftener, perhaps, I know they do not. Once it has got hold of us, it is hard to get away from morbid introspection, and I sometimes hear of them consulting others. All of these patients are improved for a time after their consultation by the reassurance that so long as they have a good appetite—which is the case with all of them—and their bowels are regular—which unfortunately is not the case with most of them—and so long as they sleep well and have no acute pain, there is little likelihood of any serious latent abdominal condition.
Such reassurance cannot be given until the abdominal region is carefully palpated, and especially the right side explored as thoroughly as possible. [{303}] Here lies the appendix, the head of the colon, which is sometimes the seat of trouble not necessarily originating in the appendix. Just above them one may find a loose kidney, for the right kidney is more likely to be movable than the left, because of the overhanging liver, and finally the gall-bladder, and the bile passages, so likely to be the seat of serious trouble. If none of these organs are tender on deep palpation, if the kidney does not come down when the patient is examined in the standing position, if there are no serious derangements of digestion, except such as can be attributed to nervous indigestion, and if there is no dilatation of the stomach, and no enlargement of the spleen, there is no reason why one should do anything but try to get the patient's mind off himself.
There is always the danger of overlooking an abdominal cancer, in these eases, though with the care in diagnosis I have suggested this is minimal. The best therapeutic test that I know to determine this, if there should be any doubt, is to put the patient on an increased diet and watch the scales. If he is able to digest the added food well, and without trouble, and if he proceeds promptly to gain in weight, there is much less than one chance in a hundred that he is the subject of latent cancer in the abdominal region. The old farmer's maxim is: "A sick hog don't get fat." When human beings properly respond to increased feeding, it is probable, not only that there is nothing serious the matter with them, but that the symptoms of which they complained before may very likely have been due to lack of nutrition. The digestive organs not having enough to occupy them, were tempted to digest themselves, or at least to have their function disturbed by the short circuiting of nervous energy looking for something to do.
I have seen a number of these cases that had been operated on for vague discomfort—some whose appendices had been removed, some whose kidneys had been fastened up because they were slightly movable, some whose gall passages had been examined for adhesions that were supposed to exist, or perhaps for a stone that it was thought might be found there, and except where some actual organic lesion was found and relieved, none of them was materially improved when seen several years after operation. I have heard reports of cures of these cases by surgeons who felt that the removal of an appendix presumed to show a catarrhal process, or a hyperemia, or an adhesion at its tip, had meant the cure of vague abdominal discomfort which had continued for many years and made the patient profoundly miserable. But these reports were founded on the patient's condition at the end of convalescence after the operation, and not on the condition that established itself some months, or perhaps a year, later. Operations on the abdomen, except for very definite indications, have, in my experience, always done more harm than good, and I have seen serious conditions—hernia, displacement of organs and disturbance of the peristalsis of the intestines—develop subsequent to them.
I have in mind two typical cases. One was a physician whom I had seen on a number of occasions, and who complained of vague discomfort, mainly in the right side of the abdomen, though never acute, never accompanied by fever, nor even by any disturbance of pulse when he was not in an excitable mood. His bowels were not always regular, and he had had some disturbance of circulation as the result of thrombosis of veins on that side after an [{304}] attack of typhoid fever. My opinion was that his discomfort was entirely due to the disturbance of circulation. There was probably some interference with the normal full circulation to the large intestine, in its ascending portion, that gave him a feeling of uneasiness, or of consciousness of its function. Eventually he became convinced that he was suffering from a chronic form of appendicitis. After considerable persuasion he convinced a surgeon friend that his appendix should be removed, and the operation was done. I saw his appendix afterwards. It was supposed to be thickened, but considering the normal limits of size of the appendix, I could not think that it was beyond them in any marked way. At most there was but a slight catarrhal inflammation.
For a time after operation he was much improved. He felt confident that all his trouble has disappeared, and he took some pains to impress me with the supposed fact that in these vague cases of discomfort there was always some underlying organic lesion that needed surgical treatment. During convalescence he had gained in weight, and was looking very well. When I met him a year and a half later he said that some of his discomfort had returned. He had grown thinner and was feeling discouraged. Six months later he was about to submit to another operation, this time for the breaking up of adhesions in the neighborhood of his gall-bladder. He had become convinced that this must be the seat of the difficulty. After this operation he was sure, beyond peradventure, that his trouble was gone never to return. Two years later I found him preparing to have his right kidney sewed up. I had known that his right kidney was slightly movable, but it did not move sufficiently to cause any disturbance of kidney function, and certainly not enough to justify serious surgical intervention.
After this operation I met him once casually and he assured me that now everything was surely all right. I have since heard that he submitted to an operation either for the breaking up of some adhesions around his stomach or in order to tuck up that organ for ptosis. It had not been quite decided whether an adhesion caused a slight hour-glass constriction of the stomach, with some dilatation of the splenic end of the fundus, or whether there had been some actual sagging. I am sure that after this operation, as after preceding ones, with the strong suggestion that he ought to be better and an increase of weight during convalescence, he lost his vague abdominal discomfort for a time, though I have no doubt that it either has or will return. When he gets something to so occupy his mind that he does not dwell too much on his discomfort, he will not increase it to the extent that makes it intolerable. Then he will remember that most people have some discomfort, and he will learn to distract his mind, rather than allow it to dwell on the thought of his particular ailment until it becomes intolerable.