Surgical differentials

Front matter

Class WU3S*

Book tyfhST

Copyright^ _

Preface

"Diagnosis" has for some time been accepted as meaning "Differential Diagnosis." This term is too long for convenient nse and of the two words, clearness seems to demand that "diagnosis" be dropped. This is offered as an explanation of the title of this book.

The subject matter has been compiled with but a single purpose. This is to present to students intending to enter the competitive examinations of the New York Hospitals, a welltried scheme and its mode of application. It is not the actual learning of surgical facts but their selection and grouping which is most difficult to the student.

In the opinion of over one hundred graduates who during the past six years secured hospital positions, the ability to apply this scheme was the primary cause of their success. These ■ pages represent simply an effort to present as tersely as possible the system which has proved so highly efficacious. It will therefore be seen that no attempt to make a text-book or book of reference has been thought of.

Ability to sketch rough outlines in place of giving long word answers has always been very helpful in securing hospital positions. In recognition of this, forty graphic illustrations have been introduced. They were made by Dr. Chas. K. Stillman, a successful graduate of last year. Having been made by a student they can be duplicated by a student, for they have been drawn with studied simplicity and it is believed, with accuracy. Except in three or four instances they are entirely original; — I cannot too cordially thank Dr. Stillman for his care, or endorse his work too highly.

Copies of some recent hospital examination papers have been added, in the interest of students at Universities outside of New York City.

The Differentials have been made with care and by painstaking- reference to leading text-books. It is feared, nevertheless, that many errors may be found. These Differentials have been chosen with the intention of indicating the general broad trend of to-day's hospital questions. The time for memorizing special material for each examiner is happily past and with it the value of the obnoxious "quiz compend.'* Examiners no longer ask for narrow isolated facts but require the broad practical Differential.

Dr. Jos. A. Blake, Dr. Geo. E. Brewer, Dr. R. H. M. Dawbarn, Dr. John Rogers and Dr. L. A. Stimson may recognize in the text some of their own familiar aphorisms. The author wishes to acknowledge the debt which he owes these Teachers of Surgery.

J. W. Draper Maury.

September 1st, 1904.

Chapter I. Scheme

A clear and uniform recitation scheme is essential to every student of medicine. This is particularly true of those who enter competitive hospital examinations.

For more general surgical diseases the same scheme may be applied which is universally used in the practice of medicine.

., ^ \ Simple — Such as is given in a modern gen-

1 — Definition j . * , ,. & .. &

I eral dictionary.

f Predisposing — Age, sex, race, color,

„ p j occupation, social status, climate.

tiolo y i j p-erms or

Exciting — Iraumadueto - **. -,

., -r, i Gross.

3 — Pathology < ■»»• . / Minute.

f Subjective or / s s , _ chenie T 1 General Symptoms \ bee ^ ub " scheme l 4 o 1 Inspection

4 SYMPTOMATOLOGY -^ A , • ■ t» 1 *«

Objective or I Palpation | Local Symptoms { Percussion

J Auscultation

5 — Differentials — (See Sub-scheme II)

,. n o i Immediate, mediate and

b —Complications and Sequelae ■{ '

/ remote

7- Prognosis j ifcdtate** I As t0 life a f ndvet " m ot " function / Remote of ,n J ured P art

Nurse Medical r

| Medical ,- Feed

) Stimulate

• i ) Pallative Surgical r -n -,. , & Radical

SCHEME.

SUB-SCHEME I.

Many surgical lesions, however, require further detail than this familiar scheme affords.

In giving subjective symptoms, for example, it has been found convenient to follow the course of a particle of food through the body. All the patient complains of in the usual surgical lesions is pain or disability. One or both of these symptoms may occur in the

1,

Mouth

8,

Heart

2,

Pharynx

9,

Lungs

3,

Esophagus

10,

Brain

4,

Stomach

11,

Special senses

Small and great gut

12,

Peripheral nerves

6,

Liver (Jaundice) or other

13,

Kidneys and G. U.

glands

14,

Extremities

Here the food enters the blood from which indirectly is derived the T. P. R.

SUB-SCHEME II.

■Historic Differentials, #, History of Tumor, Injury, Disease or Malformation.

Note.

-T. I. D. as used in prescription writing, convenient way to remember this.

b, History of previous Injury, Disease or Operation. .

c, Age, Sex, Race, Occuption, Social State, Climate.

2 — Subjective Differentials. <?, Pain — Local and referred.

b, Disability

c, Vomiting J, Bladder

and Rectum e, Jaundice /, T. P. R.

j Important always to give the actual ( figures. Never say elevated or depressed.

120 is the danger line of the pulse.

Pulse has six characteristics : Force, Frequency, Rhythm, Length, Foll- P— { ness, Compressibility* The first three are determined by the heart, the last three by the condition of the vessel wall.

SCHEME.

f Central (vertigo, delirium, con-

AT , J sciousness, convulsions)

*' r Peripheral (paresthesiae, special

sense)

h, Urinary symptoms.

3 — General Physical Differentials

Inspection Facies Nutrition Glands

Superficial and Deep Reflexes r Inspection Palpation / Pressure 4 — Local Physical J Percussion [ pain Differentials ' Auscultation

I Mensuration / Serous Sangui-

[ Exploratory Puncture f nous Purulent

5 — Laboratory Differentials.

A, Sputum

B, Stomach

t FreeH. CI. (N. = T \f )

a, Chemical of contents ■! Combined H. CI.

( Carbon Compound Acids

b, Physical of contents — Color, sediment, odor, etc.

( Boas-Oppler r, Microscopic of Contents < Sarcinae

( Atypical Cells

<aT, Motor Power of Stomach •<

X-ray (with Bismuth).

K. I. in capsules Asparagin

Measured quantity of liquid

C, Blood

a, Leucocyte Count, Differential Count

Small lymphocites, 20-30 % Large ' ' 4-8 %

(Normal) -{ Polymorphonuclear neutrophiles,

62-70 #

^ Eosinophiles, ^-4^

ID SCHEME.

/;, Hemoglobin per cent

c, Color Index (Hemoglobin per cent divided by per cent of red cells. Normally one.)

J, Parasites (Malaria, Spirillum, Bacteria, etc.) c\ Injection into animals /, Widal and other tests

D, Urine in addition to usual tests

Indican (Intestinal putrefaction) Cryo^feopy (In renal involvement)

E, Feces: Undigested Food, Blood, Ova, Parasites, Bac-

teria.

F, Tissue Section and Staining Reactions

/- T7 • r -n i. n • i ( Specific Gravity.

G, Examination of Punct. rluid, ] *K.

Exudate, Transudate or Pus ) p

•6 — Drug Differenhals.

Effect of K. I. Hg., Quinine, etc.

7 — Mechanical Differentials.

Effect of Rest, Extension, X-ray, Hydrotherapy, etc.

SUB-SCHEME III.

To answer the frequently asked question "Causes of." For example: Causes of hemorrhage; of dyspnea; of vomiting, etc. All such questions are answered by reference to the first portion of Sub -Scheme II, viz.

(T.I.D.) TUMOR. INJURY, DISEASE OR MALFORMATION.

If the question is so framed as to require the causes of a lesion of one of the hollow viscera T. I. D. M. should be applied, — within the lumen : to the wall of the viscus, and to the region about it. It will thus be seen that by applying this simple scheme to such question as the causes of intestinal obstruction, no less than twelve points are immediately suggested by the scheme for discussion.

Such a system of schemes would be too long and cumbersome for practical use unless abbreviated and adjusted to each subject, and in recitation work it is not intended that the negative, but only the positive and most important factors be dwelt upon. The advantage of knowing a system such as has been given is that if called upon to talk on any given subject or to write about it, the work can be done speedily, fully and without hesitation. In the pages which follow, an attempt will be made to pursue in general the outlines suggested, but it will be readily seen that they cannot advantageously be followed in full. It may be well before going on to a general consideration of certain surgical questions, to illustrate in some detail the mode of application of these schemes.

Apply, for example, the general scheme to such a disease as erysipelas. This is intended to be used if a general description of erysipelas be asked for. If, however, the subjective or general. symptoms of the disease be desired, apply "Sub-Scheme I." If the differential diagnosis, — and it may here be said that in any case, whenever diagnosis is asked for, it is understood to signify differential diagnosis. — apply "Sub-Scheme II."

As the application of this scheme is possibly a little more complicated than that of the preceding, it may not be amiss to follow it out in detail.

As suggested, the phrase "T. I. D." with an M added to it is the first thing to think of for differential diagnosis.

Tumor? Negative. Injury? The patient may or may not be cognizant of having been injured. Disease? Onset sudden and severe. Malformation? Negative.

History of previous injury? 'Slay or may not be negative. Of previous disease? Often affirmative.

History of operation? Positive or negative.

Age? More common in early adult life.

Sex? Somewhat more common in the male.

Occupation? More common in those exposed to traumatism.

Social State? Negative.

Pain? Usually not marked. "Stiff."

Disability? Present.

Vomiting? Often a prominent symptom.

Bowels? Irregular.

Jaundice? Absent.

Nervous Symptoms? Early delirium.

Glands? Typical involvement of glands in the neighborhood, specially true of facial infection.

Reflexes? Negative.

Inspection? Swelling; peculiar color.

Palpation? Typical harsh feel.

Sputum ? Negative.

Stomach? Negative.

Blood? Leucocyte count roughly parallel with temperature chart. (A^on-Limbeck).

Differential Count? Marked increase in polymorphonuclear cells.

Hemoglobin per cent? Negative.

Color Index? Less than one.

Parasites? Bacteria not in sufficient numbers to be readily seen.

Injection? Toxic to animals.

L T rine? Free amount of albumin and finely granular casts, if far enough progressed.

Indican? Negative.

Cryoscopy? Negative, except in presence of renal disease.

Feces ? Negative.

Tissue Section? Bacteria seen crowding the lymphatic spaces.

Such a scheme as this is of necessity cumbersome, but it affords the only known means of covering a given subject rapidly without omitting any important details.

It will clearly be seen that the points established here will serve to differentiate this disease as clearly as it may be from any disorder with which one might confound it.

Throughout these notes, the terms "Proximal" and "Distal" will be used, the heart being understood to be the center.

In less detail apply this scheme for differentials to: —

Non-impacted Fracture of Dislocation of Femur.

Neck of Femur. (Dorsal)

TUMOR.

Moderate fullness in Scarpa's If thin, marked, postero, ex-

triangle, ternal.

INJURY.

Moderate violence. Great violence.

PREVIOUS INJURY.

Not infrequent. Absent.

PREVIOUS DISEASE.

Some form of rarifying osti- Absent,

tis, not uncommon.

AGE.

Past adult life. Adult life.

SEX.

Female. Male.

OCCUPATION.

Sedentary Hard labor.

PAIN.

Great, but not constant. Excruciating, constant.

DISABILITY.

Typically complete unless Complete,

impacted.

INSPECTION.

Characteristic attitude, ex- Flexion, internal rotation,

tension and external rota- adduction,

tion. Postero-external swelling.

Moderate swelling in Scarpa's . triangle.

PALPATION.

Pain increased on crowding Pain decreased on crowding extremity upward. extremity upward. In- Decreased by traction. Mod- creased by traction. May erate tenderness in Scarpa's ^ e Crepitus. triangle. May be Crepitus.

MENSURATION.

Fracture, Nelaton's Line. Dislocation.

Tip of great tuberosity, prox- Relation to line, not constant,

imal to, instead of upon it.

BRYANT'S TRIANGLE.

Negative or minus. May be approximately nor-

mal. Variable.

TAPE MEASURE.

Shortening from ^ to 3 in- May be shortening or length-

ches A. S. S. to internal ening.

maleolus.

LABORATORY FINDINGS.

Obviously negative in this class of cases.

Subjective symptoms are frequently asked for. It must be understood in the use of the schemes that that one is intended to be utilized, which is obviously most applicable to the disease or injury under consideration. For example, as has been said before, the general scheme is indicated chiefly in the wider or more general surgical diseases, although there is hardly any form of lesion to which it may not be applied. In the case of more localized injuries, as for example fractures, the scheme must necessarily be a narrow and exact one. This is further considered in the Chapter on Fractures.

The giving of subjective symptoms is very much facilitated by remembering that practically all surgical lesions present but two subjective symptoms — Pain and Disability.

Should a disease presenting such multifarious symptoms as, for example, colelithiasis, be asked for, the subjective symptoms are easily given by Sub^Scheme I. Disability can be understood to include a broad variety of conditions, — almost anything deviating from the normal. It may be local or general, and of any degree. In this disease, the patient will not have observed anything abnormal in Mouth, Pharynx or Esophagus.

Stomach ? This is typically the seat of pain and disability so great that eminent authorities have found it difficult to differentiate between colelithiasis and carcinoma of the pylorus.

Small and great gut? There is no pain save that attending^ habitual constipation. The disability results in clay colored stools.

Liver or other glands? Jaundice depending on the position of the stomach and other factors. Often pain at Robson's. point.

Lungs? Foul breath.

Brain? Headache and increasing dyscerebration.

Peripheral Nerves? Paresthesiae frequent.

Kidneys and G. U.? Bile stained urine.

Extremities? Progressive disability.

No claim for special excellence or for any originality is; made for these schemes. They have been printed in their present form on the conviction that what has worked well for one series of men will work well for another. Individuals will probably be able to modify them to suit their needs and fancies, but adherence to some such general system will win in the future as it has in the past, the much coveted Appointments, in the New York Hospitals.

Chapter II. Inflammation

In the erection of any building, a scaffolding is the first consideration. Even if the work be simply the repair of an existing edifice, this scaffolding must begin at the ground and reach to the break. It often costs more than the repairs.

Such a scaffolding is used in nature. A clear grasp of this simple proposition makes the subject of inflammation, generally considered a great bugbear difficult to understand and uninteresting, a very simple matter.

The subject of tissue repair is by no means intricate. The process naturally depends, as in the case of a building, on the degree of repairing which is to be done. The red cells and the plasma are the bricks and mortar ; the phagocytes and nature's other agents are the laborers.

If the injury to the parts be not so severe as to have actually destroyed cellular life, the scaffold erection naturally does not take place. Consider the familiar case of a weal on the back of a horse. It rises soon after the horse is struck with the lash. What happens? Something very easy to understand. There is a disturbance of the vaso-motor nerves. The small vessels along the line of the traumatism immediately dilate ; as a natural consequence, the current slows. The leucocytes, presenting a greater degree of resistence from their larger size and coarser texture, naturally lag behind and are arranged around the outside of the stream against the vessel wall. Following their instinct, they immediately begin to emigrate through the chinks of the endothelial lining.

Fig. 1.

Figure showing emigration of leucocytes.

SIMPLE EXUDATIVE INFLAMMATION. 17

Coincidental with this the fluid part of the blood leaks out into the intercellular spaces. If the blow has been a hard one, a certain number of red cells will pass out in a manner somewhat similar to that described for the white cells. This process is called diapedesis. In most cases of moderate injury, probably a few of these erythrocytes escape from the vessels.

This process, in the case of the horse under consideration, continues at so rapid a rate, that a local swelling is produced, This is because the exudate, as the materials which pass out are called, cannot be diffused into the neighboring tissues as rapidly as they are extruded. It requires only common sense to see that as this process continues, the characteristic weal will form. After the recovery of the vaso-motor nerves, a balance is gradually established between the rate of exudation, — the vessels gradually assuming their normal tone, — and the absorption of the exudate into neighboring uninjured vessels. The establishment of this balance marks a cessation in the growth of the weal and immediately thereafter, the ridge begins to be absorbed. Any one, who has had anything to do with horses, knows that this may take twelve, twenty-four or even more hours before its completion.

In this case there has been no need of a scaffolding, for the only moderately injured tissues have returned entirely to normal. The process which has been here portrayed has been named Simple Exudative Inflammation.

This simple exudative inflammation will be found to be the direct cause of the symptoms of many of the minor sicknesses, both medical and surgical. Whether it attacks the mucous membranes, as is evidenced by a cold in the head, an inflammation of the uterus or of the gut ; whether it occurs in connective tissue, in the muscles, or in any of the hard or soft parts of the body, the process is always the same, a simple affair easy to understand.

However, the organism is not always so fortunate as to have its cells live after the primary injury, and it may therefore become necessary for it to replace those which have been lost. It is not meant by this that the organism is always able to replace the special cells which were lost if they belong to a very specialized type, but connective tissue cells, at any rate,

18 (GRANULAR CHANGE.

are created to repair the loss of continuity and prevent the danger of infection.

Now suppose a case in which the injury has been sufficiently severe and of such nature as to have admitted pus producing germs to the part. It is wise to remember that almost any germs with the exception of a few such as the tetanus bacillus and the diphtheria bacterium, which remain localized, can all produce pus. Now, if some of these germs, either in pure culture or in mixed, are introduced into this wound of graver character which we are considering, the tissues have, in addition to the primary injury, to fight against the poisonous toxins which are created by the germs. They are simply the products of the life of these organisms, but they produce when in small quantity what is knOwn as Cloudy Swelling, — a condition in which the protoplasm of the cell is seen under the microscope to be granular and the nucleus to have become indistinct — and when in large quantities, early death of the cell.

Undoubtedly, in a great many cases which grossly appear to be simple exudative inflammation, as in the case of a weal before referred to, there are a moderate number of cells w T hich undergo this cloudy swelling. It is to be understood that this condition gives rise to no marked symptom by which it may be recognized clinically. The cells, w r hich have undergone this granular change, either return to their normal condition in the course of a few days, or else they die. If they die, they disintegrate, and the particles are removed by the phagocytes and t by the circulating plasma. This process takes place slowly and gives no gross external evidence.

Suppose the double trauma of injury and poison to have been so great that the cells, not only underwent granular change, but actually died. What then takes place? Death occurs not only in the cells of the inflamed connective tissue, but also in any parenchymatous cells which may be in the neighborhood. The entire mass becomes 'saturated with the body fluids. It is "Walkd Off" by nature from the living parts and an effort is made by the organism to extrude it.

This is the type of the process which takes place when a stitch abscess forms, or an ordinary boil develops. The so-called core of the boil is the mass of dead lymphatics and

PRODUCTIVE INFLAMMATION. 19

other vessels, nerves, muscular and other tissues, together with the blood elements which extrude into the tissues, as before described, immediately after the beginning of the injury. In the case of the boil, the traumatism is either absent or insignificant as compared with the infection. This core, so familiar to all, is removed, and the parts are then in position to begin to heal. Now it is that the scaffolding is erected. It consists of a reticulum or net work of fibrin, whica fills the whole part as though a spider had woven a web in every direction within the cavity. Leucocytes and erythrocytes swarm along the strands of this network and become entangled in its meshes. The process of creation of what is known as scar tissue is technically called Productive Inflammation. It will be noted that whereas the changes referred to in exudative inflammation have affected the vessels only, those in productive inflammation have to do particularly with the changes in the cells of the affected part.

Productive Inflammation may or may not be accompanied by an appreciable degree of exudative inflammation. In any reconstructive process, there is probably always a certain amount of exudation taking place. Nevertheless, it is certain that there are types of productive inflammation which are to be seen at certain periods in the healing of granulating wounds in which the fluid is taken up by the parts just as rapidly as it is extruded. This may be called dry productive inflammation, as contrasted to the combined or wet form. The typical example, however, of dry productive inflammation is to be seen in the so-called sclerotic changes of the arteries and the cirrhoses of the liver, kidneys and other organs.

The boil under consideration has reached the condition in which the scaffolding has been erected and the laborers with their bricks and mortar are aloft. It is obviously not possible for them to recreate the intricate arrangement of the tissues as it existed prior to the toxemic injury. What they proceed to do, therefore, is to make granulation tissue, which in course of time turns white, and is known as a Scar.

How is this done? A great deal is heard now-a-days about abscesses being "walled off." This term is used every day

20 CHEMOTAXIS.

in speaking of appendicitis. What is the wall and where does it come from?

]>y a process which has been called Chemotaxis, white cells from far and near have been called into the neighborhood of the injury. They arrange themselves in the form of a hollow sphere about the dead part and after assuming the function of thus protecting the general body from invasion, they are called instead of leucocytes, phagocytes from the Greek phagein — to eat. From having been simple white cells, they become, by a process of conscription, or chemotaxis, the eating or defending cells.

Nowhere can the process about to be described be seen more beautifully than in one of the small tubercles so frequently observed in the muscular tissue of the diaphragm. These tubercles may for the purposes of description be regarded as miniature boils, and as the whole tubercle may be seen under one field of the microscope, which is not the case with a boil, the process of "walling off" may be conveniently and accurately studied in it. What is true of the wee tubercle is equally true of the large boil, and what is true of the boil is true of the appendicular or pyemic abscess containing a pint to a quart of pus. The point is to understand that this process is the same for all like conditions irrespective of their size or position. So in the great abscess, the tubercle or the boil, this hollow spherical layer of protecting white cells masses itself between the well tissues on the one hand and the dead on the other, — between the sterile body on the one side and the infected wound on the other. Between the phagocytes there is some fibrin. This is what is meant by "walling off." There are other elements in the "wall" as will be seen later, but this "Round Cell Zone" is all-important.

The next element to consider in the process of dry productive inflammatory regeneration are the so-called Fibroblasts. Whether they are derived from pre-existing connective cells, or whether they spring from certain of the white cells, is not definitely known, but the practical point is that coincidental with the establishment of the -zone of white cells, already described, there is laid down between the dead part and the outer wall of leucocytes, a secondary wall of these fibroblasts. These

HOW TO KNOW A FIBROBLAST. 21

are to strengthen the "wall." A convenient way to remember about these fibroblasts is to ask the question :

How does a fibroblast differ from a woman? The answer is that the fibroblast is fat when it's young and thin when it's old, whereas a woman is thin when she's young, and fat when she's old.

This is a homely and perhaps ungallant means of stating the life history of the fibroblast. By mutual pressure, and by pressure derived from the outside shell of phagocytes ; called "Round Cell Inflammatory Zone," — the fibroblasts assume first a hexagonal form and are finally pressed out into the familiar ribbons characteristic of fibrous tissue. A good illustration to show how this process begins may be seen in the Giant's Causeway at the North of Ireland, where by mutual pressure columns many feet in length have been formed, each and every one being hexagonal. Drops of mercury, when allowed to press upon each other, will also become hexagonal before they are confluent.

As the young fat fibroblast gradually elongates, its nucleus becomes more and more indistinct until it is finally lost. Before this takes place, however, the cell accomplishes the purpose for which it was in part designed, viz. — the deposition of intercellular material. This aids largely in the formation of the fibrous tissue.

Starting with a comparatively small number of these young fibroblasts, it is necessary that they should be multiplied as rapidly as possible. This is accomplished in part by emigration, just as among people in a new territory; in part by reproduction. This takes place by the process formerly known as karyokinesis, but now commonly called mytosis. The great care of nature in splitting the nucleus so that it shall be accurately divided between the tw r o new cells shows what an important function it plays in human life.

The fibroblasts are now increasing at a rapid rate and are beginning to be crowded into the fibrinous reticulum. It must not be lost sight of that this net work is a well defined definite visible mass, spongy to the touch and red to the eye, because of included red blood cells. The whole structure is shortly to be swept away. How is this accomplished? Before nature

22 CAPILLARY FORMATION.

attempts it, she makes sure that the permanent structure destined to take its place is well established. This cannot be done without providing food and nourishment for the new cells to live upon. How is this brought there? When the sphere of fibroblasts is only one or two cells thick, they can readily be fed by the transudation to them of life giving plasma, but there is a limit to the distance to which this food can percolate between the cells, and it becomes necessary to establish channels to carry it toward the interior of the structure.

Capillary Formation begins by a head to tail union of a series of specialized connective tissue cells. The walls at the point of juncture break down, their included protoplasm guided by unknown forces, begins to circulate, and what was a simple series of end to end cells, has become a tunnel through which blood soon begins to flow.

These Capillary "Tufts" are by a marvellous provision constructed in a loop so that they start and end in the living parts. If they coursed straight away into the new territory, they would obviously soon become blockaded. Through their delicate endothelial walls along the whole course of the new vessel, but more particularly at the turn of the loop which is nearest the dead part, the plasma with its cell feeding elements streams, and the products of metabolic cellular life are in like manner returned.

It will often have been noticed how closely this microscopic picture conforms to the clinical findings when granulation tissue is treated. Such tissue frequently has to be curretted. This can be done without pain to the patient, because there are no nerves in the part. The hemorrhage, however, is always very brisk. This is because the tissue, as already described, is largely made up of young capillaries.

At about this time, supposing a large number of successive spherical walls of endothelial cells to have arranged themselves, like the many skins of an onion, about the scaffolding which had filled in the site of the extruded dead tissue, nature begins to realize that in the region of capillary development the scaffolding is no longer necessary. The builders, which were instrumental in creating the new and permanent wall,

WET PRODUCTIVE INFLAMMATION. 23

are now obliged to see to their own removal and to the destruction of the net work which supported them. As is often the case with people, they are "turned down" by those whom they have helped.