Cope’s Early Diagnosis of the Acute Abdomen

340 Pages·2010·3.45 MB·English

by  William Silen

Cope’s Early Diagnosis of the Acute Abdomen

Cope’s Early
Diagnosis of the
Acute Abdomen
TWENTY-SECOND EDITION
Revised by
WILLIAM SILEN, MD
Johnson & Johnson Professor of Surgery, Emeritus
Harvard Medical School
1
2010
3
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Copyright © 1957, 1963, 1968, 1972 by Oxford University Press, Inc.
Copyright © 1979, 1983, 1987, 1991, 1996, 2000, 2005, 2010 by P. A. L. Grace
First edition 1921
Twenty-second edition 2010
Published by Oxford University Press, Inc.,
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Library of Congress Cataloging-in-Publication Data
Silen, William, 1927-
Cope’s early diagnosis of the acute abdomen. — 22nd ed. / revised by William Silen.
p. ; cm.
Includes index.
ISBN 978–0–19–973045–2 (pbk. : alk. paper) 1. Acute abdomen—Diagnosis.
I. Cope, Zachary, 1881–1974. II. Title. III. Title: Early diagnosis of the acute abdomen.
[DNLM: 1. Abdomen, Acute—diagnosis. 2. Digestive System Diseases—diagnosis.
WI 900 S582c 2010]
RD540.S495 2010
617.5’5075—dc22 2009013093
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Preface
Over 40 years ago, I was asked by a publisher to write a treatise on acute
abdominal pain, but after serious consideration, I declined because it
seemed impossible to improve on what Cope had already accomplished.
In 1967, when I was given the opportunity to revise and update Cope’s
book, it seemed to me that my responsibility in accepting the assignment
was to preserve the basic structure that has made Early Diagnosis of
the Acute Abdomen a classic for so long, at the same time bringing the
text up to date in light of recent advances and of my own experience.
This burden was lightened by the remarkable agreement I found in most
areas between my experiences and those of the original author.
I have made every attempt to follow Cope’s aim of including only
those dicta that have been repeatedly confi rmed by personal experience
and observation. In keeping with this I have not added a bibliography.
The book’s major emphasis continues to be on clinical rather than labo-
ratory diagnosis. There is little doubt that improved methods of resus-
citation and a better understanding of surgical physiology have had a
great impact in improving the survival of patients with acute abdominal
disease, but a detailed consideration of these topics would entail the
writing of another book.
Recent years have brought a proliferation of both invasive and nonin-
vasive laboratory and radiological tests, the likes of which undoubtedly
would have been a great surprise to Sir Zachary Cope. With these tests
vi PREFACE
has come the unfounded belief that a number or a laboratory report
is somehow more reliable than the clinical history or physical fi ndings.
The consequence has been an ever-increasing reliance on expensive
and sometimes dangerous laboratory examinations. This trend is partly
responsible for increasing the cost of medical care, and perhaps for some
morbidity and even mortality. The more pernicious outcome, however, is
the continuing atrophy of the clinical skills of history taking and physical
examination. The vicious cycle of more tests and X-rays, together with
less history and physical examination, has been accentuated even more
in the past few years by managed care, whose administrators insist on
our seeing more patients in less and less time.
Even today, however, it remains true that the vast majority of diagno-
ses of patients with acute abdominal pain are still made on the basis of a
careful history and physical examination. The major delays in diagnosis
today are those imposed by the failure to recognize the presence of a
signifi cant intra-abdominal process and by the need that some feel to
obtain special complicated tests and X-ray examinations.
Reviewers of recent editions of this book have criticized the omission
of these new tests in favor of continued emphasis on the clinical aspects
of acute abdominal pain. In response, I have expanded a chapter that
attempts to guide the reader in selecting appropriate tests rather than
employing every conceivable investigation that comes to mind. I have
also added a short section describing personal observations of serious
errors made because the responsible physician (surgeon) did not fully
appreciate or understand the pitfalls of some radiological examinations.
I am more convinced than ever that overreliance on these new and
costly tests at the expense of a careful clinical evaluation will diminish
rather than improve the quality of care of patients with acute abdominal
pain. For this reason, I shall continue to emphasize the clinical pointers
that were found to be so useful by Cope and whose value has been reaf-
fi rmed by my own experience.
Sir Zachary Cope set out to write the fi rst edition because he encoun-
tered so many cases where inordinate delay in clinical diagnosis led to
a disastrous outcome that might have been averted by earlier detection
of the true state of affairs. I am told that the publisher accepted the
manuscript for the fi rst edition after commenting that it contained little
PREFACE vii
that was terribly new. I suspect that these two conditions pertain today
as much as they did in 1921.
I am deeply indebted to Mr. William J. Lamsback of the Oxford
University Press, who made it possible for me to accept the challenge of
revising this book. I am particularly grateful to Ms. Nancy Kaufman for
her superb assistance in preparing the manuscript.
I am especially grateful to Dr. Vassilios Raptopoulos, director of Body
CT in the Department of Radiology at the Beth Israel Hospital, Boston,
who has provided the illustrations of the various imaging techniques. He
has been enormously helpful in placing into perspective the appropriate
indications for the large menu of imaging techniques. It has been a joy
to work with him.
Finally, I should like to pay special tribute to all who have taught me
about acute abdominal pain, including my teachers, my pupils, and par-
ticularly my patients.
Boston W. S.
2009
This page intentionally left blank
Extract from the preface to
the fi rst edition
All who have had much experience of the group of cases known gener-
ally as the acute abdomen will probably agree that in that condition early
diagnosis is exceptional. There are still many who do not appreciate to
the full the signifi cance of the earlier and less fl agrant symptoms of acute
abdominal disease, who regard an increased frequency of the pulse and
rigidity of the overlying abdominal muscles as necessary accompani-
ments of the early stage of appendicitis, or fi nd it hard to believe that a
patient with a non-distended abdomen and normal pulse and tempera-
ture can be the victim of a perforated gastric ulcer.
It would appear, therefore, that there is room for a small book dealing
solely with the early diagnosis of such cases, for there is little need to
labour the truism that earlier diagnosis means better prognosis. Though
the present attempt to supply the defi ciency may be inadequate, the
author has at least endeavoured to assist the reader to attain a correct
judgment in the evaluation of the various puzzling symptoms present in
urgent abdominal disease.
Few references are inserted and no bibliography is appended; for
whilst the writer readily acknowledges the great debt which he owes to
the teaching of such leaders as Murphy, Moynihan, Rutherford Morison,
Maylard, and many others, it has been his aim to put down nothing
which has not been frequently confi rmed and demonstrated in his own
experience.