the acute abdomen

21 Pages·2008·6.59 MB·English

THE ACUTE ABDOMEN
By H. W. S. WRIGHT. M.S., F.R.C.S.
"Our Natures are the Physicians ofour Diseases."-Epidemics, VI. 5.
"Those Diseases that Medicines do not cure are cured by the Knife."-Aphorisms, VII. 87.
HIPPOCRATES.
The acute abdomen may be defined as an It is not proposed in this article to describe in
intra-abdominal lesion which, apart from appro- detail abdominal conditions which are adequately
priate treatment, immediately threatens the life of dealt with in all standard textbooks, but rather to
a patient. In England, with a population of analyse theirsymptomatologyanditsmechanismin
nearly 42 millions, considerably more than I2,000 such a way that a clinical pattern emerges quite
people die annually from what is called "an acute simply from a mosaic of apparently unrelated
abdomen." The annual crude death4ate from symptoms, and to show that the treatment sug-
appendicitis is 62 per million, and from hernia gestedisalogicalsequence topathologicalfindings.
andintestinalobstructionIO9permillion. Ingreater The symptoms and signs which give evidence of
London, with a population of nearly nine million an acute intra-abdominal lesion are as a rule few
persons, at least Io,ooo per annum are -admitted and simple. They are pain, superficial and deep
with a diagnosis which implies a major abdominal tenderness, rigidity, andvomiting. Withthese are
catastrophe. Because they are incomplete, these associated the general effects of the lesion on the
figures underestimate the magnitude of a problem whole organism, such as temperature changes, and
which claims a large and important share of every alterations both absolute and relative, in the
surgeon's time and attention. It would be sur- composition of the blood and urine. The integra-
prising if such a group of cases, with so much in tion of these signs and symptoms into familiar
common, did not have an embryological and clinical patterns usually enables a diagnosis to be
biological background which deserves understand- made with rapidity and certainty, often on the
ing andconsideration. telephone; butinmanycasesthemostmeticulously
When, in the course of biological evolution, the careful history, precise examination, andthe nicest
mesoderm became differentiated as a separate cell judgment are necessary before reliable conclusions
mass which later split to form a body cavity or can be reached, and in order to do this some
coelom, the formation of this cavity marked a knowledge of the nature and mechanism of
critical stage pregnant with possibilities. The symptom production is necessary.
organs inside the cavity were separated from the The pain of abdominal disease is of two kinds,
exterior for their specialised functions of digestion, visceral and somatic, and they can frequently be
absorption, and respiration. Such an advance distinguished from each other by the description
removed many obstacles to increase both in size given by an intelligent patient, and sometimes by
and variety, and determined the possibilities of the patient's appearance. Visceral pain arises
coelomate forms. But the differentiation of an directly from pathological changes in the involved
intestinal canal within a serous cavity implies the viscus or its mesentery and vascular connections,
provision of a vascular system forits own nourish- and somatic pain arises from the parietes as the
ment andthe transport ofmetabolites, alymphatic result ofsecondary andcoincidental changes. The
system for absorption and protection, and a classic example. of visceral pain is that due to
nervous and endocrine system for co-ordination coronary thrombosis, to renal or intestinal colic.
andcontrol. Withthisincreasedcomplexity there It is tearing, crushing, or bursting in quality, often
is necessarily an increased danger of breakdowns severe enough to cause vomiting, rapid pulse, and
fraught with disastrous and far-reaching conse- some degree ofcollapse; the patient mayrollabout
quences. The existence of a coelom, in fact, or double himself up in what he may well call
implies the probability of the acute abdomen. agony. In the case of colic it rises to a crescendo
Itiseasytoseethatorgans, suchasthcappendix and then diminishes, only to recur again. This
and the gallbladder, which are developed as blind type of pain is characteristic in that it can be
diverticulae from the midgut, must always be abolishedbysectionoftheappropriatesympathetic
liable to obstruction and subsequent infection, a pathways. It is usually imprecisely localised but
series of changes so aptly called "the hollow viscus has an area of reference which depends on the
pathology." Inherent in the localising and pro- embryology of the implicated viscus. Very often
tective functions of the peritoneum and omentum the patient willsaythe painis inside the abdomen.
is the possibility of adhesions and obstruction, This type of pain is most easily distinguished at
andthe presence oflymphatic tissue thinlycovered the onset ofthe attack before the adjacent parietal
with muscle and peritoneum makes occasional peritoneum is involved, and other protective
swelling, necrosis, and perforation a certainty. reflexes are established. It is frequently but not
POST-GRADUATE MEDICAL JOURNAL June, 1946
invariably associated with rigidity and deep pheral end of a novocaine-blocked sensorynerve.
tenderness. For instance, the pain of renal colic Since it arises some time after the stimuli, which
is sometimes accompanied by rigidity and tender- probably do not reach the cord, have ceased, it is
ness over an area wide enough to be suggestive of unlikely that it has its origin in the cord itself.*
a perforation, whereas the pain of intestinal colic Muscularrigidityisassociated withboth parietal
frequentlyisnot, andifrigidityand tenderness are and visceral pain. It may affect part of a muscle
present, asarulethevdisappearsoonafterthecolic whose total nerve supply comes from several
ceases. Thereasonfortheoftenvaguelocalisation segmental nerves, thus producing a so-called
of visceral pain is that-the afferent nerves from phantom tumour, and it maypersist forsome days
viscera traverse the ganglia of the autonomic after the pain has ceased. This suggests that it
system to the posterior nerve roots which are may be due to a "facilitated reflex" and that a
arranged segmentally, but the subjective aspect of stimulus qualitatively below the threshold of pain
localisation takes place in the brain where pain is may continue to produce rigidity when the pain
registeredintermsofqualityandposition. Neither has ceased. This persistence is not uncommon in
of these latter attributes are constant, and vary inflammation of the gallbladder or appendix, and
from individual to individual. becauseofthis, asurgeononopening the abdomen,
For instance, the early pain in a typical attack may sometimes find much less evidence of acute
of acute appendicitis is usually felt around the inflammation than he had previously led himself
umbilicus. This might well be expected as the to expect.
appendix is part of a mnedially developed midgut, The mechanism of deep tenderness is much more
but the pain is often described by the patient as difficult to understand. It is as a rule coincident
arising in the epigastric region, and occasionally in time both with the pain and rigidity. It
elsewhere. An analogy may perhaps make these probably arises in the muscle itself because, as
individual differencescomprehensible,ifnotreason- Lewis has shown experimentally, muscle is tender
able. The quality of tones registered in a photo- after contracting for two or three minutes, and
graph varies with the composition of the film, so afterspasm oflonger duration muscular tenderness
also do the spatial relationships vary with its may persist for some time. This tenderness is
contour. Seen in this way it does not seem probablyrelatedtopartialischaemia, butwhatever
.unlikely that different individuals will describe its cause everyone is familiar with the stiffness
the quality andposition oftheir visceral sensations and tenderness which follow prolonged unac-
differently. Thattheydosoisafactofobservation customed exercise. It is however certain that
which has to be constantly bome in mind when ischaemia does not represent the whole story,since
assessing the value of a patient's statements. deep tenderness in the testicle may be produced
The other type of pain which occurs in acute either by renal colic or by the intraligamentary
abdominal disease arises from inflammation of the injection of saline.
neighbouring peritoneum, or reflexirritation of the Pain, rigidity, deep tenderness, and hyperaes-
overlying muscles. It is constant in position, thesia then are the cardinal symptoms of acute
unvarying in quality, and in the nature of buming abdominal pathology. It is wise to remember that
or aching. When severe, it is difficult to dis- the severer types of visceral and somatic pain may
tinguish from any other severe pain except that it be indistinguishable, and that either or both
is more precisely localised. It is nearly always together are often associated with their reflex
associatedwithrigidityanddeeptendemess. Since effects, rigidity, deep tenderness, and hyperaes-
it arises from the parietes, the nerves of which thesia. These last three may also be caused by
pass through the appropriate posterior roots- and inflammation in the muscles and ligaments of the
retain their original segmental arrangement rela- appropriate segments and can be exactly repro-
tively undisturbed, localisation in the cerebral duced by the intra-ligamentary injection of saline.
cortex is much more precise. (LewisandKelgren). Obviously,itwouldbeunwise
With both these types of pain is associated to assume that an understanding ofthe mechanism
hyperaesthesia-pain whichis superficial andhas a of symptom production is unimportant for the
stingingoritchingquality. Itisalsocharacterised diagnosis of acute abdominal disease. Every
by the fact thatit often persists forsomelongtime casualty officer is aware that the diagnosis is
after the original stimulus has ceased and may sometimes made correctly by a parent or a police-
even be the last sign to disappear. Its mechanism man, but every surgeon has on his conscience a
is incompletely understood, but its characteristics death orweeks ofhospitalisationwhichmighthave
suggest that it arisesin the skinofthe painful area. been avoided had an obscure case been more
Itisstrictlysegmentalindistribution. SirThomas carefully considered.
Lewis and his co-workers have shown that it may * For a full discussion of this question the reader is
be produced by electrically stimulating the peri- referred to ch. xiiiof SirThomas Lewis's book on Pain.
June, I946 THE ACUTE ABDOMEN 151
Acute abdomens may, for descriptive purposes, rectus. Such a mass may be so protected by
be divided into four groups which, of course, omentum that it is not very tender and even
necessarily overlap. allows a limited mobility on palpation. An
(i) The obstructive visceropathy of which ap- appendix situated so that its tip rests on the
pendicitis and cholecystitis are examples. psoas will give rise to spasm of this muscle, flexion
(2) Perforations of ulcers or inflamed and gan- ofthe thigh, and pain, when the latter is extended.
grenous viscera. The most difficult situation arises when the
(3) Obstructions with or without interference to appendix is in the pelvis. The area of peritoneum
the vascular supply. within the true pelvis is a silent area and gives
(4) Vascular obstructions due to intravascular, rise to little rigidity, abdominal pain, or hyper-
or extravascular mechanical causes, such as aesthesia. The disturbances of defaecation and
mesenteric thrombosis or the torsion of an ovarian micturition so often mentioned in textbooks are
pedicle. An analysis of 348 cases admitted to moreoftenabsentthannot, butwhenthe condition
an emergency hospital which served a large semi- is well developed there is usually. tenderness per
urban and rural area, shows that these types rectum or per vagina.
occurred in the following proportions: One type of obstructive appendicitis, specially
Obstructive visceropathys 6i.5 per cent; Per- emphasised by the late Sir David Wilkie, requires
forations 9 5 per cent; Obstructions 25-3 per cent; special mention. There occurs an acute obstruc-
Vascularobstructions due to Torsions 3 7 per cent. tion of an infected appendix, and a virulent
-
organism causes inflammation and early gangrene.
(I) The Obstructive Visceropathy Often there is early vascular thrombosis. The
onset is very sudden and the pain is very severe,
Acute appendicitis.-Though most cases occur in colicky in type, and referred as a rule to the
adolescence and early adult life, it may occur at all umbilicus. The patient is doubled up and vomits
ages. It is particularly dangerous and often diffi- with each spasm. He is often collapsed and
cult to diagnose in childhood and old age. More- anxious looking during and after the attack of
over,theappendixissubjectto such great variation pain. At the onset there is little to show in
in position that its manifestations are apt to betweenthespasms;theremaybealittletenderness
be anomalous. It is therefore wise to rememberin deepintherightiliacfossaandsomehyperaesthesia.
obscure cases that one is always more likely to To an experienced observer the patient gives the
encounter an unusual variant of a common disease impression of having suffered a great deal of pain,
than a rare disease. Its onset is usually sudden and often seems a little more "knocked" than he
and begins with colicky or cramping pain referred would be if it were mere intestinal colic. In this
to the midline near the umbilicus. This pain is typeofcaseeveryhourthatpassesisofimportance,
accompanied by vomiting in many cases. It can forperforationandgeneralperitonitismayoccurearly
be reproduced by pulling on or squeezing the without preliminary signs of local peritonitis. If
appendix when the abdomen is opened underlocal the doctor who is responsible for such a case is in
anaesthesia. If the patient is examined at this doubt he may well remember Moynihan's dictum
stage there will generally be deep tenderuess over thateveryabdominalpainwhichrequiresmorethan
McBurney's point. A little later there is pain, one dose of morphiaforitsrelief, probablyrequires
more or less severe and constant, associated with laparotomy for its cure; or Zachary Cope's advice
the defense musculaire of the French writers. This that if pain, assumed to be due to intestinal colic,
consists of rigidity, deep and superficial tender- persists for more than three or four hours,
ness over an area corresponding to the position the condition calls for surgical interference.
of the appendix, usually the right lower quadrant Gentle palpation starting from the silent to the
of the abdomen. By this time the vomiting has symptomatic side of the abdomen will generally
ceased, the patient may seem quite well, the detect some guarding andrigidity. Ifthe pressure
temperature normal or only slightly raised, and of the hand on the normal side issuddenlyreleased
the pulse hardly raised at all. The exact physical there will be pain over the area of any inflamed
signs vary with the position of the appendix; a viscus, and this is often valuable evidence of early
retrocaecal appendix may give little rigidity or localised peritonitis. A tentative diagnosis can
pain in the early stages, a pelvic appendix often often be made by watching the abdomen closely
almost none, but here rectal or vaginal examin- inagoodlight; alocalisedareaofmuscularrigidity
ation will help. When the appendix is situated can then be seen as the rest of the abdomen moves
lateral to the caecum a localised mass may with respiration, and over such an area the
be felt or there is rigidity in the loin, and abdominal reflex is almost invariably absent..
when it is surrounded by omentum a mass may be There is nearly always a slight rise in the
palpable near, or beneath the edge of the right leucocyte count or a "shift to the left" in. the
**
152 POST-GRADUATE MEDICAL JOURNAL June, I946
Arnethcount. Thesechangesmaybeofimportance the base of the appendix divided and buried. It
in distinguishing appendicitis from other extra should then be detached from above downwards to
peritoneal conditions causing localised pain and where it is adherent to the posterior abdominal
rigidity. The total whitecount israrelymorethan wall, and then the lumen may be opened, the pus
I2-I4,000, and it is of more prognostic than wiped away and the necrotic mucosa gently
diagnostic importance. curetted and the raw surface cauterized. Some-
These clinical findings represent, in terms of times it is possible to divide the muscle down to
gross pathology, inflammation of the appendix the mucosaand remove unbroken a tube of mucosa
and the adjacent peritoneum. containingpus. Boththeseproceduresareoccasion-
From this stage onwards three things may ally life-saving. (Figs. i and 2.)
happen. The whole process may, and often does, It is still important to emphasise that in general
completely subside, leaving increased liability to a the treatment of acute appendicitis is immediate
future attack. But the appendix is largely com- operation. A few hours in bed to get the patient
posed of lymphatic tissue, and if it is obstructed, rested and quiet is often judicious. A doubtful
as it nearly always is, either by its mesenteric diagnosis in the patient's house or casualty room
attachments or by a faecolith, it may necrose can often be cleared up in this way, but if the
and perforate. Such cases will gradually develop diagnosisisstilldoubtfulandappendicitis probable,
first a localised, and later a general peritonitis. it is wise to look and see. Some years ago a very
Sudden perforation is often the signal for the distinguished surgeon in a presidential address to
temporary cessation of the symptoms, butsoonthe the Royal Society of Medicine rightly emphasised
pulse rate rises, rigidity and pain increase, the how often acute appendicitis settled down and
temperature drops, or occasionally rises according resolved. This perfectly proper statement to a
to the patient's resistance, and vomiting and other medical audience unfortunately got into the lay
toxic symptoms supervene. Finally, the whole Press, and in the succeeding three months the
process may become localised and an abscess or writer of this article saw two deaths which were
inflammatory mass be formed. Ifthishappens, as the direct result of this statement. In the writer's
the general rigidity diminishes a mass becomes experience of 200 cases diagnosed as appendicitis,
*differentiated; the temperature and white count every doubtful case was operated on, two un-
behave as they do in any other abscess. necessary laparotomies and appendicectomies
The treatment of acute appendicitis is by now werehoweverperformed. Inanothernearlyparallel
standardised, it is operative; but this does not series in which operation was delayed until the
mean that it is unnecessary to exercise wise diagnosis was absolutely certain there occurredone
judgment and carefulconsideration. Itisnotvery sub-diaphragmatic abscess, and another casewhich
helpful to say that the surgeon should hold his had a subdiaphragmatic abscess and an abscess of
hand after the first 24 or 48 hours, because cases the lung which required drainage andlateraplastic
develop at very different rates. Perhaps the procedure. There is one sinister fact which
indications for conservative treatment are best emerges from any series of cases of acute appendi-
described by saying that no wise man would citis, and that isthatno one can say what the out-
either interfere with a localising peritonitis, or comewillbe. Theoperationfindings are frequently
disturb an inflammatory mass where there were at variance with what one would expect. This is
no indications that it contained pus. counterbalanced by the incontrovertible truth that
In principle the appendix should be removed operations performed while the disease is limited
by an incision as far from the midline as possible to the appendix and its immediate surroundings
when this can be done without unduly breaking carry a very low mortality, little morbidity, and a
down adhesions or spreading the infection. The rapid convalescence.
abdomen should be drained if there is pus, an During the period I943-I945 in which the
oozing surface, or necrotic material left behind. figures previously mentioned were collected, five
In a few suitable borderline cases it is justifiable normal appendices were removed as the result of
to use a spinal anaesthetic because the "quiet" an erroneous diagnosis. In twelve cases the
abdomen it gives may enable an appendix to be abdomen was opened because appendicitis was
safely removed Nvhen removal would otherwise be diagnosed, andotherconditionsrequiringoperation
dangerous. were found, and in ten cases other conditions were
If an appendix containing pus is attached to the diagnosed when the patient ?ictually had acute
posterior abdominal wall, the protective barrier on appendicitis. In four cases the only pre-operative
its posterior surface should in no waybe disturbed, diagnosis was general peritonitis.
since thismayresultin aretroperitonealcellulitis, a It is also interesting to note that of the I94cases
condition of affairs which is frequently fatal. The of proved acute appendicitis, 50 were drained, and
area should be carefully surrounded by packs, and in I4 of these fifty, the appendix was-not removed.
June, I946 THE ACUTE ABDOMEN 153
Twenty-three of the fifty drained cases occurred in Horace, who lived in an age of gastronomic
the "flying bomb period" when it was noticeable indulgence, was familiar with the referred pain of
that patients tended to arrive at a later stage than 'gallstones, forin describing an attackofcolicwhich
the average. Maecenas suffered, he mentions the burning in the
shoulder.*
Acute cholecystitis bears close comparison with Thephysicalsignsmaybedifficulttodifferentiate
acute appendicitis, for the gall bladder is a hollow fromthoseduetolaterocaecal appendicitisuntilthe
viscuswithanarrow,tortuous,andeasilyobstructed abdomen is relaxed under an anaesthetic, when a
outlet. Itis,however, amuscular organ connected characteristic mass may be palpable. The tem-
with a normally sterile biliary tract, and so is less perature ishigherthaninappendicitis (IoI'-Io20F.)
likely to be acutely inflamed than anorgan mainly asisalsothewhitecount. Thereisfrequently some
composed of lymphatic tissue drainingdirectlyinto congestion at the base of the right lung. The
what may be regarded as a septic tank. patient very often seems ill and toxic.
For purposes of description cases may be con- Thecourse ofthe disease fromthispoint onwards
veniently divided into those associated with gall- varies. It has to be conceded that by far the
stones and those without, but this classification is greater majoritv of the cases settle down. The
notso convenient clinically as it appear4on paper, rigidity passes off, leaving a palpable mass which
because an acutely inflamed gallbladder which is is usually omentum attached to the gallbladder,
obstructed by a gallstone does not always cause but sometimes a large pyriform, distended gall-
biliary colic, and conversely, a gallbladder ob- bladdercanbefelt. Thisoccurswhenacholesterin
structed by oedema or a plug of mucus in the stone is impacted in the neck of the gallbladder
cystic duct sometimes is associated with colicky and has previously caused a mucocoel.
pains at the onset. It is, moreover, frequently In other cases signs of toxic absorption may
stated that an acute cholecystitis without gall- increaseandtheprocessgoontogeneralperitonitis;
stones is the result of a general infectious disease or some early localisation and abscess formation
such as typhoid. This is by no means always true. maytakeplace, tobesucceededlaterbywidespread
However difficult it may be accurately to generalisation. There is a frequently expressed
integrate the clinical with the pathological findings difference of opinion between experienced surgeons
in any given case, it is always clear, as in appendi- about the treatment of acute cholecystitis. Some
citis, that obstruction of some kind or other maintain that, like acute appendicitis, the outcome
determines the onset of acute suppurative or isuncertain andit shouldbeoperateduponat once,
gangrenous cholecystitis. The operation findings since operation in the first 24-48 hours is easy, and
make this so obvious that the bacteriology is apt little different from the inevitable operation later
to receive insufficient attention. on. Against this is the fact that one seldom sees
The infection is usually mixed, the bacillus coli cases so early, and that the majority of them do
predominating but associated with a streptococcus. settle down. There is no type of acute abdomen
In the severer cases, particularly those associated which requires more careful individual considera-
with marked toxaemia and a rapid progress, the tion, and probably opinions which seem to differ
dominant factor is often the presence of anaerobic fundamentally when expressed in writing, would
gas-forming organisms. (Gordon Taylor and agree more closely when applied to-an actual case.
Whitby. B.J.S. I930, xviii, 38.) There would be general agreement upon the
Clinically the patientsoften (60-70 percent) give following points:
a history of flatulent dyspepsia suggestive of (i) That with few exceptions, every case may
cholelithiasis, and gallstone colic, more or less safely be given a few hours of rest in bed for
severe, initiates the attack. The pain is sudden in adequate preparation, in particular the administra-
onset, situated in the right hypochondrium, and tion of fluid and glucose and one dose of morphia
radiating outwards to the axilla or across the and atropine.
abdomen. It doubles the patient up and may (2) That a case seen in the first 24 hours and
cause vomiting. Hyperaesthesia and deep tender- before the succeeding inflammatory reaction is
nesswhich persist after the colichaspassedoff, are marked, can be safely operated upon early since
present at a spot just medialtoandbelow the angle adhesions are oedematous and strip easily.
of the scapula. Instead of passing off as colic (3) That after this early period has passed, the
usually does, it is succeeded by pain, soreness and case may be carefully watched to see whether or
rigidityintherightupperquadrantoftheabdomen,
* Nec munushumeris efficacis Herculis
which is due to local peritonitis, and if the dia- Inarsit aestuosius. (Epodes iii, I7, i8.)
phragm is involved, pain is referredtothetipofthe
Nor did Nessius' gift burn with fiercer flame into
shoulder. The rigiditymayextendalldowntheright theshoulderof Hercules. (Gordon Taylor. B.J.S.,
side but is at its maximum above. 1937, xxv, i6.)
154 POST-GRADUATE MEDICAL JOURNAL June, 1946
notthe temperature andparticularly thepulserate left behind and lightly coagulated, for it is under
diminish, and that any steady increase in the pulse these circumstances that Thorck's technique best
rate is an indication for immediate interference. serves its purpose.
(4) That a total and differential leucocyte count Six of the twelve cases in this series had a
should be done at once, not so much for its imme- cholecystectomy, and in six the gallbladder was
diate value as for comparison later. drained.
(5) That if, after rest and glucose, the patient In these acute cases anaesthesia is supremely
still looks toxic and the pulse is raised out of important; probablygas,oxygenandcyclopropane,
proportion to the rest of the physical signs, opera- with or without local block, is the ideal, but it
tion should be immediate in view of the possibility needs a skilled and experienced anaesthetist. Fail-
of an anaerobic infection. ing this, careful upper abdominal field block
(6) That if it is decided to allow the case to combined with gas, oxygen and a little ether is
settle down, it should be most carefully watched, satisfactory and very safe.
and that, although they may cause pain, breathing
exercises should be instituted, and sulphonamides
and penicillin should be administered. Acute Perforative Diverticulitis
The ideal treatment for acute cholecystitis is Another.exampleofthesametypeofpathological
cholecystectomy, but this is often more easily said process is seen when a diverticulum of the left side
than done, and beyond peradventure it is no of the colon perforates. Acute perforative diverti-
operation for an inexperienced surgeon. Apart culitismustbedistinguishedfromamoregeneralised,
from gangrene, it should not be done unless the less acuteinflammationwhichsometimesflaresupin
cystic duct and the common bile duct are com- a segment of bowel already the site of chronic
pletely exposed, a procedure which may be time- diverticulitis. In the latter case there is a general
consuming, difficult, and even impossible. As a inflammation of the whole mass accompanied by a
rule the common bile duct should be explored, a localised peritonitis. The whole process is rather
T tube put in, and after removing the-gallbladder, similar toacute appendicitis, but the constitutional
the whole region adequately drained through a symptoms tendtobemore severe. There may, for
separate stabwound. Failing this, the gallbladder instance, be arigor, andthe patient looksill. This
shouldbeaspirated, theobstructing stoneremoved, is preceded by an exacerbation of the previous
and then simply drained, the tube being passed rathermilddiscomfort; forexample,someincreased
first through a hole in the omentum and then difficulty in defaecation, and colic referred to the
through a stab wound in the abdominal wall at a left side of the large bowel. It should be treated
point correspondingtothelowerborderoftheliver. conservatively with absolute rest, and until it sub-
In the writer's experience with a proper selection sides, only enough fluid and glucose given by
of cases, this has proved rapid, simple, and safe, mouth to prevent thirst.
whereas, although cholecystectomy has been tech- In contrast, the perforation of an inflamed
nically successful, seemingly satisfactory, and diverticulum precipitates a dangerous condition
associated with a low mortality, the morbidity and which cannot but give rise to great anxiety. It is
complication ra'e of cholecystectomy in severe strictly comparable to the perforation of an
cases has seemed unduly high. Furthermore, the inflamed appendix. The patient, often obese, is as
secondary cholecystectomy done in a few months' a rule too ill to give a detailed historywhich would
time has invariably been easier than one would reveal recent colic, localised pain, tenderness, and
expect, and the convalescence rapid and smooth. constipations against a background of previous
Ithasinfactbeensmootherthan aftercholecystec- diverticulitis. The temperature at first is high
tomy done a fortnight or three weeks after the (Ioo-o40F.) and there are the physical signs of a
acute attack has subsided. This latter is what rapidly spreading peritonitis which has its origin
many surgeons tend to do when the condition is in the left iliac fossa. Rigidity, which the gentlest
obviously subsiding.. and most persuasive palpation fails to overcome,
If there is a patch of gangrene present on the hides the characteristic tumour lying parallel to
fundus, it is always possible, after aspiration and Poupart's ligament. If untreated and unrecog-
adequate packing, to divide the gallbladder below nised the inevitable consequence is general peri-
this and to cut awayits walls up to where they are tonitis, the terminal phases of which was vividly
attached to the liver. The remainder is then described by Hippocrates and even recognised by
thoroughly coagulated with a diathermy button. Shakespeare-"I saw him fumble with the sheets.
A drainage tube is tied into the stump and the .For his nose was as sharp as a pen and a'
. .
whole covered with omentum. Even if a complete babbled of green fields."
formal cholecystectomy can be done, the part of Operation should be immediate and a plasma or
the gallbladder attached to the liver may well be glucose drip transfusion is advisable. When the
Juwne, 1946 THE ACUTE ABDOMEN 155
abdomen is relaxed the tumour can be felt, and recent case, diagnosed as diverticulitis, they were
this gives the clue both to the diagnosis and to taken out of reach and covered by a large fibroid,
an appropriate incision, which should preferably previously known to be present.
be oblique, splitting or dividing the internal The diagnosis is often missed because the con-
oblique and transversalis muscles. The pelvis and dition is not well recognised by general surgeons.
left side of the abdominal cavity is found full of Out of seven such cases, four were thought to be
evil, foul-smelling pus, but the actual perforation acute appendicitis, one a leaking ectopic gestation,
is seldom seen. The involved bowel should be and in two no exact diagnosis was made.
wrapped with omentum, or, if this is impossible, There is usually no doubt that the abdomen
covered with a free omental graft. As much as oughttobeopened, andastheconditionisbilateral
possible of the pus should be aspirated and the a median or paramedian subumbilical incision
pelvis drained through a suprapubic stab wound. should be used, in fact these cases are almost
Five to ten grammes of a sulphonilamide powder unique in that they are examples of lower abdo-
may then properly be put in the peritoneal cavity, minal infection which it is wise to approach from
though perhapsitisbetter addedto anintravenous the middle line. When the abdomen is opened no
drip. The wound should be sewn up with single attempt should be made to remove the tubes,
catgut stitches, leaving a drain at the lower end loculi in front of and behind the broad ligament
which reaches the left iliac fossa-and the pelvis. should be gently opened and the pelvis drained.
However desperate the state of the patient, Many gynaecologists would prefer a drain inserted
under no circumstances should he or she be sent through the posterior vaginal fornix. The prog-.
back to bed without some form of right-sided nosis is good if the operation is promptly and
transverse colostomy designed completely to divert rapidly carried out.
the faecal stream from the sigmoid. If time
presses and anxiety for the patient's life dominates (II) Perforations
the situation, a large suprapubic drain through a
small incision combined with a quick transverse The perforation of a gastric or duodenal ulcer is
colostomy over a glass rod are good tactics and one of the most serious and imperative of all
may save a desperate situation. From then on surgical emergencies, but compared with many
till the tide of battle begins to turn, the most others it is easy to diagnose and simple to treat.
useful weapons are morphia and prostigmine, a Like the entirely mythical Celt in Kipling's poem,
Ryle's tube and an intravenous drip, each used "One knows what he will do, and you can logically
with discretion and judgment. predicate his finish byhis start." Most perforated
Another condition which falls naturally into this ulcers are situated on the anterior wall of the
group and clinically very much resembles the last, pyloric antrum or duodenum. Ulcers on the
is an acute suppurative salpingitis. This arises in lesser curve or posterior wall are more likely to
an old and cold bilateral salpingitis of gonococcal penetrate the pancreas or liver. Most of them are
or puerperal origin. From the bowel or blood chronic ulcers in which activity has recrudesced
stream it gets reinfected with a virulent colon by a rapidly spreading infection beneath the
bacillus which is sometimes accompanied by a callus edge. The condition has been described by
streptococcus. The infection, after a brief and Bolton as the acute spreading ulcer. Occasionally
relatively silent sojourn in the pelvis, spreads acute ulcers may perforate, especially when they
rapidly and virulently to the lower abdomen. In are embolic in origin, the primary infection being
the early stages one side or other bears the brunt a burn or a septicaemia.
of the attack, and it is by general surgeons often The base of a perforated ulcer is usually rigid
mistaken for a perforated pelvic appendicitis or andfriable andshows signs ofrecent inflammation.
an acute perforative diverticulitis. As far as the This is reflected in the immediate history. As
abdominal cavity is concerned, the peritonitis has Moynihan has pointed out, an ulcer very rarely
an abrupt onset, and, unlike the conditions which perforates without giving some warning of the
it mimics, it is unheraldedbysvmptomsreferredto impendingcatastrophe. Painincreasesandtender-
the abdominal viscera, but a long-standing dys- ness is present although the patient may be too
menorrhea and some symptoms referable to illtomentionit. Thatperforationmayoccurwhile
micturition or defaecation may obtrude themselves the patient is under treatment is not sufficiently
into the clinical picture. It has, however, some well known, and more than one has been
invariable characteristics indicating its origin. "cooked" for twelve hours because the doctor or
There is always a previous vaginal discharge and the house physician thought that an ulcer under a
a bilateral tender mass in the fornices which corre- strict medical regime could not possibly perforate.
sponds to the infected obstructed tubes. These Everyone is familiar with the sudden onset of
are not, however, quite always palpable, for in a a perforated ulcer. The resulting acute epigastric
156 POST-GRADUATE MEDICAL JOURNAL juxl,e, I946
pain is associated with boardlike upper abdominal abdominal emergency is delay more dangerous and
rigiditywhichthenspreadsdownwards, moreto the it should never await the convenience of the
rightthantheleft,andgraduallybecomesgeneralised. surgical team for more than an hour or two. The
The pain is constant, widespread, and very severe, shortness of the time that elapses between per-
differing from colic in its unvarying intensity and foration and operation overshadows in importance
the way it makes the patient hold himself quite every other prognostic factor. This statement
still. It is noticeable that respiration is almost perhaps has one exception of practical importance.
entirely intercostal, and although the rigidity is The outlook is bad if the patient has had a recent
widespread, it reaches its maximum in the upper haematemesis, and the technique of closure should
abdomen. Such patients also only vomit once or beadaptedto prevent its recurrence. Blood inthe
twice in the early stages. What is not so often transfusionmay thenbeindicatedaswellasplasma.
realised andneedsemphasisis, thatthetemperature The following figures serve to emphasise these
is seldom raised, or even is a little sub-normal, facts. Of twenty-two perforated ulcers of the
and that the pulse rate is frequently normal or stomach or duodenum, seven died. One of these
only slightly raised, though the volume may be a had a carcinoma, one was first seen eighteen hours
little increased. These patients occasionally walk afterperforation, and two had had arecent haema-
into hospital. Only later does the pulse rate temesis. Of the remaining three, one had a sub-
increase andcollapse supervene. Notwithstanding phrenic abscess, and two were too ill for any
all this, to an experienced eye, the patient nearly interference whatever. The first of these had a
always gives the impression of having suffered a concomitant coronary thrombosis and the second
good deal of pain. General toxaemia comes had perforated three days before admission.
relatively late and rigidity passes off as the irrita- As far as anaesthesia is concerned, perhaps it is
tion of the concentrated gastric contents subsides here that cyclopropane or curari will easily come
owing to dilution with inflammatory exudate. At into their own. They give rapid and immediate
the beginning of this stage the patient may even relaxation without anoxaemia. Local anaesthesia
seemalittlebetter. Thenthetemperaturerises,heis canbeused,but painful impulses comefrom such a
flushed,andthepulserateincreases. Laterstill,pain, wide area that relaxation is difficult to obtain, but
rigidity and tenderness decrease as the long grey combined with gas, oxygen and ether, it is very
shadow of collapse and toxaemia due to general satisfactory. Except in specially selected cases,
peritonitis slowly obliterates the outlines ofa clear- spinal anaesthesia, with all its obvious advantages,
cut clinical silhouette. too often increases the percentage of respiratory
One difficulty in diagnosis often arises. A complications.
perforatedduodenalulcermaydischargeitscontents The operative technique should be as simple as
downtherightparacolicgutterandtheywillaccumu- possible. The essentials are a right paramedian
late first in the right iliac fossa. As a result the incision, three widely placed catgut stitches, one
defense musculaire reaches its maximum here and just beyond each end of the friable ulcer base,
acute appendicitis isclearlymimicked. Butnearly and one in the middle. These are tied, not too
always, in the history, the symptoms of a duodenal tightly, over a thick piece of omentum, which
ulcer can be discerned building up to a sudden mayifnecessarybedoubled. Thenaspiratetheright
acute epigastric pain which leaves in its wake some kidney pouch and mop up anv obvious soiling.
definite rigidity and tenderness over the upper Put a tube in the pelvis in most cases, and close
part of the right rectus muscle. the peritoneum. When this has been done spend
Of ancillary methods ofdiagnosis the most useful any time there is to spare in carefully cleansing
is a plain X-ray which may show a bubble of gas and sewing up the abdominal wall.
beneath the diaphragm. Thisismorereliablethan At this juncture a word should be said about
obliteration of the liver dullness, but neither of those cases of obvious general peritonitis which
these findings is by any means constant. are admitted to hospital so ill that a history is
Soon after the patient is admitted it is wise to unobtainable, and with such widespread rigidity
pass a Ryle's tube and by frequent aspiration keep that reliable assessment of its origin is impossible.
the stomach empty. If the patient is collapsed a Under these circumstances the only policy for a
continuous plasma drip should be put up, the first surgeon to pursue is to emulate the bookmakers
bottlebeingruninratherrapidly, forthesepatients and back the most probable winner. Appendicitis
lose a lot of protein in the voluminous peritoneal is by far the most common cause of general
exudate which is literally poured out. When on peritonitis. Therefore a short incision should be
account of venous collapse the transfusion will not made either over the appendix or in the midline
run well, an occasional case may be saved by just above the pubis. If the pus is foul and
using two veins at the same time. Operation stinking it probably comes from the appendix.
should be early and expeditious. In no type of If it is thin, slimy, and contains particles of food
June, I946 THE ACUTE. ABDOMEN 157
it is probably due to a perforated ulcer. In either ofallthecases, andifthelower abdomen issuspect,
case the pelvis should be drained. It never does gives away the- diagnosi -"An acute appendix
any harm to make a short incision in the wrong with shoulder pain is a ruptured ectopic."
place, but much harm is frequently done by an On pelvic examination one expects to find
attempt at exploration in the presence of sepsis generalised tenderness or a tender mass in one or
through a median subumbilical incision. other fornix, but this is also found with acute
Another type of acute abdomen which falls a salpingitis. It is also characteristic that movement
little uneasily within the category of a perforation of the cervix in an anterio-posterior direction
is a ruptured ectopic gestation. This is popularly causes asuddensharppainwhichmakesthepatient
supposed to produce a very clear-cut and charac- stiffen and catch her breath.
teristic clinical picture. The patient misses a Acute appendicitis, acute salpingitis, and an
period and a few weeks afterwards bleeds more early abortion are the three conditions which
profusely and longer than she would expect from confuse the issue. The differences between rup-
her previous experience of menstruation. About tured ectopic gestation and acute appendicitis
the same time she is seized with severe abdominal have already been indicated. A mistake is not
pain, and on examination she has the other signs important and its worst consequence is ashort
of peritoneal irritation. The diagnosis is clinched incision in the wrong place.
by the discovery of a mass in one or other vaginal When acute salpingitis is confused with a
fornix. My colleague, Mr. R. L. Dodds, has subacute ruptured ectopic, three or four days'
recently pointed out (Proceedings of the Roy. Soc. observation will settle the question; the salpingitis
Med., Vol. XXXIII, No. I2) that this is in fact a will invariably subside.
film version of a not very common tragedy, and Examinationunderanaesthesiamaybenecessary
its widespread acceptance results in the diagnosis to differentiate an early abortion. Tenderness and
being made incorrectly in about 70 per cent of all resistance is abolished and it is usually clear
the cases. There are three good reasons for this whether the uterus or a Fallopian tube is the seat
otherwise deplorable state of affairs. Firstly, in of the pregnancy.
the practice of a general physician or surgeon the Little needs to be said about treatment once the
condition is distinctly rare. Secondly, the differ- diagnosisismade. Theabdomenshouldbeopened
ential diagnosis is often really difficult, andthirdly, in the middle line and the involved tube removed.
as has already been pointed out, the facts that A blood transfusion is often wise and sometimes
emerge from an analysis of the clinical findings necessary. If strict antiseptic* precautions are
are at variance with the average conception of the taken the patient's own blood may be used for
disease. The missed period, usually regarded as replacement.
the keyto the clinical puzzle, cannot be established
in just under half the cases. In more than a (III) Obstructions
third of them it is masked by the fact that the
bleeding occurs just when the next period is due. Intestinal obstruction is by no means the most
Only a wary cross-examination will elicit the fact frequent cause of an acute abdomen, but it has a
that the period just before the pain came on was higher percentage mortality than any of the
more profuse and more prolonged than usual. othertypes ordinarilymetwithin surgicalpractice.
Veryoccasionallythispseudo-menstruation appears That a large part of this mortality is preventable
a week early. The pain too is without distinctive because it is due to delay in diagnosis will readily
features. Itis felt typically in the lower abdomen, be conceded by anyone who has to deal with
often more on one side than another, and when it many cases.
appears it remains constant for some time; then There is a legend that elaborate classifications
there may be an interval of relative freedom. ofacuteintestinal obstructionare much beloved of
This must be distinguished from colic, which examiners, and most surgical coaches have their
reaches its maximum quickly and then fades with own favourite table of causes. These may indeed
equal rapidity. Sometimes the pain is generalised, form auseful framework for an examination paper,
occasionallyitisreferredtotheepigastrium. There but they are not of much practical clinical im-
is always tenderness, and as often as not more portance. When a clinician is confronted with a
rigidity than the intensity of the pain would seem probable case, these are the intensely practical
to warrant, but cases are seen with a lower abdo- questions he has to ask himself:
minal wall which reacts to and resists the slightest (i) Is obstruction present or not?
intrusion of an examining hand. Unlike appendi- (2) If so, is it in the colon or the small intestine?
citis, this abdominal pain is never preceded by (3) Does it, or does it not threaten the integrity
peri-umbilical colic and vomiting. Shoulder pain, of the bowel wall, or in other words, is it accom-
sometimes quite severe, occurs in about one-third panied by vascular obstruction?
158 POST-GRADUATE MEDICAL JOURNAL June, I946
It is not possible to over-emphasise the fact that colicky painreferred to adistendedcaecummaybe
an answer to these questions is possible in nearlv the presenting symptom. In nearly all cases of
every case by simple clinical examination assisted large intestinal obstruction the ileocaecal valve is
only by a plain X-ray of the abdomen, which may competent, so that vomiting is absent and the
well be taken between the casualty-room and the small intestine is not distended. The colic is
ward. Now intestinal obstruction produces four referred to the segment of the colon proximal to
cardinal symptoms, pain, vomiting, distension and the obstruction, and the distended bowel may be
sometimes tenderness, symptoms which are com- seen to contract, but this colic is not so prolonged
mon to every other type of acute abdomen. It is as when the small intestine is involved, as the
therefore obvious that their significance lies in relatively short colon distends rapidly, is soon
their mutual relationships. paralysed, and so cannot contract.
Pain.-The pain is due to intestinal colic. It is Occasionally, however, the ileocaecal valve is
intermittent, cramping, reaches its maximum incompetent, and then the whole intestinal tract
quickly and retains its intensity only for three or becomes involved in the resulting distension. A
four minutes. Its onset and departure are both plain X-ray, taken in the supine position, will show
equally abrupt. The colic due to intestinal ob- the outline of a dilated colon down to the obstruc-
struction is always accompanied by bubbling and tion. The jejunum is recognised by its "feathery"
gurgling which can be heard and often felt as the appearance and the numerous cross striations. In
pain reaches its maximum intensity. Except in contrast, the ilium is thinner, less "interesting,"
pyloric stenosis and obstruction at the efferent and has fewer cross markings. Fluid levels may
loop of a gastrojejunal stroma, this relationship is also be seen, especially if it is possible to take a
invariable and generallv establishes the presence of film in the upright position. (Figs. 3, 4 and 5.)
obstruction of some kind. Rigidity and guarding make it clear that trans-
Vomiting.-In all obstructions of the small udation is taking place through the bowel wall,
intestine vomiting is present. It is frequently and, since this fluid is very irritating, it may even
copious because it comes from the regurgitation of cause shoulder pain. There is an occasional but
the intestinal contents into the stomach. The important exception to this last statement. A
higher the obstruction the earlier it appears and typical inflammatorylesion causingsimple obstruc-
the less likely it is to be faeculant. It gives only tion may cause localised tenderness and rigidity.
temporary relief or no relief at all to the patient's The distinction can as a rule be made by relating
distress since more fluid from below is again the history to the physical signs, although it has
regurgitated into the stomach. This vomiting to be admittedthat this may sometimes be difficult
tends to recur soon after a spasm of pain. or even impossible. It is, however, none the less
The vomiting of pyloric stenosis relieves the important, because hasty interference in such cases
patient for the time being and, except in the very usually results in spreading the infection, and not
early stages before the stomach is dilated, is pain- infrequently in the death of the patient. Suction,
less. The vomiting due to biliary or renal colic is with a duodenal tube, at least for some time, is
not copious, is very exhausting, and is more in the correct treatment, and not seldom saves the
the nature of continuous retching which brings no patient's life.
alleviation of the patient's suffering. For reasons One other question now demands consideration.
which will be discussed later most patients with Is the obstruction complete or not? Complete
obstruction of the colon do not vomit. obstruction in the large intestine is evidenced by
Distension.-Distension is visible or palpable in absolute constipation (after an enema) and rapid
most cases and can always be demonstrated by a distension of the colon.
properly taken plain X-ray of the abdomen. In the small intestine complete obstruction is
Gentle palpation with a warm hand may detect indicated by the absence of gas in the evacuated
the smooth, tense outline of a coil of small bowel, colon andin the coils belowthe distendedloop. If
or general distension may be obvious. the obstruction is incomplete a second film will
The "ladder pattern" illustrated in textbooks is demonstrate its re-accumulation after evacuation
so late a manifestation that it has littlerealclinical by an enema.
interest. Visible peristalsis, which may be seen in Having established in this way the fact of
thin abdomens. apart from obstruction, is of obstruction, its probable cause has to be deter-
immense diagnostic importance when it is asso- mined. It is manifestly impossible in an article of
ciated with colic. this kind to consider in detail each variety; this is,
In obstruction of the large intestine the colon is moreover, adequately done in all standard text-
always distended and can usually be palpated. books. It is sufficient to saythat, having carefully
Even with obstruction of the distal colon the excluded strangulated hernia, and in particular a
caecum is the first to dilate, and in the early stages Richter's hernia, the most probable cause of small