THE ACUTE ABDOMEN - Postgraduate Medical Journal

22 Pages·2008·6.63 MB·English

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THE ACUTE ABDOMEN s
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By H. W. S. WRIGHT. M.S., F.R.C.S. rad
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"Our Natures are the Physicians ofour Diseases."-Epidemics, VI. 5. e
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"Those Diseases that Medicines do not cure are cured by the Knife."-Aphorisms,HIVIPIP.O8C7R.ATES. : firs
The acute abdomen may be defined as an It is not proposed in this article to describe in t pu
pirnitartae-atbrdeoamtimnenatl,liesmimoendiwahtieclhy, tahpraerattefnrsotmhealpipferoo-f ddeetaalitlwaibtdhoimninalallsctoannddiatridontsexwthbioockhs,arbeutadreaqtuhaetreltoy blish
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a patient. In England, with a population of analyse theirsymptomatologyanditsmechanismin d
nearly 42 millions, considerably more than I2,000 such a way that a clinical pattern emerges quite as
people die annually from what is called "an acute simply from a mosaic of apparently unrelated 1
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abdomen." The annual crude death4ate from symptoms, and to show that the treatment sug- .1
appendicitis is 62 per million, and from hernia gestedisalogicalsequence topathologicalfindings. 13
andintestinalobstructionIO9permillion. Ingreater The symptoms and signs which give evidence of 6/p
London, with a population of nearly nine million an acute intra-abdominal lesion are as a rule few g
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wpeirtshonas,diaatgnloesaisstwIhoi,cohooimppelrieasnanmuamjoarrea-baddommiitntaeld taennddesrinmepslse,.rigTidhietyy,aarnedpvaoimni,tisnugp.erfiWciiatlhatnhdesedeaerpe j.22
catastrophe. Because they are incomplete, these associated the general effects of the lesion on the .2
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figures underestimate the magnitude of a problem whole organism, such as temperature changes, and 8
which claims a large and important share of every alterations both absolute and relative, in the .14
surgeon's time and attention. It would be sur- composition of the blood and urine. The integra- 9 o
prising if such a group of cases, with so much in tion of these signs and symptoms into familiar n
common, did not have an embryological and clinical patterns usually enables a diagnosis to be 1 J
biological background which deserves understand- made with rapidity and certainty, often on the u
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ing andconsideration. telephone; butinmanycasesthemostmeticulously e
When, in the course of biological evolution, the careful history, precise examination, andthe nicestc 19
mesoderm became differentiated as a separate cell judgment are necessary before reliable conclusionsop46
cmoaeslsomw,hitchhe lfaoterrmastpiliotn toofftohrims acavbiotdyymcaarvkiteydoar kcannowlbeedgreeacohfed,thaendnaitnuroerdearndtomdeochathniissmsomoefyrigh. Dow
critical stage pregnant with possibilities. The symptom production is necessary. t.n
organs inside the cavity were separated from the The pain of abdominal disease is of two kinds, loa
exterior for their specialised functions of digestion, visceral and somatic, and they can frequently be de
rabesmoorvpteidonm,anayndobsrtesapcilreastitoon.incSruecashe baonthadivnasniczee gdiisvteinngbuyisahnedinftreollmigeeantchpaottiheentr,bayndthseomdeetsicrmiepstiboyn d fro
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and variety, and determined the possibilities of the patient's appearance. Visceral pain arises h
coelomate forms. But the differentiation of an directly from pathological changes in the involved ttp
ipnrtoevsitsiinoanl ocfanaalvawsictuhlianr sayssetreomusfocravitistyowinmpnloieusritshh-e vainsdcussomoratiitcs pmaeisnenatreirsyesafnrdomvatshceulaprariceotnensecatsiontsh,e ://pm
ment andthe transport ofmetabolites, alymphatic result ofsecondary andcoincidental changes. The j.b
system for absorption and protection, and a classic example. of visceral pain is that due to m
nervous and endocrine system for co-ordination coronary thrombosis, to renal or intestinal colic. j.c
andcontrol. Withthisincreasedcomplexity there It is tearing, crushing, or bursting in quality, often om
is necessarily an increased danger of breakdowns severe enough to cause vomiting, rapid pulse, and o/
fraught with disastrous and far-reaching conse- some degree ofcollapse; the patient mayrollabout n
quences. The existence of a coelom, in fact, or double himself up in what he may well call M
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implies the probability of the acute abdomen. agony. In the case of colic it rises to a crescendo rc
Itiseasytoseethatorgans, suchasthcappendix and then diminishes, only to recur again. This h 5
adinvdertthiecuglaalelbflardodmer,thwehimcihdgaurte,demvuesltopeadlwaasysblibned tabyopleisohfedpbayinseicsticohnaorfacttheeriasptpircopirniattheatsymitpactahnetibce , 20
liable to obstruction and subsequent infection, a pathways. It is usually imprecisely localised but 23
series of changes so aptly called "the hollow viscus has an area of reference which depends on the b
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pathology." Inherent in the localising and pro- embryology of the implicated viscus. Very often g
tective functions of the peritoneum and omentum the patient willsaythe painis inside the abdomen. ue
iasndthtehepporsessibeinlcietyofolfymapdhhaetsiicontsissauendthionblsytrcuocvteiroen,d Tthheisontsyepteofofthpeaianttiasckmobseftoreeastihleyaddijsatcienngtuipsahreidetaatl st. P
wswietlhlinmgu,sncelcerosaisn,danpderpietrofnoerautmionmaakceesrtaoicnctays.ional preefrlietxeosneaurme eisstabilnivsohlevde.d, Itanisdfroetqhueerntlpyrobtuetctniovte rotec
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POST-GRADUATE MEDICAL JOURNAL June, 1946 os
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invariably associated with rigidity and deep pheral end of a novocaine-blocked sensorynerve. ra
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tenderness. For instance, the pain of renal colic Since it arises some time after the stimuli, which M
is sometimes accompanied by rigidity and tender- probably do not reach the cord, have ceased, it is e
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ness over an area wide enough to be suggestive of unlikely that it has its origin in the cord itself.* J
afrepeqrufeonrtaltyioisn,nowth,earnedasiftrhiegipdiatiynaonfditnetnedsteirnnaelsscoalriec anMdusvicsucleararlripgaiidni.tyiIstamssaoyciaaftfeedctwiptahrtbootfhapmaruisectlael : firs
present, asarulethevdisappearsoonafterthecolic whose total nerve supply comes from several t p
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ceases. Thereasonfortheoftenvaguelocalisation segmental nerves, thus producing a so-called b
of visceral pain is that-the afferent nerves from phantom tumour, and it maypersist forsome days lis
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viscera traverse the ganglia of the autonomic after the pain has ceased. This suggests that it e
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system to the posterior nerve roots which are may be due to a "facilitated reflex" and that a a
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arranged segmentally, but the subjective aspect of stimulus qualitatively below the threshold of pain 1
localisation takes place in the brain where pain is may continue to produce rigidity when the pain 0.1
registeredintermsofqualityandposition. Neither has ceased. This persistence is not uncommon in 1
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of these latter attributes are constant, and vary inflammation of the gallbladder or appendix, and 6
from individual to individual. becauseofthis, asurgeononopening the abdomen, /p
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For instance, the early pain in a typical attack may sometimes find much less evidence of acute m
of acute appendicitis is usually felt around the inflammation than he had previously led himself j.2
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umbilicus. This might well be expected as the to expect. .2
appendix is part of a mnedially developed midgut, The mechanism of deep tenderness is much more 48
but the pain is often described by the patient as difficult to understand. It is as a rule coincident .1
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arising in the epigastric region, and occasionally in time both with the pain and rigidity. It 9
elsewhere. An analogy may perhaps make these probably arises in the muscle itself because, as o
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individual differencescomprehensible,ifnotreason- Lewis has shown experimentally, muscle is tender 1
able. The quality of tones registered in a photo- after contracting for two or three minutes, and Ju
graph varies with the composition of the film, so afterspasm oflonger duration muscular tenderness n
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also do the spatial relationships vary with its may persist for some time. This tenderness is 1
contour. Seen in this way it does not seem probablyrelatedtopartialischaemia, butwhatever co94
.tuhneliqkueallyittyhaatnddpiofsfeirteinotn oifndtihveiirduvailsscerwailllsendseastcriiobnes iatnsdcatuesnedeervneerssyonwehiicshfamfiollilaorw wpirtohlotnhgeedstiufnfnaecs-s pyrig6. Do
differently. Thattheydosoisafactofobservation customed exercise. It is however certain that ht.wn
which has to be constantly bome in mind when ischaemia does not represent the whole story,since lo
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assessing the value of a patient's statements. deep tenderness in the testicle may be produced d
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The other type of pain which occurs in acute either by renal colic or by the intraligamentary d
abdominal disease arises from inflammation of the injection of saline. fro
neighbouring peritoneum, or reflexirritation of the Pain, rigidity, deep tenderness, and hyperaes- m
overlying muscles. It is constant in position, thesia then are the cardinal symptoms of acute h
unvarying in quality, and in the nature of buming abdominal pathology. It is wise to remember that ttp
or aching. When severe, it is difficult to dis- the severer types of visceral and somatic pain may ://p
tinguish from any other severe pain except that it be indistinguishable, and that either or both m
is more precisely localised. It is nearly always together are often associated with their reflex j.b
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aitssaorciisaetsedfwriotmhrtihgeidpiatryiaetneds,detehpetennedrevmeessso.f wShiincche tefhfeescitas., rTihgiedsiety,lasdteetphreteenmdearynesasl,soabned chayupseerdaebsy- j.co
pass through the appropriate posterior roots- and inflammation in the muscles and ligaments of the m
retain their original segmental arrangement rela- appropriate segments and can be exactly repro- o/
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tively undisturbed, localisation in the cerebral duced by the intra-ligamentary injection of saline. M
cortex is much more precise. (LewisandKelgren). Obviously,itwouldbeunwise a
With both these types of pain is associated to assume that an understanding ofthe mechanism rch
hyperaesthesia-pain whichis superficial andhas a of symptom production is unimportant for the 5
stingingoritchingquality. Itisalsocharacterised diagnosis of acute abdominal disease. Every , 2
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by the fact thatit often persists forsomelongtime casualty officer is aware that the diagnosis is 2
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after the original stimulus has ceased and may sometimes made correctly by a parent or a police- b
even be the last sign to disappear. Its mechanism man, but every surgeon has on his conscience a y g
is incompletely understood, but its characteristics death orweeks ofhospitalisationwhichmighthave u
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suggest that it arisesin the skinofthe painful area. been avoided had an obscure case been more s
Itisstrictlysegmentalindistribution. SirThomas carefully considered. t. P
bLeewipsroadnudcehdisbcyo-ewloerctkreircsalhlyavsetismhuolawtnintghattheit pmeariy- ref*erFroerd taofcuhl.lxdiiiiscoufssSiironThoofmtahsisLqeuweiss'tsiobnotohkeonrePaadienr.is rotec
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June, I946 THE ACUTE ABDOMEN 151 o
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Acute abdomens may, for descriptive purposes, rectus. Such a mass may be so protected by ra
be divided into four groups which, of course, omentum that it is not very tender and even d
necessarily overlap. allows a limited mobility on palpation. An M
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(i) The obstructive visceropathy of which ap- appendix situated so that its tip rests on the d
pen(d2i)ciPteirsfoarnadticohnoslecoyfstuiltciesrsaroerexianmfpllaemse.d and gan- pofsotahsewtihlilghg,ivaenrdispeaitno,swphaesnm tofhethliasttmeursicsleex,tfelnedxeido.n J: firs
grenous viscera. The most difficult situation arises when the t p
(3) Obstructions with or without interference to appendix is in the pelvis. The area of peritoneum ub
the vascular supply. within the true pelvis is a silent area and gives lis
(4) Vascular obstructions due to intravascular, rise to little rigidity, abdominal pain, or hyper- he
or extravascular mechanical causes, such as aesthesia. The disturbances of defaecation andd a
mesenteric thrombosis or the torsion of an ovarian micturition so often mentioned in textbooks ares
pedicle. An analysis of 348 cases admitted to moreoftenabsentthannot, butwhenthe condition 10
an emergency hospital which served a large semi- is well developed there is usually. tenderness per.1
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urban and rural area, shows that these types rectum or per vagina. 3
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occurred in the following proportions: One type of obstructive appendicitis, specially/p
Obstructive visceropathys 6i.5 per cent; Per- emphasised by the late Sir David Wilkie, requiresgm
forations 9 5 per cent; Obstructions 25-3 per cent; special mention. There occurs an acute obstruc-j.2
Vascularobstructions due to Torsions 3 7 per cent. tion of an infected appendix, and a virulent2
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organism causes inflammation and early gangrene.4
(I) The Obstructive Visceropathy Often there is early vascular thrombosis. The8.1
onset is very sudden and the pain is very severe,4
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Acute appendicitis.-Though most cases occur in colicky in type, and referred as a rule to the o
adolescence and early adult life, it may occur at all umbilicus. The patient is doubled up and vomitsn 1
ages. It is particularly dangerous and often diffi- with each spasm. He is often collapsed and J
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cult to diagnose in childhood and old age. More- anxious looking during and after the attack ofn
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over,theappendixissubjectto such great variation pain. At the onset there is little to show in 1
in position that its manifestations are apt to betweenthespasms;theremaybealittletendernescs9
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be anomalous. It is therefore wise to rememberin deepintherightiliacfossaandsomehyperaesthesiap.6
obscure cases that one is always more likely to To an experienced observer the patient gives thyrige. Do
encounter an unusual variant of a common disease impression of having suffered a great deal of painh,w
than a rare disease. Its onset is usually sudden and often seems a little more "knocked" than ht.enlo
and begins with colicky or cramping pain referred would be if it were mere intestinal colic. In thisa
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to the midline near the umbilicus. This pain is typeofcaseeveryhourthatpassesisofimportance,e
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baeccormepparnoiduecdedbybvyompiutlilnignginonmanory scaqsueese.zinIgt ctahne wfoirtpheoruftorparteiloinmainndagreynesriaglnpserofitloonciatlispmeraiytooncictuirs.earlIyf from
appendix when the abdomen is opened underlocal the doctor who is responsible for such a case is inh
anaesthesia. If the patient is examined at this doubt he may well remember Moynihan's dictumttp
stage there will generally be deep tenderuess over thateveryabdominalpainwhichrequiresmorethan://p
McBurney's point. A little later there is pain, one dose of morphiaforitsrelief, probablyrequiresm
more or less severe and constant, associated with laparotomy for its cure; or Zachary Cope's advicej.b
the defense musculaire of the French writers. This that if pain, assumed to be due to intestinal colic, m
consists of rigidity, deep and superficial tender- persists for more than three or four hours, j.c
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ness over an area corresponding to the position the condition calls for surgical interference. m
of the appendix, usually the right lower quadrant Gentle palpation starting from the silent to the o/
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of the abdomen. By this time the vomiting has symptomatic side of the abdomen will generally M
ceased, the patient may seem quite well, the detect some guarding andrigidity. Ifthe pressure a
temperature normal or only slightly raised, and of the hand on the normal side issuddenlyreleasedrc
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the pulse hardly raised at all. The exact physical there will be pain over the area of any inflamed 5
signs vary with the position of the appendix; a viscus, and this is often valuable evidence of early, 2
retrocaecal appendix may give little rigidity or localised peritonitis. A tentative diagnosis can02
pain in the early stages, a pelvic appendix often often be made by watching the abdomen closely3 b
almost none, but here rectal or vaginal examin- inagoodlight; alocalisedareaofmuscularrigidityy
ation will help. When the appendix is situated can then be seen as the rest of the abdomen moves gu
lateral to the caecum a localised mass may with respiration, and over such an area thees
be felt or there is rigidity in the loin, and abdominal reflex is almost invariably absent.. t. P
when it is surrounded by omentum a mass may be There is nearly always a slight rise in thero
palpable near, or beneath the edge of the right leucocyte count or a "shift to the left" in. thete
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152 POST-GRADUATE MEDICAL JOURNAL June, I946 o
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Arnethcount. Thesechangesmaybeofimportance the base of the appendix divided and buried. It tgra
in distinguishing appendicitis from other extra should then be detached from above downwards to d
peritoneal conditions causing localised pain and where it is adherent to the posterior abdominal M
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rigidity. The total whitecount israrelymorethan wall, and then the lumen may be opened, the pus d
dIi2a-gIn4o,s0t0i0c,imapnodrtaintce.is of more prognostic than wcuirpeetdtedawaanyd tahnedratwhesurnfeaccreoticcautmeruiczoesd.a gSeonmtel-y J: firs
These clinical findings represent, in terms of times it is possible to divide the muscle down to t p
gross pathology, inflammation of the appendix the mucosaand remove unbroken a tube of mucosa ub
and the adjacent peritoneum. containingpus. Boththeseproceduresareoccasion- lis
From this stage onwards three things may ally life-saving. (Figs. i and 2.) he
happen. The whole process may, and often does, It is still important to emphasise that in general d a
completely subside, leaving increased liability to a the treatment of acute appendicitis is immediate s
future attack. But the appendix is largely com- operation. A few hours in bed to get the patient 10
posed of lymphatic tissue, and if it is obstructed, rested and quiet is often judicious. A doubtful .1
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as it nearly always is, either by its mesenteric diagnosis in the patient's house or casualty room 3
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attachments or by a faecolith, it may necrose can often be cleared up in this way, but if the /p
and perforate. Such cases will gradually develop diagnosisisstilldoubtfulandappendicitis probable, gm
first a localised, and later a general peritonitis. it is wise to look and see. Some years ago a very j.2
Sudden perforation is often the signal for the distinguished surgeon in a presidential address to 2
temporary cessation of the symptoms, butsoonthe the Royal Society of Medicine rightly emphasised .24
pulse rate rises, rigidity and pain increase, the how often acute appendicitis settled down and 8.1
temperature drops, or occasionally rises according resolved. This perfectly proper statement to a 4
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to the patient's resistance, and vomiting and other medical audience unfortunately got into the lay o
toxic symptoms supervene. Finally, the whole Press, and in the succeeding three months the n 1
process may become localised and an abscess or writer of this article saw two deaths which were J
inflammatory mass be formed. Ifthishappens, as the direct result of this statement. In the writer's un
the general rigidity diminishes a mass becomes experience of 200 cases diagnosed as appendicitis, e 1
*differentiated; the temperature and white count every doubtful case was operated on, two un-c9
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behave as they do in any other abscess. necessary laparotomies and appendicectomiesp6
staTnhdeardtirseeadt,meinttiosfoapceurtaetivaep;penbduitcittihsisisdobeysnnoowt wseerrieeshoiwnevwehripcehrfoopremreadt.ionInwaansotdheelranyeeadrluynptairlaltlheelyrigh. Dow
mean that it is unnecessary to exercise wise diagnosis was absolutely certain there occurredonet.nlo
judgment and carefulconsideration. Itisnotvery sub-diaphragmatic abscess, and another casewhich a
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helpful to say that the surgeon should hold his had a subdiaphragmatic abscess and an abscess of ed
hdeavnedloapfteartthveerfiyrstd2if4feorren4t8 rhaotuerss., bPeecrahuaspescatshees tprhoecleudnugrew.hicThherreequiirsedodnreainasgineisatnerdlaftaecrtapwlhasitcihc from
indications for conservative treatment are best emerges from any series of cases of acute appendi- h
described by saying that no wise man would citis, and that isthatno one can say what the out- ttp
ediitshteurrbinatnerfienrfelawmimtahtoarylomcaaslissiwngherpeerittohneirteis,weroer catomvearwiialnlcbee.wiTthhewohpaetraotnieonwfoiundlidngesxpaercet.freqTuheinstliys ://pm
no indications that it contained pus. counterbalanced by the incontrovertible truth that j.b
In principle the appendix should be removed operations performed while the disease is limited m
by an incision as far from the midline as possible to the appendix and its immediate surroundings j.co
when this can be done without unduly breaking carry a very low mortality, little morbidity, and a m
down adhesions or spreading the infection. The rapid convalescence. o/
abdomen should be drained if there is pus, an During the period I943-I945 in which the n M
oozing surface, or necrotic material left behind. figures previously mentioned were collected, five a
tIon uasefewa ssupiitnaablleanbaoersdtehreltiince bceasceasusiet itshejus"tqiufiiaebtl"e naonrmearlroanpepoeunsdicdeisagwnoesries.remIonvetdwealsvethecarseessultthoef rch 5
abdomen it gives may enable an appendix to be abdomen was opened because appendicitis was , 2
safely removed Nvhen removal would otherwise be diagnosed, andotherconditionsrequiringoperation 02
danIgfearnouasp.pendix containing pus is attached to the wdeiragenfoosuendd,whanedninthteenpactaiseenstot?hiecrtucalolnydithiaodnsawceurtee 3 by
posterior abdominal wall, the protective barrier on appendicitis. In four cases the only pre-operative gu
its posterior surface should in no waybe disturbed, diagnosis was general peritonitis. es
csaiornnecdaeistthihooisnulmodafbyaefrfeacisarursletfwuihlnilycahrseuitsrrrfoorpueenqrudieteondntelbayylfpcaetalacllku.lsi,tiTas,hneda oinfIpIt4riosovfaeltdshoeascienuttfeeirfetaysp,tpietnnhgdeitcaoiptnpioestn,ed5it0xhawwtearosef-ntdohrteairIne9em4do,cvaaesnde.ds t. Prote
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June, I946 THE ACUTE ABDOMEN 153 o
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Twenty-three of the fifty drained cases occurred in Horace, who lived in an age of gastronomic tgra
the "flying bomb period" when it was noticeable indulgence, was familiar with the referred pain of d
that patients tended to arrive at a later stage than 'gallstones, forin describing an attackofcolicwhich M
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the average. Maecenas suffered, he mentions the burning in the d
shoulder.* J
Acute cholecystitis bears close comparison with Thephysicalsignsmaybedifficulttodifferentiate : firs
acute appendicitis, for the gall bladder is a hollow fromthoseduetolaterocaecal appendicitisuntilthe t p
viscuswithanarrow,tortuous,andeasilyobstructed abdomen is relaxed under an anaesthetic, when a u
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outlet. Itis,however, amuscular organ connected characteristic mass may be palpable. The tem- lis
with a normally sterile biliary tract, and so is less perature ishigherthaninappendicitis (IoI'-Io20F.) h
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likely to be acutely inflamed than anorgan mainly asisalsothewhitecount. Thereisfrequently some d
composed of lymphatic tissue drainingdirectlyinto congestion at the base of the right lung. The as
what may be regarded as a septic tank. patient very often seems ill and toxic. 10
For purposes of description cases may be con- Thecourse ofthe disease fromthispoint onwards .1
1
veniently divided into those associated with gall- varies. It has to be conceded that by far the 3
6
stones and those without, but this classification is greater majoritv of the cases settle down. The /p
notso convenient clinically as it appear4on paper, rigidity passes off, leaving a palpable mass which gm
because an acutely inflamed gallbladder which is is usually omentum attached to the gallbladder, j.2
obstructed by a gallstone does not always cause but sometimes a large pyriform, distended gall- 2
biliary colic, and conversely, a gallbladder ob- bladdercanbefelt. Thisoccurswhenacholesterin .24
structed by oedema or a plug of mucus in the stone is impacted in the neck of the gallbladder 8.1
cystic duct sometimes is associated with colicky and has previously caused a mucocoel. 4
9
pains at the onset. It is, moreover, frequently In other cases signs of toxic absorption may o
ssttaotneeds itshattheanresaucluttoef cahogleenceyrsatlitiinsfewctiitohuosutdisgeaalsle- ionrcrseoamseeaenadrltyhelporcaolciessastigoonoanntdogaebnsecreaslspefroirtmonaittiiosn; n 1 J
such as typhoid. This is by no means always true. maytakeplace, tobesucceededlaterbywidespread un
However difficult it may be accurately to generalisation. There is a frequently expressed e 1
integrate the clinical with the pathological findings difference of opinion between experienced surgeonsc9
in any given case, it is always clear, as in appendi- about the treatment of acute cholecystitis. Someop46
cdiettise,rmithnaets otbhsetruocntsieotn ooff ascoutmee skuipnpduraotrivoetheorr imsauinnctearitnaitnhaat,ndliiktesahcouutledabpepeonpdeircaitteisd,utphoenoauttocnocmee,yrigh. Dow
gangrenous cholecystitis. The operation findings since operation in the first 24-48 hours is easy, andt.n
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make this so obvious that the bacteriology is apt little different from the inevitable operation later a
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to receive insufficient attention. on. Against this is the fact that one seldom sees e
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preTdhoemiinnfaetcitnigonbuistuassusaolcliyatmeidxweidt,htahestbraecpitlolcuoscccuosl.i sceatstelse sdoowenar.ly,Thaenrdetihsatnothteypmeajoofriatcyutoefatbhdeommedno fro
m
In the severer cases, particularly those associated which requires more careful individual considera- h
with marked toxaemia and a rapid progress, the tion, and probably opinions which seem to differ ttp
gdaosm-ifnoarnmtinfgactoorrgaisniosfmtse.n the(GporresdeonnceToafyalnoareroabnidc fagurnedeammeonrtealcllyosewlhyewnheenxparpepslsieedditno-warnitaicntgu,alwocausled. ://pm
Whitby. B.J.S. I930, xviii, 38.) There would be general agreement upon the j.b
Clinically the patientsoften (60-70 percent) give following points: m
a history of flatulent dyspepsia suggestive of (i) That with few exceptions, every case may j.c
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cholelithiasis, and gallstone colic, more or less safely be given a few hours of rest in bed for m
severe, initiates the attack. The pain is sudden in adequate preparation, in particular the administra- o/
onset, situated in the right hypochondrium, and tion of fluid and glucose and one dose of morphia n M
radiating outwards to the axilla or across the and atropine. a
abdomen. It doubles the patient up and may (2) That a case seen in the first 24 hours and rc
cause vomiting. Hyperaesthesia and deep tender- before the succeeding inflammatory reaction is h 5
nesswhich persist after the colichaspassedoff, are marked, can be safely operated upon early since , 2
present at a spot just medialtoandbelow the angle adhesions are oedematous and strip easily. 0
2
of the scapula. Instead of passing off as colic (3) That after this early period has passed, the 3
usually does, it is succeeded by pain, soreness and case may be carefully watched to see whether or by
rigidityintherightupperquadrantoftheabdomen, g
* Nec munushumeris efficacis Herculis u
which is due to local peritonitis, and if the dia- Inarsit aestuosius. (Epodes iii, I7, i8.) es
pshhorualdgemr.isTihnevorlivgeiddi,typamianyisexretfeenrdreadlltdootwhenttihpeorfitghhet NotrhedsihdouNledsesriuosf'Hegrifctulbesu.rn w(iGtohrdfoinerTcaeyrlofrl.amBe.Ji.nSt.o, t. Pro
side but is at its maximum above. 1937, xxv, i6.) te
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154 POST-GRADUATE MEDICAL JOURNAL June, 1946P
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notthe temperature andparticularly thepulserate left behind and lightly coagulated, for it is undertg
diminish, and that any steady increase in the pulse these circumstances that Thorck's technique bestrad
rate is an indication for immediate interference. serves its purpose. M
(4) That a total and differential leucocyte count Six of the twelve cases in this series had aed
should be done at once, not so much for its imme- cholecystectomy, and in six the gallbladder was J
dia(t5e) vTahlaute aifs,faofrtecromrpeastriasnodn lgaltuecr.ose, the patient draIinnetdh.ese acute cases anaesthesia is supremely: first p
still looks toxic and the pulse is raised out of important; probablygas,oxygenandcyclopropane,u
b
proportion to the rest of the physical signs, opera- with or without local block, is the ideal, but itlis
tion should be immediate in view of the possibility needs a skilled and experienced anaesthetist. Fail-h
e
of an anaerobic infection. ing this, careful upper abdominal field blockd
(6) That if it is decided to allow the case to combined with gas, oxygen and a little ether is as
settle down, it should be most carefully watched, satisfactory and very safe. 1
0
and that, although they may cause pain, breathing .1
exercises should be instituted, and sulphonamides 13
and penicillin should be administered. Acute Perforative Diverticulitis 6
/p
The ideal treatment for acute cholecystitis is Another.exampleofthesametypeofpathologicalg
m
tchhoalnecdyosntee,ctoamnyd, bbuetytohnids ispeorfatdevnemnoturreeeaistilyissaniod porfotcheesscoilsosneepnerwfohreatnesa.diAvecruttiecupleurmfoorfattihveeldeifvtesritid-ej.22
operation for an inexperienced surgeon. Apart culitismustbedistinguishedfromamoregeneralised,.2
4
from gangrene, it should not be done unless the less acuteinflammationwhichsometimesflaresupin8
cystic duct and the common bile duct are com- a segment of bowel already the site of chronic.14
pletely exposed, a procedure which may be time- diverticulitis. In the latter case there is a general9 o
consuming, difficult, and even impossible. As a inflammation of the whole mass accompanied by an
rule the common bile duct should be explored, a localised peritonitis. The whole process is rather 1 J
T tube put in, and after removing the-gallbladder, similar toacute appendicitis, but the constitutionalu
n
the whole region adequately drained through a symptoms tendtobemore severe. There may, fore
separate stabwound. Failing this, the gallbladder instance, be arigor, andthe patient looksill. Thics 19
shouldbeaspirated, theobstructing stoneremoved, is preceded by an exacerbation of the previouops46
fainrsdt tthhernousgihmpalyhodlreainiend,thteheomteubnetubmeinagndpatshseend rdiaftfhiecrulmtiylidndidsecfoaemcfaotrito;n,foranexdamcoplliec,rseofmerereidnctroeastehyrighde. Dow
through a stab wound in the abdominal wall at a left side of the large bowel. It should be treatet.dn
point correspondingtothelowerborderoftheliver. conservatively with absolute rest, and until it sub-loa
In the writer's experience with a proper selection sides, only enough fluid and glucose given byd
e
wofhecraesaess,, athlitshohuagshpcrhoovleedcysratpeicdt,omsyimhpalse,beaenndtseacfhe-, moIunthctoontprrasetv,entthtehirspte.rforation of an inflamedd fro
m
nically successful, seemingly satisfactory, and diverticulum precipitates a dangerous condition
accasossmeopscliihactaaestdisowenietmhreaa'deluonowdfumlocryhtoahllieigcthyy.,stteFhcuetromtmohyrebrimidonirtesy,evatenhrdee wistnhrfiilccathmlyecdancanopopmtepnabdruiatxb.lgeivTehtroeispetathtoeiegnrtpe,earotffotarenanxtiioeobtneys.eo,fiIstaainsshttp://p
m
tseicmoendhaarsyicnhvoalreicaybsltyecbteoemny edaosnieerinthaanfeownemownotuhlsd' raervuelaeltroeoceilnlttocogliicv,elaocdaeltiasieldedpahiins,totreyndwehrincehssw,oaunlddj.bm
expect, and the convalescence rapid and smooth. constipations against a background of previousj.c
Ithasinfactbeensmootherthan aftercholecystec- diverticulitis. The temperature at first is highom
tomy done a fortnight or three weeks after the (Ioo-o40F.) and there are the physical signs of a o/
acute attack has subsided. This latter is what rapidly spreading peritonitis which has its originn
many surgeons tend to do when the condition is in the left iliac fossa. Rigidity, which the gentlest M
obviously subsiding.. and most persuasive palpation fails to overcome,arc
If there is a patch of gangrene present on the hides the characteristic tumour lying parallel toh
faudnedquusa,teitpiasckailnwga,ystopodsisviibdlee,thaeftgearllabslpaidradteironbealnodw nPiosuepdartth'es ilniegvaimteanbtl.e coIfnseuqnutreenacteedisagnedneruanlrepceorgi-- 5, 20
this and to cut awayits walls up to where they are tonitis, the terminal phases of which was vividly23
attached to the liver. The remainder is then described by Hippocrates and even recognised by b
y
thoroughly coagulated with a diathermy button. Shakespeare-"I saw him fumble with the sheets. g
A drainage tube is tied into the stump and the . . .For his nose was as sharp as a pen and a'ue
wfohromlaelcocvheorleedcywsittehctoommeyntcuamn.beEdvoenne,iftahecopmaprltetoef babObpelreadtoifongrseheonulfdielbdes.i"mmediate and a plasma orst. P
the gallbladder attached to the liver may well be glucose drip transfusion is advisable. When thero
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Juwne, 1946 THE ACUTE ABDOMEN 155 os
tg
abdomen is relaxed the tumour can be felt, and recent case, diagnosed as diverticulitis, they were ra
this gives the clue both to the diagnosis and to taken out of reach and covered by a large fibroid, d M
an appropriate incision, which should preferably previously known to be present. e
d
be oblique, splitting or dividing the internal The diagnosis is often missed because the con- J
olebfltiqsuiedeanofdtthreansavbedrosamliinsamlusccalveist.y isThfeoupnedlvifusllanodf dOiuttionofissenvoetnwselulchreccaosegsn,isfeodurbywegreenetrhaolugshutrgteoonbse. : firs
evil, foul-smelling pus, but the actual perforation acute appendicitis, one a leaking ectopic gestation, t p
u
is seldom seen. The involved bowel should be and in two no exact diagnosis was made. b
wrapped with omentum, or, if this is impossible, There is usually no doubt that the abdomen lis
h
covered with a free omental graft. As much as oughttobeopened, andastheconditionisbilateral e
d
possible of the pus should be aspirated and the a median or paramedian subumbilical incision a
pelvis drained through a suprapubic stab wound. should be used, in fact these cases are almost s 1
Five to ten grammes of a sulphonilamide powder unique in that they are examples of lower abdo- 0
may then properly be put in the peritoneal cavity, minal infection which it is wise to approach from .11
though perhapsitisbetter addedto anintravenous the middle line. When the abdomen is opened no 36
drip. The wound should be sewn up with single attempt should be made to remove the tubes, /p
g
catgut stitches, leaving a drain at the lower end loculi in front of and behind the broad ligament m
which reaches the left iliac fossa-and the pelvis. should be gently opened and the pelvis drained. j.2
However desperate the state of the patient, Many gynaecologists would prefer a drain inserted 2.2
under no circumstances should he or she be sent through the posterior vaginal fornix. The prog-. 4
8
back to bed without some form of right-sided nosis is good if the operation is promptly and .1
4
transverse colostomy designed completely to divert rapidly carried out. 9
the faecal stream from the sigmoid. If time o
n
presses and anxiety for the patient's life dominates (II) Perforations 1
the situation, a large suprapubic drain through a J
u
small incision combined with a quick transverse The perforation of a gastric or duodenal ulcer is n
e
colostomy over a glass rod are good tactics and one of the most serious and imperative of all 1
may save a desperate situation. From then on surgical emergencies, but compared with manyco94
utislelfutlhewetaidpeonosf abraettlmeorbpehgiiansatnodtpurrons,titghmeinme,osta oLtihkeersthiet einstieraeslyytmoytdhiiacganlosCeelatnidn sKiimpplilneg'tsoptoreeamt,.pyrig6. Do
Ryle's tube and an intravenous drip, each used "One knows what he will do, and you can logicallyht.wn
with discretion and judgment. predicate his finish byhis start." Most perforated lo
Another condition which falls naturally into this ulcers are situated on the anterior wall of the ad
group and clinically very much resembles the last, pyloric antrum or duodenum. Ulcers on the ed
is an acute suppurative salpingitis. This arises in lesser curve or posterior wall are more likely to fro
an old and cold bilateral salpingitis of gonococcal penetrate the pancreas or liver. Most of them are m
or puerperal origin. From the bowel or blood chronic ulcers in which activity has recrudesced h
stream it gets reinfected with a virulent colon by a rapidly spreading infection beneath the ttp
bacillus which is sometimes accompanied by a callus edge. The condition has been described by ://p
streptococcus. The infection, after a brief and Bolton as the acute spreading ulcer. Occasionally m
relatively silent sojourn in the pelvis, spreads acute ulcers may perforate, especially when they j.b
m
trahpeidelayrlyansdtavgiersuloennetlsyidteootrheotlhoewrerbeaabrdsotmheen.brunItn aarbeuermnboolriacsienptoirciageinm,iat.he primary infection being j.co
of the attack, and it is by general surgeons often The base of a perforated ulcer is usually rigid m
mistaken for a perforated pelvic appendicitis or andfriable andshows signs ofrecent inflammation. o/
n
an acute perforative diverticulitis. As far as the This is reflected in the immediate history. As M
abdominal cavity is concerned, the peritonitis has Moynihan has pointed out, an ulcer very rarely a
an abrupt onset, and, unlike the conditions which perforates without giving some warning of the rch
it mimics, it is unheraldedbysvmptomsreferredto impendingcatastrophe. Painincreasesandtender- 5
the abdominal viscera, but a long-standing dys- ness is present although the patient may be too , 2
0
menorrhea and some symptoms referable to illtomentionit. Thatperforationmayoccurwhile 2
3
micturition or defaecation may obtrude themselves the patient is under treatment is not sufficiently b
into the clinical picture. It has, however, some well known, and more than one has been y g
invariable characteristics indicating its origin. "cooked" for twelve hours because the doctor or u
e
There is always a previous vaginal discharge and the house physician thought that an ulcer under a s
a bilateral tender mass in the fornices which corre- strict medical regime could not possibly perforate. t. P
sponds to the infected obstructed tubes. These Everyone is familiar with the sudden onset of ro
are not, however, quite always palpable, for in a a perforated ulcer. The resulting acute epigastric te
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P
156 POST-GRADUATE MEDICAL JOURNAL juxl,e, I946os
tg
pain is associated with boardlike upper abdominal abdominal emergency is delay more dangerous andra
rigiditywhichthenspreadsdownwards, moreto the it should never await the convenience of thed M
rightthantheleft,andgraduallybecomesgeneralised. surgical team for more than an hour or two. Thee
The pain is constant, widespread, and very severe, shortness of the time that elapses between per-d J
tdihfefewrianyg fitrommakcoelsictihneitpsatuinevnatryhionldg ihnitmesnesliftyquaintde feovreartyionotahnedr oppreorgantoisotnicovefracsthoard.owsThiinsimsptoartteamnecnet: firs
still. It is noticeable that respiration is almost perhaps has one exception of practical importance.t p
entirely intercostal, and although the rigidity is The outlook is bad if the patient has had a recentub
widespread, it reaches its maximum in the upper haematemesis, and the technique of closure shouldlis
h
abdomen. Such patients also only vomit once or beadaptedto prevent its recurrence. Blood inthee
d
twice in the early stages. What is not so often transfusionmay thenbeindicatedaswellasplasma. a
realised andneedsemphasisis, thatthetemperature The following figures serve to emphasise theses 1
is seldom raised, or even is a little sub-normal, facts. Of twenty-two perforated ulcers of the0
and that the pulse rate is frequently normal or stomach or duodenum, seven died. One of these.11
only slightly raised, though the volume may be a had a carcinoma, one was first seen eighteen hours36
little increased. These patients occasionally walk afterperforation, and two had had arecent haema-/p
g
into hospital. Only later does the pulse rate temesis. Of the remaining three, one had a sub-m
increase andcollapse supervene. Notwithstanding phrenic abscess, and two were too ill for anyj.2
all this, to an experienced eye, the patient nearly interference whatever. The first of these had a2.2
always gives the impression of having suffered a concomitant coronary thrombosis and the second4
8
good deal of pain. General toxaemia comes had perforated three days before admission. .1
relatively late and rigidity passes off as the irrita- As far as anaesthesia is concerned, perhaps it is49
tion of the concentrated gastric contents subsides here that cyclopropane or curari will easily come o
n
owing to dilution with inflammatory exudate. At into their own. They give rapid and immediate 1
the beginning of this stage the patient may even relaxation without anoxaemia. Local anaesthesia J
u
seemalittlebetter. Thenthetemperaturerises,heis canbeused,but painful impulses comefrom such an
e
flushed,andthepulserateincreases. Laterstill,pain, wide area that relaxation is difficult to obtain, but 1
rigidity and tenderness decrease as the long grey combined with gas, oxygen and ether, it is vecory94
spehraidtoonwitiosfscloolwllaypsoebliatnedratteosxtaheemioautldiuneestoofagecnleeraarl- ssaptiinsaflacatnoareys.thesEixac,epwtithinallspietcsioabllvyiousesleacdtveadntcaagseepyrigss,,6. Do
cut clinical silhouette. too often increases the percentage of respiratoht.rywn
One difficulty in diagnosis often arises. A complications. lo
perforatedduodenalulcermaydischargeitscontents The operative technique should be as simple asad
downtherightparacolicgutterandtheywillaccumu- possible. The essentials are a right paramedianed
late first in the right iliac fossa. As a result the incision, three widely placed catgut stitches, one fro
defense musculaire reaches its maximum here and just beyond each end of the friable ulcer base,m
acute appendicitis isclearlymimicked. Butnearly and one in the middle. These are tied, not tooh
always, in the history, the symptoms of a duodenal tightly, over a thick piece of omentum, whichttp
ulcer can be discerned building up to a sudden mayifnecessarybedoubled. Thenaspiratetheright://p
acute epigastric pain which leaves in its wake some kidney pouch and mop up anv obvious soiling.m
definite rigidity and tenderness over the upper Put a tube in the pelvis in most cases, and closej.b
part of the right rectus muscle. the peritoneum. When this has been done spendm
Of ancillary methods ofdiagnosis the most useful any time there is to spare in carefully cleansingj.co
is a plain X-ray which may show a bubble of gas and sewing up the abdominal wall. m
beneath the diaphragm. Thisismorereliablethan At this juncture a word should be said about o/
n
obliteration of the liver dullness, but neither of those cases of obvious general peritonitis which M
these findings is by any means constant. are admitted to hospital so ill that a history isa
Soon after the patient is admitted it is wise to unobtainable, and with such widespread rigidityrch
pass a Ryle's tube and by frequent aspiration keep that reliable assessment of its origin is impossible. 5
the stomach empty. If the patient is collapsed a Under these circumstances the only policy for a, 2
continuous plasma drip should be put up, the first surgeon to pursue is to emulate the bookmakers02
bottlebeingruninratherrapidly, forthesepatients and back the most probable winner. Appendicitis3 b
lose a lot of protein in the voluminous peritoneal is by far the most common cause of generaly
exudate which is literally poured out. When on peritonitis. Therefore a short incision should be gu
account of venous collapse the transfusion will not made either over the appendix or in the midlinees
run well, an occasional case may be saved by just above the pubis. If the pus is foul andt. P
using two veins at the same time. Operation stinking it probably comes from the appendix.ro
should be early and expeditious. In no type of If it is thin, slimy, and contains particles of foodte
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June, I946 THE ACUTE. ABDOMEN 157 P
o
s
it is probably due to a perforated ulcer. In either ofallthecases, andifthelower abdomen issuspect, tg
case the pelvis should be drained. It never does gives away the- diagnosi -"An acute appendix rad
any harm to make a short incision in the wrong with shoulder pain is a ruptured ectopic." M
place, but much harm is frequently done by an On pelvic examination one expects to find ed
attempt at exploration in the presence of sepsis generalised tenderness or a tender mass in one or J
tlihtrAtloneuougtnhheeaarsmilteyydpiweaintohfsiunabcutumhtbeeiclaiatcbeadlgooirmnyecinosfiowanh.ipcerhfofraaltlsiona osoaftlhpetirnhgeiftoicrsen.rivxi,Ixtbisiuntalstaohnicshaarinsatcetarelirsoio-sptofiscotuetnrhdiaotrwmiotdhvireeamccteuintoten : first pu
is a ruptured ectopic gestation. This is popularly causes asuddensharppainwhichmakesthepatient blis
supposed to produce a very clear-cut and charac- stiffen and catch her breath. h
e
teristic clinical picture. The patient misses a Acute appendicitis, acute salpingitis, and an d
period and a few weeks afterwards bleeds more early abortion are the three conditions which as
profusely and longer than she would expect from confuse the issue. The differences between rup- 1
0
her previous experience of menstruation. About tured ectopic gestation and acute appendicitis .1
the same time she is seized with severe abdominal have already been indicated. A mistake is not 13
pain, and on examination she has the other signs important and its worst consequence is ashort 6/p
of peritoneal irritation. The diagnosis is clinched incision in the wrong place. g
m
bfoyrntihxe. diMsycovecroylloefagauem,asMsr.in oRn.e oLr. otDhoedrdsv,agihnaals subWahceutne arcuuptteuresdalpeicntgoiptiics, itshrceeonfoursefdourwitdhays'a j.22
recently pointed out (Proceedings of the Roy. Soc. observation will settle the question; the salpingitis .2
4
Med., Vol. XXXIII, No. I2) that this is in fact a will invariably subside. 8
film version of a not very common tragedy, and Examinationunderanaesthesiamaybenecessary .14
its widespread acceptance results in the diagnosis to differentiate an early abortion. Tenderness and 9 o
being made incorrectly in about 70 per cent of all resistance is abolished and it is usually clear n
the cases. There are three good reasons for this whether the uterus or a Fallopian tube is the seat 1 J
otherwise deplorable state of affairs. Firstly, in of the pregnancy. u
n
the practice of a general physician or surgeon the Little needs to be said about treatment once the e
condition is distinctly rare. Secondly, the differ- diagnosisismade. Theabdomenshouldbeopenedc 19
ential diagnosis is often really difficult, andthirdly, in the middle line and the involved tube removed.op46
easmehragse aflrroemadyanbeaennalypsoiisntoefdtohuet,cltihniecaflacftisndtihnagts nAecbelssoaordy.traInfsfusstiroinctisanotfitseenptiwci*sepraencdaustioomnestimaersyrighe . Dow
are at variance with the average conception of the taken the patient's own blood may be used fot.r n
disease. The missed period, usually regarded as replacement. loa
the keyto the clinical puzzle, cannot be established de
tihnirjdusotfutnhdeemr ihtalifs mtaheskecadsesb.y tIhne mfaocrtethtahtanthea (III) Obstructions d fro
m
bleeding occurs just when the next period is due. Intestinal obstruction is by no means the most h
Only a wary cross-examination will elicit the fact frequent cause of an acute abdomen, but it has a ttp
tmhoartethperopfeursieodajnudstmboerfoereptrhoelopnagiend ctahmaenonusuwaals. hoitghheerrtyppeesrcoerndtinaagreilymomrettalwiittyhitnhsaunrgiacanlyproafctitche.e ://pm
Veryoccasionallythispseudo-menstruation appears That a large part of this mortality is preventable j.b
a week early. The pain too is without distinctive because it is due to delay in diagnosis will readily m
features. Itis felt typically in the lower abdomen, be conceded by anyone who has to deal with j.c
often more on one side than another, and when it many cases. om
appears it remains constant for some time; then There is a legend that elaborate classifications o/
there may be an interval of relative freedom. ofacuteintestinal obstructionare much beloved of n
This must be distinguished from colic, which examiners, and most surgical coaches have their M
a
reaches its maximum quickly and then fades with own favourite table of causes. These may indeed rc
equal rapidity. Sometimes the pain is generalised, form auseful framework for an examination paper, h 5
occasionallyitisreferredtotheepigastrium. There but they are not of much practical clinical im- , 2
is always tenderness, and as often as not more portance. When a clinician is confronted with a 0
2
rigidity than the intensity of the pain would seem probable case, these are the intensely practical 3
to warrant, but cases are seen with a lower abdo- questions he has to ask himself: by
minal wall which reacts to and resists the slightest (i) Is obstruction present or not? g
u
intrusion of an examining hand. Unlike appendi- (2) If so, is it in the colon or the small intestine? e
cpietriis,-umtbhiilsicaabldocomliincaalndpavionmiitsinnge.verShporuelcdeedredpaibny, of(t3h)eDbooewselit,waolrl,dooersiint nootthetrhrweoartdesn,tihseitinatcegcroimt-y st. P
sometimes quite severe, occurs in about one-third panied by vascular obstruction? rote
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158 POST-GRADUATE MEDICAL JOURNAL June, I946 P
o
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It is not possible to over-emphasise the fact that colicky painreferred to adistendedcaecummaybe tg
an answer to these questions is possible in nearlv the presenting symptom. In nearly all cases of ra
d
every case by simple clinical examination assisted large intestinal obstruction the ileocaecal valve is M
only by a plain X-ray of the abdomen, which may competent, so that vomiting is absent and the e
d
well be taken between the casualty-room and the small intestine is not distended. The colic is J
wcsaaorrmddei.tniamlNessoywmtpentidnoetmresns,teisnspa,alins,oybmvsotpmrtiuoctmtiisnogn,whdpiircsothdeunacsreiesoncfaoonmu-dr rsteehfeeenrortbeosdtcrtouoncttrtiahocnet,,saebngudmtetnthhtiesodfciosltithceenidsceondlootbnoswpoerlopxrmiolmaoaynlgbetedo : first pu
mon to every other type of acute abdomen. It is as when the small intestine is involved, as the blis
therefore obvious that their significance lies in relatively short colon distends rapidly, is soon h
e
their mutual relationships. paralysed, and so cannot contract. d
Pain.-The pain is due to intestinal colic. It is Occasionally, however, the ileocaecal valve is a
s
intermittent, cramping, reaches its maximum incompetent, and then the whole intestinal tract 1
0
quickly and retains its intensity only for three or becomes involved in the resulting distension. A .1
four minutes. Its onset and departure are both plain X-ray, taken in the supine position, will show 1
3
equally abrupt. The colic due to intestinal ob- the outline of a dilated colon down to the obstruc- 6
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struction is always accompanied by bubbling and tion. The jejunum is recognised by its "feathery" g
m
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," j.2
2
pyloric stenosis and obstruction at the efferent and has fewer cross markings. Fluid levels may .2
4
loop of a gastrojejunal stroma, this relationship is also be seen, especially if it is possible to take a 8
invariable and generallv establishes the presence of film in the upright position. (Figs. 3, 4 and 5.) .1
4
obstruction of some kind. Rigidity and guarding make it clear that trans- 9
o
Vomiting.-In all obstructions of the small udation is taking place through the bowel wall, n
intestine vomiting is present. It is frequently and, since this fluid is very irritating, it may even 1
J
copious because it comes from the regurgitation of cause shoulder pain. There is an occasional but u
n
the intestinal contents into the stomach. The important exception to this last statement. A e
higher the obstruction the earlier it appears and typical inflammatorylesion causingsimple obstruc- 1
c9
the less likely it is to be faeculant. It gives only tion may cause localised tenderness and rigidityo. 4
p6
dtiesmtpreosrsarsyinrceeliefmoorrenoflrueliideffartomallbteoltohwe pisatiaegnati'ns Tthheehdiissttoirnycttioontchaenpahsysaicraullesibgnes,maadltehobuyghreiltathiansyrigg . Do
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regurgitated into the stomach. This vomiting to be admittedthat this may sometimes be difficult.t n
tends to recur soon after a spasm of pain. or even impossible. It is, however, none the less lo
a
The vomiting of pyloric stenosis relieves the important, because hasty interference in such cases d
e
patient for the time being and, except in the very usually results in spreading the infection, and not d
early stages before the stomach is dilated, is pain- infrequently in the death of the patient. Suction, fro
less. The vomiting due to biliary or renal colic is with a duodenal tube, at least for some time, is m
ntaholletevnciaoatptuiirooenus,oofficstohnevteiprnaytuioeeunxsth'arsueststucifhnfiegnr,ginwga.hnidcFhiosbrrmironergaessonniosn tpahteOinecneotr'orstechlitefre.tqrueeasttmieonnt,noawnddenomtansdesldcoomnsisdaevreastitonh.e http://p
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wobhsitcrhucwtiilolnboef tdhiesccuoslsoenddloatneortmvoosmtit.patients with oIsbsttrhuectoibonstriuncttihoenlacrogmeplinetteestionre nisote?vidCeonmcepdlebtye j.bm
Distension.-Distension is visible or palpable in absolute constipation (after an enema) and rapid j.c
most cases and can always be demonstrated by a distension of the colon. o
m
pGreonptelrelypaltpaakteinon pwliatihn aX-wraarymohfantdhemaaybdodemteenc.t indIincattheed bsmyaltlheinatbessetnicnee cofomgpalsetien tohbestreuvcatciuoanteids on/
the smooth, tense outline of a coil of small bowel, colon andin the coils belowthe distendedloop. If M
or general distension may be obvious. the obstruction is incomplete a second film will arc
The "ladder pattern" illustrated in textbooks is demonstrate its re-accumulation after evacuation h
sinotelraetset.a maVniisfibelsetapteiroisntatlhsaist,itwhhiacshlimttaleyrebaelcsleiennicianl byHaanvienngemae.stablished in this way the fact of 5, 20
thin abdomens. apart from obstruction, is of obstruction, its probable cause has to be deter- 23
immense diagnostic importance when it is asso- mined. It is manifestly impossible in an article of b
y
ciated with colic. this kind to consider in detail each variety; this is, g
In obstruction of the large intestine the colon is moreover, adequately done in all standard text- ue
Ealvweanyswidtihsteonbdsetdrucatnidoncaonf tuhseualdliystable cpoallopnatetdh.e eboxocklsu.dedItstirsasnugffuilcaiteendt thoersnaiya,thaatn,dhianvipnagrtciacruelfaurllay st. P
caecum is the first to dilate, and in the early stages Richter's hernia, the most probable cause of small ro
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