CHAPTER XXXVII DIAGNOSIS OF ACUTE ABDOMINAL (Part 2)

we are considering— tubal gestation, pyosalpinx, and twisted ovarian tumour— limited to the female sex, but l)iliary colic, rotation of spleen, and dis- placement of the kidney are more common m women than in men ; acute pancreatitis, ] erforation of a duodcii.il or gastric ulcer, and renal colic are more coninioji ill juen. xxxvii] ACUTE ABDOMINAL AFFECTIONS 535 (b) Age. — Appendicitis may occur at any ago, from infancy to extreme old age, but it is most common in children and adolescents, and is by far the most common cause of sudden abdominal illness at this period of life ; indeed, it is almost the only cause in boys and young men. Rupture of a gastric or duodenal ulcer is common between the ages of 25 and 50, and occurs in men more commonly than women. Ovarian tumours may l)e met with at any age, and even girls before jjuberty may l)e the subjects of rotation of the pedicle. Tubal gestation is, of course, hmited to the child-bearing period of life, and pyosalpinx is chiefly met with in young adults. Biliary colic may occur in children, but is most common at and after middle life, and intestinal obstruction from an impacted gall-stone is almost limited to middle-aged women. Acute intussusception is chiefly met with in young ciiildren, and internal hernia is met with at an early age. Kenal colic is most common in middle-aged adidts. Speaking broadly, then, we may say that an acute abdominal illness is most probably due in children to appendicitis or intussusception ; in adolescents, to appendicitis, internal hernia, or rotated ovarian tumour ; in young women, to appendicitis, ruptured tubal gestation, or pyosalpinx ; in 3^oung men, to appendicitis or internal hernia ; in middle-aged women, to appendicitis, ruptured tube, ruptured ulcer, biliary colic, or displaced kidney or spleen ; in middle-aged men, to renal colic, lead colic, aji- pcmlicitis, ruptured duodenal or gastiic ulcer, or pancreatitis. (c) Occupation. — Workers in lead are liable to severe intestinal colic ; the gums should be examined for a blue line. Acute pancreatitis is commoner in stout alcoholics, such as barmen, brewers' draymen etc. 536 SURGICAL DIAGNOSIS [chap. {d) Previous condition— Under this heading there are three or four important points. Inquiry should j first of all be directed to the existence of slighter ! symptoms of disease before ; the existence of even slight previous indigestion may serve to indicate the cause of a sudden severe abdominal illness. Thus | a previous attack of appendicitis, or the occurrence of sudden sharp fleeting pain in the right iliac fossa, woidd indicate a diseased appendix. Pain soon after food, relieved by vomiting, and perhaps hsemat- j emesis, would be evidence of gastric ulcer. If the pain has come on from one to two hours after food, has been relieved for a time by taking food, and especially if there has been melsena with or without ha3matemesis, it will mdicate a duodenal ulcer. Flatulent dyspepsia with pain— often severe pain, called "the spasms "—coming on after meals, especially in the latter part of the day, and referred to the upper part of the abdomen, and more especially on the right side, and to the right shoulder, would be evidence of the existence of gall-stones ; fm-ther corroboration is often afforded by the patients say- ing they have sufiered from a feeling of constriction in the upper abdomen — leading a woman to remove her corsets, for instance. A history pointing to the presence of gall-stones, or of chronic indigestion with obesity and chronic alcoholism, is often met with in cases of acute pancreatitis. In some cases of internal strangulation the patient gives a history of previous attacks of colic, or of slight fleetmg obstruction ; but in many cases there has been no premonitory symptom of any kind. Pre\aous prick- ing, or more severe, pain in one loin, possibly shoot- ing down the side, or " neuralgia " of the testicle, or hsematuria, or frequent micturition would suggest the presence of a stone in the kidney. A loose kidney xxxvii] ACUTE ABDOMINAL AFFECTIONS 537 or spleen has almost always caused slighter attacks of the same kind before a severe attack of pain comes on. This does not hold good of rotation of an ovarian tumour — there may have been no previous symptoms whatever, in other cases the tumour has been large enough to be noticed ; in cases of rupture of an ovarian tumour the abdominal swelling has always been previously noticed, and usually has been of great size. The existence of a tumour beneath the upper part of the right rectus muscle has some- times been noticed before the onset of symptoms due to rupture of gall-bladder. In women of child- bearing age special inquiry will be made in refer- ence to the catamenia, previous pregnancies, irreg- ular uterine haemorrhages, vaginal discharge, aiid pelvic pain ; tlie breasts must be examined for signs of pregnancy. Tubal gestation may occur in a first pregnancy, but it ratlier frequently follows upon a period of sterility in a married woma)i. One or more missed periods, or a very slight loss at the time when the period was due, are significant signs of tubal pregnancy. The breasts may show no, signs of pregnancy, but if they contain milk, or the areolae are dark, these would be valuable indications of pregnancy. A purulent vaginal dis- charge and pelvic pain would suggest the presence of pyosalpiux. A previous abdominal operation is an important point ; It may have left adhesions, causing kink- ing or strangulation of the bowel. After a recent operation a deep abscess may have suddenly extended or burst. 10. Action of bowels.— With the oncoming of acute appendicitis there is often one, sometimes there are two or three loose evacuations from the bowel In acute intussusception there is frequent straining 538 SURGICAL DIAGNOSIS [chap. at stool, and tlie passage of mucus and blood ; this may occur with each paroxysm of pain. In vol- vulus the patient may make wholly inefiectual, straining efforts at defsecation during the paroxysms of pain. The absolute constipation of acute intes- tinal obstruction of all kinds is characteristic. The previous and existing constipation attending lead colic is, of course, to be noted. Bloody, very putrid stools are suggestive of mesenteric thrombosis. 11. The uriuc. — Frequency of micturition is often associated with renal colic. The urine may contain blood, or crystals of uric acid or oxalate of lime, in renal colic ; if it contains much indican it shows that there is intestinal obstruction. The detec- tion of lead in the urine would support a diagnosis of lead colic. 12. Bloocl-eounl.— The effect of a severe htenior- rhage will be shown in a marked diminution of the number of red cells, but unless the bleeding is severe, and therefore recognizable by other signs, the change will not be so pronounced as to be of diagnostic value. Polymorphonuclear leucocytosis is met with in acute and in gangrenous appendicitis, m pyo- salpinx, cholecystitis, pancreatitis, and in peritonitis from any acute infection; it is not found in the early stage of a perforated ulcer, ruptured tube, or rotated viscus, nor in renal, biliary, or lead co ic. But if the toxa3inia is so severe as to inhibit tins reaction, as in some of the worst cases of gangrenous appendicitis, leucocytosis is absent. 13 Examiuatioirol the chcst.-In any case of acute abdominal pain in which the symptoms oi disease in the abdomen are equivocal, or the char- acter and rate of the respiration suggest disea c ot the lungs or pleura, the chest should be caic. examuuxl for abnormal dullness, ^nction, alteration xxxvii] ACUTE ABDOMINAL AFFECTIONS 539 iu the intensity and character of the breath-sounds, and for crepitation. At the onset of pleurisy or pneumonia the typical physical signs may be absent. 14. X-rays. — Urinary calculi, miless consisting of pure uric acid, can be shown in a skiagram, and under favourable circumstances a very good skia- gram wiU show certain gall-stones and appendicular stercoliths — ^those that contain lime salts. The out- line of the kidney, spleen, and liver, and of uterine, ovarian, and gall-bladder tumours, as well as of abscesses, can also be seen. In most cases there is no time or opportunity to get a sufficiently good skiagram to be of real value in the diagnosis. 1-5. Nervous pheuomena. — Inquire for a history of "lightning pains" in the legs, and of ataxy. Test the knee-jerks, and the reaction of the pupils to a bright light. If gastric crises occur at ail in a case of locomotor ataxy, they are usually recurrent. It is impossible to exaggerate the need for care in this class of case, if on the one hand the golden moment for treatment is not to be lost, and on the other hand the patient is to be saved from an uncalled-for operation. Special attention should be paid to the suddenness of the onset of the illness, to signs of grave interference with function, to physical evidence of severe lesion, to the history of previous ilhiess, and to the assured absence of signs of pulmonary or spinal-cord disease. It is not possiljle to represent all the many combinations of symptoms that may be met with, but it may be useful to state broadly the evi<leiicc ou which a dia(jiiosis is arrived at in a large number of cases. 540 SURGICAL DIAGNOSIS [chap. 1. When a patient is seized with sudden pain at the epigastrium, which soon passes down into the right iliac fossa, and is associated with tenderness in the iliac fossa from the first, the case is one of acute appendicitis. If the attack comes on in the early morning hours, and in one who appeared to be at the time quite well, or had sufiered previously either from appendicitis, or slight occasional sudden pains in the same region, the diagnosis is still more certain. There may be vomiting, and one or even more loose motions, at the outset of the illness. In some cases there is very sHght, or no tenderness in the right iliac fossa, but there are found tenderness and some muscular rigidity in the right loin, or on rectal examination tenderness is elicited by pressure on the right side of the pelvis, or pain is produced when the hip is fully rotated inwards whereby the obturator intern us muscle is stretched. Having arrived at this diagnosis, the surgeon may further endeavour to de- termine what form of the disease he has to deal with. If the initial symptoms are very severe, especially if the pulse-rate is high, and vomiting persists, if the facies is " abdominal," the abdomen motionless, and there is no swelling or lump to be made out m the iliac fossa, loin, or pelvis, it is a case of gangrenous or perforative appendicitis! Marked leucocytosis at the onset of the attack would confirm this diagnosis. The development of general peritonitis, if the case is seen later, would only too cogently confii'm the diag- nosis. The temperature may be normal, subnormal, or raised ; it affords no aid to the diagnosis. If quickly after the onset of the pain a swelling or circumscribed resistance can be made out around tlic appendix, and if muscular rigidity and tender- ness arc limited to the right lower quadrant of the abdomen and the tcmperatui'e is raised, the pulse XXXVIl] APPENDICITIS 641 is moderately quickened, aud there is moderate leucocytosis, there is a circumscribed plastic peritonitis around tlie appendix. When in such a case rest in bed has been followed by a gradual improvement in all the symptoms, resolution has set in. But when the swelling persists — still more if it increases — and the pain and the tenderness grow more acute, and blood-counts show an augmenting leucocytosis, and the temperature rises, especially if it rises after previous lysis, there is suppurative appen- dicitis or a periappendicular abscess. Surface redness and oedema, or even distinct pointing, may rhake this condition very evident. Rectal tenesmus with proctorrhea — a discharge of a large quantity of mucus from the rectum— is often a sign of an abscess near, and about to burst into, the rectum ; and very frequent and very painful straining mic- turition may indicate an abscess near and involving the bladder wall. As a rule the pulse-rate rises with the occurrence of suppuration, but exceptions occur. The abrupt onset of appendicitis usually serves to distmguish it from local tubercidosis, which in other features may resemble it. When the case is first seen the signs and symptoms may be those of general peritonitis, and the diagnosis of the causative appendicitis will rest upon the history of the situation of the initial pain, or of previous mild attacks. 2. If a patient is suddenly seized with severe epigastric pain shortly after a meal and while maldng some slight effort, with perhaps an imniecUate act of vomiting, and collapse is well marked, and on exam- ination the upper abdomen is immobile, rigid, very tender at the epigastrium, perforated ulcer' may be diagnosed. A distinct liistory of gastric ulcer a httle blood in the vomit, the demonstration of free 642 SURGICAL DIAGNOSIS . [chap. gas in the peritoneum, the absence of all tenderness in the right iliac fossa and of swelling in the pelvis, will support the diagnosis of perfofateil gastric ulcer. If the same symptoms— pain, vomiting, collapse —come on two to three hours after a meal, and particularly if the patient is a man who gives a history of duodenal dyspepsia, and the seat ot greatest tenderness is to the right of the midcUe line, a ^^erjorated duodenal ulcer may be diagnosed. Pelvic examination as a rule reveals m both these conditions acute tenderness due to early inflam- mation of the pelvic peritoneum set up by the free gastric or duodenal contents. 3. If a woman of child-bearing age is suddenly seized with severe pain in the hypogastrium, becomes faint, then vomits, and on examination acute tender- ness with or without a sweUing is found in one broad ligament on rectal or vaginal examination, and she has become blanched and anaemic since the pam came on, and there is a history of one or more missed periods, with perhaps some irregular uterine haemor- rhage, a diagnosis of ruptured tubal gestation may be made. If free fluid is demonstrable in the peritoneal cavity, or if the breasts show signs of pregnancy, the diagnosis is made clearer. 4. If a young girl or woman who is seized witli sudden severe pain in the lower abdomen, vomitmg, ' and more or less collapse is fomrd to have a tense, tender tumour in the lower abdomen, it is probab y an ovarian cyst with twisted pedicle. If it as movable at all or is wholly within the abdomen, or of large size, or with evident fluctuation, tins diagnosis is established. . , - <, A small ovarian cyst, the size of a hen s egg or a lemon, connected with the riglit ovary, .on its pedicle is twisted may come to lie m the riglit Hiac XXXVIl] OVATIIAN CYST 543 fossa, and closely resemble an appendicitis tumour. It occupies the same position, is equally tender, the belly-wall over it is motionless and rigid, the tempera- ture and pulse are raised, there may also be vomit- ing and constipation. A diagnosis can be arrived at if the tumour is noticed at the very commence- ment of the illness, or if it is found to be movable within the abdomen, to be very tense and to have a well-defined outline. In a doubtful case examina- tion under an auiEsthetic would reveal its mobility aud establish the diagnosis. 5. If, in a young or middle-aged woman who complains of acute abdominal pain, and is feverish, there is found a pelvic swelling, seated in one or in both broad ligaments or behind the uterus, fixed to the uterus, which is partially fixed by the swelling, and pain is produced by attempts to move the uterus, and if there is evidence of purulent vaginal discharge^ it is a pyosalpinx with actual or threatened rupture or extension of inflammation to the peritoneum. Similar pain and fixity with pain on movement of the uterus without a definite swelling suggest acute salpingitis. In both these conditions the tempera- ture may be high, but as a rule the increase in the pulse-rate is much less than with the same degree of fever caused by appendicitis or peritonitis. 6. If a woman known to have an abdominal tumour, or possibly only known to have a prominent, tense abdomen, when making some eSort or move- ment experiences pain in the belly, vomits, and be- comes somewhat collapsed, aud on examination the tumour ]s seen to be less prominent, or a flaccid tumour, or a flaccid part of a tumour, is found and there is free fluid in one|or both loins, the diagnosis of ruptured ovarian cyst is justified. 7. When a patient of middle age who has for a 544: SURGICAL DIAGNOSIS [chap. long time suffered from " spasms " or flatulent dys- pepsia, with pain especially in the right hypochon- drium, is seized with severe cramping pain at the epigastrium, passing round the right side to the back and light shoulder, with a sense of severe con- striction in this region, vomits repeatedly, and be- comes collapsed, and there is found acute tender- ness in the middle line a little below the xiphoid cartilage, it is biliary colic. There may be a history of similar previous attacks with the finding of gall- stones in the motioDS, or there may be tenderness over the gall-bladder, or signs of a distended gall- bladder, to confirm the diagnosis. Jaundice with clay-coloured stools and bile in the urine may come on if the stone passes into the common bile-duct, or if inflammation extends fi'om the cystic to