CHAPTER XXXVII DIAGNOSIS OF ACUTE ABDOMINAL (Part 1)

CHAPTER XXXVII DIAGNOSIS OF ACUTE ABDOMINAL AFFECTIONS There are several acute affections of the abdominal viscera, the symptoms of which are so closely alike that they can only be distinguished by great care. The symptoms common to this group of diseases are abdominal pain, vomiting, and collapse ; they come on with more or less abruptness and with varying degrees of intensity. The causes may be — Appendicitis. Displaced kidney. Ruptured gastric oi' duo- Torsion of spleen. denal ulcer. Intussusception. Ruptured tubal pieg- Internal hernia. nancy. Volvulus. Torsion of ovarian tu- Gall-stone impacted in in- mour. testine. Ruptured pyosalpinx. Intestinal colic. Ruptured ovarian tu- Acute pancreatitis. nrour. Mesenteric thrombosis. Acute or gangrenous Diaphragmatic pleurisy. cholecystitis. Gastric crisis of tabes dor- Ruptured gall-bladder. sails. Ruptured hepatic abscess. Acute osteo - myelitis of Renal colic. spine. Cortical abscess of kidney. To distinguish between these various affections attention should be paid to the following points : i. The paiu.— (a) 3Iocle of onset, whether sudden or gradually increasing in intensity, whether constant or intermittent, whether coming on spontaneously or during some effort, (b) Time of onset, at what 525 526 SURGICAL DIAGNOSIS [chaf. period of the day or night, its rehition to food and exercise, (c) Seat, where first felt, where it subse- quently becomes localized, and especially the direction ill which the pain shoots, {d) Character of the pam whether griping, burning, cutting, or nausea: mg, and whether it is modified by position, movement, or respiration, (e) Tenderness, if present and where, whether localized or diffused, slight or intense. Sudden intense pain is characteristic of ruptured ulcer, appendicitis, ruptured tubal pregnancy, rup- tured pyosalpmx, rup.ured gall-bladder, and may be met with in intussusception. Pam that very quickly becomes intense is met with in renai and biliary colic, twisted ovarian tumour, mtussiisception, and diaphragmatic pleurisy. The pain of mtestmal . colic internal hernia, volvulus, displaced kidney, and 'torsion of the spleen more slowly reaches its greatest intensity. It is a striking fact that appendicitis comes on very frequently in the early hours of the morning while the patients are quietly sleepmg : there is no other acute abdominal affection m which this is so frequently the case. If a patient goes to bed feeling quite well and is aroused about 2 a.m. by acute pain about the umbilicus and then vomits it IS nearly always due to the onset of appendici is. Appendicitis, however, may come on at any other time Renal colic almost always comes on durmg the day, and during or shortly after -^^^^ Biliary colic is prone to come on dunng the latjci pait of the day, or after a full m al. Rupture of a gas- t, ic or duodenal ulcer is nmst likely to come on soon after a full meal, and durmg some effort. Rupt r. of a tubal gestation occurs m the dayt:mo a generally dunng some effort. Torsion of an ovat an tumour o of the spleen and nnsplaccment of the XXXVII ABDOMINAL PAIN 527 kidney nearly always occur during the active move- ments of the daytime. Internal hernia and volvulus also come on during active movement. Many acute abdominal pains are first felt at or near the umbilicus, and this is especially true of appendicitis, pancreatitis, internal hernia, intussus- ception, gall-stone impacted in the intestine, and some cases of ruptured ulcer. In some of these cases the pain soon leaves this region : in appendicitis, for instance, it passes down into the right iliac fossa, and in ruptured ulcer it becomes more diffused over the abdomen. Pain beneath the upper part of the right rectus muscle, passing round the right half of the trunk, with tenderness just below the tip of the xiphoid cartilage and at the upper end of the right semilunar line, is characteristic of biliary colic. Pain in the loin and below the false ribs, shooting down into the groin, hypogastrium, penis, testicle, or thigh, is characteristic of renal colic. This may be accompanied by great local tenderness, or may be relieved by firm pre -sure over the kidney. Pain about midway between the umbilicus and xiphi- sternum is often due to rupture of a gastric ulcer ; the pain may be farther to the left ; that of duodenal ulcer is a little to the right of the middle line. The pain of a ruptured tube is felt below the umbilicus, often close above the pelvis ; it may be median or to one side. The pain of a twisted ovarian tumour, spleen, or misplaced kidney is over the part, is always accompanied by local tenderness, and in the case of the kidney is always relieved by lying on the back, especially if to this is added gentle upward pressure below the tumour. A twisted spleen may be simi-- larly reliexed ; while this is always on the left side, a painful displaced kidney is nearly always on the right side. 523 SURGICAL DIAGNOSIS [chap. The pain of a ruptured ulcer is usually described as of a hot, burning character, often agonizing m intensity, and some patients speak of a sensation as of hot liquid flowing down the abdomen, ihe pain of biliary colic varies in intensity, but is gener- ally a sense of constriction, as if the right side were tightly gripped or held in a vice ; it is usually telt acutely in tlie back, and sometimes also in the right shoulder. The pain of renal colic is a sharp, cutting, lancinating pain ; that of displaced kidney, twisted spleen, or ovarian tumour is a gradually intensifying ache The pain of ruptured gestation is less severe than the others; it may be almost momentary. The pain of intussusception and volvulus is griping in character and intermittent ; intestinal cohc is also griping, intermittent, referred to the umbdicus, and relieved by pressure. The pain of diaphragmatic pleurisy is felt with each deep inspiration, especially at the end of the act, is sharp, shooting m character, and passes round the side or sides of the trunk to the front, usually about the level of the umbilicus ; it may be so severe that the patient feels as if held in a vice on both sides. The tenderness at or near McBurney's spot is a feature of appendicitis ; tlie exact seat of perforated ulcer is often tender, but the difltused tenderness of acute peritonitis quickh foUows ; intussusception is tender only durmg tiie paroxysms of pain ; there is some tenderness over a tight internal hernia and over a gall-stone impacted in the bowel. The pain of acute pyosalpinx ma; closely simulate that of appendicitis, but it is generally more above the pubes than in th il ac fossa, and as severe on the left side as on th. Vomili..n— (") Time and M''ency. ^f^^^ ■ ad of- vomiting accompanying the onset of acute pam xx.KVii] ACUTE ABDOMINAL AFFECTIONS 529 is of no diagnostic significance : it is a symptom common to all severe abdominal disasters — the per- foration of a viscus, the torsion of a pedicle, the first invasion of the peritoneum, the acute displacement of a viscus — and it may occur at the very commence- ment of a pleurisy. Frequent and repealed vomUhig is met with in any form of intestinal obstruction, in acute peritonitis, in renal and biliary colic, and in acute pancreatitis, {h) Character of the act. In renal and biliary colic, vomiting is attended with nausea and much retching ; in intestinal obstruction and in the later stages of peritonitis there is no nausea, and the act is little more than a regurgita- tion from the stomach, coming on independently of taking food, (c) Vomited matters. In perforation of a gastric ulcer a little bright blood may be mixed with the food ; in colic, or torsion of a viscus, or appendicitis the vomit becomes bilious ; in peritonitis it becomes dark brown or black and fiocculent from admixture with altered blood ; in intestinal obstruc- tion it is alkaline and consists of the regurgitated contents of the bowel ; the longer the obstruction lasts, and the more acute the symptoms, the lower down the bowel the vomited matter comes from. Regurgitant vomiting is often incorrectly spoken of as "fjecal"; it is really feecal only in the late stage of obstruction in the large bowel, or in cases of ulceration between the colon and the stomach. 3. Collapse. — Besides the intensity of the col- lapse, which is a measure of the gravity of the catas- trophe, the time of onset, its progressive increase, and the coexistence of marked anjemia are the points especially to notice. Severe initial collapse most often occurs in perforation of a viscus — stomach, duodenum, appendix, tube, gall-bladder. Increasing collapse may be caused by pain, as in severe renal or 530 SURGICAL DIAGNOSIS [chap. hepatic colic, or by ha3morrhage, as in ruptured tubal gestation. Collapse comes on late in intestinal obstruction and peritonitis. The subjects of gastric ulcer may be anaemic from a previous hasmorrhage, and this fact may aid in the diagnosis ; but if a patient becomes blanched during the acute illness, with all the cigns of acute anosmia, it is strong evidence in favour of a ruptured tubal gestation. It is important to remember that the collapse caused by apparently similar' Lsioiis may vary widely — a perforated ulcer may cause almost instantly fatal collapse, or only trivial and fleeting shock ; the same is true in greater or less degree of the collapse from intussusception, internal hernia, colic, and appendicitis. In cases of ruptured ulcer and appendicitis there is often a misleading calm following a temporary collapse and preceding the development of peritonitis ; in acute pancreatitis the collapse is always pronoimced. 4. Pulse aud lempciaturc— The frequency and loss of tone m the pulse depend chiefly upon the severity of the abdominal disaster and not upon its seat or natu . As a rule, the puis: is much less ali'ected by acute salpingitis than by acute appendi- citis, while it may very rapidly become uncountable at the wrist in a case of ruptured tubal pregnancy with severe hajmorrhage. The temperature is less trustworthy as a guide to diagnoiis than is the puL^de—it IS lowered in shock from a ruptured viscus and in severe haemorrhage ; it is raised in intiammations, but it may be normal or subnormal in some of the worst cases of gangrenous appendicitis. 5. IJiyidity oi the abdomiual wall and sus- pension of abdominal respiration is invariably a serious symptom. It is the muscular rehcx ex- pression of peritoneal hypera3.sthesia, and is seen eipecially in ruptured ulcer, appendicitis, ai.d pc:i- XXXVII J ACUTE ABDOMINAL AFFECTIONS 531 tonitis. The hard retracted abdomeu of lead colic is well known; but in biliary, renal, and common in- testinal colic, in intestinal obstruction, in twisted viscera before the onset of peritonitis, and in rup- tured tube it is not so marked. It may be well marked in diaphragmatic pleurisy owing to the intense pain caused by any descent of the dia- phragm. Difference in the rigidity of the abdominal wall above and below the navel, or on the two sides of the abdomen, is to be carefully noted : when localized it indicates a lesion beneath the immobile part. This sign is often present in appendicitis, biliary colic, ruptured ulcer, and ruptured tube. Ab- dominal rigidity is the most constant of all the symptoms of peritonitis, but even this is very oc- casionally absent in this disease, whose symptoms vary so much. There is usually an absence of muscular ligidity in acute pancreatitis. 6. Tumour. — The abdomen should be carefully and gently examined for a tumour, and the exact position, shape, size, and tension of any tumour found noted, together with its relation to the reson- ant viscera. By this means an ovarian tumour may be found rising up from the pelvis — lying perhtCps in# one iliac fossa if small, and, if on the right side, simulating the swelling of appendicitis; it will be noticed, however, immediately at the onset of the attack, and not gradually formed as in appen- dicitis. If the cause of the trouble is torsion of its pedicle, the ovarian tumour will be tense and tender, and it will increase in size. If, however, rupture of an ovarian cyst is the accident that has occurred, the tumour will be smaller than before, less tense, not especially tender, and there will be signs of free Huid in the peritoneum. An ovoid or globular, tense, tender tumour in the right loin or iliac fossa, which 532 SURGICAL DIAGNOSIS [chap. can be pushed up beneath the false ribs with relief to the patient, will be recognized as a renal tumour. An ovoid tumour, tense and tender, in the left side of the belly, beneath the rectus, may be the s-pleen with torsion of its pedicle ; if a notch can be felt in one edge, or if it can be reduced beneath the left false ribs, this diagnosis will be confirmed. A rounded, tense swelling beneath the upper part of the right rectus muscle, extending up to the costal margin, moving with the descent of the diaphragm, tender, dull on percussion, will be recognized as a distended cjall-hladder. A tumour which can only be felt at times, hardening under the fingers, and associated then with pain, tenderness, and perhaps nausea and vomiting, is iniesiinal. In the intervals between the active peristalsis which makes it readily palpable, little or nothing can be felt, and there may be neither pain nor tenderness. It may be evidently an intussusception, or a greatly distended coil of intestine from volvulus, or several such coils from some other form of intestinal obstruction. Intussusception is more often felt near the centre of the abdomen; a volvulus is especially frequent in the left iliac fossa. A tumour just rising up over the brim of the pelvis may be a tubal gestation or a fyosalinnx. An ill-defined, slightly tender swelling deep in the abdomen may be an internal hernia. A considerably distended ap'pendix may sometimes be felt in the right iliac fossa at the very outset of the acute illness; later on in an attack of apfendicitis with circumscribed peritonitis a firm, tender, fixed swelling will be recognized in the lowest part of the right iliac fossa, on its inner or outer side, or reaching up towards the loin. Some fullness at the epigastrium may be all that is noticed in acute fancrealilis. XXX VII] ACUTE ABDOMINAL AFFECTIONS 533 7. Pcreussiou results. — Four points are to be investigated : (a) Free gas in the peritoneal cavity due to per- foration of some part of the alimentary canal. If quite small in amount it is generally shut in close around the perforation, and gives a very tympanitic note at that spot, e.g. the epigastrium, or right iliac fossa. If more abundant it will separate the liver from the surface and diminish or abohsh the normal liver dullness ; it will then give the bell-sound on auscultation. It must be borne in mind that a dis- tended transverse colon will push up and narrow the area of liver diUlness. When it is plain that there is free gas in the peritoneum, it is a very important sign of perforation of stomach or intestine. (6) Free fluid in the peritoneal cavity at the onset of the acute illness is evidence of rupture of a cyst or of hfemorrhage, or possibly of the escape of a large amount of liquid from the stomach, duodenum, or gall-bladder. The dullness from hasmorrhage due to a ruptured tubal gestation appears first just above the pubes, then extends into the iliac fossaj and the loins. Dullness from a ruptured ovarian cyst is in each loin, unless adhesions limit it to one loin. The contents of a ruptured gall-bladder pass chiefly into the right loin. The contents of the stomach escap- ing from an ulcer on the anterior surface pass mostly into the left loin ; food escaping from a perforation in the left end of the stomach may cause dullness beneath the left false ribs ; chyme escaping from the duodenum passes chiefly into the right iliac fossa ; a perforation of the posterior wall of the stomach may distend the lesser sac of the omentum and cause an area of dullness in the central rcgior.s of the abdomen, with resonance all around it. (c) Tympanites, or accumulation of gas within tlio 534 SURGICAL DIAGNOSIS [chap. alimentary canal, may be general, and indicate a widespread x^eritonism or peritonitis or an obstruc- tion low down. Or it uuiy be local as in acute dilatation of the stomach, a large volvulus, or a local peritonitis. An internal hernia is less resonant than the surrounding intestine. [d) Local dullness indicates either a collection of fluid, of food, of blood, or of pus, the displacement of a solid organ, or the presence of a tumour. 8. Pelvic examinaliou is especially important in women, as it enables ns to recognize the swelhng of a tubal gestation or of a pyosalpiux in one or other broad ligament, and the tense swelhug of a rotated ovarian tumour, especially when this is so small as to be mainly a pelvic tumour. In both sexes we can occasionally feel an enlarged appendix on the right side, or, later on in the case, the fixed tender swelling of a pelvic periappendicular abscess In cases of intestinal obstruction high up, empty coils of small bowel may be felt filling the fossa in front of the rectum, and when felt they are very important evidence of obstruction. The finger in the rectum, too, can feel blood fiUing out Douglas s fossa, or appreciate the acute tenderness caused by pelvic peritonitis. 9. Previous history.— The previous history of the patient is often of great importance, and should always be inquired into. (a) Sex.— Not only are certain of the attections