THE ACUTE Postgrad Med J: first published as 10.1136/pgmj.22.248.149 on 1 June 1946. Downloaded from By H. W. S. WRIGHT. M.S., F.R.C.S. "Our Natures are the Physicians of our Diseases."-Epidemics, VI. 5. "Those Diseases that Medicines do not cure are cured by the Knife."-Aphorisms, VII. 87. HIPPOCRATES. The may be defined as an It is not proposed in this article to describe in intra-abdominal lesion which, apart from appro- detail abdominal conditions which are adequately priate treatment, immediately threatens the life of dealt with in all standard textbooks, but rather to a patient. In England, with a population of analyse their symptomatology and its mechanism in nearly 42 millions, considerably more than I2,000 such a way that a clinical pattern emerges quite people die annually from what is called "an acute simply from a mosaic of apparently unrelated abdomen." The annual crude death4ate from symptoms, and to show that the treatment sug- is 62 per million, and from gested is a logical sequence to pathological findings. and intestinal obstruction IO9 per million. In greater The symptoms and signs which give evidence of London, with a population of nearly nine million an acute intra-abdominal lesion are as a rule few persons, at least Io,ooo per annum are -admitted and simple. They are pain, superficial and deep with a diagnosis which implies a major abdominal tenderness, rigidity, and . With these are catastrophe. Because they are incomplete, these associated the general effects of the lesion on the figures underestimate the magnitude of a problem whole organism, such as temperature changes, and which claims a large and important share of every alterations both absolute and relative, in the surgeon's time and attention. It would be sur- composition of the blood and urine. The integra- prising if such a group of cases, with so much in tion of these into familiar common, did not have an embryological and clinical patterns usually enables a diagnosis to be Protected by copyright. biological background which deserves understand- made with rapidity and certainty, often on the ing and consideration. telephone; but in many cases the most meticulously When, in the course of biological evolution, the careful history, precise examination, and the nicest mesoderm became differentiated as a separate cell judgment are necessary before reliable conclusions mass which later split to form a body cavity or can be reached, and in order to do this some coelom, the formation of this cavity marked a knowledge of the nature and mechanism of critical stage pregnant with possibilities. The symptom production is necessary. organs inside the cavity were separated from the The pain of abdominal disease is of two kinds, exterior for their specialised functions of digestion, visceral and somatic, and they can frequently be absorption, and respiration. Such an advance distinguished from each other by the description removed many obstacles to increase both in size given by an intelligent patient, and sometimes by and variety, and determined the possibilities of the patient's appearance. Visceral pain arises

coelomate forms. But the differentiation of an directly from pathological changes in the involved http://pmj.bmj.com/ intestinal canal within a serous cavity implies the viscus or its mesentery and vascular connections, provision of a vascular system for its own nourish- and somatic pain arises from the parietes as the ment and the transport of metabolites, a lymphatic result of secondary and coincidental changes. The system for absorption and protection, and a classic example. of visceral pain is that due to nervous and endocrine system for co-ordination coronary , to renal or intestinal . and control. With this increased complexity there It is tearing, crushing, or bursting in quality, often is necessarily an increased danger of breakdowns severe enough to cause vomiting, rapid pulse, and fraught with disastrous and far-reaching conse- some degree of collapse; the patient may roll about on September 23, 2021 by guest. quences. The existence of a coelom, in fact, or double himself up in what he may well call implies the probability of the acute abdomen. agony. In the case of colic it rises to a crescendo It is easy to see that organs, such as thc appendix and then diminishes, only to recur again. This and the gallbladder, which are developed as blind type of pain is characteristic in that it can be diverticulae from the midgut, must always be abolished by section of the appropriate sympathetic liable to obstruction and subsequent infection, a pathways. It is usually imprecisely localised but series of changes so aptly called "the hollow viscus has an area of reference which depends on the pathology." Inherent in the localising and pro- embryology of the implicated viscus. Very often tective functions of the and omentum the patient will say the pain is inside the abdomen. is the possibility of adhesions and obstruction, This type of pain is most easily distinguished at and the presence of lymphatic tissue thinly covered the onset of the attack before the adjacent parietal with muscle and peritoneum makes occasional peritoneum is involved, and other protective swelling, necrosis, and perforation a certainty. reflexes are established. It is frequently but not POST-GRADUATE MEDICAL JOURNAL June, 1946 Postgrad Med J: first published as 10.1136/pgmj.22.248.149 on 1 June 1946. Downloaded from invariably associated with rigidity and deep pheral end of a novocaine-blocked sensory nerve. tenderness. For instance, the pain of Since it arises some time after the stimuli, which is sometimes accompanied by rigidity and tender- probably do not reach the cord, have ceased, it is ness over an area wide enough to be suggestive of unlikely that it has its origin in the cord itself.* a perforation, whereas the pain of intestinal colic Muscular rigidity is associated with both parietal frequently is not, and if rigidity and tenderness are and visceral pain. It may affect part of a muscle present, as a rule thev disappear soon after the colic whose total nerve supply comes from several ceases. The reason for the often vague localisation segmental nerves, thus producing a so-called of visceral pain is that-the afferent nerves from phantom tumour, and it may persist for some days viscera traverse the ganglia of the autonomic after the pain has ceased. This suggests that it system to the posterior nerve roots which are may be due to a "facilitated reflex" and that a arranged segmentally, but the subjective aspect of stimulus qualitatively below the threshold of pain localisation takes place in the brain where pain is may continue to produce rigidity when the pain registered in terms of quality and position. Neither has ceased. This persistence is not uncommon in of these latter attributes are constant, and vary inflammation of the gallbladder or appendix, and from individual to individual. because of this, a surgeon on opening the abdomen, For instance, the early pain in a typical attack may sometimes find much less evidence of acute of acute appendicitis is usually felt around the inflammation than he had previously led himself umbilicus. This might well be expected as the to expect. appendix is part of a mnedially developed midgut, The mechanism of deep tenderness is much more but the pain is often described by the patient as difficult to understand. It is as a rule coincident arising in the epigastric region, and occasionally in time both with the pain and rigidity. It elsewhere. An analogy may perhaps make these probably arises in the muscle itself because, as

individual differences comprehensible, if not reason- Lewis has shown experimentally, muscle is tender Protected by copyright. able. The quality of tones registered in a photo- after contracting for two or three minutes, and graph varies with the composition of the film, so after of longer duration muscular tenderness also do the spatial relationships vary with its may persist for some time. This tenderness is contour. Seen in this way it does not seem probably related to partial ischaemia, but whatever .unlikely that different individuals will describe its cause everyone is familiar with the stiffness the quality and position of their visceral sensations and tenderness which follow prolonged unac- differently. That they do so is a fact of observation customed exercise. It is however certain that which has to be constantly bome in mind when ischaemia does not represent the whole story, since assessing the value of a patient's statements. deep tenderness in the testicle may be produced The other type of pain which occurs in acute either by renal colic or by the intraligamentary abdominal disease arises from inflammation of the injection of saline. neighbouring peritoneum, or reflex irritation of the Pain, rigidity, deep tenderness, and hyperaes- overlying muscles. It is constant in position, thesia then are the cardinal symptoms of acute unvarying in quality, and in the nature of buming abdominal pathology. It is wise to remember that http://pmj.bmj.com/ or aching. When severe, it is difficult to dis- the severer types of visceral and somatic pain may tinguish from any other severe pain except that it be indistinguishable, and that either or both is more precisely localised. It is nearly always together are often associated with their reflex associated with rigidity and deep tendemess. Since effects, rigidity, deep tenderness, and hyperaes- it arises from the parietes, the nerves of which thesia. These last three may also be caused by pass through the appropriate posterior roots- and inflammation in the muscles and ligaments of the rela- can be retain their original segmental arrangement appropriate segments and exactly repro- on September 23, 2021 by guest. tively undisturbed, localisation in the cerebral duced by the intra-ligamentary injection of saline. cortex is much more precise. (Lewis and Kelgren). Obviously, it would be unwise With both these types of pain is associated to assume that an understanding of the mechanism hyperaesthesia-pain which is superficial and has a of symptom production is unimportant for the stinging or itching quality. It is also characterised diagnosis of acute abdominal disease. Every by the fact that it often persists for some long time casualty officer is aware that the diagnosis is after the original stimulus has ceased and may sometimes made correctly by a parent or a police- even be the last sign to disappear. Its mechanism man, but every surgeon has on his conscience a is incompletely understood, but its characteristics death or weeks of hospitalisation which might have suggest that it arises in the skin of the painful area. been avoided had an obscure case been more It is strictly segmental in distribution. Sir Thomas carefully considered. Lewis and his co-workers have shown that it may * For a full discussion of this question the reader is be produced by electrically stimulating the peri- referred to ch. xiii of Sir Thomas Lewis's book on Pain. June, I946 THE ACUTE ABDOMEN 151 Postgrad Med J: first published as 10.1136/pgmj.22.248.149 on 1 June 1946. Downloaded from Acute may, for descriptive purposes, rectus. Such a mass may be so protected by be divided into four groups which, of course, omentum that it is not very tender and even necessarily overlap. allows a limited mobility on palpation. An (i) The obstructive visceropathy of which ap- appendix situated so that its tip rests on the pendicitis and are examples. psoas will give rise to spasm of this muscle, flexion (2) Perforations of ulcers or inflamed and gan- of the thigh, and pain, when the latter is extended. grenous viscera. The most difficult situation arises when the (3) Obstructions with or without interference to appendix is in the pelvis. The area of peritoneum the vascular supply. within the true pelvis is a silent area and gives (4) Vascular obstructions due to intravascular, rise to little rigidity, , or hyper- or extravascular mechanical causes, such as aesthesia. The disturbances of defaecation and mesenteric thrombosis or the torsion of an ovarian micturition so often mentioned in textbooks are pedicle. An analysis of 348 cases admitted to more often absent than not, but when the condition an emergency hospital which served a large semi- is well developed there is usually. tenderness per urban and rural area, shows that these types rectum or per vagina. occurred in the following proportions: One type of obstructive appendicitis, specially Obstructive visceropathys 6i .5 per cent; Per- emphasised by the late Sir David Wilkie, requires forations 9 5 per cent; Obstructions 25 -3 per cent; special mention. There occurs an acute obstruc- Vascular obstructions due to Torsions 3 - 7 per cent. tion of an infected appendix, and a virulent organism causes inflammation and early gangrene. Often there is early vascular thrombosis. The (I) The Obstructive Visceropathy onset is very sudden and the pain is very severe, Acute appendicitis.-Though most cases occur in colicky in type, and referred as a rule to the adolescence and early adult life, it may occur at all umbilicus. The patient is doubled up and vomits ages. It is particularly dangerous and often diffi- with each spasm. He is often collapsed andProtected by copyright. cult to diagnose in childhood and old age. More- anxious looking during and after the attack of over, the appendix is subject to such great variation pain. At the onset there is little to show in in position that its manifestations are apt to between the ; there may be a little tenderness be anomalous. It is therefore wise to remember in deep in the right iliac fossa and some hyperaesthesia. obscure cases that one is always more likely to To an experienced observer the patient gives the encounter an unusual variant of a common disease impression of having suffered a great deal of pain, than a rare disease. Its onset is usually sudden and often seems a little more "knocked" than he and begins with colicky or cramping pain referred would be if it were mere intestinal colic. In this to the midline near the umbilicus. This pain is type of case every hour that passes is of importance, accompanied by vomiting in many cases. It can forperforationandgeneralperitonitismay occurearly be reproduced by pulling on or squeezing the without preliminary signs of local . If appendix when the abdomen is opened under local the doctor who is responsible for such a case is in

anaesthesia. If the patient is examined at this doubt he may well remember Moynihan's dictum http://pmj.bmj.com/ stage there will generally be deep tenderuess over that every abdominal pain which requires more than McBurney's point. A little later there is pain, one dose of morphia for its relief, probably requires more or less severe and constant, associated with laparotomy for its cure; or Zachary Cope's advice the defense musculaire of the French writers. This that if pain, assumed to be due to intestinal colic, consists of rigidity, deep and superficial tender- persists for more than three or four hours, ness over an area corresponding to the position the condition calls for surgical interference. of the appendix, usually the right lower quadrant Gentle palpation starting from the silent to the of the abdomen. By this time the vomiting has symptomatic side of the abdomen will generally on September 23, 2021 by guest. ceased, the patient may seem quite well, the detect some guarding and rigidity. If the pressure temperature normal or only slightly raised, and of the hand on the normal side is suddenly released the pulse hardly raised at all. The exact physical there will be pain over the area of any inflamed signs vary with the position of the appendix; a viscus, and this is often valuable evidence of early retrocaecal appendix may give little rigidity or localised peritonitis. A tentative diagnosis can pain in the early stages, a pelvic appendix often often be made by watching the abdomen closely almost none, but here rectal or vaginal examin- in a good light; a localised area of muscular rigidity ation will help. When the appendix is situated can then be seen as the rest of the abdomen moves lateral to the caecum a localised mass may with respiration, and over such an area the be felt or there is rigidity in the loin, and abdominal reflex is almost invariably absent.. when it is surrounded by omentum a mass may be There is nearly always a slight rise in the palpable near, or beneath the edge of the right leucocyte count or a "shift to the left" in. the ** 152 POST-GRADUATE MEDICAL JOURNAL June, I946 Postgrad Med J: first published as 10.1136/pgmj.22.248.149 on 1 June 1946. Downloaded from Arneth count. These changes may be of importance the base of the appendix divided and buried. It in distinguishing appendicitis from other extra should then be detached from above downwards to peritoneal conditions causing localised pain and where it is adherent to the posterior abdominal rigidity. The total white count is rarely more than wall, and then the lumen may be opened, the pus I2-I4,000, and it is of more prognostic than wiped away and the necrotic mucosa gently diagnostic importance. curetted and the raw surface cauterized. Some- These clinical findings represent, in terms of times it is possible to divide the muscle down to gross pathology, inflammation of the appendix the mucosa and remove unbroken a tube of mucosa and the adjacent peritoneum. containing pus. Both these procedures are occasion- From this stage onwards three things may ally life-saving. (Figs. i and 2.) happen. The whole process may, and often does, It is still important to emphasise that in general completely subside, leaving increased liability to a the treatment of acute appendicitis is immediate future attack. But the appendix is largely com- operation. A few hours in bed to get the patient posed of lymphatic tissue, and if it is obstructed, rested and quiet is often judicious. A doubtful as it nearly always is, either by its mesenteric diagnosis in the patient's house or casualty room attachments or by a faecolith, it may necrose can often be cleared up in this way, but if the and perforate. Such cases will gradually develop diagnosis is still doubtful and appendicitis probable, first a localised, and later a general peritonitis. it is wise to look and see. Some years ago a very Sudden perforation is often the signal for the distinguished surgeon in a presidential address to temporary cessation of the symptoms, but soon the the Royal Society of Medicine rightly emphasised pulse rate rises, rigidity and pain increase, the how often acute appendicitis settled down and temperature drops, or occasionally rises according resolved. This perfectly proper statement to a to the patient's resistance, and vomiting and other medical audience unfortunately got into the lay toxic symptoms supervene. Finally, the whole Press, and in the succeeding three months the process may become localised and an abscess or writer of this article saw two deaths which were Protected by copyright. inflammatory mass be formed. If this happens, as the direct result of this statement. In the writer's the general rigidity diminishes a mass becomes experience of 200 cases diagnosed as appendicitis, *differentiated; the temperature and white count every doubtful case was operated on, two un- behave as they do in any other abscess. necessary laparotomies and appendicectomies The treatment of acute appendicitis is by now were however performed. In another nearly parallel standardised, it is operative; but this does not series in which operation was delayed until the mean that it is unnecessary to exercise wise diagnosis was absolutely certain there occurred one judgment and careful consideration. It is not very sub-diaphragmatic abscess, and another case which helpful to say that the surgeon should hold his had a subdiaphragmatic abscess and an abscess of hand after the first 24 or 48 hours, because cases the lung which required drainage and later a plastic develop at very different rates. Perhaps the procedure. There is one sinister fact which indications for conservative treatment are best emerges from any series of cases of acute appendi- described by saying that no wise man would citis, and that is that no one can say what the out- http://pmj.bmj.com/ either interfere with a localising peritonitis, or come will be. The operation findings are frequently disturb an inflammatory mass where there were at variance with what one would expect. This is no indications that it contained pus. counterbalanced by the incontrovertible truth that In principle the appendix should be removed operations performed while the disease is limited by an incision as far from the midline as possible to the appendix and its immediate surroundings when this can be done without unduly breaking carry a very low mortality, little morbidity, and a down adhesions or spreading the infection. The rapid convalescence. abdomen should be drained if there is pus, an During the period I943-I945 in which the on September 23, 2021 by guest. oozing surface, or necrotic material left behind. figures previously mentioned were collected, five In a few suitable borderline cases it is justifiable normal appendices were removed as the result of to use a spinal anaesthetic because the "quiet" an erroneous diagnosis. In twelve cases the abdomen it gives may enable an appendix to be abdomen was opened because appendicitis was safely removed Nvhen removal would otherwise be diagnosed, and other conditions requiring operation dangerous. were found, and in ten cases other conditions were If an appendix containing pus is attached to the diagnosed when the patient ?ictually had acute posterior abdominal wall, the protective barrier on appendicitis. In four cases the only pre-operative its posterior surface should in no way be disturbed, diagnosis was general peritonitis. since this may result in a retroperitoneal cellulitis, a It is also interesting to note that of the I94 cases condition of affairs which is frequently fatal. The of proved acute appendicitis, 50 were drained, and area should be carefully surrounded by packs, and in I4 of these fifty, the appendix was-not removed. 153 June, I946 THE ACUTE ABDOMEN Postgrad Med J: first published as 10.1136/pgmj.22.248.149 on 1 June 1946. Downloaded from Twenty-three of the fifty drained cases occurred in Horace, who lived in an age of gastronomic the "flying bomb period" when it was noticeable indulgence, was familiar with the referred pain of that patients tended to arrive at a later stage than ', for in describing an attack of colic which the average. Maecenas suffered, he mentions the burning in the shoulder.* Acute cholecystitis bears close comparison with The physical signs may be difficult to differentiate acute appendicitis, for the gall bladder is a hollow from those due to laterocaecal appendicitis until the viscus with a narrow, tortuous, and easily obstructed abdomen is relaxed under an anaesthetic, when a outlet. It is, however, a muscular organ connected characteristic mass may be palpable. The tem- with a normally sterile biliary tract, and so is less perature is higher than in appendicitis (IoI'-Io20F.) likely to be acutely inflamed than an organ mainly as is also the white count. There is frequently some composed of lymphatic tissue draining directly into congestion at the base of the right lung. The what may be regarded as a septic tank. patient very often seems ill and toxic. For purposes of description cases may be con- The course of the disease from this point onwards veniently divided into those associated with gall- varies. It has to be conceded that by far the stones and those without, but this classification is greater majoritv of the cases settle down. The not so convenient clinically as it appear4 on paper, rigidity passes off, leaving a palpable mass which because an acutely inflamed gallbladder which is is usually omentum attached to the gallbladder, obstructed by a does not always cause but sometimes a large pyriform, distended gall- , and conversely, a gallbladder ob- bladder can be felt. This occurs when a cholesterin structed by oedema or a plug of mucus in the stone is impacted in the neck of the gallbladder cystic duct sometimes is associated with colicky and has previously caused a mucocoel. pains at the onset. It is, moreover, frequently In other cases signs of toxic absorption may stated that an acute cholecystitis without gall- increase and the process go on to general peritonitis; stones is the result of a general infectious disease or some early localisation and abscess formation Protected by copyright. such as typhoid. This is by no means always true. may take place, to be succeeded later by widespread However difficult it may be accurately to generalisation. There is a frequently expressed integrate the clinical with the pathological findings difference of opinion between experienced surgeons in any given case, it is always clear, as in appendi- about the treatment of acute cholecystitis. Some citis, that obstruction of some kind or other maintain that, like acute appendicitis, the outcome determines the onset of acute suppurative or is uncertain and it should be operated upon at once, gangrenous cholecystitis. The operation findings since operation in the first 24-48 hours is easy, and make this so obvious that the bacteriology is apt little different from the inevitable operation later to receive insufficient attention. on. Against this is the fact that one seldom sees The infection is usually mixed, the bacillus coli cases so early, and that the majority of them do predominating but associated with a streptococcus. settle down. There is no type of acute abdomen In the severer cases, particularly those associated which requires more careful individual considera- with marked toxaemia and a rapid progress, the tion, and probably opinions which seem to differ http://pmj.bmj.com/ dominant factor is often the presence of anaerobic fundamentally when expressed in writing, would gas-forming organisms. (Gordon Taylor and agree more closely when applied to-an actual case. Whitby. B.J.S. I930, xviii, 38.) There would be general agreement upon the Clinically the patients often (60-70 per cent) give following points: a history of flatulent dyspepsia suggestive of (i) That with few exceptions, every case may cholelithiasis, and gallstone colic, more or less safely be given a few hours of rest in bed for severe, initiates the attack. The pain is sudden in adequate preparation, in particular the administra- onset, situated in the right hypochondrium, and tion of fluid and glucose and one dose of morphia on September 23, 2021 by guest. radiating outwards to the axilla or across the and atropine. abdomen. It doubles the patient up and may (2) That a case seen in the first 24 hours and cause vomiting. Hyperaesthesia and deep tender- before the succeeding inflammatory reaction is ness which persist after the colic has passed off, are marked, can be safely operated upon early since present at a spot just medial to and below the angle adhesions are oedematous and strip easily. of the scapula. Instead of passing off as colic (3) That after this early period has passed, the usually does, it is succeeded by pain, soreness and case may be carefully watched to see whether or rigidity in the right upper quadrant of the abdomen, * Nec munus humeris efficacis Herculis which is due to local peritonitis, and if the dia- Inarsit aestuosius. (Epodes iii, I7, i8.) phragm is involved, pain is referred to the tip of the Nor did Nessius' gift burn with fiercer flame into shoulder. The rigidity may extend all down the right the shoulder of Hercules. (Gordon Taylor. B.J.S., side but is at its maximum above. 1937, xxv, i6.) 154 POST-GRADUATE MEDICAL JOURNAL June, 1946 Postgrad Med J: first published as 10.1136/pgmj.22.248.149 on 1 June 1946. Downloaded from not the temperature and particularly the pulse rate left behind and lightly coagulated, for it is under diminish, and that any steady increase in the pulse these circumstances that Thorck's technique best rate is an indication for immediate interference. serves its purpose. (4) That a total and differential leucocyte count Six of the twelve cases in this series had a should be done at once, not so much for its imme- , and in six the gallbladder was diate value as for comparison later. drained. (5) That if, after rest and glucose, the patient In these acute cases anaesthesia is supremely still looks toxic and the pulse is raised out of important; probably gas, oxygen and cyclopropane, proportion to the rest of the physical signs, opera- with or without local block, is the ideal, but it tion should be immediate in view of the possibility needs a skilled and experienced anaesthetist. Fail- of an anaerobic infection. ing this, careful upper abdominal field block (6) That if it is decided to allow the case to combined with gas, oxygen and a little ether is settle down, it should be most carefully watched, satisfactory and very safe. and that, although they may cause pain, breathing exercises should be instituted, and sulphonamides and penicillin should be administered. Acute Perforative The ideal treatment for acute cholecystitis is Another.example of the same type of pathological cholecystectomy, but this is often more easily said process is seen when a diverticulum of the left side than done, and beyond peradventure it is no of the colon perforates. Acute perforative diverti- operation for an inexperienced surgeon. Apart culitis must bedistinguished froma moregeneralised, from gangrene, it should not be done unless the less acute inflammation which sometimes flares up in cystic duct and the common bile duct are com- a segment of bowel already the site of chronic pletely exposed, a procedure which may be time- diverticulitis. In the latter case there is a general consuming, difficult, and even impossible. As a inflammation of the whole mass accompanied by a rule the common bile duct should be explored, a localised peritonitis. The whole process is ratherProtected by copyright. T tube put in, and after removing the-gallbladder, similar to acute appendicitis, but the constitutional the whole region adequately drained through a symptoms tend to be more severe. There may, for separate stab wound. Failing this, the gallbladder instance, be a rigor, and the patient looks ill. This should be aspirated, the obstructing stone removed, is preceded by an exacerbation of the previous and then simply drained, the tube being passed rather mild discomfort; for example, some increased first through a hole in the omentum and then difficulty in defaecation, and colic referred to the through a stab wound in the abdominal wall at a left side of the large bowel. It should be treated point corresponding to the lower border of the . conservatively with absolute rest, and until it sub- In the writer's experience with a proper selection sides, only enough fluid and glucose given by of cases, this has proved rapid, simple, and safe, mouth to prevent thirst. whereas, although cholecystectomy has been tech- In contrast, the perforation of an inflamed nically successful, seemingly satisfactory, and diverticulum precipitates a dangerous condition a associated with low mortality, the morbidity and which cannot but give rise to great anxiety. It is http://pmj.bmj.com/ complication ra' e of cholecystectomy in severe strictly comparable to the perforation of an cases has seemed unduly high. Furthermore, the inflamed appendix. The patient, often obese, is as secondary cholecystectomy done in a few months' a rule too ill to give a detailed history which would time has invariably been easier than one would reveal recent colic, localised pain, tenderness, and expect, and the convalescence rapid and smooth. constipations against a background of previous It has in fact been smoother than after cholecystec- diverticulitis. The temperature at first is high tomy done a fortnight or three weeks after the (Ioo-o40F.) and there are the physical signs of a acute attack has subsided. This latter is what rapidly spreading peritonitis which has its origin on September 23, 2021 by guest. many surgeons tend to do when the condition is in the left iliac fossa. Rigidity, which the gentlest obviously subsiding.. and most persuasive palpation fails to overcome, If there is a patch of gangrene present on the hides the characteristic tumour lying parallel to fundus, it is always possible, after aspiration and Poupart's ligament. If untreated and unrecog- adequate packing, to divide the gallbladder below nised the inevitable consequence is general peri- this and to cut away its walls up to where they are tonitis, the terminal phases of which was vividly attached to the liver. The remainder is then described by Hippocrates and even recognised by thoroughly coagulated with a diathermy button. Shakespeare-"I saw him fumble with the sheets. A drainage tube is tied into the stump and the . . .For his nose was as sharp as a pen and a' whole covered with omentum. Even if a complete babbled of green fields." formal cholecystectomy can be done, the part of Operation should be immediate and a plasma or the gallbladder attached to the liver may well be glucose drip transfusion is advisable. When the Juwne, 1946 THE ACUTE ABDOMEN 155 Postgrad Med J: first published as 10.1136/pgmj.22.248.149 on 1 June 1946. Downloaded from abdomen is relaxed the tumour can be felt, and recent case, diagnosed as diverticulitis, they were this gives the clue both to the diagnosis and to taken out of reach and covered by a large fibroid, an appropriate incision, which should preferably previously known to be present. be oblique, splitting or dividing the internal The diagnosis is often missed because the con- oblique and transversalis muscles. The pelvis and dition is not well recognised by general surgeons. left side of the abdominal cavity is found full of Out of seven such cases, four were thought to be evil, foul-smelling pus, but the actual perforation acute appendicitis, one a leaking ectopic gestation, is seldom seen. The involved bowel should be and in two no exact diagnosis was made. wrapped with omentum, or, if this is impossible, There is usually no doubt that the abdomen covered with a free omental graft. As much as ought to be opened, and as the condition is bilateral possible of the pus should be aspirated and the a median or paramedian subumbilical incision pelvis drained through a suprapubic stab wound. should be used, in fact these cases are almost Five to ten grammes of a sulphonilamide powder unique in that they are examples of lower abdo- may then properly be put in the peritoneal cavity, minal infection which it is wise to approach from though perhaps it is better added to an intravenous the middle line. When the abdomen is opened no drip. The wound should be sewn up with single attempt should be made to remove the tubes, catgut stitches, leaving a drain at the lower end loculi in front of and behind the broad ligament which reaches the left iliac fossa -and the pelvis. should be gently opened and the pelvis drained. However desperate the state of the patient, Many gynaecologists would prefer a drain inserted under no circumstances should he or she be sent through the posterior vaginal fornix. The prog-. back to bed without some form of right-sided nosis is good if the operation is promptly and transverse colostomy designed completely to divert rapidly carried out. the faecal stream from the sigmoid. If time

presses and anxiety for the patient's life dominates Protected by copyright. the situation, a large suprapubic drain through a (II) Perforations small incision combined with a quick transverse The perforation of a gastric or duodenal ulcer is colostomy over a glass rod are good tactics and one of the most serious and imperative of all may save a desperate situation. From then on surgical emergencies, but compared with many till the tide of battle begins to turn, the most others it is easy to diagnose and simple to treat. useful weapons are morphia and prostigmine, a Like the entirely mythical Celt in Kipling's poem, Ryle's tube and an intravenous drip, each used "One knows what he will do, and you can logically with discretion and judgment. predicate his finish by his start." Most perforated Another condition which falls naturally into this ulcers are situated on the anterior wall of the group and clinically very much resembles the last, pyloric antrum or duodenum. Ulcers on the is an acute suppurative salpingitis. This arises in lesser curve or posterior wall are more likely to an old and cold bilateral salpingitis of gonococcal penetrate the pancreas or liver. Most of them are or puerperal origin. From the bowel or blood chronic ulcers in which activity has recrudesced stream it gets reinfected with a virulent colon by a rapidly spreading infection beneath the http://pmj.bmj.com/ bacillus which is sometimes accompanied by a callus edge. The condition has been described by streptococcus. The infection, after a brief and Bolton as the acute spreading ulcer. Occasionally relatively silent sojourn in the pelvis, spreads acute ulcers may perforate, especially when they rapidly and virulently to the lower abdomen. In are embolic in origin, the primary infection being the early stages one side or other bears the brunt a burn or a septicaemia. of the attack, and it is by general surgeons often The base of a perforated ulcer is usually rigid recent mistaken for a perforated pelvic appendicitis or and friable and shows signs of inflammation. on September 23, 2021 by guest. an acute perforative diverticulitis. As far as the This is reflected in the immediate history. As abdominal cavity is concerned, the peritonitis has Moynihan has pointed out, an ulcer very rarely an abrupt onset, and, unlike the conditions which perforates without giving some warning of the it mimics, it is unheralded by svmptoms referred to impending catastrophe. Pain increases and tender- the abdominal viscera, but a long-standing dys- ness is present although the patient may be too menorrhea and some symptoms referable to ill to mention it. That perforation may occur while micturition or defaecation may obtrude themselves the patient is under treatment is not sufficiently into the clinical picture. It has, however, some well known, and more than one has been invariable characteristics indicating its origin. "cooked" for twelve hours because the doctor or There is always a previous vaginal discharge and the house physician thought that an ulcer under a a bilateral tender mass in the fornices which corre- strict medical regime could not possibly perforate. sponds to the infected obstructed tubes. These Everyone is familiar with the sudden onset of are not, however, quite always palpable, for in a a perforated ulcer. The resulting acute epigastric 156 POST-GRADUATE MEDICAL JOURNAL juxl,e, I946 Postgrad Med J: first published as 10.1136/pgmj.22.248.149 on 1 June 1946. Downloaded from pain is associated with boardlike upper abdominal abdominal emergency is delay more dangerous and rigidity which then spreads downwards, more to the it should never await the convenience of the right thantheleft, andgraduallybecomesgeneralised. surgical team for more than an hour or two. The The pain is constant, widespread, and very severe, shortness of the time that elapses between per- differing from colic in its unvarying intensity and foration and operation overshadows in importance the way it makes the patient hold himself quite every other prognostic factor. This statement still. It is noticeable that respiration is almost perhaps has one exception of practical importance. entirely intercostal, and although the rigidity is The outlook is bad if the patient has had a recent widespread, it reaches its maximum in the upper haematemesis, and the technique of closure should abdomen. Such patients also only vomit once or be adapted to prevent its recurrence. Blood in the twice in the early stages. What is not so often transfusion may then be indicated as well as plasma. realised and needs emphasis is, that the temperature The following figures serve to emphasise these is seldom raised, or even is a little sub-normal, facts. Of twenty-two perforated ulcers of the and that the pulse rate is frequently normal or stomach or duodenum, seven died. One of these only slightly raised, though the volume may be a had a carcinoma, one was first seen eighteen hours little increased. These patients occasionally walk after perforation, and two had had a recent haema- into hospital. Only later does the pulse rate temesis. Of the remaining three, one had a sub- increase and collapse supervene. Notwithstanding phrenic abscess, and two were too ill for any all this, to an experienced eye, the patient nearly interference whatever. The first of these had a always gives the impression of having suffered a concomitant coronary thrombosis and the second good deal of pain. General toxaemia comes had perforated three days before admission. relatively late and rigidity passes off as the irrita- As far as anaesthesia is concerned, perhaps it is tion of the concentrated gastric contents subsides here that cyclopropane or curari will easily come owing to dilution with inflammatory exudate. At into their own. They give rapid and immediate the beginning of this stage the patient may even relaxation without anoxaemia. Local anaesthesiaProtected by copyright. seem a little better. Then the temperature rises, he is can be used, but painful impulses come from such a flushed, and the pulse rate increases. Laterstill, pain, wide area that relaxation is difficult to obtain, but rigidity and tenderness decrease as the long grey combined with gas, oxygen and ether, it is very shadow of collapse and toxaemia due to general satisfactory. Except in specially selected cases, peritonitis slowly obliterates the outlines of a clear- spinal anaesthesia, with all its obvious advantages, cut clinical silhouette. too often increases the percentage of respiratory One difficulty in diagnosis often arises. A complications. perforated duodenal ulcer may discharge its contents The operative technique should be as simple as down the right paracolicgutter andtheywillaccumu- possible. The essentials are a right paramedian late first in the right iliac fossa. As a result the incision, three widely placed catgut stitches, one defense musculaire reaches its maximum here and just beyond each end of the friable ulcer base, acute appendicitis is clearly mimicked. But nearly and one in the middle. These are tied, not too always, in the history, the symptoms of a duodenal tightly, over a thick piece of omentum, whichhttp://pmj.bmj.com/ ulcer can be discerned building up to a sudden may if necessary be doubled. Then aspirate the right acute epigastric pain which leaves in its wake some kidney pouch and mop up anv obvious soiling. definite rigidity and tenderness over the upper Put a tube in the pelvis in most cases, and close part of the right rectus muscle. the peritoneum. When this has been done spend Of ancillary methods of diagnosis the most useful any time there is to spare in carefully cleansing is a plain X-ray which may show a bubble of gas and sewing up the abdominal wall. beneath the diaphragm. This is more reliable than At this juncture a word should be said about obliteration of the liver dullness, but neither of those cases of obvious general peritonitis which on September 23, 2021 by guest. these findings is by any means constant. are admitted to hospital so ill that a history is Soon after the patient is admitted it is wise to unobtainable, and with such widespread rigidity pass a Ryle's tube and by frequent aspiration keep that reliable assessment of its origin is impossible. the stomach empty. If the patient is collapsed a Under these circumstances the only policy for a continuous plasma drip should be put up, the first surgeon to pursue is to emulate the bookmakers bottle being run in rather rapidly, for these patients and back the most probable winner. Appendicitis lose a lot of protein in the voluminous peritoneal is by far the most common cause of general exudate which is literally poured out. When on peritonitis. Therefore a short incision should be account of venous collapse the transfusion will not made either over the appendix or in the midline run well, an occasional case may be saved by just above the pubis. If the pus is foul and using two veins at the same time. Operation stinking it probably comes from the appendix. should be early and expeditious. In no type of If it is thin, slimy, and contains particles of food June, I946 THE ACUTE. ABDOMEN 157 Postgrad Med J: first published as 10.1136/pgmj.22.248.149 on 1 June 1946. Downloaded from it is probably due to a perforated ulcer. In either of all the cases, and if the lower abdomen is suspect, case the pelvis should be drained. It never does gives away the- diagnosi -"An acute appendix any harm to make a short incision in the wrong with shoulder pain is a ruptured ectopic." place, but much harm is frequently done by an On pelvic examination one expects to find attempt at exploration in the presence of sepsis generalised tenderness or a tender mass in one or through a median subumbilical incision. other fornix, but this is also found with acute Another type of acute abdomen which falls a salpingitis. It is also characteristic that movement little uneasily within the category of a perforation of the cervix in an anterio-posterior direction is a ruptured ectopic gestation. This is popularly causes a sudden sharp pain which makes the patient supposed to produce a very clear-cut and charac- stiffen and catch her breath. teristic clinical picture. The patient misses a Acute appendicitis, acute salpingitis, and an period and a few weeks afterwards bleeds more early abortion are the three conditions which profusely and longer than she would expect from confuse the issue. The differences between rup- her previous experience of menstruation. About tured ectopic gestation and acute appendicitis the same time she is seized with severe abdominal have already been indicated. A mistake is not pain, and on examination she has the other signs important and its worst consequence is a short of peritoneal irritation. The diagnosis is clinched incision in the wrong place. by the discovery of a mass in one or other vaginal When acute salpingitis is confused with a fornix. My colleague, Mr. R. L. Dodds, has subacute ruptured ectopic, three or four days' recently pointed out (Proceedings of the Roy. Soc. observation will settle the question; the salpingitis Med., Vol. XXXIII, No. I2) that this is in fact a will invariably subside. film version of a not very common tragedy, and Examination under anaesthesia may be necessary its widespread acceptance results in the diagnosis to differentiate an early abortion. Tenderness and being made incorrectly in about 70 per cent of all resistance is abolished and it is usually clear the cases. There are three good reasons for this whether the uterus or a Fallopian tube is the seatProtected by copyright. otherwise deplorable state of affairs. Firstly, in of the pregnancy. the practice of a general physician or surgeon the Little needs to be said about treatment once the condition is distinctly rare. Secondly, the differ- diagnosis is made. The abdomen should be opened ential diagnosis is often really difficult, and thirdly, in the middle line and the involved tube removed. as has already been pointed out, the facts that A blood transfusion is often wise and sometimes emerge from an analysis of the clinical findings necessary. If strict antiseptic* precautions are are at variance with the average conception of the taken the patient's own blood may be used for disease. The missed period, usually regarded as replacement. the key to the clinical puzzle, cannot be established in just under half the cases. In more than a third of them it is masked by the fact that the (III) Obstructions bleeding occurs just when the next period is due. Intestinal obstruction is by no means the most

Only a wary cross-examination will elicit the fact frequent cause of an acute abdomen, but it has a http://pmj.bmj.com/ that the period just before the pain came on was higher percentage mortality than any of the more profuse and more prolonged than usual. other types ordinarily met with in surgical practice. Very occasionally this pseudo-menstruation appears That a large part of this mortality is preventable a week early. The pain too is without distinctive because it is due to delay in diagnosis will readily features. It is felt typically in the lower abdomen, be conceded by anyone who has to deal with often more on one side than another, and when it many cases. appears it remains constant for some time; then There is a legend that elaborate classifications there may be an interval of relative freedom. of acute intestinal obstruction are much beloved of on September 23, 2021 by guest. This must be distinguished from colic, which examiners, and most surgical coaches have their reaches its maximum quickly and then fades with own favourite table of causes. These may indeed equal rapidity. Sometimes the pain is generalised, form a useful framework for an examination paper, occasionally it is referred to the epigastrium. There but they are not of much practical clinical im- is always tenderness, and as often as not more portance. When a clinician is confronted with a rigidity than the intensity of the pain would seem probable case, these are the intensely practical to warrant, but cases are seen with a lower abdo- questions he has to ask himself: minal wall which reacts to and resists the slightest (i) Is obstruction present or not? intrusion of an examining hand. Unlike appendi- (2) If so, is it in the colon or the ? citis, this abdominal pain is never preceded by (3) Does it, or does it not threaten the integrity peri-umbilical colic and vomiting. Shoulder pain, of the bowel wall, or in other words, is it accom- sometimes quite severe, occurs in about one-third panied by vascular obstruction? 158 POST-GRADUATE MEDICAL JOURNAL

June, I946 Postgrad Med J: first published as 10.1136/pgmj.22.248.149 on 1 June 1946. Downloaded from It is not possible to over-emphasise the fact that colicky pain referred to a distended caecum may be an answer to these questions is possible in nearlv the presenting symptom. In nearly all cases of every case by simple clinical examination assisted large intestinal obstruction the ileocaecal valve is only by a plain X-ray of the abdomen, which may competent, so that vomiting is absent and the well be taken between the casualty-room and the small intestine is not distended. The colic is ward. Now intestinal obstruction produces four referred to the segment of the colon proximal to cardinal symptoms, pain, vomiting, distension and the obstruction, and the distended bowel may be sometimes tenderness, symptoms which are com- seen to contract, but this colic is not so prolonged mon to every other type of acute abdomen. It is as when the small intestine is involved, as the therefore obvious that their significance lies in relatively short colon distends rapidly, is soon their mutual relationships. paralysed, and so cannot contract. Pain.-The pain is due to intestinal colic. It is Occasionally, however, the ileocaecal valve is intermittent, cramping, reaches its maximum incompetent, and then the whole intestinal tract quickly and retains its intensity only for three or becomes involved in the resulting distension. A four minutes. Its onset and departure are both plain X-ray, taken in the supine position, will show equally abrupt. The colic due to intestinal ob- the outline of a dilated colon down to the obstruc- struction is always accompanied by bubbling and tion. The jejunum is recognised by its "feathery" gurgling which can be heard and often felt as the appearance and the numerous cross striations. In pain reaches its maximum intensity. Except in contrast, the ilium is thinner, less "interesting," pyloric stenosis and obstruction at the efferent and has fewer cross markings. Fluid levels may loop of a gastrojejunal stroma, this relationship is also be seen, especially if it is possible to take a invariable and generallv establishes the presence of film in the upright position. (Figs. 3, 4 and 5.) obstruction of some kind. Rigidity and guarding make it clear that trans- Vomiting.-In all obstructions of the small udation is taking place through the bowel wall, intestine vomiting is present. It is frequently and, since this fluid is very irritating, it may evenProtected by copyright. copious because it comes from the regurgitation of cause shoulder pain. There is an occasional but the intestinal contents into the stomach. The important exception to this last statement. A higher the obstruction the earlier it appears and typical inflammatory lesion causing simple obstruc- the less likely it is to be faeculant. It gives only tion may cause localised tenderness and rigidity. temporary relief or no relief at all to the patient's The distinction can as a rule be made by relating distress since more fluid from below is again the history to the physical signs, although it has regurgitated into the stomach. This vomiting to be admitted that this may sometimes be difficult tends to recur soon after a spasm of pain. or even impossible. It is, however, none the less The vomiting of pyloric stenosis relieves the important, because hasty interference in such cases patient for the time being and, except in the very usually results in spreading the infection, and not early stages before the stomach is dilated, is pain- infrequently in the death of the patient. Suction, less. The vomiting due to biliary or renal colic is with a duodenal tube, at least for some time, is not copious, is very exhausting, and is more in the correct and not seldom saves the

treatment, http://pmj.bmj.com/ the nature of continuous retching which brings no patient's life. alleviation of the patient's suffering. For reasons One other question now demands consideration. which will be discussed later most patients with Is the obstruction complete or not? Complete obstruction of the colon do not vomit. obstruction in the large intestine is evidenced by Distension.-Distension is visible or palpable in absolute (after an enema) and rapid most cases and can always be demonstrated by a distension of the colon. properly taken plain X-ray of the abdomen. In the small intestine complete obstruction is

Gentle palpation with a warm hand may detect indicated by the absence of gas in the evacuated on September 23, 2021 by guest. the smooth, tense outline of a coil of small bowel, colon and in the coils below the distended loop. If or general distension may be obvious. the obstruction is incomplete a second film will The "ladder pattern" illustrated in textbooks is demonstrate its re-accumulation after evacuation so late a manifestation that it has little real clinical by an enema. interest. Visible peristalsis, which may be seen in Having established in this way the fact of thin abdomens. apart from obstruction, is of obstruction, its probable cause has to be deter- immense diagnostic importance when it is asso- mined. It is manifestly impossible in an article of ciated with colic. this kind to consider in detail each variety; this is, In obstruction of the large intestine the colon is moreover, adequately done in all standard text- always distended and can usually be palpated. books. It is sufficient to say that, having carefully Even with obstruction of the distal colon the excluded strangulated hernia, and in particular a caecum is the first to dilate, and in the early stages Richter's hernia, the most probable cause of small THE ACUTE ABDOMEN H. W. S. WRIGHT. M.S.. F.R.C.S. .4i.)'.,>. .... :;: Postgrad Med J: first published as 10.1136/pgmj.22.248.149 on 1 June 1946. Downloaded from ::.,,'..'.:....:::::'..'':.. .. :....o:' . *4xt} , j iaRis>:;-NXj.ijii.,,isi''

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....!t.. -; *a-E' .@ .., . * s- |l | -- Ia --.- i - - -i --- ..- w -B i-Y.i'is r FIG. I (b) -it- i+t ¢h,. -:a,iii',,9liRi:i':i''... - BW S3XSj: i i:''e>^. 1-RE,W! Di; -" ;>U ti&*Xk I .'.t.,8 j,4C,.'(:FIG. (a) j,j'.::!tSi",Jii i

FIG. I.-(a), (b) and (c) illustrating Kelly's .I:

method of stripping out the mucosa and Protected by copyright. submucosa of a densely adherent appen- dix. (Taken from "Appendicitis," by H. A. Kellv.)

FIG. I (C) http://pmj.bmj.com/

FIG. 2.-(a) and (b) illus-

trating another method on September 23, 2021 by guest. of dealing with a densely adherent ap- pendix. The base is divided, the proximal end buried and the appendix slit along its lumen. (Taken from "Appendicitis," by H. A. Kelly.)

FIG. 2 (a) FIG. 2 (b) 7M. Postgrad Med J: first published as 10.1136/pgmj.22.248.149 on 1 June 1946. Downloaded from Protected by copyright.

-F . FIG. 3 (C) FIG. 3 (a)

'IIG. 3.-Plain X-ray of the abdlomen of a clhild with post-operative obstruction of the ilium. http://pmj.bmj.com/ (a) and (b) Antero-posterior and lateral viewNs in the supine position. (c) Filmn taken in the upright position shoxving flulid levels. on September 23, 2021 by guest.

4

FIG. 3 (b) June, 1946 THE ACUTE ABDOMEN 161 Postgrad Med J: first published as 10.1136/pgmj.22.248.149 on 1 June 1946. Downloaded from intestinal obstruction is strangulation by bands or "cold" and a clean sweep of involved bowel can adhesions. The history is of great assistance. be made with a safe end-to-end anastomosis. Symptoms suggestive of tuberculous peritonitis Obstruction due to plastic lymph and adhesions may give an important clue, and the scar of a is very prone to recur. Recently abrased surfaces previous operation is equally significant. A very are difficult to cover adequately. localised tender spot along or adjacent to the scar points to bowel adherent beneath it, and is a help in planning the incision. Median subumbilical incisions are very prone to produce this kind of aftermath, especially when the operation begins as an exploratory laparotomy and ends as an appendi- cectomy. Good judgment and experience both indicate that this course should rarely be taken. Apart from a history of an appendicectomy with either drainage or a stormy convalescence, in eight cases out of ten the trouble will be found in the pelvis. Many cases of post-operative adhesions or bands give a history of previous subacute attacks. When no suggestive history is available, a Meckel's diverticulum, a due to some abnormality of the mesenteric attachments, or an internal hernia naturally come to mind. The latter is rare, sometimes not so acute as other types, and is associated with localised swelling and distension; a soft, rounded fixed tumour may sometimes be felt. Protected by copyright. Obstruction by a gallstone is apt to be overlooked. A history of cholecystitis and then the onset of progressively severe attacks of colic at decreasingly short intervals are very suggestive. In nine cases out of ten obstruction of the large intestine is due to carcinoma. Volvulus of the sigmoid produces such characteristic distension that it need seldom be missed, and the same may be said of the intus- susception of childhood. In 88 cases of intestinal obstruction the incidence was as follows: strangulated hernia 40, intussuscep- tion 8, and 40 other varied causes. http://pmj.bmj.com/ Treatment * FG. .6.-Diagram. ilhls'.. In all intestinal obstruction where the integrity *continuous gastric or.': duodenfaltrainthesuctionapaau of bowel wall is involved, and in large intestinal .. obstruction where the competence of the ileo-caecal valve converts it into a "closed loop," operation is imperative. In simple obstructions of the small intestine on September 23, 2021 by guest. there is much to be gained by instituting suction through an indwelling duodenal tube. (Fig.6). The distended bowel can be decompressed and altera- tions in the mechanics may even allow a kink to Even when immediate operation is clearly undo itself. This course is especially indicated in indicated, it is wise first to aspirate the stomach post-operative obstruction due to fresh adhesions and upper jejunum, for many a patient has been or pelvic infective conditions which are best left to drowned in his own regurgitant vomit. Moreover, subside. Unless obviously necessary it should not most of these patients have some degree of be continued for more than about 24 hours, and dehydration and chloride deficiency, and so partial is safe only if controlled by films taken every replacement may with-advantage be part of the three to four hours. Such a procedure has the preoperative treatment. The same is also true of advantage that the condition can be dealt with large intestinal obstruction as the patients have 162 POST-GRADUATE MEDICAL JOURNAL Juxne, I946 Postgrad Med J: first published as 10.1136/pgmj.22.248.149 on 1 June 1946. Downloaded from often drunk little or nothing for some days and A loop should be pulled through a short incision, have lost a considerable amount of fluid into their the omentum detached, the colon fixed over a closed loop. In this connection it must not be glass rod, and the wound closed. Gas can then be forgotten that fluid aspirated and vomited must evacuated through a wide-bored needle and the be replaced parenterally. The best clinical index bowel opened next day. Never put an intra- of fluid requirements is the amount of urine passed, peritoneal stitch through the wall of a recently and its chloride content. A patient should pass obstructed colon, for it is certain that infective 700-I,000 c.c. of urine daily, containing at least material will seep along its track. By the tech- 3 grammes of sodium chloride. The normal plasma nique suggested no such stitches need be used chloride values are 560-600 mg. per cent. For at all. every I00 mg. below this the patient should be given 0 5 grammes for every kilo of body weight. (IV) Vascular Occlusions More salt than this should not be given as there is no object in putting a further burden on the Mesenteric Thrombosis and Embolism kidneys. Fluid requirements, 2,000-2,500 C.C., plus Acute vascular occlusion of the cardiac coronary what has been aspirated, and something in addition vessels with its characteristic symptom, angina if fever is present (say up to 3,500), can be given pectoris, is so well known that it is almost a synonym as 5 per cent glucose intravenously. In providing for the sudden end to a fruitful middle age. It is the this fluid, never forget that every intravenous drip penalty that many a doctor pays for twenty or has its own dangers, and that the most satisfactory thirty years of overwork and overstrain. Its way of giving fluid is tap water by rectum. In the counterpart in the abdominal cavity might well be immediate post-operative period a proportion can called "angina abdominis," for it is as dramatic, as always be administered in this way. In closed painful, and as fatal as its better-known elder loop obstructions and where strangulation of bowel brother. Fortunately it is probably less common is suspected, blood and plasma to replace that lost and is amenable to direct surgical attack which,Protected by copyright. into the lumen of the bowel may be advisable. although not invariably successful, has saved Inhalation of oxygen (70 per cent) combined many lives; as much as i8 feet of small intestine with suction certainly helps in some cases to having been successfully resected on more than one diminish distension, as the nitrogen from the bowel occasion. is excreted in order to restore the diminished In any series of cases large enough to be statisti- alveolar tension, the oxygen which replaces it is cally significant, cardiac disease and arterio- rapidly absorbed. But it should be administered sclerosis account for 65 per cent of all the cases intermittently, an hour or two at a time. of arterial occlusion, the one producing embolism In operating on this type of obstruction the and the other thrombosis. greatest possible care should be taken not to break Splenectomy for splenic anaemia, acute abdomi- the continuity of the bowel wall, for any spill of nal infections, and hepatic disease are mainly intestinal contents gravely prejudices the outcome. responsible for thrombosis of the mesenteric veins.

In some clinics, particularly in America, there is a In both cases the result is and gangrene http://pmj.bmj.com/ tendency to insist on aseptic anastomosis should of a varying length of the small intestine. This resection be necessary. There is, however, no is caused, not directly by the occlusion itself, but doubt that it is technically more difficult satis- because from it secondary thrombosis spreads to factorily to achieve, but is probably justified by the terminal vascular arches adjacent to the results. (Fig. 7.) mesenteric border of the bowel, thus preventing Operation for acute obstruction in the large the existing rich vascular connections from being intestine requires little comment. Where dilatation effective (Cokinis: Mesenteric Vascular Occlusion, is marked, some form of proximal colostomy is I926). on September 23, 2021 by guest. necessary. More is rarely wise. The only question The inferior mesenteric vessels are also subject which arises is whether to do a blind caecostomy to similar occlusions, but the unimpeded anasto- or a transverse colostomy. The former has the mosis between its branches often prevents in- disadvantage that it is sometimes followed by farction. serious infection of the abdominal wall. It can, Like coronary thrombosis, it is commoner in however, be rapidly performed under local anaes- men than in women in the proportion of 62-38, thesia, and is equally easily closed. The caecum but the occasional case occurring in children should be pulled well out and sewn not only to following acute enteritis must not be forgotten. the peritoneum but also to the aponeurosis. The The natural history of the disease again resembles mere insertion of a catheter is most disappointing coronary thrombosis in that a good many cases in its results. A right transverse colostomy under have periodical attacks of abdominal pain recurring these circumstances should be as simple as possible. over a period of weeks or months, and also in that F.R.C.S. THE ACUTE ABDOMEN H. W. S. WRIGHT, M.S., Postgrad Med J: first published as 10.1136/pgmj.22.248.149 on 1 June 1946. Downloaded from

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FIG. 4.-Plain X-ray of a patient with intestinal obstruction showing coils of dilated jejunum. The increased number of striations are in marked contrast to the appearance of the ileum shown in Fig. 3. on September 23, 2021 by guest. THE ACUTE ABDOMEN H. W. S.

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FIG. ..-7Shows the enormous dilation of the sigmoid in a case of volvalus and also dilatation of the caecum, the result of the obstruction. June, I946 THE ACUTE ABDOMEN 165 Postgrad Med J: first published as 10.1136/pgmj.22.248.149 on 1 June 1946. Downloaded from there are two clinical types, the fulminating vessels on the same side which may produce some hyperacute case, and the more prolonged type menorrhagia or metrorrhagia. The predominant corresponding to a slower spread of the secondary symptom is pain referred to one side or the whole thrombosis. In about half the cases as much as lower abdomen. It is severe and intermittent but eight days' pain and discomfort may precede the not true colic; it lasts much longer. There is very diagnosis of a serious lesion (Jackson, Porter often a history of milder previous attacks. A and Quinby, J.A.M.A., 42, I469; 43, 25, I904). considerable amount of free fluid may be poured Surgeon Rear-Admiral Sir Gordon Gordon-Taylor out, especially if in the early stages there is venous has given me permission to quote in full his graphic obstruction leaving the arteries patent; early account of the fulminating attack: "The onset is complete obstruction produces gangrene and signs most dramatic, the anguish intolerable, the of local peritonitis. There is tenderness if the profound, and the vomiting severe. The pain is cyst is out of the true pelvis, and the diagnosis experienced all over the abdomen, at first inter- can always be made on pelvic examination. In mittent rather than continuous, but later, during cases of doubt examination -under anaesthesia is its greatest intensity, the patient draws up his desirable and decisive. knees and raising the hands in supplication, calls Treatment consists in removal of the cyst. out in agony" (The Essentials of Modern , Abortion does not usually occur if this is done in Handfield-Jones and Porritt). Indeed the quality the first four months of pregnancy. of the pain often suggests the correct diagnosis. Pain approaching this in intensity is seen both in A cute acute pancreatitis and in perforated ulcers, but Whatever classification of abdominal calamities is the patients with both these conditions may be in adopted, acute pancreatitis remains in a class by a fit state to walk to hospital; with a mesenteric itself because, although vascular changes may con- thrombosis or an embolism, never. stantly dominate the clinical picture, infection by Whether the occlusion is primarily venous or one or other of the possible routes is a necessaryProtected by copyright. arterial, embolic or thrombolic, the secondary concomitant factor. Haemorrhage unaccompanied venous thrombosis causes considerable blood loss by infection does not cause acute pancreatitis. It into the lumen of the bowel. Shock is therefore is possible that either haemorrhage or infection generally obvious, the patient having a rapid may be the primary lesion. In the former case the irregular pulse and a subnormal temperature. The superadded infection disintegrates the gland and extravasated blood may be vomited, but bloody increases the haemorrhage, and in the latter it diarrhoea is the general, but not invariable, rule. causes the haemorrhage which increases the dis- A vague abdominal tumour due to localised dis- integration of the gland. Infection may come from tension is sometimes felt, but when the patient is the blood stream, from the gallbladder and bile seen in the later stages the distension is general but ducts via the lymphatics, or directly along the not extreme. Visible peristalsis is rare and the pancreatic duct when the ampulla is blocked by a same may be said of intestinal colic. Owing to the stone. The blood stream is certainly an occasional transudation through the bowel wall, tenderness source, since the disease occurs in children, in http://pmj.bmj.com/ and "rebound tenderness" are present at some infective endocarditis, and in typhoid, but the stage of the disease. Later the pain often dimi- most significant pathological fact is that the gall- nishes or even stops and the clinical picture bladder contains stones in over 8o per cent of all gradually approaches that of an adynamic ileus, the cases, and in 6o per cent they are also present due to general peritonitis. The only treatment in the common bile duct. In less than 20 per cent likely to be effective is earlv and wide excision of are they impacted in the ampulla. When these the involved bowel. In a few cases simple exteri- pathological data are related to the .intimate and orisation and subsequent anastomosis has been rich anatomical connections between the lymphatics on September 23, 2021 by guest. successful. Operation should always be supple- of the bile tract and the head of the pancreas behind mented by transfusion of blood and plasma. the peritoneum, it is difficult to avoid the conclusion Another condition in which vascular obstruction that the lymphatics are the most probable pathway is a factor of primary importance, is torsion of the for infection to travel from the gallbladder to the pedicle of an ovarian cyst. This occurs more pancreas. Regurgitation of the infected bile suffi- frequently with small cysts, during the early cient to cause pancreatitis is only a convincing months of pregnancy or the puerperium. It may explanation in those cases which have stones be precipitated by any strenuous effort. Torsion impacted in the ampulla of Vater. However, may take place in either direction and may at initiated, there follows a complex cause-effect first not be complete; frequently it gets untwisted, chain of events infection, haemorrhage, disinte- with a tendency to recurrence. In a few cases gration, the setting free of trypsin and its activation there is an associated hyperaemia of the uterine by colon bacilli, blood and serum. This may POST-GRADUATE MEDICAL JOURNAL June, I946 Postgrad Med J: first published as 10.1136/pgmj.22.248.149 on 1 June 1946. Downloaded from produce anything from a massive haemorrhage to In the first twelve hours of an attack there is the oedema of the pancreatic head so often seen nearly always a rise in the urinary diastase, the when operating for gallstones. Herein lies the normal being 20 units, this may be increased to explanation of the diverse clinical accounts given between 200 and 6oo units. The blood diastase is of acute pancreatitis. There may be a fulminating probably more reliable but is less often done. haemorrhagic type, which is rapidly fatal, a tense These two tests are in practice valuable because all generalised white oedema which subsides, or descriptions of acute pancreatitis tend to over- necrosis and abscess formation which needs drainage. simplify the clinical picture, and the diagnosis at Moynihan's classic description based on his own the bedside is often really difficult. experience and the work of Fitz in I899 is familiar to everyone. Time and experience have brought changes only in perspective, and these hyperacute Treatment cases must now be seen against a background of There is a tendency nowadays to adopt a more many others not nearly so severe, which subside conservative attitude to treatment, which comes naturally and are often imprecisely diagnosed. with the realisation that many of the less acute There is frequently a history suggestive of cases will settle down, though perhaps later it may cholelithiasis and sometimes a slight tinge of be necessary to drain the abscess or remove a , and there may be a few days or hours of slough, either through the loin or the lesser sac. -intermittent upper abdominal pain varying in Even in the hyperacute cases it is hard to see what severity, but the onset of the main attack is surgery has to offer beyond the evacuation of blood- apt to be catastrophic. The pain is agonising, stained exudate from the small omental bursa, ,causing shock and prostration. The patient first and unless localised abscess formation is present writhes in bed and thereafter lies still, cold, nothing more than this should be done. In spite sweating, and motionless, with a pulse rapidly of the fact that surgeons are nowadays "acute mounting to 2o-i60 per minute. The pain is pancreatitis conscious," laparotomy is quite often Protected by copyright. generalised in the region above the umbilicus, performed because of the imperative necessity and in the less severe cases, to the right hypo- for diagnostic certainty. When a rapid explora- chondrium. It is not relieved by morphia and is tion of the stomach and gallbladder has proved rhythmic in quality, perhaps corresponding to the negative, the lesser sac should be explored, either fresh haemorrhages which occur from time to time. from above or below the stomach, and the pancreas Characteristically it radiates to the back and left examined. Sometimes fat necrosis gives the shoulder, and after some hours, subsides to become diagnosis away as soon as the abdomen is opened. a heavy, dull, unvarying ache in the epigastrium In such cases, before closing the abdomen, a and the back. With this goes the most resistant drainage tube should be placed down to the rigidity, a tenderness which makes any attempt at pancreas. If the gallbladder or common bile ducts deep palpation merely fruitless torture. This contain stones, the gallbladder should be simply rigidity tends to remain localised in the upper drained, and the whole condition dealt with later, abdomen, certainly does not spread downwards when time for the precision necessary for exposure http://pmj.bmj.com/ with the same rapidity and certainty as does the of the ducts is available. The complete abdominal peritonitis caused by a perforated ulcer. The rest which can be obtained by suction through a early rise in pulse rate, too, is in marked contrast, Ryle's tube, morphia, and the intravenous admini- so is the continuous retching and vomiting of small stration of blood, plasma, and glucose saline are amounts of fluid, probably due to the accumulation the most important and do more than anything of toxic irritating fluid in the lesser sac and round else to lead to subsidence or localisation. the coeliac ganglia. Milder cases do not present In an article of this kind, where the author has either this marked unvarying rigidity or persistent of necessity to adopt the role of a "surgical on September 23, 2021 by guest. -vomiting, probably because the changes are more columnist," oversimplification, improper emphasis, limited; a vague mass corresponding to a distended and apparent dogmatism are as unavoidable as lesser sac or the pancreas itself may be felt. they are obvious. These faults are justified only Another characteristic of acute pancreatitis often if they lead an observer to see acute abdominal described is a blotchy cyanosis, generalised, but lesions and their protean manifestations as part of often most marked around the umbilicus. This, a biological process rather than as isolated events in however, is seen in other conditions and was most clinical experience. Regarded in this way they striking in a case seen recently with a perforation always retain their fascination, as each successive of an acute lower oesophageal ulcer. Patchy case continues to call for the best judgment of haemorrhagic areas around the umbilicus and in even the most experienced surgeon. the loin have been noticed by Cullen and Grey For the statistical material contained in this Turner. article I have to thank my registrar, Mr. Eric THE ACUTE ABDOMEN H. W. S. WRIGHT, M.S., F.R.C.S. Postgrad Med J: first published as 10.1136/pgmj.22.248.149 on 1 June 1946. Downloaded from FIG. 7.-Drawings illustrating our method of performing aseptic anastomosis of the large intestine. For thesmall intestine the clamps are placed obliquely to conserve the blood- supply, of the anti- mesenteric border and increase the size of the lumen.

FIG. 7A.-A posterior view of mattress sutures has been placed ready to be tied after three or four have been inserted. Protected by copyright.

FIG. 7B.-A further pos- terior layer consisting of a continuous"bast- ing" stitch, each end held loosely by artery forceps. http://pmj.bmj.com/ on September 23, 2021 by guest.

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FIG. 7c.-A similar anterior basting stitchi inserted over the clamps. These are tightened by traction at each end and the ends tied together after the clamps have been single mattress sutures. ADIPOSITY RAYMOND GREENE, M.A., D.M., M.R.C.P. Postgrad Med J: first published as 10.1136/pgmj.22.248.149 on 1 June 1946. Downloaded from Protected by copyright.

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Mr. Edward Bright of Maldon, who died November I0, I750, on September 23, 2021 by guest. aged 29 years. His height was 5 ft. 94 ins., chest 66 ins., waist 83 ins., around the arm 26 ins., and around the leg 32 ins. His weight was 44'stone, or 6I6 lbs. net. After his death, to decide a wager, seven men were buttoned up in his waistcoat. 169 june, I946 ADIPOSITY Postgrad Med J: first published as 10.1136/pgmj.22.248.149 on 1 June 1946. Downloaded from Gardiner, and both he and many other senior I have to thank Mr. Mortimer Woolf for per- assistants are responsible for much of what I mission to reproduce Fig. 5 and Dr. Leonard have learnt and for a large part of whatever success Symonds for the drawings in Figs. ra and 7. I have had in treating patients who are critically ill. Finally, it is a pleasure to thank Sir Gordon My friend and colleague Mr. Albert Davis, has Gordon-Taylor for permission to quote his writings. always put his knowledge and experience at my His experience is a sort of National Trust for his disposal and any merit which the part of this colleagues, and this is a welcome opportunity to article dealing with pelvic surgery may have are acknowledge much wise advice given freely over due to his guidance; the faults are mine. many years.

ADIPOSITY By RAYMOND GREENE, M.A., D.M., M.R.C.P. (Hon. Physician Metropolitan Hospital) The Importance of Adiposity* Table 2 In the words of Donald Hunter (I933) "the Influence of Weight on Mortality. Effect of age, victims of obesity are . . . to be pitied for many Deaths per I00,000 reasons. They must of necessity suffer from a Weight Age Under 45 Over 45 restriction of physical. activity, they have a Protected by copyright. tendency to develop flat-feet and arthritis, they Standard .. 463 I,308 also have an unpleasant tendency to excessive Underweight 498 I,274 sweating, and they are difficult to anaesthetise, Overweight 527 I,824 operate on, and nurse. Moreover, they are pre- disposed to diabetes, bronchitis, and possibly to Table 3 hyperpiesia." It may be added that obesity is a Influence of Overweight on Mortality in Persons aged cause of great unhappiness to many women. 45 to 50 Though a lucky few are prone to laugh and grow Increase in Death Rate fat, the majority are sufficiently conscious of the Pounds Overweight over Average preference for slimness of the ordinary man to I0 8 become self-conscious and self-critical, to lose their 20 I8 self-confidence and sometimes to sink into a state 30 28 of severe depression. The importance of adiposity 40 45 is well shown by the analysis by Dublin and Lotka 50 56 http://pmj.bmj.com/ (1936) of the life histories of I92,304 men accepted 6o 67 for life insurance. 70 8I 90 ii6 In other words, a mere stone of extra weight in Table i middle age, lessens a man's expectation of life by Influence of Weight on Mortality. Deaths per I00,000 about I0 per cent, and "fifty pounds overweight at

age 45 imposes as much extra mortality as valvular on September 23, 2021 by guest. Weight Deaths heart disease" (Fisk, quoted by Newburgh, I942). Standard ...... 4 Underweight .. .. 848 Overweight ...... I,III The Definition of Adiposity Overweight 5-I4 % .. .. I,027 The decision as to whether a patient is too fat .. .. or not must obviously be largely a question of Overweight I5-24 % I,2I5 taste. Many Oriental races prefer fat women and Overweight 25 % and over I1,472 even in one country fashions change. We must fall When the age of the "life" is considered, the backupon.averagesconsidered in thelight ofcommon influence of adiposity becomes still more obvious. sense. The most reliable averages for children are those of the Child Health Association * Adiposity is derived from the Latin adeps (fat), probably obesity from the Latin ob and esus (having eaten). The and for adults those of Fisk (I923). Anderson's former is more generally accurate. Nomogram is very convenient in practice.