T JOURm 6 APRIL 21, 19231 THE CHRONIO ABDOMEN. I MTDICAL JUmSA 667 I Now: Pains in bladder-intestines dropping. Rectum feels as if pressed on. A tight belt to push up all ins:de-makes nerves better. An Abbras Always " intoxication "-constipation and flatulence. ON CASE II. THE CHRONIC ABDOMEN.* Miss M., aged 48. Seen in 1913, complaining of constant acidity, flatulence, vomiting of green fluid, etc. BY ROBERT HUTCHISON, M.D., F.R.C.P., History. At 5 years of age had severe jaundice and stoppage of bowels; PHYSICIAN TO THE LONDON HOSPITAL. always constipated. At 20: Influenza and bronchitis with prolonged fever; this left OumR surgical coleagues describe a condition which they "stomach trouble " which persisted. speak of, iu their clinical slang, as the "acute abdomen." At 32: " Dilatation of stomach," and was in bed three months. There is, another more At 33: Uter-us curetted; indigestiou better for a time. however, condition familiar to the At 36: Complete hysterectomy and Digestion physician may be appeudicectcmy. which designated with equal propriety the much better for over a year. chlronic abdomen," and if the one is, as we are told, a At 38: Digestion bad again-stomach lavage-much benefit for catastropbe, the ohfber is certainly a conundrum. a month. TThe subject of the clhronic abdomen is usually a woman, At 40: Cbolecystitis and "ulcer of stomach." At 42: Rest cure in hospital. Stomach massage. "Much generally a spinster, or, if married, childles and belonging to benefit." what are commonly termed-rather ironically nowadays- At 48: Exploratory operation. Profound visceroptosis with the '"comfortable" classes. To such a degree, moreover, do dilatation of stomach an pylorus. Stomach and colon fixed with her abdominal troubles colour her life and personality that catgut sutures. we may conveniently speak of her as an abdominal woman." One and a half years later she wrote: An abdominal man, -on the other hand, is by comparison " . Am glad to say I never now (since operation) get those a rare bird, and when caught has a way of turning out to turns of agonizing pain in region of gall bladder whicli used to be a Jew-or a doctor. suggest gall stones; but there is always a sore burning spot thlere, sometimes pretty bad, with often slight cutting sort of pains (but SYMPTOMS. only slight), and it goes when the apparent cause of corrosion of wind or food has moved. The symptoms of the chronic abdomen are many, various, " My old 'sore spot' (on left side under lowest rib near middle) and ever-renewed. Some of them refer directly to the has come back, and I am in constant distress from the buruing, abdominal organs, others are of a more remote and general gnawing sensation right across below waist line. Also all over character; but, whatever they are, they are always described back and under shoulder blades. witlh great prolixity and in minute detail. Amongst those "I have really been little more than an invalid for montlhs, finding it most difficult to continue my teaching, having scarcely commonly complained are abdominal aches and pains most of strength to speak. It seems to be the continued acidity and ot various sorts and in various places, but especially in the tremendous flatulence, and the sensation of wealiuess (I suppose) is right iliac fossa. Instead of actual pain the patient may because the heart is being almost continiually chioked ;viti dilata- speak of a "raw feeling inside," or of- "an indescribable tion of stomach. About a month ago it was ' nmurmuring'-I do not know if it is still doing so. It feels as if a heavy wveight is sensation in the stomach," or of a "dragging." Constipation pressing the heart and sometimes there is neuralgic pain in its of greater or less degree almost always figures prominently in region and in left arm and I can't breathe easily. But doctor says tlhe list of symptoms, and flatulence is also frequent. Amongst it is not due to heart itself; that appears strong, but the effect of the commoner remote symptoms one finds a feeling of general faintness and exhaustion is very bad sometimes, thouglh occa- weakness or " exhaustion " (especially after an action of the sionally I am able to forget it for a day or more. Of course it hinders when bad. Am to say the bowels), " mental and physical torpor," "inability to think," sleep glad fearful violent jumping-which- was such a trial all the time in hospital anid for " a poisoned feeling," and "neuralgic pains all over." Head. eighteen months after-is almost gone and the rheumatisnm is aches and insomnia are also very frequent, and a great many better and the sudden turns of sickness less frequent. I rest all patients complain of undue susceptibilitv to cold and of a I can and do most of my work at home, so that if I find a heart constant catarrll in the throat. turn coming on I can drop lesson and let off the tremendous flatulence in violent noisy 'spasms.' If I check them J become helpless. EVOLUTION OF THE CHRONIC ABDOMEN. " I have just started to try and take olive oil (a large teaspoon a since so have felt easier and no If one inquires of a patient with a fully developed chronia day) and doing had spasms, but this may be chance, but shall persevere. Bowels need 20 or abdomen how her lamentable state has been arrived at it will 25 senna pods now to move them." be found tlhat the process of evolution is fairly constant. These sufferers are very fond of presenting anyone whom CASE III. they may consult with a full record of their previous medical MissJ., aged 29. Been in January, 1908. She had always been history and experiences, and the following are a few such delicate, especially as regards digestion. records as supplied by the-patients in their own words. They may be taken as typical. History. June, 1889: Peritonitis. Abscess came away into rectum. January, 1897: Entered on office work-health became worse. CASE I. October, 1898: Influenza (high temperature) followed by jaundice. Mrs. L., aged 47, gave the following record of her various Since have always had constipation. illnesses and their treatment: 1899-1900: Indigestion becoming worse. Bad fall at 2 years of age. Rheumatic fever at 13. Always bad June, 1900: Operation-two abscesses in glands on right side of digestion anid overloaded bowel. Married at 21. After birth of abdomen, one of which had broken ; considerable amounjt of first child, ulceration of rectum. Uterus never strong. mat.er; slight perforation. Since digestionbas always been very 1900: Two operations for fistulae and abscesses-tumour (fibroid) troublesome. discovered in uterus. Always feeling ill -from auto-intoxication 1902-4: Digestion becoming worse and worse. (enemas curing this) and rheumatism in knees (cured by,inocu- October, 1903: Six weeks' " rest cure" in bed with massage; no lationi). permanent improvement. 1901: Cocaine poisoning. February to April, 1904: Being in Switzerland, six weeks' treat- 1902-1909: Cures at Aix, Strathpeffer, Bath, Carlsbad, and ment in hospital there; no improvement. Lausaune. May and June, 1904: Seven weeks' treatment in Zurich; no 1910: Operation for "chronic appendicitis" and six tumours in improvement. uterus. Intestines never felt in place or strong after this. Same October, 19C4: Operation (gastro-enterostomy)-pylorus said to year: Pyorrhoea; inoculations. be fixed by adhesions. Digestion has sinice been very indifferent. 1911: Cancer of the breast-operation. Since last date, pain and distension at intervals of from tNvo to 1912: Went to Bath for "nerves." Several teeth extraoted. four weeks, lasting from periods varying from one to six or nmore 1913 (March): Played golf for first time and thought intes- weeks. tnes were dragged down. Jumped out of train and ran hard CASEIV. (April1st); iniside never comfortable since then; pains in bladder; Mrs. T., aged 41. Seen 1917, complaining of pain in epigastrium nerves I and left hypochondrium, flatulence and acidity. May: Small fibroid discovered. Uterus half size too large. In 1907 rightkidney fixed. and general Inflammation of bladder, uterus, tissue; nerves In 1908 appendix removed. terribly bad; douches, etc., in a home. In 1909 operation for tubal pregnancy. August: Contrex6ville (concentrated urine and excess of urio In 1913 other tube and ovary removed-since then indigestion. acid). Contraction of intestines; pains in kidneys; always pain-in In 1915 rest cure. bladder-diarrhoea. Nerves-nerves. Constipation. Passed large In 1917 exploratory operation-nothing found except that the quantities of sand. omentum was adherent to the scar in tle riglht iliac region. Remained well for four months, when epigastric pain returned I Delivered before the Clinical Society of Manchester, March 8th, 1923. acutely with the symptoms described above. 113251I] LT 82mm"M 668 APRIL Ir, 1923] THE CHRONIC ABDOMEN, M ZDoAz. JOUNUAIL CACE V. PHYSICAL AND MENTAL STATE. Mrs. aged 53. Seen for " H., 1915 obstinate constipation; neuritis" On a case in various parts of the body, swellinjg and tenderness of the examination of fully developed of the chronic breasts, etc. abdomen one will find that it lhas boih a physical and a mental aspect, and that more History. the latter is often the importaut i886: Haemorrhoids removed. of the two. 1837: Curetting. Physically the patient is undernourislhed and sallow. To- 1888: Five cauterizations of uterus. use an abominable term current at the moment, she looks 1898: Haemorrhoids retinuved again, and bowel stretched as far "toxic." The abdomen is of visceroptotic shape and the as they could reach. This resulted in loss of power in lower bowel and aggravated the trouble.