[_=,A JUN. x17, 1"p'] AA7U!miABDOMNALl.SXMTI,S. 1 33 tion of operation must not, however, be dismissed, but mut still remain the most prominent one for consideration. ON PAIN. The character and situation of the pain are of considerable ACUTE ABDOMINAL SYMPTOMS. assistance. In perforations of the stomach, intestine, gall bladder, etc., the pain is usually extremely severe, constant, the Delivered before the Walthametowv Division of and of a burning character, and in first instance usually Counties Branch of the British Medical Association. limited to the seat of rupture, though it soon spreads over the abdomen. In rupture of cysts the pain is more diffase from By W. WATSONC-CHEYNE, C.B., F.R.S., the first-and not so severe, but there also it is most marked at Professor of Clinical Surgery at King's the seat of rupture. In rupture of the appendix the severity of the pain varies much, but it may be severe and located in PERHAPS there is no more difficult and responsible the appendix region; usually, however, it is from an early that a medical practitioner can be placed period associated with or may be preceded by colicky pains in fronted. with a case presenting the characteristics we, the neighbourhood of the umbilicus. Other forms of appen- " may call an acute abdominal illness " ; dicitis usually commence with coricky pains at or above the an illness with an acute onset of which umbilicus, and pain develops later in the appendix region. symptoms are severe abdominal pain, vomiting, In internal strangulations and other obstructive conditions less collapse. In such cases the medical as, there may be pain at the site of the lesion, but the chief com- quickly as possible to some conclusion, firstly, is plaint of the patient is recurring attacks of severe colicky pain the matter with the patient,-and secondly, referred to the umbilical region. Gall-stone pain is epigastric, bility of immediate operative interference. passing through to the backand shoulder, and much less of cases it is not possible to make an exact the; spasmodic. Renal or ureteral pain is of the same character, early stage of the disease, but, nevertheless, shooting down to the scrotum and thigh. The chief points to surgical kntervention.,may be quite evident. is, be noted as regards the pain are its severity and position, very advisable to come as near to an diagnosis, whether it is constant or spasmodic or both, whether localized especially as to the position of the lesion,as because or diffused, and whether the spasmodic pain is intestinal we can thereby form a general idea as to or not. interference which is advisable, and thus TENDERNESS. time and shock. At the present time there This may vary according to pressure or percussion. It is to trust to the results of an exploratory marked from the first in cases of inflammation and rupture, diagnosis of abdominal affectionsrather laborious andis generally greater on percussion than on pressure. The and careful weighing of the evidence. This Is reverse is the case in strangulation. At firSt the whole a great pity, and in these acute cases it especially abdomen may seem tender, but the seat of the disease is tant to, have some idea of the part affected, generally indicated by an area of marked tenderness, although are not in a condition to stand aproologed exploration this is not always so. As time goes on, unless general periton- abdomen and one or more extensive incisions. itis sets in, the tenderness diminishes, except over the seat the decision as to surgical interference is of the disease, where it increases. On the other hand, in the tant and must be come to at once or within hours. In passage of biliary or renal calculi the pain may be apparently if many cases surgical treatment is too eased by pressure, and this is sometimesalso the case in the favourable period is lost and the dangers early stage of strangulation before peritonitis or enteritis has greatly increased, while unnecessary surgical on set in. The points are its presence or absence, whether the other hand, may have disastrous results. limited or not, its seat, its relation to pressure and percussion Let us suppose that one is sent for has anditS tendency to spread or to remain localized. been suddenly taken ill with severe vomiting, faintness, etc. On the ABDOMINAL RIGIDITY. review a great variety of complaints Rigidity of the abdomen is a very marked symptom in these symptoms.. I may enumerate some peritonism. It is most marked over the seat of the disease trouble may have to do with the urinary and may be limited to that, but in the early stage it is in kidney or ureter, displacements of general over the abdomen. If as time goes on the abdomen intermittent hydronephrosis, etc. It remains rigid all over, it means either rupture of some viscus pancreatic calculi; it may be twists of or general peritonitis, or, in the early stage, strangulation; in ovarian tumours, retained testicle, etc. localized inflammations it, like the tenderness, relaxes with the intestine, for example, colic, except over the area of the disease, and in bad cases of internal), strangulation by bands, intussusception, obstruc- peritonitis it disappears and gives place to distension of the tion by foreign bodies or tumours, etc. -rptureA abdomen.- The points are its presence, its situation, whether of various organs, for example, stomach, appendix,. localized or diffuse, and whether in the former case it tends gall bladder, tubes (extrauterine pregnancy), etc.; too spread or not. ovarian, hydatid, or pancreatic cysts. VOMITING. poisoning. Or it may be some inflammatory Vomiting occurs early in quite a number of these abdominal or inflammation when the patient first seen, it not of -example, appendicitis, appendages,, cases, and, as a sign is is as Meckel's, the appendices epiploicae, uterineappendages, any very great diagnostic value. It occurs early in rupture etc.; peritonitis from 'these and other causes, such of the stomach, and is also one of the early symptoms in pneumococcal or tuberculous peritonitis; various other ruptures, in appendicitis, in strangulations, titis, gastritis, enteritis, colitis, abscess ete. It is the persistence of the vomiting which is of the liver, etc., pylephlebitis, perirenal abscess, greatest importance. This points strongly to some mechanical are various other conditions which obstruction, for in most other cases it is usually only an early account as well, but they are quiterare;; and reflex effect which passes off very soon. The character of not be in the abdomen at all but in the thorax, the vomited materials may also be a guide, for example, fecu- pneunonia or. pleurisy may sometimes begin vomiting, lent vomiting usually means obstruction; blood indicates ulcer epigastric pain, and tenderness, and of the stomach, etc. eubphrenic abscess. COLLAPSE. I cannot, of course, go into the differential diagnosis Collapse is very indicative of a rupture or of an internal these cases to-day, but it may be useful strangulation or haemorrhage and may be -very marked in significance of the chief symptoms and separate these cases. Its degree depends to a great extent on the eases into-groups and then consider the indicationsJfor severity of the case, more especially on the suddenness and mediate operation. I am taking the difficult amount of the -extravasation. A slight leak, gradually in- subject from-the point of view of diagnosis creasing, as in an old ulcer of the stomach, will not have the see what are the indications for operation is same effect as a sudden and free- discharge into a previously first seen, or, at any rate, within the first 12 to healthy.peritoneal. cavity, and, in the same way, in internal the onset of the -case. As time goes on the strangulations, the amountof collapse depends on the sudden- easier, but there are many cases where cannot ness of the strangulation and the tightness of the cord. On the wait. if it is decided not to operate ques- other hand, in inflammatory affections, Even once,, collapse is[22220ornotabsent TMI 11314I XUDICA B1uEaolow=NA 1l1 ACUTE ABDOMINAL SYMPTOMS. [JUNEM 17, 1909. at all marked. If it is present with other symptoms pointing to AFTER HISTORY. appendicitis, for example, it indicates a very grave condition, These are the chief symptoms which may be observed at probably either perforation or gangrene. The presence of first if the practitioner is called at quite an early period of collapse is a strong indieation for operative interference, the attack, but as the hours iun on these symptoms alter although it may be considered advisable to wait for two or and other symptoms appear which may aid the diagnosis and three hours to let the collapse pass off to some extent. The determine the question of surgical interference. For example, points are its presence or absence, its degree, whether reaction the spreading of the pain and tenderness over the abdomen, sets in or not, whether when slight or absent at first it indicates a grave lesion and a development of general peri- gradually increases. tonitis, while the localization of the pain to one spot or RIoOR. region indicates a shutting off of the inflammatory action The occurrence of a rigor or chilliness at the commence- and'a much more favourable condition. ment generally indicates some inflammatory condition and Persistence of colicky pains is another important indica- not infrequently ushers in an attack of appendicitis for tion; if they persist, the probability of strangulation is example. increased, while in appendicitis, for example, though colic may be most marked at the beginning, it soon subsides and PULSEE. become located in the region.