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Full text of "The acute abdomen"

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THE ACUTE ABDOMEN 




Fio. 1.- Strangulation of Intestine by Fibrous Band (1) : 379, St. Thomas- 
Hospital Museum. 



3 



THE ACUTE ABDOMEN 



WILLIAM HENRY BATTLE, 

Senior Surgeon to St. Thomas's Hospital. 
Formerly Joint Lectuyer on Systematic Surgery, and on Practical Surgery 
to St. Thomas's Hospital Medical School ; Surgeon to the Royal Free 
Hospital; Assistant Stirgeon to the East London Hospital for Children ; 
Hunterian Professor, Royal College of Surgeons ; Orator to the Medical 
Society of London, etc. ; Joint Author (with Mr. Corner) of the Surgical 
Diseases of the Vermiform Appendix and their Complications (2nd ed), etc. 






SECOND EDITION. ENLARGED AND ILLUSTRATED 






^'-:<h\^:^ 




THE MACMILLAN COMPANY OF CANADA, LTD., 

TORONTO 

1914 



''/.,/ A I 



PREFACE 



The first edition of Lectures on " The Acute Abdomen " 
having become exhausted some months ago, I was requested 
by the pubhshers to write a second edition, with suclrllterations 
and additions as might seem advisable. The continued advance 
of our knowledge of the acute conditions which may arise in 
the abdomen has necessitated an increase in size of the volume, 
whilst it has appeared desirable to add the accounts of many 
cases and illustrations with the view of more thoroughly 
elucidating the subject. So many acute abdominal diseases 
have proved curable by operation, when it is performed early, 
that I hope my readers will not consider the subject unduly 
magnified considering its importance in modern practice. The 
treatment of the acute abdomen (including that of lesions the 
result of traumatism) demands an acquaintance with the 
surgical part of the subject which cannot always be obtained 
in text-books on surgery. In addition, it may be added that 
in order to be of general application the methods described 
should be as simple as possible, so that no practitioner need 
fear to make an attempt to save a threatened life because he 
has not some particular clamp, bobbin or brand of catgut in 
his possession. Silk is still recommended, because it is strong 
and can be trusted. Moreover, it is easily sterilised by boiling, 
even in a cottage. 

The principal additions to the present volume, which is 
divided into sections, are those on the planning of abdominal 
incisions and injuries to the abdomen, external and internal, 
including most of the subject-matter of the Oration given 
before the Medical Society of London in 1910. There is a 
special section on the after effects of abdominal injuries. 
An endeavour has been made to differentiate clinically some 



vi PREFACE 

of the varieties of peritonitis dependent on infection of the 
peritoneum through the blood stream ; whilst in addition 
there are sections on perforations of tuberculous ulceration of 
the intestine ; perforations of diverticula of the large bowel ; 
intraperitoneal abscesses ; concealed abscesses ; sigmoiditis ; 
important changes compUcating tumours of the uterus and 
tumours of the ovaries ; and torsion of the omentum. In 
Part VII. an account is given of diverticulum of the cystic duct 
of congenital origin. Since I commenced my task a book has 
appeared by my colleagues, Messrs. Adams and Cassidy, which 
covers the same field to a great extent. It is an excellent one, 
and will meet with a wide acceptance. As this book is written 
from a different standpoint, I hope it will also prove useful 
and fulfil a want. The subject-matter has been mostly given 
in the form of lectures to students, and the personal form of 
address has been retained, as it seems to present advantages 
from the teaching point of view. 

With the approval of my colleague, Dr. Hector Mackenzie, 
the plan of placing a mark •)(• when the patient was admitted 
into St. Thomas's Hospital under his care has been adopted in 
order to economise space and prevent repetition. It is hardly 
possible to speak too highly of the help which he has afforded 
during the years that we have been colleagues, but the reader 
of the following pages will be able to appreciate some of the 
debt which I owe him, and will understand that I am not 
ungrateful. 

I have much pleasure in acknowledging the great assistance 
which Dr. John Harold has given me in passing the book 
through the press. Mr. Stewart Rouquette has been very 
helpful in the preparation of some of the subject-matter and 
statistics, whilst I am indebted to him (and to Mr. W. K. 
Bigger) for some photographs. 

Most of the illustrations have been made for this edition by 

Mr. Sewell, whose excellent work is in such request by medical 

authors. 

William Henry Battle. 

Harley Street, 
London, W. 

September, 1914. 



CONTENTS 



PAGE 

PEEFACE V 

INTEODUCTION. 
The Planning of Abdominal Incisions .... 1 
Suggestions regarding Anjesthesia . . . . .11 



PART 1. 
Injuries of the Abdomen. 
Contusions 13 

A. Without Evidence of Rupture of Abdominal 

Contents . . . . . . . .13 

B. Those in which there is Evidence of Internal 

Injury ......... 15 

Wounds : 

Superficial— Penetrating — Gunshot .... 18 

Rupture of the Abdominal Contents without External 
Wound : 

The Stomach . 34 

The Small Intestine ....... 38 

The Large Intestine 50 

The Pancreas . . . . . . . .52 

The Liver ......... 54 

The Gall-bladder and Bileducts .... 58 

The Spleen 61 

TiiE Kidney .66 

The Urinary Bladder . . . . . . ,70 

The After-Effects of Abdominal Injuries . . .74 



viii CONTENTS 

PART II. 

PAGE 
PeRITOKITIS— WITH SPECIAL REFERENCE TO THE VARIETIES 

Depekdekt on the Entrance of Germs by the Blood 
Stream : 
Pneumococcal, Streptococcal, Tuberculous . .86 

The Influence of the Appendix Vermiformis and its Diseases 96 

The Diagnosis of the Acute Conditions having their Origin 

IN the Appendix Vermiformis . . . . .110 

The Treatment of Acute Appendicitis with Peritonitis . 119 

Appendicular Abscess . . . . . . .130 

Other Varieties of Localised Suppuration within the 
Peritoneum: 

Hepatic Abscess 139 

Perigastric and Sub-diaphragmatic Abscess . . 141 

Perisigmoiditis in Children 147 

Concealed Abscesses ....... 147 



PART III. 

Pathological Perforations of the Digestive Tract: 

Perforations of Simple Ulcer of the Stomach, Duo- 
denum AND Jejunum ....... 152 

Perforations during the Course of Typhoid Fever . 179 

Perforations of Tuberculous Ulcers .... 186 

Perforations of Diverticula of the Large Bowel . 188 
Perforations of Stercoral Ulcers . . . .189 



PART IV. 

Acute Conditions having their Origin in the Female 
Generative Organs : 
Salpingitis, Pyo- salpinx, Extra-uterine Gestation . 196 



CONTENTS ix 



PART IV.— continued. 

PAGE 

Importan't Chan'ges complicating Tumours of the Uterus and 

Tumours of the Ovaries ...... 206 



PART V. 

Some of the more rare Causes of the Acute Abdomen: 

Acute Hemorrhagic Pancreatitis . . . .214 

Acute Dilatation of the Stomach .... 220 

Embolism and Thrombosis of Mesenteric Vessels . 224 
Acute Cholecystitis and Perforations of the Gall- 
bladder and Bile-ducts ...... 225 

Torsion of the Omentum and other Abdominal Struc- 
tures ......... 229 

Hemorrhage from Gastric and Duodenal Ulcers . 230 

Some Neuroses which may cause Symptoms of Urgency . 228 



PART VI. 

Obstructions of the Digestive Tract below the Diaphragm: 

Strangulation of the Stomach 236 

Obstruction of the Small Intestine — Acute . . 239 

Intussusception ........ 260 

Obstructions of the Large Intestine (Growths and 

Volvulus) 269 



PART VII. 
Congenital Diverticulum of the Cystic Duct . . . 286 

APPENDIX. 
The Operation of Gastrostomy ...... 28S 

A.A. b 



LIST OF ILLUSTR.VnONS 



Fio. *'^^^ 

1. Strangulation of Intestine by Fibrous Band . . ii 

2. From a Dissection of the Muscles of the Abdominal 

Wall by Professor F. G. Parsons .... 3 

3. Bayonet Wound of Liver 24 

4. Portion of Intestine excised by Mr. John Croft in 

FIRST successful CASE OF OPERATION FOR TRAUMATIC 

Rupture ......... 35 

5. Extensive Laceration of Liver, Hemorrhage . . 56 

6. Traumatic Laceration and Contusion of the Spleen. 62 

7. The Larang 63 

S. Opening in the Mesentery of the Small Intestine of 

Traumatic Origin ....... 79 

D. Pin protruding through a Perforation of the Appendix 

and causing peritonitis ...... 87 

10. Diagram to illustrate by Shading the Relative Pro- 

portions of the various Perforations of the Hollow 
Viscera ......... 97 

11. Appendix, half-size, showing Localised Gangrene with 

Perforation, secondary to a Fecal Concretion, from 

A Child with General PeritojJitis .... 98 

12. Atrophied Left Kidney containing Calculi, which pro- 

duced Symptoms resembling those of Acute Appen- 
dicitis ' . .116 



LIST OF ILLUSTRATIONS xi 

Ftg. page 

13. Diagrammatic Representation of Seats of Maximum 

Reflex Pain IN Disease OF THE Abdominal Viscera . 117 

14. Incision for Appendicectomy (Battle) . . . 120 

15. "The Fowler Position" ...... 124 

16. Simple Apparatus used for the Continuous Administra- 

tion of Fluids per rectum . . . . .125 

17. Clinical Diagram with the Regional Percentages of 

Appendix Abscesses . . . . . . . 131 

18. Diagram of the Paths of Peritoneal Infection in 

Relation to Appendicitis . . . . .132 

19. Sagittal Section of the Female Pelvis . . . 136 

20. Diagram of the Anatomical Relations of a Right-sided 

Sub-diaphragmatic Abscess ..... 144 

21. Diagram of the Anatomical Relations of a Left-sided 

Sub -DIAPHRAGMATIC Abscess ..... 144 

22. Clinical Diagram of the Incision for Exploring the 

Right Side of the Abdomen . . . . .145 

23. Acute Perforation of a Gastric Ulcer . . .153 

24. Stomach Perforations. Diagram to illustrate most 

Common Positions of Perforation . . . .153 

25. Perforation of Gastric Ulcer. Insertion of Sutures 

where there is much Thickening of the Base . 159 

26. To Illustrate the Relations between Jejunum and 

Stomach in the Operation of Anterior Gastro- 
enterostomy . . . . . • • .166 

27. Perforation of Typhoid Ulcer . . . . .179 

28. The Temperature after Perforation of Typhoid Ulcer 

and Successful Operation . . . . .183 



Xll 



LIST OF ILLUSTRATIONS 



Fio. 
29. 



30. 
31. 

32. 

33. 
34. 

35. 

36. 

37. 

38. 
39. 
40. 

41. 
42. 
43. 
44. 
45. 
46. 
47. 
48. 



PAGE 

Perforation of Tuberculous Ulcer of the Small 
Intestine . . . • • • . • • .187 

Fat Necrosis of the Omentum ..... 217 

End-to-end Anastomosis after Excision of Small 
Intestine — Application of Clamps . . ' . .241 

End-to-end Anastomosis of Small Intestine — The 
Continuous Sutures 242 

Obstruction produced by Meckel's Diverticulum . 244 

Sarcoma of Small Intestine producing Obstruction 
IN A Child 254 

Sarcomatous Tumour of the Mesentery invading the 
Lumen of the Small Intestine .... 255 

Gall-stone removed from the Small Intestine during 
Life. It caused Acute Obstruction . . . 258 

Reduction of an Intussusception by Manipulation 

OUTSIDE THE AbDOMEN ...... 265 

Left Iliac Colostomy. The Incision .... 277 

The Supporting Suture . 277 

Position of Opening in the 
Colon 278 

Method of Insertion of Tube 278 

„ ,, The Operation Completed . 279 

. 280 

. 281 

. 282 

. 283 

. 284 



Lateral Anastomosis 



Ileo-colostomy 



The External Opening Two Years after Gastrostomy 289 



THE ACUTE ABDOMEN 



INTRODUCTION 
THE PLANNING OF ABDOMINAL INCISIONS 

Owing to the frequency with which incisional hernia follows 
the making of an abdominal wound, it would be well that 
any one engaged, or hoping to be engaged, in the practice of 
abdominal surgery should have clearly in mind the anatomical 
structure of the parts through which he will have to pass 
in order to treat lesions of the viscera whether acute or not. 
It must be fully recognised, however, that in some acute 
abdominal conditions it is not always possible, or perhaps wise, 
to elaborate an incision ; the quickest and most direct route 
must be followed at any cost. Professor F. G. Parsons has 
kindly made a dissection which he has permitted me to 
show in this illustration. It gives clearly the relationship 
of the parts. The rectus muscle appears, however, as usual in 
the dead subject, more narrow than it is in the living. It then 
covers two thirds instead of half of the distance between the 
anterior superior spine and the umbilicus, as shown. This is 
important, as will be seen later on. 

There are certain lines and arrangements of muscular fibres 
which must be remembered, and of the former the most 
important is the linea alba, the second in importance the 
linea semilunaris. 

It was once the rule to do all abdominal operations through 
one of these lines, and most commonly the linea alba was 
selected. For this there were many reasons : — 

1. Such an incision gave direct access to the diseased parts, 
could be easily extended upwards or downwards, and permitted 

A.A. B 



2 THE ACUTE ABDOMEN 

the operator to secure the pedicle of an ovarian tumour with 
equal facility on either side. Operation was mostly required 
for disease in the lower abdomen or pelvis, and not for acute 
conditions, or for diseases of the stomach, gall-bladder, or 
appendix. 

2. The wall was at its thinnest in this line ; therefore it 
took Httle time to get through it, and a comparatively short 
time to close it when the surgeon had finished. 

3. There was hardly any haemorrhage to embarrass the 
operator, and in the days when Spencer Well's artery forceps 
were unknown this was of great importance. 

Once it appeared to be the aim of an operator to extract an 
ovarian tumour from the abdomen through an incision as 
minute as possible. In a short correspondence in the Lancet 
on this question I ventured to protest against the principle 
of such an incision. The immediate danger of suppuration 
was considerable, and fear of peritonitis great, in those days. 
Experience had not shown the danger of subsequent yielding 
of the scar. The dislike of making a large opening only 
departed when our methods of wound treatment rendered 
any cut in the abdominal wall made by a surgeon practically 
safe. The injury inflicted on the edges of a small wound by 
the surgeon's hands and retractors increased the danger of the 
suppuration which it was intended to minimise, whilst it 
limited the area which it was possible to adequately explore. 

We have for a long time reached a stage when we not only 
plan a particular operation but try to do it in such a manner 
that the abdominal wall at the site selected for the necessary 
incision shall afterwards be as strong as it was before the 
operation was commenced. We want, in other words, an 
incision which will give adequate access to the disease but leave 
behind no weakness which can give uneasiness in the future. 
An accurate knowledge of the anatomical structure of the 
abdominal wall is therefore of the utmost importance. You 
must appreciate the pecuUar arrangement of the rectus muscle 
as regards its sheath, also the extent of the wall which this 
muscle covers. The part which the lateral muscles play in 
rendering the abdomen secure must also be remembered, for 
neglect to do so may lead to trouble, in consequence of a badly - 
planned incision. 



THE PLANNING OF ABDOMINAL INCISIONS 3 

For practical purposes there are two muscular groups, the 
anterior and the lateral : of the former, we need only mention 
the recti -abdominis, running from above downwards ; in the 





Fig. 2. — From a Dissection of the Muscles of the Abdominal Wall by Professor 
F. G. Parsons : — 1. Serratus magnus. 2. Sheath of the rectus. 3. External 
oblique. 4. Rectus muscle. 5. Deep epigastric artery. 6. Dorsal 
nerves. 7. Cord and cremaster muscle. ^8. Semilunar line of transversalis 
fascia. 9. Internal oblique. 10. Costal .'cartilages. 

b2 



4 THE ACUTE ABDOMEN 

latter, the external and internal obliques and the transversalis, 
running in different directions but united in action. The 
recti -abdominis hold the front of the abdomen, extending 
laterally towards the iliac spines over a space greater than 
is usually allotted to them, for they reach to within 2 inches 
of the anterior superior spine of the ilium on each side in the 
adult, being thus spread over a great part of the anterior 
abdominal wall. Each muscle is unusual, inasmuch as it is 
mostly contained in a sheath, is broad, long, flattened and 
very strong. The sheath, although of great strength, is 
loosely attached to the muscle which it encloses, excepting 
at the linea3 trans versse, and permits of no outward deviation 
in the line of pull, so long as the two are attached together by 
an uninjured linea alba. The tendinous intersections of the 
recti possess value from the surgical as well as from other 
points of view. 

There is no difference of opinion on one point, for all surgeons 
are agreed that suppuration within the abdomen which requires 
the employment of drainage after inci^on through the ab- 
dominal wall is likely to be followed by weakness later on ; 
they are apt to differ in their replies when asked their experience 
concerning incisions which have not been complicated by 
suppuration either before or after operation. Some do not 
admit that hernia occurs in their practice, others perhaps 
confess that operation is followed by weakness of the incision 
in a small percentage of clean cases. It is of course very 
annoying to find that a patient for whom an exploratory 
operation has been done, or perhaps one for the rectification of 
a painless disease, has developed a ventral hernia which is 
causing more inconvenience than the trouble for which the 
incision was made. When the original operation was for 
something which required a long and difficult manipulation, 
or the patient knows that life was saved by it, there is less 
disposition to gird at the operator should a hernia afterwards 
develop, and less surprise is expressed by the surgeon when 
it is met with. It must be recognised, however, that even at 
the present day, with our greatly improved technique, it is 
impossible to guarantee absolutely that an incision in the linea 
alba, whether made above or below the umbilicus, will not 
yield during after -fife. ^Convalescence may have been quite 



THE PLANNING OF ABDOMINAL INCISIONS 5 

perfect, no cough troubled the patient, nor did the anaes- 
thetic cause undue strain or vomiting, yet the unpleasant fact 
remains and has to be faced, a hernia may form in spite of all 
our care.^ All scar tissue has a tendencyto contract, but^Ehis 
may be overcome, and there are special reasons why a cicatrix 
should stretch when it enters into the formation of the 
abdominal wall. In every part of this it is subjected to the 
action of two forces — (a) int ra-abdominal tensi on, which 
varies considerably at different times of the day, and tends 
to a more permanent increase as we get older and more 
sedentary in our habits ; and (h) the act ion of the muscle s 
of_t he abdome n , which again is of varying power, and sometimes 
indeed violent and irregular, in consequence of disease. The 
intra-abdominal pressure is fairly evenly distributed over the 
whole of the anterior part of the abdomen, but in addition, 
over the lower part especially, there js the add ed weight of 
the abd ominal conte nts when the patient is either sitting or 
in the erect position. 

It may be asked what kind of incision should be substituted 
for those through the linea alba and the linea semilunaris. 
It is obvious that if the rectus muscle can be temporarily 
displaced to one side during an operation, and put back 
uninjured in its normal bed after the operation has been 
finished, there will be no possibility of the development of a 
hernia at the site of the incision. In the operation for the 
removal of the appendix which I suggested many years ago, 
and have practised regularly since, advantage is taken of the 
anatomical arrangement of the rectus. An opening is made to 
the inner side of the linea semilunaris through the anterior 
sheath of the muscle, the muscle itself is drawn inwards with 
a retractor, the posterior sheath incised, the appendix removed, 
and the incision sutured. This operation possesses many 
advantages, not the least important of which is the possibility 
of extending it to any reasonable distance. Modifications of 
this method have since been adopted for other operations, 
the advantages of it being so obvious. 

At an appendix operation, if the right ovary or tube be 
found diseased and requires removal, this can be done through 
the same incision. Should the left ovary or tube require 
removal, it can be excised through a similar incision on the 



6 THE ACUTE ABDOMEN 

other side at the same sitting, and a perfect wall will 
be left. 

Displacement of the rectus outwards after incision of the 
sheath should be substituted in the early stage of many opera- 
tions for those which were formerly carried out entirely through 
the middle Une, e.g., the removal of fibroids, ovariotomy, tubal 
disease, etc. ; exploratory operations generally, and operations 
on the stomach. 

It is occasionally advisable to go through the substance 
of the rectus muscle in some operations, such as gastrostomy 
by the method of Senn, operations on the gall-bladder and bile- 
ducts, and for the treatment of acute suppurative peritonitis 
in children and young adults, for although such an incision 
may be followed by hernia, it is not so in every case, and there 
is less danger of its giving way during the immediate after- 
treatment than if it is made through the linea semilunaris. 

If the anterior sheath of the rectus is not restored after 
these incisions going directly through the muscle, then there 
will be some bulging of the muscle with consequent weakness 
of the abdominal wall. It is sometimes mistaken for a 
paralysis, but the rectus cannot fulfil its functions properly 
without a sheath, and will act perfectly again when the defect 
is remedied. 

In the majority of patients benefit is gained by a careful 
and legulated course of exercises after all abdominal opera- 
tions ; the danger is still that of keeping them recumbent or 
fettered by bandages and belts for too long a time. Abdominal 
hernia may be prevented by appropriate exercises, but it is 
not of much use prescribing a " course of Sandow " for an 
irreducible ventral hernia ! 

During an abdominal operation in which the linea semilunaris 
is exposed it is easy to observe the action of the external 
oblique, for should the patient make any effort to cough or 
vomit, tendinous fibres forming its insertion are pulled upwards 
and outwards, frequently forming parallel folds which are 
continuous with the anterior sheath of the rectus. The 
continued pull of the muscles in the lateral group is strongly 
backwards away from the middle line, and if an incision has 
left any weakness either at the linea alba or linea semilunaris 
the weak incision will be stretched, as these lines are really 



THE PLANNING OF ABDOMINAL INCISIONS 7 

insertions of the lateral muscles. It is not necessary for the 
weak spot to be a large one in the first instance, for the omentum 
seems to have the power of finding the most minute and of 
dilating it. We owe much to the omentum for the use of its 
defensive powers against intra-abdominal disease, and perhaps 
its pushing character and insinuating qualities in cases of a 
defective abdominal wall are only an effort of Nature to give the 
individual early notice of his danger, so that he may remedy 
the defect in his armour as soon as possible. Be that as it 
may, such warnings should not be so frequently neglected. 

Not only, then, are incisions in the median line very liable 
to be followed by hernial protrusion possibly years later, but 
also those which have been placed in the linea semilunaris, 
and for a similar reason the lateral pull of the muscles, which 
is so difficult to regulate and control. In both these situations 
there are practically only three layers which prevent a pro- 
trusion from forming, and an incision through the middle 
layer places a weak line between peritoneum and skin, for in 
the prevention of abdominal hernia the resistance of the 
skin, and indeed of the peritoneum, may be regarded as non- 
existent ; they are both of them too elastic and easily stretched, 
even when uninjured, to afford any permanent protection. 
The aponeurotic structures constitute our main reliance, their 
value after division again depending almost entirely on the 
accuracy of apposition secured by the method of suturing 
adopted. If the line of suture is not accurate but irregular, 
the edges not meeting well, then we must expect to have a 
weak scar — ^indeed the wonder is, not that we occasionally get 
one, but that we do not get one more often. The edges to 
be joined are commonly so narrow that they can rarely be in 
perfect apposition over the whole length of the incision. Both 
this layer and the peritoneum must be sutured with the greatest 
care, for although we may hold it as a fact that if the aponeurotic 
layer becomes perfectly united no hernia will develop, should 
there be any depression in the peritoneal line of suture you 
may be sure that a piece of omentum will find and insinuate 
itself into it. By this means, and also as a possible result 
of the inclusion of a piece of omentum during the process of 
the insertion of sutures, a great pressure may be exerted on 
the aponeurotic union at one or more points, one of which may 



8 THE ACUTE ABDOMEN 

yield. The tendency to-day, therefore, should be to avoid the 
linea alba and the linea semilunaris as much as possible, and, 
if it is necessary to open the abdomen in these Hnes, to plan 
an incision which shall not divide more than is absolutely 
necessary, since weak points in the semilunar Hne, the line 
formerly chosen for Langenbiich's incision, will not prove to 
be easily managed if of old standing with contracted muscles 
posteriorly. A strong aponeurotic layer is most useful, but 
the transversahs fascia is also of service, and its accurate 
union will assist in keeping the contents of the abdomen in 
their proper place. It is sutured with the peritoneum as the 
innermost layer, and as a reinforcement to it its value is great, 
especially in men, in whom the peritoneum is often less elastic 
than in women, and does not stretch or hold sutures with 
satisfaction. But I do not think that the most accurate 
apposition of this layer by any method of suturing is calculated 
to prevent a protrusion taking place unless the line of incision 
is reinforced externally by other structures. If it is possible 
to place the lines of reunion of the divided tissues so that these 
lines are not exactly superimposed, the result may sometimes 
be better. 

As regards the other positions in which incisions may be 
made, we cannot over-estimate the great importance of the 
rectus abdominis, and we should endeavour to preserve it from 
injury as much as possible. If its fibres have been separated 
by a blunt instrument instead of having been cut by a knife, 
the resulting imion may be less secure, for the parallel bundles 
of fibres when rolled apart may not unite when placed side by 
side. Wire sutures have been tried, and when their presence 
was not resented it was hoped they would ensure that security 
for all time which is obtained whilst the patient is in bed and 
his wound kept free from any possible strain or adverse 
influence. I do not myself use any other material than silk 
(mostly No. 1) for the suturing of wounds of the abdominal 
wall ; all the buried sutures are of this material, and it is 
rehable : you can always trust it, and the interrupted silk 
suture gives me a sense of security which catgut never affords. 
The only cases in which I have known a bursting open of an 
abdominal wound aft^r operation, during the course of my 
personal experience, have been when I have employed catgut, 



THE PLANNING OF ABDOMINAL INCISIONS 9 

or silk of less strength than that of No. 1. Perhaps I am 
prejudiced, but I am not alone in my preference for silk, for 
Sir Alfred Pearce Gould, whose experience is large, also 
advocates its use for the deep sutures. As some of you may 
know, I have advised silk for the routine sutures in these cases 
for many years in the lecture -room, and used it in the operat- 
ing theatre. Kocher asks : " How can people go on using 
catgut for suturing the wall of the abdomen, when Madelung 
has recorded over a hundred cases where the wound has 
burst open because of it ? " 

If the surgeon has to operate quickly because of the urgency 
of the case, then he must insert strong sutures which will 
include all the layers on both sides of the wound, and there 
are none better for this purpose than the larger -sized fishgut, 
which is readily sterilised, makes a good knot, and will resist 
any strain. This necessity for rapid operating is found in 
cases of the " acute abdomen " in stout adults, when the 
operation must be rapid to be successful ; there is another 
point in the urgent operations for this class of case, and that 
is the incision through the semilunaris should be chosen 
deliberately, as this gives much the least difficulty when it 
comes to closing the wound and the surgeon is short-handed. 
The possibility of a hernia after recovery is not worth a 
moment's consideration in such cases ; it can be easily put 
right by a second operation. In the ordinary operation where 
the surgeon is not hurried, the abdominal wall should be closed 
in layers : forty -four out of the fifty -five German and Austrian 
surgeons quoted by Dr. Swaifield were in favour of this pro- 
cedure, and it agrees with the experience of most British 
surgeons. The importance of operating early when a wound 
shows signs of yielding later on, because of the greater benefit 
to be derived from the operation when practised on a small 
hernia, must be self-evident ; there is also the smaller risk 
of an operation of short duration in a bad type of patient to 
be considered, for shock is absent, and the administration of 
an anaesthetic need not be prolonged, or one may be employed 
locally. In bad cases we can use the intra -venous infusion 
of a solution of hedonal. 

It must not be forgotten that muscles that have been con- 
tracted undergo change, so that after a long interval of time 



10 THE ACUTE ABDOMEN 

it may be impossible to stretch them to their former length 
sufficiently to cover the weak place in the abdominal wall. 
I think this statement particularly applies to the lateral 
muscles on the spinal side of a hernia followiag an incision 
through the upper right rectus in an operation for treatment 
of some hepatic disease. 

The hemise which occupy the middle line below the umbilicus 
sometimes assume rather startling proportions, falling down 
between the thighs and causing distress both from the dragging 
of their contents and their occasional disturbance or inflamma- 
tion. Their formation is therefore a real danger to be guarded 
against. 

In the herniae which follow incisions for the relief of appendix 
abscesses, although much may be done to prevent them by 
the gridiron method, the skin and peritoneum become joined 
together in a thin cicatricial layer to which the omentum is 
often adherent. This covering may be dangerously thin, for 
sometimes it does not much exceed the thickness of paper. 
Hernia is rare after operations on the kidney by the 
lumbar route, if the incision is made obliquely from above 
downwards and the fascial planes are sutured after the 
operation. 

Never cut across muscular fibres unless it is absolutely 
necessary from the particular needs of the case ; muscular 
fibres must always be separated, not cut, and as the aponeurosis 
of the external oblique forms the strongest layer in the lateral 
wall, incisions should follow the direction of that muscle. There 
are nerves likewise to be considered, and often a little care in 
the arrangement of a wound will result in the avoidance of 
any injury to them. In some instances when the fibres of the 
rectus have been split in the performance of cholecystotomy 
or gastro -enterostomy, without reference to the position of the 
nerves, that part of the muscle to the inner side of the incision 
has imdergone atrophy and a hernia has consequently developed. 
At Czerny's instance Assmy investigated the after -results of 
cases in which a wide vertical splitting of the rectus fibres 
had been performed, and he showed that an atrophy of that 
part of the muscle dissociated from its nerve supply always 
followed.^ 

^ Moynihan, "Abdominal Operations," p. 91. 



THE PLANNING OF ABDOMINAL INCISIONS 11 

The Administration of Anesthesia in Acute 
Conditions of the Abdomen. 

Dr. Z. Mennell, who has most ably administered anaesthetics 
for me for some years, advises as follows : — 

" For the successful performance of an operation for acute 
abdominal disease, the method of anaesthesia and choice of one 
to be used must be carefully considered. 

" In the first place the patients are generally suffering from 
more or less severe toxaemia due to absorption from the 
abdominal condition, and secondly, it is rarely possible to 
prepare them for operation on account of urgency. 

" Generally speaking, ether should be selected and chloro- 
form avoided, and in the less severe cases the ordinary nitrous 
oxide ether sequence may be used : the number of cases in 
which a perfectly satisfactory anaesthesia can be obtained by 
this means varies directly with the skill of the anaesthetist in 
the use of this method. 

" When morphine has been given before the operation it is 
usually possible to obtain anaesthesia by means of open ether, 
that is ether dropped on to a Skinners or Schimmelbusch 
mask : there are, however, many cases in which a prehminary 
narcotic (morphine, scopolamine) is inadmissible. 

" In cases where there is already severe shock the responsi- 
bility of the anaesthetist is great ; the condition may appear 
to be desperate, but usually the anaesthetic is taken better than 
would appear to be likely. Here the minimum of the anaes- 
thetic must be used which is compatible with the necessary 
surgical manipulations, and the less anaesthetic used the less 
addition there is to the pre-existing shock. Oxygen must be 
used freely to counteract any cyanosis, and saline infusion 
subcutaneously, or if necessary intravenously, should be 
resorted to at the commencement of the operation. The use of 
strychnine and other cardiac stimulants is to be deprecated. 
The body warmth must be maintained ; the room should be kept 
at a temperature of 70° F. ; the body must not be unnecessarily 
exposed, and the legs and arms may be bandaged and covered 
with cotton wool ; any saline or lotions used must be slightly 
above the body temperature. 

" Children take ether well, but are specially liable to th*e 



12 THE ACUTE ABDOMEN 

condition known as acidosis ; when this is present the dangers 
of a general ansesthetic are greatly increased — when the breath 
of a patient smells of acetone or when there is the acetone 
reaction in the urine, ether, and especially chloroform, are 
contra-indicated, and it is in such cases that intra -spinal 
anaesthesia is specially useful. 

" For some years in America, and more recently in this 
country, a mixture of nitrous oxide and oxygen in definite 
percentages has been used for prolonged operations. In severe 
abdominal conditions it may be used with advantage, either 
with or without nerve blocking by means of novocaine sub- 
cutaneously. This without doubt diminishes shock, but the 
method is difficult and has its limitations. 

" At St. Thomas's Hospital hedonal, and elsewhere ether, 
has been used intravenously. 

" The most dangerous perhaps of cases met with under the 
heading of the Acute Abdomen are those of acute intestinal 
obstruction with consequent severe vomiting. When an 
anaesthetic is given in such cases, great care must be taken of 
the position in which the patient is placed : the head must be 
on a level or little below that of the body and turned to one 
side with a gag in the mouth, the danger being that of inhahng 
the vomit into the air passages. Here again intra -spinal 
anaesthesia is indicated, and more recently we have been using 
intratracheal ether ; with this method, as soon as the catheter 
has been passed into the trachea, all danger of inhalation of 
vomit ceases." 



PAET I 
INJURIES OF THE ABDOMEN 

CONTUSIONS 

For purposes of clearness it will be best to divide these 
injuries into two groups : — 

A. Contusions without Bupture of the Abdominal Contents. 

B. Contusions in which there is Evidence of Internal Injury. 

A. These contusions are of varying degrees of gravity, 
according to the severity of the injury, the region of the 
abdomen struck, the physical condition of the individual, 
his preparedness for the blow, the time which has elapsed since 
the last meal, etc. Any contusion of the abdomen may be 
serious, and it must be remembered that a patient without 
symptoms of importance, when seen soon after an injury, 
may be suffering from a rupture of the intestine or other 
internal organ, which will prove fatal if not recognised in 
time. Such cases have been only too frequent in the history 
of surgery, and whenever the cause of the injury has been 
" possibly " sufficient to produce internal damage, however 
slight, the case should be taken under observation and carefully 
watched. There may be no bruising of the skin and yet 
there may be a rupture of the intestine. In these days, when 
football is so popular, it is hardly necessary to say that a 
contusion of the abdomen is frequently followed by severe 
pain, shock and vomiting, yet the effects pass off in a short 
time. There are not many cases recorded in which the shock 
of a contusion without internal injury has proved fatal, but at 
least one is known about which there can be no doubt. On 
the other hand, the absence of an unusual amount of initial 
shock has been frequently observed when an injury has been 
inflicted which has caused death in a few hours. 

The amount of extravasation of blood following a contusion 
of this part of the body varies much, according to the nature of 



14 THE ACUTE ABDOMEN 

the injury, but beyond stiffness and pain on movement, swelling 
and the usual discoloration of skin, does not as a rule produce 
continued inconvenience unless there is associated vi^ith it a 
rupture of some muscular tissue. In a case under the care of 
Mr. C. A. Ballance in which extravasation of blood had taken 
place in the subperitoneal tissue, there was a large area of 
dulness over the front of the abdomen not attended with 
evidence of free fluid in the peritoneal cavity. If the blood is 
not absorbed, a fluid swelling may be found long afterwards ; 
in one case I opened such a swelling the contents of which were 
serous, which persisted five years after an injury. Suppura- 
tion may follow but is not common, yet in the aged it may- 
cause anxiety, and an early incision is indicated should there 
be evidence that it has commenced. 

Rupture of part of an abdominal muscle is not unusual as a 
result of a direct injury, especially if the condition of the 
muscle has deteriorated from some illness. The patient will 
complain of local pain on movement, and tenderness of the 
part, whilst a defect may be felt on examination when the muscle 
is put into action. Such an injury, if involving a complete 
rupture of the rectus muscle, will give rise to much discomfort 
but not to a hernia. In rupture of the muscles, on the lateral 
aspect of the abdominal wall, a protrusion may be found as a 
temporary condition forming at the site of the laceration, or 
as a permanent one from yielding of the scar tissue formed in 
the process of healing. 

An operation for the closure of such a weak spot is indicated, 
because, although the danger of strangulation may appear 
remote, a truss is inconvenient, is not always easily kept in 
position, and does not prevent an increase in size. 

Rupture of the recti muscles is sometimes seen as a result of 
intense strain, during parturition, vomiting, tetanic spasms, 
and gymnastic feats. Professor Alexis Thomson says that it has 
been chiefly observed in cavalry recruits, through attempting 
to mount a horse without placing the foot in the stirrup. 

These ruptures always occur in the lower part of the rectus 
muscle, because of the absence of the posterior layer of its 
sheath in that situation. There is violent pain at the site of 
the rupture, with inabihty to straighten the body, which is 
kept flexed to prevent traction on the part. There is found a 



INJURIES OF THE ABDOMEN 15 

very tender swelling to one side of the middle line ; this swelling 
is chiefly produced by extravasation between the ruptured 
ends which are concealed by it. 

In cases where operation can be performed the sheath of the 
muscle should be opened and the ends sutured ; in this way the 
patient will obtain a stronger union and recover most quickly. 
Should his condition not permit of the operation, he should be 
placed on his back in bed, in such a position that the abdominal 
wall is fully relaxed. On account of the strength of the anterior 
sheath of the muscle it is unnecessary to make the patient wear 
a truss afterwards. 

The ruptures of the diaphragm which occur independently 
of gunshot wounds, stabs, etc., are usually found on the 
left side, and are produced by a sudden and great increase 
of intra-abdominal pressure. Severe muscular efforts, as in 
vomiting and parturition, have caused this lesion, but there 
may be a less evident cause, as in the patient whose case is 
recorded in the British Medical Journal of 1858. 

Here a man of 20 was admitted to St. Mary's Hospital " suffering 
from pneumothorax and diaphragmatic hernia," from which he died 
thirty-two hours after admission. He had slipped while walking in his 
own house, and in trying to save himself from falling given himself a 
severe twist, when he felt something snap at the lower ribs on the left 
side, followed by great pain, to such an extent that he could hardly 
breathe for some minutes. 

B. When complicated with injury to the viscera there has 
been some severe violence inflicted, such as a crush between 
buffers in shunting, or the subject has been run over. 

In Holmes's " System of Surgery," Vol. IT., the case of a man aged 24 
who had fallen from a scaffold is given. He lived for eleven weeks, 
and at the post-mortem examination the inferior surface of the diaphragm 
was lacerated from the median line to the extent of 6 inches to the left 
side. The spleen had been separated into two pieces ; there were the 
remains of an extensive extravasation of blood and much suppuration 
both below and above the diaphragm in the region of the rupture. 

A wound of the diaphragm may be very readily produced. 
A stab from a knife in civil brawls or a lunge from a bayonet 
in warfare may produce it, either from the front or the side. 
It is then likely to be seriously complicated with injury to one 
of the viscera and dangerous haemorrhage. If the patient 
recovers from the immediate dangers incidental to such wounds 



16 THE ACUTE ABDOMEN 

he will very probably develop a hernia into the pleural cavity 
at a later date. 

A good example of the course of such cases will be found on 
p. 236. 

A case in which a rupture of the diaphragm was associated 
with escape of viscera into the chest was operated on by 
Mr. Berry in the Royal Free Hospital. 

Male, aged 19, buffer accident. Admitted November 11, 1898, in a 
state of collapse, with superficial evidence of injury over the upper part 
of the abdomen, in the loin, and over the lower ribs. No air could be 
heard in the chest below the third rib on the left side, and the left side 
was dull behind the mid-axillary line. Very marked pallor was a 
prominent sign. There was much sickness (beginning on the 
third day), the vomit being coffee-coloured, great thirst, and not much 
pain. On November 15 the heart was evidently displaced to the right 
and a tympanic resonance extended over the front of the left chest 
almost to the clavicle, and blended below with the abdominal resonance. 
A "bruit d'airain'' was heard over the tympanitic area. The breath 
sounds were normal over the right lung. The diagnosis lay between 
pneumothorax and gastric hernia. Operation, midnight of 16th. A 
large hole was felt in the diaphragm, through which about half the 
stomach, the transverse colon, the duodenum, half the spleen, and the 
upper half of the left kidney had passed into the thorax. The hole was 
as large as a man's fist, situated between the diaphragm and the last 
rib. Two stitches secured the liver over the opening after reduction 
of the protrusion . The patient died at the close of the operation . 

It is possible in performing an operation for empyema in a 
child to pass through the diaphragm when making the incision, 
if the lower part of the pleural cavity is obliterated by 
adhesions. Such an opening should be carefully sutured and 
the pleura drained at a higher point. 

In gunshot injuries the diaphragm is frequently traversed 
by a ball, but the injury to this muscle need not be specially 
considered, as it is probably unimportant compared with that 
inflicted on the other structures. 

From the great danger of diaphragmatic hernia which almost 
invariably follows rupture or wound of €he diaphragm, such 
injuries should be repaired as much as possible by means of 
direct interrupted sutures when the condition of the patient 
permits. The transpleural route will be the better one to use. 

I cannot too strongly impress upon those responsible for 
any patient suffering from an abdominal injury the importance 
of watching the pulse. It is necessary to insist upon a careful 



INJURIES OF THE ABDOMEN 17 

examination from hour to hour ; it is now many years since 
I tried to impress the importance of this careful observation 
upon my juniors, and I still strongly urge it. The small pulse 
of the patient with shock should not increase in frequency in 
cases of simple contusion, when the shock is passing away. If 
it does so, and the temperature is falhng, you have a danger 
signal which may mean much. Other signs of importance, 
to which reference will be made later, are severe local pain, 
rigidity of the abdominal wall, alteration in the percussion 
note, continued vomiting, and an anxious and distressed 
appearance. A rise in temperature may indicate the need for 
exploration, but less importance may be attached to the onset 
of distension unless other symptoms show it to be the result 
of an inflammation of the peritoneum. 

Meteorism without any lesion that can be found on abdominal 
exploration may result from a simple contusion of the abdomen. 

Some years ago a boy of 12 was admitted to St. Thomas's Hospital 
under my care, and a somewhat rapid .distension of the abdomen with 
rise of temperature ensued. There was, however, no rigidity, special 
complaint of pain, or vomiting. The resident assistant -surgeon explored 
the abdomen at my request, but could find nothing abnormal. The 
distension subsided after operation and the boy made a good recovery. 
It was very much on a par with the excessive meteorism which is some- 
times seen after surgical interference with the peritoneum, for instance 
in the performance of a radical cure of hernia. 

A far more important condition as indicative of internal injury 
is a rigid abdomen without any distension. Absence of liver 
dulness will be referred to later ; it is not a sign to which any 
importance should be attached. In no case should a surgeon 
wait for its development, or refuse to operate because it is 
not demonstrable. 

When the shock has passed off, there is usually no difficulty 
in coming to a conclusion, but in many cases, especially the 
more severe injuries, it is the wisest plan to interfere before 
the patient is further exhausted by loss of blood. The damage 
must be treated in the same way as a wounded artery is 
attacked in more accessible parts of the body. 

Statistical tables show how very important it is to operate 
early both in these cases of haemorrhage and in those in which 
an infection of the peritoneum may follow. There are, how- 
ever, many instances in which it may be necessary to consider 

A.A 



is THE ACUTE ABDOMEN 

the question of operation in apparently hopeless and neglected 
cases ; here the verdict in favour of operation should not be 
put aside too readily. The many ways now available of pro- 
ducing anaesthesia and treating collapse, with the evidences 
given of recovery under the most desperate circumstances 
which pubUshed cases afford, justify and often compel an 
attempt, however hazardous it may appear. 

WOUNDS OF THE ABDOMEN. 

I remember very well when we were taught that it was a 
wrong practice to interfere with wounds of the abdomen ; 
appropriate dressings were to be appUed and we were to wait 
for symptoms. The important thing in all these injuries is 
to ascertain whether there is penetration of the peritoneum, 
and a careful examination of the part should be made under 
anaesthesia. Let the region be painted with iodine as soon as 
the wound can be exposed, and do not complicate matters by 
doing an imperfect examination either with probe or finger. 
Cover it with a sterilised or antiseptic dressing, and bandage 
this into position. In cases where there is haemorrhage from 
the parietes this must be arrested in the usual manner. When 
the bleeding point is not easily found, it may be advisable to 
place a temporary plug in the wound. Explore as soon as 
possible, and so make certain of the extent of the wound ; if 
the peritoneum has not been penetrated, the bleeding is arrested, 
the wound cleaned, and cut muscles sutured. The most 
dangerous cases are not necessarily those in which the escape 
of abdominal contents proves the fact that the peritoneum 
has been invaded ; they are subjected to operation without 
loss of time. Do not wait for symptoms ; it is bad surgery. 
If at the operation the wound is found to extend into the 
peritoneal cavity, then a most careful examination of the parts 
within should be made through an incision of adequate size. 
Should the patient not apply for treatment until some days 
have elapsed, you must be guided by the symptoms which are 
present, paying special attention to the condition of the pulse 
and signs of local inflammation. It may still be necessary to 
explore. If there are no symptoms it would be best to keep 
the patient under observation — for serious symptoms have 
developed after some days in cases of stab wounds. 



INJURIES OF THE ABDOMEN 19 

In making these exploratory incisions through the abdominal 
wall, it is usually possible to extend them in such a direction 
that the anatomical arrangement of the muscles is taken into 
consideration, as already advised in the planning and making of 
abdominal incisions. Avoid the middle line if possible. The 
after -development of a ventral hernia may make the life of a 
man miserable and his support a burden to the community, 
still the first consideration is the making of an adequate 
opening for the examination. 

If the wound is of considerable size and permits of 
the protrusion of intestine, omentum, etc., the parts pro- 
truded must be carefully washed with warm sterilised 
saline solution, boracic acid solution, or even boiled water 
before they are returned to the abdomen. The question of 
treatment of the wounds inflicted on these parts will be con- 
sidered later. General principles must guide you in the first 
place. The herniated contents will be reduced after repair of 
wounded parts and enlargement of the opening. Reduction 
should then be no more difficult than it is after examination 
during an operation, where it has been necessary to bring much 
bowel outside in exploring for the cause of an obstruction. 
If the bowel has not been compressed by the small opening 
for any great length of time, there should be no distension of it. 
The protruded parts must be most carefully cleansed, let it be 
repeated, for if there is any contamination of the peritoneum 
later it will be most commonly caused by septic material carried 
in when the herniated part is reduced. Drainage is seldom 
required, and should be avoided if possible. The wound should 
be carefully sutured in layers, as- after the making of irregular 
wounds by the surgeon. If the state of the patient does not 
permit of careful suturing in layers, use strong interrupted 
sutures of salmon gut, passing through all the layers. 

When the wounds are of longer standing, and the protrusion 
is adherent to the lips of the wound, it must be cleansed and 
returned if its structure is not injured beyond repair. When 
there is a septic wound with possibly gangrenous protrusion, 
in some instances little can be done beyond cleansing the part 
and making provision for relief of any constriction. The 
question of excision of the whole protrusion will have to be 
considered ; in some this would be the best treatment, if the 

c2 



20 THE ACUTE ABDOMEN 

condition of the patient is hopeful and the surroundings 
permit of it. Drainage is usually necessary in all late cases. 

There may be occasions when attempts at reduction of a protrusion 
would be bad surgery. I remember when the subject of internal 
injuries was under discussion at the Portsmouth meeting of the British 
Medical Association an officer in the K.A.M.C. gave an account of a case 
of protrusion of the omentum, which followed a bullet wound, when 
the patient was on active service in the Hills. The enemy was sniping 
the retreating force, and the wound was an oblique one of the abdominal 
wall. The circumstances were against successful operation, therefore 
it was postponed. After removal of the omentum a few days later 
the soldier made a good recovery. 

Even large intestinal protrusions have been safely reduced 
without surgical help when the opening has not been too 
constricted and the usual septic inflammation has not super- 
vened. Some of these accounts appear almost incredible. 

It may be well to mention here the protrusions which follow 
spontaneous rupture of the coverings of large hernise. These 
accidents may occur when the skin and other tissues have 
become very thin from stretching, but are more likely to 
happen when there is weakness in the parts due to scar tissue 
resulting from a former operation. 

In one case in which the coverings of a femoral hernia had ruptured, 
Mr. Bernard Pitts, who treated the case, found a woman applying for 
admission " because something had given way." When her clothing 
was lifted, almost the whole of her small intestine was found to be out- 
side, covered more or less with a towel. She recovered after cleansing, 
reduction, and suturing of the parts. Here a former operation for 
strangulation had left a large femoral ring from too free division of 
Gimbemat's ligament. 

It is easy to make the section of Gimbernat's ligament too 
freely during an operation for strangulated femoral hernia. 

There are two cases included amongst the ventral and umbilical 
hemiae in the St. Thomas's Hospital records in which a similar accident 
occurred ; one of these died. The sloughing of skin which sometimes 
follows faical abscess in gangrenous hernia is quite a different thing, and 
is far more frequent. The mortality is very high. 

Gunshot wounds of the abdomen in civil life should be 
subjected to immediate exploration, or to an operation at the 
earliest possible moment. I do not recollect a single case in 
which the patient recovered where operation was dechned or 
not advised when there was reason to suspect from the direction 



INJURIES OF THE ABDOMEN 21 

of the bullet that the intestine had been injured. There may be 
many wounds in the bowel, the operation will be not only pro- 
longed but difficult, wound after wound may present itself, each 
succeeding one proving more certainly the need for the opera- 
tion. There must be no waiting for symptoms. The surgeon 
has more reason for urging operation than in cases of suspected 
subcutaneous rupture of the gut. It is true that there may be 
doubt as to a wound of intestine in the latter injury, but in the 
former there can be none. The incision should extend through 
the track of the bullet down to the peritoneum, any foreign 
substance that may be found being removed and kept. The 
edges of this wound should be excised, especially in wounds 
which have been inflicted for some time. An opening large 
enough to admit of thorough inspection of the abdominal 
contents underlying should be made through the peritoneum, 
and after packing off the area of probable injury with sterilised 
gauze any blood or escaped fluid should be wiped away and the 
track of the bullet followed further. Wounded gut should be 
drawn outside and immediately sutured. As there may be 
many openings in opposed loops, no abdomen should be closed 
until actual inspection has proved that none have been over- 
looked. Cleanse the intestine and parts involved in the 
examination with sterilised saline. Do not hesitate to bring 
all the intestine outside the wound inch by inch if necessary, 
beginning at the caecum and working from that as a fixed point. 
If the operation has been done early, there will be no distension, 
of the intestine, and manipulation of the parts will be compara- 
tively easy and quickly performed. When there is commencing 
infection and distension of the intestine, it will be best to empty, 
possibly through a puncture, one or more of the most dis- 
tended coils, and the need for drainage will be evident. 

Although it will be advisable to follow the track of the 
wound down to the peritoneum in all cases, this incision may 
require to be supplemented by another nearer the middle lino 
to enable you to deal adequately with the injured bowel. 
In most cases, however, the linea alba can and should be 
avoided, on account of the danger of later development of a 
hernia ; but rapidity of operating is important, and for the 
surgeon who has not had a great deal of practice the less 
complicated incision may be best. 



22 THE ACUTE ABDOMEN 

Some American surgeons, pioneers in this branch of surgery, 
have successfully dealt with multiple bullet wounds of the intes- 
tine which have been inflicted with a revolver. In these they have 
boldly brought the whole of the small intestine outside through 
a long incision and sutured the wounds. Hamilton not only 
sutured eleven wounds of the small intestine, but two of the large, 
and ligatured a bleeding mesenteric artery. The amount of 
shock must be proportionally greater, but there is no doubt that 
this method of total evisceration has a great advantage over 
the more careful method of exploration, for it enables a inore 
thorough examination to be made of parts which might other- 
wise escape attention. In addition, the surgeon knows quickly 
the amount of damage which has been inflicted, and can arrange 
either to suture perforations singly, or to resect when there are 
several closely situated, and perform an anastomosis. 

As regards the treatment of bullet wounds of the abdomen on 
active service, the opinion of my senior colleague, Mr. G. H. 
Makins, as expressed after his experiences in the South African 
war, is valuable. He writes : — 

" A careful consideration of the whole of the cases that I saw leaves 
me with the firm impression that perforating wounds of the small 
intestine differ in no way in their results and consequences when 
produced by small-calibre bullets from those of every-day experience, 
although when there is reason merely to suspect their presence an 
exploration is not indicated under circumstances that may add a fresh 
danger to the patient." i 

He gives general rules regarding the treatment of injuries to 
the intestine," which we also venture to quote because of their 
importance, coming as they do from such an eminent authority. 
" First the patients must be removed with as little disturbance as 
possible, and absolute starvation must be insisted on. If the patients 
be suffering from severe shock, hypodermic injections of strychnine 
should be administered, or possibly some stimulant by the rectum." 
He advises that all abdominal injuries should be placed in the 
same marquee, and kept absolutely quiet until they are 
evidently out of danger. 

" When feedmg is commenced at the end of twenty -four or thirty-six 
hours. It must be in the form at fct of warm water, then milk adminis- 
tered m teaspoonfuLs only. In doubtful cases morphine must be avoided. 
Operative treatment is required in a certain number of cases, but in the 

1 *' ^"/gical Experiences in South Africa," p. 467. 

2 Ibid., p. 452. ' f 



INJURIES OF THE ABDOMEN 23 

majority we are met with the extreme difficulty that in a very large 
proportion of the occasions on which these womids are received an 
abdominal section is not warranted in consequence of the conditions 
under which it would have to be performed." 

It is necessary to emphasise the fact that bullet wounds of 
the intestine are often widely separated, and a search limited 
to the parts underlying the surface wound may be inadequate 
to reveal their number. 

Gunshot wounds of the stomach vary very considerably 
according to the nature of the weapon, the size of the bullet, 
its shape, the distance from which it was fired, etc. The state 
of the organs as to distension or emptiness must be taken into 
consideration. The bullet may contuse the anterior wall, pass 
into the cavity of the stomach and remain there, or more 
probably penetrate the posterior wall also. The angle at which 
it entered must also be taken into consideration, as the prob- 
ability of damage to other parts will much depend upon this. 

Early operation in these as in other injuries penetrating, or 
possibly penetrating, the intestinal tract is very important. 
Forgue and Jeanbrau ^ give a series of 112 cases, in which the 
stomach was wounded by bullets, and the results of operation 
are shown as follows : — 

When the stomach only was wounded — 

Operations within six hours 
,, after this period 

Wounds of stomach and other parts — 
Operations within six hours 

,, ,, six to twelve hours 

,, after twelve hours 

,, time not stated 

In these cases the opening should be a median one, made 

quickly and freely, so that the stomach may be easily seen and 

manipulated. If escape of the contents of the stomach has 

taken place, the peritoneum underlying the wound must be 

cleansed, the stomach wound located and sutured, a double 

row of sutures being used. The gastro -colic omentum should 

then be freely opened below the greater curvature of the 

stomach and its main vessel and search made tor a posterior 

opening. This will probably afford evidence of its existence 

1 Bevue de Chirurgie, 1903. 



Recovered. 


Died. 


9 


4 


2 


4 


13 


16 


2 


11 


2 


11 


3 


5 



24 



THE ACUTE ABDOMEN 



by the blood and stomach contents present in the lesser sac. 
The opening in the omentum must be of adequate size and the 
wound in the posterior surface sutured in a similar manner to 
the anterior wound. Search may be made for the bullet 
and any other injury which it may have caused in its progress. 
Omission to make an examination of the other structures 
possibly involved may render useless all your efforts. 
Sir Berkeley Moynihan^ writes : — 

" It is remarkable how often they are overlooked. Forgue and 
Jeanbrau quote many cases where at the post-mortem examination 
gross damages, overlooked at the operation, were laid bare. Bertram 
records a case where the spleen and left kidney were found injured ; 




,vv;:-.:^---w - ^^...-.AS**.* 



Fig. 3.— Bayonet Wound of Liver : 432, St. Thomas's Hospital Museum. 

Briddon, one where four perforations of the small intestine were found ; 
Gabzewicz, one where an injury to the colon was seen ; and Poucet and 
others, examples of injury to the liver. The minutest search must be 
made, despite the fact that, because of the patient's coUapse from 
shock or haemoiThage, a prolongation of the operation is not without 
its own danger." 

The treatment of the stomach wounds and the general 
peritoneal conditions does not differ very much from that 
required after perforation of a gastric ulcer, and will vary 
according to the position of the wound as regards the pylorus 
and the time that has elapsed since the escape of the stomach 

* "Abdominal Operations," p. 321. 



INJURIES OF THE ABDOMEN 25 

contents began. Gastro-enterostomy is rarely required, but 
in a large number, however careful the peritoneal toilet may 
have been, drainage will be necessary. 

In gunshot wounds and stabs of the liver it is best to open 
up and cleanse the wounds, although more serious signs of 
internal haemorrhage may be absent. Attention must again 
be drawn to the fact that a case which may be quite without 
symptoms at first may become alarming in a few hours as a 
result of internal haemorrhage. Later there may be infection of 
effused blood or bile-stained fluid which has become localised. 

When the injury has been inflicted below the ribs, it will be 
necessary to conduct the operation as in explorations for the 
treatment of biliary calculus in the bileducts. The important 
thing is to get an opening of adequate size through which 
full exploration and, if necessary, suturing can be done. 

In wounds penetrating the pleura and the diaphragm, it 
has been found necessary to enlarge the opening and follow 
the track, resecting ribs to give more room. A further incision 
of the diaphragm may be required. A combination of the 
thoracic and abdominal routes has been very successfully 
employed by Professor M. Ferrier and Professor Lejars. 

The actual wound in the liver must be treated by suture 
or by gauze packing, as described in subcutaneous ruptures of 
this organ. The thermocautery is very unreliable, and should 
be avoided in abdominal surgery. 

In bullet wounds of the liver both surfaces must be examined, 
for if the wound of exit is overlooked, haemorrhage may continue 
from that and cause a fatal ending. As a rule, it is not possible 
(even in civil life) to localise the bullet before these opera- 
tions ; and no prolonged search should be made for it. If 
easily found and accessible it should be removed, and search 
should also be made for any portion of clothing which may 
have been carried in with it. The danger to the patient is 
not the presence of a bullet in the liver, it is the internal 
haemorrhage from the wound. 

Wounds of the portal vessels usually prove rapidly fatal 
and seldom present much chance of surgical aid. When the 
gall-bladder has been wounded, its greater accessibility permits 
of rapid suture of the lesion. If bile is found in the peritoneum 
mixed with the blood, a most careful search should be made 



26 THE ACUTE ABDOMEN 

for the opening from which it has escaped. No abdomen 
should be closed without drainage if a definite opening cannot 
be found. Wounds of the gall-bladder may be treated in 
one of three ways : — (1) Suture, as in the operation of 
cholecystotomy, sometimes after excision of the edges of the 
wound. (2) Suture of the opening to the wound in the parietes, 
as in cholecystostomy. (3) Excision of the whole of the gall- 
bladder, with drainage of the part. 

In wounds of the splenic region a possibly penetrating wound 
makes exploration imperative. This should be carried out 
through an incision to the left of the abdomen. An incision 
through the median line will not give adequate approach to 
it, yet such an incision may be advisable for exploration in 
the first place. In very few instances has it been of any use 
to apply sutures to wounds of this organ, but in some slight 
lacerations and one or two cases of gunshot it has proved success- 
ful. As a rule it is necessary to excise it quickly, on account of 
the amount of bleeding which is taking place (see p. 61). 
Packing may be successful when it is evident that excision 
would be unusually difficult and dangerous on account of the 
added shock. It may enable the patient to tide over the shock 
which results from the serious nature of such an injury. 

In cases of protrusion of the spleen (recent protrusion) when 
there is no wound of that organ, cleansing and replacement 
should be carried out. The danger of replacing a septic spleen 
is so great that the wound should be enlarged, the intra- 
abdominal part of the pedicle ligatured, and such a spleen cut 
away ; this should be followed by repair of the abdominal 
wall. It is not satisfactory to leave a weak spot by suturing 
the pedicle in the parietal incision. 

The possibility of a wound of other parts by the weapon or 
missile must be remembered and the kidney examined ; the 
diaphragm also requires to be searched. 

Wounds in the epigastric region may also injure the pancreas, 
but such are commonly compUcated by damage to other 
organs near. 

In a case treated by Ninni i a revolver bullet had entered quite close 
to the second lumbar vertebra, traversed the first lumbar vertebra, pro- 
duced six perforations in the small gut and another in the colon near 
the hepatic flexure, and finally emerged on the right of the epigastrium. 
> I^jars, p. 380. 



INJURIES OF THE ABDOMEN 27 

Laparotomy was performed, the seven intestinal perforations were 
found and sutured, and then, as blood was seen to be escaping from 
between the stomach and transverse colon, the gastro-colic omentum 
was opened, and a wound of the pancreas at the junction of the head 
and body was discovered; two deep sutures were introduced and 
stopped the bleeding, and drainage was provided. The patient was 
cured in five weeks. 

The use of thick catgut sutures will be required to close these 
wounds and arrest haemorrhage, and as far as possible the 
peritoneum should be closed over the wounded spot. In all 
instances the wound should be drained, the line selected being 
that through the gastro-colic omentum, another opening being 
made there, even if the gastro-hepatic omentum has been 
chosen to give access to the wound. ^ 

Wounds of the kidney are indicated by hsematuria, escape 
of urine from the wound, symptoms of internal haemorrhage, 
pain in the loin, possible renal colic, and the formation of a 
swelling in the region of the kidney. The prognosis will be much 
worse — it is already serious — ^if there is any intraperitoneal 
complication. It follows, therefore, that wounds inflicted from 
the front are the more dangerous. In any case, if there is 
reason to think that a wound of this organ is bleeding, it will 
be best to explore through a lumbar incision, clear away 
extravasated blood, and pack with gauze. Any wound in- 
volving the renal pelvis and permitting of escape of urine may 
require secondary interference on account of septic infection ; 
free drainage will then be necessary. Should it be evident 
that an important vessel has been divided, or that it is unsafe 
to trust to plugging, then a primary resection is required. 
Nephrectomy may be necessary if secondary haemorrhage 
occurs during the after-treatment. Removal through a 
lumbar incision is to be done when there is no strong indication 
in favour of the abdominal route. 

Hernia of the kidney through a wound in the loin is a rare 
effect of injury, and is rarely complete. Nephrectomy is most 
commonly required, but if the injury to the kidney is limited 
to the body of the organ and does not involve the vessels of the 
hilum, much can be done by cleansing, drainage, and appro- 
priate suturing of the wound after it has been returned to its 
bed. 

^ See " Rupture of Pancreas," p. 52. 



28 THE ACUTE ABDOMEN 

Wounds of the renal pelvis are usually inflicted by the 
surgeon in removal of calculi. It is not infrequently possible 
to take away a calculus by a posterior incision and close the 
opening with fine catgut ; in some instances, however, the main 
vessels will be in danger from the needle, and safety will be 
gained by approximating the edges of the wounds with forceps 
and passing a ligature round two opposed points. This will also 
save time. In accidental stab wounds it is not often that the 
woiuid is limited to the pelvis ; other parts are frequently 
involved, so that a removal of the whole organ is necessary. 

Wounds of the ureter are almost entirely complications of a 
surgical operation, and require to be repaired at the time. 
When the wound is an incised lateral one, suturing may be done 
as after ureterotomy for removal of calculus, the opening being 
closed with lateral catgut sutures of small size not involving 
the mucous lining. 

In complete transverse section without loss of substance 
there are three methods which may be employed : — ( 1 ) Lateral 
anastomosis, as in lateral anastomosis of the small intestine, 
the two ends being closed with ligatures. The difficulties of 
this method will be apparent when it is remembered that the 
suturing has to be done at a considerable distance from the 
surface and within the abdomen. (2) The upper end of the 
ureter is implanted in the lower through an opening in the side. 
The end of the lower is ligatured, and a lateral incision made 
about one -tenth of an inch below this. The upper end is 
incised and then implanted in the lower by means of a suture 
(passed like a mattress suture) from within outwards, opposite 
to the slit. It is then carried into the lower tube, and from 
within outwards at a distance which will permit of the complete 
invagination of the upper end. It is then tied, and the insertion 
of about four stitches, uniting the superficial parts, completes the 
junction. (3) Implantation of the upper end into the lower is 
effected by making a slit in the latter and drawing the former 
into position by means of special sutures passed like the one de- 
scribed in the last method. This slit is closed after the other 
sutures have been tied and the upper part held in its place. 

Sometimes it is not possible to unite the separated ends — 
there has been loss of substance. Under these circumstances 
there are three courses open to the surgeon : — (1) implantation 



INJURIES OF THE ABDOMEN 29 

of the upper end in the bladder ; (2) implantation in the wall 
of the large bowel, caecum or sigmoid ; (3) nephrectomy. 

In (1) and (2) the operations are similar in technique. The 
lower end must be closed with a ligature. The upper end is slit 
so that it may not contract too much afterwards. The position 
of the opening must be such that no tension will be left after the 
sutures have been put in. In the bowel the retroperitoneal 
surface nearest to the ureter will be selected. Two rows of fine 
sutures will be necessary, the inner row taking the submucous 
tissues and the outer row the muscular and cellular coverings. 
It has been recommended that the bladder wall should be lifted 
up and fixed to the pelvic peritoneum with a catgut suture, so 
as to prevent anything like dragging on the line of incision. 

Excision of the kidney can be easily performed, and may be 
the only possible method to employ on some occasions. 

Wounds of the bladder are the result of gunshot injuries, 
punctured wounds inflicted by pointed instruments, or wounds 
inflicted by a surgeon during some abdominal operation. 
Gunshot wounds inflicted in warfare are most serious, because 
of the difficulty in obtaining adequate treatment soon after the 
wound has been received. They resemble in this respect the 
intestinal injuries. Mr. Makins, in his " Experiences," p. 457, 
found that " an uncomplicated perforation in the intraperi- 
toneal portion of the viscus was frequently recovered from. 
When the perforation was at the base of the bladder, however, 
the prognosis was very bad, and, as far as I know, not a single 
patient escaped death. The increase of risk in an extra- 
peritoneal wound of this viscus is indeed very great, while an 
intraperitoneal perforation may be considered an injury of 
lesser severity, provided the urine be of normal character." 
" Drainage by a catheter tied in proved worse than useless." 
He considers that a suprapubic opening might be better, but is 
not hopeful under the conditions which obtain in war time. 

There can be no doubt that in ordinary life exploration with 
the provision of drainage will prove the most successful. 

The accidental wounds are most commonly the result of 
falls on some pointed instrument, such as a spike in a raihng, 
the broken leg of a chair, a stake, etc., when the injury is 
inflicted below the pubes, through the rectum, vagina, or 
perineum. A stab may reach the bladder above the pubes. 



30 THE ACUTE ABDOMEN 

I have no doubt about the treatment that should be employed 
here ; the wound of entry should be explored for foreign bodies, 
and cleansed as far as possible. A suprapubic opening should 
be made and the peritoneal aspect of the bladder exposed. 
If this is not injured, the peritoneum should be sutured and 
the anterior aspect of the bladder examined. If there is a 
wound which cannot be brought to the surface or sutured 
in situ, free drainage must be provided. Should no wound be 
found, it would be better to open the bladder and clear it of 
clots and foreign substances through a suprapubic opening, 
the edges of the bladder being attached to the skin. It is a 
mistake to confine your attention to the wound of entry only, 
when this is below the pubes ; these wounds are dangerous 
from their liabihty to septic infection, and the prognosis will 
depend on the perfection of the drainage provided. 

Surgical wounds of the bladder are less commonly seen at 
the present day than they were when laparotomy was an 
infrequent operation. The beginner is warned so often about 
the danger of opening a bladder which has been drawn up in 
front of a tumour or pelvic inflammatory mass that he does 
not attempt to open the peritoneum in the danger zone. It 
may, however, be injured during the separation of adhesions, 
and in doubtful cases the injection of saline solution into the 
bladder before the abdomen is closed will afford evidence as 
to whether this has occurred or not. The frequency with 
which the bladder is present in hernia varies a good deal ; it 
is most commonly found in the inguinal variety, and is then 
opened during the separation of the sac, or after the apphcation 
of a ligature to the neck of the sac. In the majority there has 
been no evidence that it was accompanying the protrusion 
before operation, and therefore it has been opened before its 
presence was suspected. Occasionally, especially in femoral 
hernia, it is included with the sac hgature ; this accident 
produces much pain, and blood in the urine, with frequent 
micturition. This mistake is very fatal. 

The appearance of an unusual amount of clear fluid in the 
wound during the separation of an inguinal sac should lead to 
careful search . In doubtful cases the injection of saline solution 
into the bladder will be of use in determining the injury. A 
probe passed into a doubtful pouch can (if it is a part of the 



INJURIES OF THE ABDOMEN 31 

bladder) be made to touch a silver catheter introduced in the 
usual manner. I have met with this complication in four out 
of one thousand cases of radical cure of inguinal hernia. 

If the wound is an irregular one, it should be trimmed up 
and the edges brought together with a row of sutures not 
invading the mucous membrane. As these hernise are often not 
covered by peritoneum, they are difficult to differentiate from 
the cellular tissue in which they lie, and nothing like a defined 
margin may be felt to enable you to recognise it. They are 
also, at times, very thin, and must be carefully sutured. After 
the bladder has been sutured, it should be reduced with the 
neck of the sac and the operation completed by the particular 
method favoured. 

The uterus is rarely ruptured by any form - of external 
violence, even when pregnancy is far advanced, but when it is, 
a very serious problem is presented. The danger is great from 
internal haemorrhage, which can only be checked by early 
operation. This is true also of a wound, and in both there 
must be no delay. When a pregnant woman has received a 
kick over the abdomen, the amount of damage to the uterine 
wall will vary considerably ; sometimes it is very extensive, 
and there is no chance of saving the patient unless the uterus 
is emptied and afterwards removed. In the case of ruptures 
of limited extent, where there has been but slight escape of 
amniotic fluid (as also in wounds of similar importance), 
strong silk sutures or catgut should be passed through the 
full thickness of the wall down to the lining and tied, others 
being introduced between them to close the peritoneum. The 
blood -clots and fluid should be cleared away and the external 
wound closed without drainage. 

If the foetus or membranes are prolapsed, then it is advisable 
to place these within the uterus and if the woimd is not a large 
one suture it, leaving the foetus to come away per vias naturales. 

In later stages of pregnancy when there is prolapse of the 
foetus, or the wound is large, rendering sutTiring unsafe, it 
will be best to empty the uterus in the manner employed 
during Caesarian section. Occasionally after extraction of 
uterine contents, when there has been prolapse of much or all 
of the foetus and membranes, it may be possible to repair 
the opening ; but the bleeding may prove difficult to arrest, 



32 THE ACUTE ABDOMEN 

whilst the condition of the patient is bad. Here and in other 
cases where the damage is extensive a safer treatment will be 
hysterectomy. 

A most important and encouraging case is one described by 
Albarran ^ : — 

"... A young woman came under his care, who was about four 
and a half months pregnant, for a self-inflicted revolver wound of the 
umbilical region. She was almost unconscious, cold and with a tem- 
perature of 95° F. The abdomen was slightly distended. Operation 
five hours after infliction of the wound. About four pints of fluid 
mixed with blood was found, and five wounds were discovered in the 
small intestine, four in the upper third of the ileum, and one in the 
jejunum about 16 inches below duodeno-jejunal junction. About 
8 inches of intestine which contained four of these was excised and 
end-to-end anastomosis performed ; the wound higher in the intestine 
was sutured. A long loop of the umbilical cord protruded through a 
wound in the fundus uteri, and low down in the posterior wall the wound 
of exit was found. Albarran resected the loop of prolapsed cord, 
reduced the stump into the uterus, and sutured the bullet openings with 
silk. The peritoneum was cleansed, a gauze drain placed in Douglas's 
pouch, and the wound closed up to it. The patient miscarried next 
day, but made a perfect recovery." 

In many cases removal of the uterus will be required if the 
rupture is large enough to permit of the escape of the foetus, 
or any considerable portion of it. 

Rupture of the uterus during parturition is a most serious 
accident, and is most frequently fatal as a result of the haemor- 
rhage. Blood may flow per vaginam, but more often escapes 
into the peritoneal cavity, producing the symptoms which 
follow extensive bleeding from one of the solid viscera without 
external woimd. If extensive external haemorrhage occurs, 
with cessation of the labour pains, etc., the vagina must be 
plugged whilst preparations are made for operation. There 
must be no attempt at delivery in the usual way. When the 
rupture is solely into the peritoneum, the danger is that it 
may be quite overlooked imtil the occurrence of a secondary 
collapse due to renewed haemorrhage. 

Nothing less than hysterectomy will be of any avail, and the 

sooner this is recognised and the operation performed the 

better chance will the patient have of recovery. A total 

removal of the uterus above the vagina is not really difficult 

1 Bull, de la Soci6t6 de Chir., 1895, p. 243. 



INJURIES OF THE ABDOMEN 33 

when the operator has had experience, but more Uves will be 
saved by removal of the uterus and extra -abdominal treatment 
of the stump, because less time is occupied in carrying it out. 

In the extra abdominal treatment of the stump (Porro's 
operation) the abdominal incision is made with due regard to 
the position of the bladder, presenting clots cleared away, and 
a rubber tube passed over the fundus and adjusted as low down 
as possible. It is drawn tight and clamped or tied. The 
uterus is then opened at one point and the incision enlarged 
or the rupture extended by quick tearing with the fingers. 
The child is rapidly extracted through the opening by pulling 
on the feet. The uterus is brought outside, the rubber tube 
tightened, and the intestine packed off. " Two knitting 
needles are passed through the flattened rubber tube and the 
cervix and the uterus cut off about | inch above the needles." ^ 
The peritoneum is cleansed and the external wound closed, 
the lowest suture being passed through the stump also. When 
time and surroundings are favourable, a supravaginal ampu- 
tation, with intraperitoneal treatment of the stump, is the 
better treatment. 

In this operation after the uterus has been emptied the 
following procedures should be carried out, provision having 
been made for the temporary arrest of haemorrhage, either by 
pressure by the hands of an assistant or by placing a rubber 
band as low as possible : — (1) Clamp the upper two -thirds 
of the left broad ligament, and cut between the clamps. 
(2) Search for the uterine vessels, which will be felt by the side 
of the cervix. Secure them with a large clamp and divide 
near uterus. (3) Make an anterior peritoneal flap and carry it 
downwards ; do the same posteriorly ; see that the bladder is 
taken down with the anterior flap. (4) Open vagina on left 
side near attachment, and cut in front and behind the cervix. 
(5) Take the cervix strongly in a pair of vulsellum forceps and 
carry it forward ; by this means the right border of the uterus 
comes well up. (6) Clamp the uterine vessels on the right 
side, and divide them near the uterus. (7) Clamp and divide 
the upper part of the broad hgament. (8) Examine for any 
bleeding vessels that may have escaped the clamps. (9) Apply 
strong ligatures beyond the clamps and not too near them. 

^ Jacobson, Vol. II., p. 869; Herman, "Difficult Labour." 
A.A. D 



34 THE ACUTE ABDOMEN 

(10) Close the vaginal vault if the conditions are favourable 
(no suspicion of possible sepsis), otherwise put a gauze drain 
in the vagina. Search for any extension of wound beyond the 
area which has been specially involved in the main laceration. 

Mr. Grimsdale,^ in relating a case of recovery after abdominal 
hysterectomy with removal of tubes and ovaries for rupture which 
occurred at the fourth confinement in a woman of 27, gives the average 
occurrence as 1 in 2,433. He gives also the average mortality in 1874 
(Hugenberger) as 95 per cent, and in 1892 (Schultz) 55 per cent., and 
says the lowest mortality is obtained when prompt abdominal opera- 
tion can be performed. He adds : "I feel confident that the safest 
treatment in the long run will be found in the boldest measures. It is 
impossible to know how much damage has been done and how much the , 
peritoneum has been soiled until the abdomen has been opened," etc. 

TRAUMATIC RUPTURE OF THE VISCERA WITHOUT 
EXTERNAL WOUND. 

In the group of injuries of the abdominal organs the result of 
violence not associated with wound of the abdominal wall are 
comprised those cases which within my recollection were 
admitted to our hospitals only to die, lulled to their last sleep 
by the administration of sufficient opium to procure physio- 
logical rest. That a person who had received a ruptured 
viscus would die was almost universally accepted as a matter of 
course, and it was only the increased boldness that came to 
surgeons as a consequence of improved wound treatment that 
enabled a different practice to be followed and many lives saved. 
The presence of a wound of the abdominal wall was considered 
by some an indication for surgical interference, but not by all. 
None were sufficiently bold to operate when there was no 
woimd, although a diagnosis was correctly made. The 
frequency with which peritonitis followed opening of the 
peritoneum and killed the patient after abdominal section made 
the suggestion of interference appear overbold. The knowledge 
that death, which would probably follow, would be ascribed to 
the operation and not to the injury, made surgeons unwilling 
to face the result. To the surgeons of St. Thomas's Hospital is 
due much of the credit for an improved prospect in this branch 
of surgery. About 1886 Mr. John Croft, surgeon to the 
hospital, performed an operation for ruptured small intestine 

' Journal of Obstetrics and Oyrcecology, 1903, p. 558. 



TRAUMATIC RUPTURE OF THE VISCERA 35 



I 



in a patient without external wound (Fig. 4). An artificial 

anus was established, and the patient survived for a month ; in 

fact he did well until 

resection of this artificial 

anus and end - to - end 

enter orraphy was done, 

but the second operation 

was not survived. It was 

not long, however, before 

a similar case came into 

the hospital ; this time 

Croft sutured the rent in 

the gut and closed the 

external wound. This 

patient made a perfect 

recovery. The same 

surgeon was the first to 

operate for a rupture of 

the spleen, and Mr. A. 0. 

Mackellar did a similar 

operation for a like injury 

in a second case. Sir W. 

MacCormac operated for intraperitoneal rupture of the urinary 

bladder, and repeated his success in another case two months 

later. These were the first of their kind in which success 

was obtained, and naturally made a deep impression on the 

profession. 

A table of abdominal injuries admitted to all the London 
hospitals which publish statistical reports is perhaps of some 
interest and is as follows : — 

St. Bartholomew's (1873-1906), St. Thomas's (1866-1907), 
Middlesex (1873-1904), University College (1879-1904), West- 
minster (1880-1903) :— 

Per cent. 
Simple contusion of the abdomen . . . .64 




Fig. 4. — ^The portion of intestine excised 
by John Croft in the first successful 
case of operation for traumatic rupture 
(St. Thomas's Hospital Museum). 



With injury to kidney . 

alimentary canal 

liver 

spleen . 

bladder 

mesentery 

omentum 



7-7 
4-7 
4-5 
2-6 
11 
0-5 
0-3 



D 2 



36 THE ACUTE ABDOMEN 

Ter cent. 



Wounds of the abdomen . 
Proportions : Non -penetrating 
Penetrating 
Indefinite 
Mixed or various .... 
{e.g., rupture of hepatic artery, bullet wound 



8-4 
40 
30 
70 
5-9 
and multiple injury.) 



This gives some idea of the relative frequency and propor- 
tions of these injuries, the total number of cases being 
about 2,500. 

Before the time already mentioned there are few rehable 
records of recoveries from these internal injuries ; it is true 
that in people who were examined post-mortem cicatrices of 
limited extent were very occasionally found in the liver and 
spleen, but the history of their formation was not always to 
be obtained. Most surgeons willingly admit that some of the 
less severe ruptures of the sohd viscera can and do get well 
without operation ; this is within our own experience, but 
without operation very many are hopeless, whilst ruptures of 
the intestines are most deadly. Dr. Le Conte (" Annal of 
Surgery," Vol. I., 1903, p. 526) quotes Petry as giving a hst 
of 160 cases of ruptured intestine where 93 per cent, died and 
7 per cent recovered, but only after formation of abscess 
associated with a faecal fistula. Other collections give an even 
higher mortaUty up to 97 and 98 per cent. Le Conte estimated 
the operative mortality from this cause as from 50 to 60 per 
cent, in 1903. Every year has added to our knowledge, and 
the results in life-saving are not only better now, but there is 
prospect of further improvement. Some of our critics forget 
that we are dealing with patients who are not only suffering 
from a ruptured bowel or other internal organ, but perhaps 
from two or more of these injuries, or from a severe crush 
affecting the lungs also, or fracture of the pelvis, ribs, or other 
bones — injuries which of themselves would be severe without 
the one which really offers the greatest danger to life. 

To those who think our best results are but meagre I would 
recommend a perusal of this section of the reports of a hospital 
before the commencement of the period, or a paper in the 
Lancet, on the " Recollections of a Hospital Surgeon," written 
about 1889. 

This paper was written by a man of eminence, and recounts 



TRAUMATIC RUPTURE OF THE VISCERA 37 

his experiences in this branch of surgery. It is most instructive 
reading. To the account of more than one out of his 19 cases 
of fatal rupture of the intestine he adds remarks to the effect 
that had he operated it seemed possible that the injury to 
the gut might have been repaired. 

Another table shows the various ways in which some patients 
were injured before they came under observation, and the 
particular part on which the stress of the injury fell. It is 
compiled from records of cases to be found in hospital reports, 
the Lancet, the British Medical Journal, and the paper by 
Messrs. Berry and Guiseppi.^ 



Causes and Situations 


9/ sovfie Internal Ruptures. 






1 


a 

a 


3 


«3 




i 


1 




P 


•5? 

27 




.^ 


n 


a, 

xn 


m 


Kun over in street . 


12 


11 


7 


57 


5 


3 


Kicked by horse 


1 


13 


8 


2 


24 


2 


4 


Crushed .... 


6 


5 


5 


3 


19 


— 


— 


Struck by moving object . 


4 


13 


7 


2 


26 


3 


2 


Fall on hard object . 


1 


5 


7 


1 


14 


5 


4 


Fall of weight on abdomen 


— 


6 


5 


— 


11 


1 


3 


Fall from height 


1 


4 


— 


1 


6 


6 


2 


Other causes, mostly un- 
















known 


1 


7 


— 


— 


8 


1 


4 




26 


80 


43 


16 


165 


23 


22 



If it is possible to ascertain the exact part of the body struck 
by the force which caused the injury, then one can make an 
approximate guess as to the organ ruptured, for it is generally 
lying beneath, between that point and the spine, and incision 
over this area gives most direct access to the damaged structure. 

You must not expect to find local signs of injury to the 
skin, for there may be none. This is of importance from a 
medico -legal aspect, for not long ago a jury, with the sapience 



* Transactions of the Royal Society of Medicine for 1909, etc. 



38 THE ACUTE ABDOMEN 

which appears to be almost the prerogative of coroners' juries, 
refused to beHeve that a kick from a man had produced a 
rupture of the gut because there was no mark of the kick. 

In all abdominal injuries it is advisable to follow a certain 
routine in the examination of the patient. Ascertain when the 
last meal was taken, when the bladder was emptied, and if 
the patient was in good health before the accident. Inquire 
as to the position and extent of pain, and then examine the 
abdomen carefully for dulness, and see if this is fixed or shifting. 
Find out if there is rigidity of the muscular wall, whether it is 
general or local, and the amount of tenderness, its position and 
extent. You should note also the state of the pulse and the 
temperature. 

Further, the patient should be re-examined nearly every 
hour, and no morphine given unless it has been decided to 
operate. 

Traumatic Rupture of the Intestine. ^ 

I have previously, when writing on the subject of traumatic 
rupture of the intestine without external wound, directed 
attention to the similarity existing between these injuries and 
perforations of the intestinal canal which constitute such a 
large part of the " acute abdomen." In the perforations from 
disease there is the initial " peritonism " at the moment of 
perforation, which corresponds to the injury and the symptoms 
immediately following the injury, in the case of rupture ; the 
effect of the escape of intestinal contents is much the same in 
the production of a spreading peritonitis in the two, but the 
peritonitis in the healthy person appears to be more rapidly 
fatal. Probably in him the fluid containing bacilli is in a con- 
centrated form, for little escapes, whilst his injured peritoneum 
is unprepared to cope with the vigour of the invasion. When it 
is recognised that in about 50 per cent, of these cases there 
is a " period of repose " before the development of the more 
characteristic symptoms, then our house surgeons will treat 
these patients with the same respect as they do now a man who 
gives a history of chronic indigestion and a recent acute pain 
in the stomach. 

With regard to the symptoms which may result from rupture 
of the intestine, there has been much written on the subject by 



I 



TRAUMATIC RUPTURE OF THE VISCERA 39 

various authors, and it is comparatively easy to take a series 
of cases and analyse the recorded symptoms in each. The 
result obtained will be fairly accurate as regards the obvious 
manifestations of the injury, such as shock, vomiting, pain, and 
perhaps rigidity, which are common to nearly all injuries in 
which the viscera are damaged. There is, however, such a 
difference of opinion between those who examine the abdomen 
as to what are to some comparatively unusual signs, that little 
reliance can be placed on statements which vary so greatly. 
Yet these minor symptoms may be most valuable with a clear 
history, for in all, I repeat, it is important to diagnose the 
lesion as early as possible, before the onset of peritonitis, and 
every symptom that may be of use in bringing about an early 
diagnosis is of importance. 

I do not propose to consider the value of all the individual 
symptoms in detail. Mr. Berry has recently done so, and his 
conclusions in the main confirm those expressed by Mr. John 
Croft and Mr. Makins, though founded on a recent and therefore 
more extended review of the subject. From the practical 
point of view, we need not consider those cases which are 
admitted with intense shock, from which they never rally. 
The others can be arranged in fairly typical groups, as they 
present themselves in actual practice : — 

A. In the first of these there is shock, vomiting, acute 
abdominal pain, with great tenderness over the part struck, 
and board -like rigidity of the abdominal wall. All these 
symptoms are present, but they vary somewhat in their 
intensity ; at one time shock is the main symptom, at another 
it is the pain, and so on. With these there should be found 
a certain amount of localised dulness on percussion. This 
group forms about 50 per cent, of all cases. 

Multiple Kuptures of the Small Intestine : Rupture op 
Mesentery : Resection : Anastomosis. (Death six days later.) — 
A stableman aged 24 admitted on August 10, 1892, suffering from the 
effects of a kick in the abdomen by a horse, about half an hour earlier. 
He was received in a very collapsed state, but had not vomited. The 
patient was a man of slight build, suffering much pain in the abdomen. 
His face was white and anxious-looking, and his pulse small and feeble. 
Below and to the left of the umbilicus was a bruise, not clearly defined, 
where the hoof of the horse had struck him. The abdomen was 
extremely hard to the touch, somewhat distended and motionless. There 
was dulness on percussion over the front of the abdomen. Clear urine 



40 THE ACUTE ABDOMEN 

was withdrawn by catheter. Soon after admission he commenced to 
vomit. At 3 p.m. he was still suffering from shock, very cold and 
shivering with anxious face, and was lying on his right side with limbs 
flexed. The abdomen was fixed like a board, very hard and very 
tender. The dulness over the front of the abdomen was more extensive, 
but did not invade the epigastrium or pass into the flanks. 

Intraperitoneal rupture of the small intestine with rupture of the 
mesentery or omentum with extravasation of blood was diagnosed, and 
at 8 p.m., when operation was performed, on sufficient recovery from 
shock, this diagnosis was fully confirmed. The mesentery was bruised 
and lacerated, and haemorrhage was still going on from it. There was 
rupture of the small intestine in two places within a distance of 8 inches, 
the gut having been divided as cleanly as with a knife. Only a small 
amount of intestinal contents had escaped, amongst which were one or 
two partly-digested beans. The intestine was contused, and in one or 
two places the peritoneal surface was torn. Thirteen inches of the 
bowel, including the damaged mesentery, were removed, the section 
being made beyond the ruptures where the bowel appeared healthy. 
Union was effected by lateral apposition, and the mesentery was 
sutured. Another rupture involving almost the entire circumference 
of the gut was then discovered, about 12 inches away ; the edges of 
this did not appear bruised, and end-to-end anastomosis with Senn's 
plates was done without resection. Saline infusion to the extent of 
5 pints was given. Progress was satisfactory until 6.15 on the evening 
of the 15th, when vomiting returned, with severe abdominal pain and 
local signs of peritonitis. The wound was reopened, and, the end-to-end 
union having been found broken down, an artificial anus was made, 
his condition not permitting of more prolonged treatment. He died a 
few houi-s later. At the necropsy it was found that the first rupture 
had occurred 20 inches from the pylorus. Extensive haemorrhage into 
the right lung was also discovered. 

KUPTURE OF THE SmALL INTESTINE WITH EUPTURE OF THE MESEN- 
TERY : Suture. (Recovery). — A small boy, aged 5, was admitted on 
December 31, 1910, having been knocked down by a tram which was 
drawn by a horse. It is not certain if the horse trod on the boy or not. 
He was very sick afterwards and was taken to a doctor, who could find 
nothing definite. His father thought the boy looked very ill and 
brought him up to the hospital, where he arrived three hours after- 
wards. He was then looking very white, and his nostrils were working 
very rapidly. On examination of the abdomen there was seen an 
abrasion with faint bruises of the skin above and to the outer side of the 
left anterior superior spine. There was dulness on percussion in the 
left flank up to the edge of the rectus, and the muscles were rigid but not 
board-like. The pulse was rapid, 128, but not feeble. Temperature 97°. 

He arrived whilst I was at the hospital, so that no time was lost, 
the boy being taken directly to the theatre. The incision was made to 
the left of the middle line and the rectus muscle pulled outwards. 
On opening the peritoneum free bright blood was found in the left 
flank. About 3 feet from the ileo-csecal valve the mesentery was torn 



TRAUMATIC RUPTURE OF THE VISCERA 41 

longitudinally, and some vessels were bleeding freely. A perforation the 
size of an ordinary hydrocele trochar was found in the antimesenteric 
border of the gut, at the same level. This was closed by a continuous 
Lembert suture of silk (No. 1). The tear in the mesentery was closed 
after ligature of vessels and the abdominal wall closed in layers. He 
developed some bronchial pneumonia, but it gradually subsided. On 
January 5 a large quantity of clear fluid came away from the lower 
part of the wound, evidently peritoneal, and continued to flow for a 
few days. The temperature became normal as the lung signs improved, 
and he left hospital on January 23, 1911, having quite recovered. 

B. In the second group there is no evident shock, and perhaps 
the patient walks to the hospital, or goes home, congratulating 
himself that he has had a " narrow escape " ! He may have 
vomited soon after the accident, which made him feel faint, 
but there are no marks of injury on the abdominal wall, or 
they are but slight. He has considerable local pain, and there 
is rigidity of muscle, sometimes confined to the side of the 
abdomen which was struck. There is tenderness on pressure, 
and perhaps localised dulness, but the man feels that he will 
soon get over it, and probably remains under treatment with 
reluctance, or neglects to call in medical advice on his return 
home. 

This group forms about 35 per cent, of the total number of 
cases. 

In a case which I communicated to the Pathological Society in 1885, 
in which there had been extensive laceration of the small intestine, the 
patient, a man of 25, an ostler, had been kicked by a horse at 5 p.m. 
the day before admission to hospital. He seemed unable to move for 
half an hour, but then went on with his work until 6.30 p.m. He had 
food on reaching home, but vomited it almost immediately, and was 
restless during the night. However, he returned to work in the morning 
at 6 o'clock : was unable to resume his work after a slight breakfast, 
because of the onset of pain and vomiting. He passed into a state of 
extreme collapse, and died twenty-seven and a half hours after the 
kick. There was an extensive rupture of the small intestine, and 
intense peritonitis. 

In the following case we were much hampered by the 
alcoholic condition of the patient. In the first place, the vomit- 
ing was mistaken for the results of drink ; in the second place, 
he was very intolerant of discipline ; and in the third, his general 
condition was very unsatisfactory from chronic alcoholism. 

On the night of April 4, 1898, a man aged 27, who was crossing 
Whitehall when in an intoxicated condition, was run over by a 



42 THE ACUTE ABDOMEN 

two -wheeled van. He was taken to a hospital near, but was refused 
admission, so was brought to St. Thomas's about three-quarters of an 
hour later. He could give no coherent account of the accident, but 
complained of pain in the abdomen, where there were marks of wheels. 
Pulse fairly good ; temperature normal. A scalp wound had been 
already stitched up, and he was admitted because of his drowsy state. 
At midnight his temperature was 100-2°. He commenced to vomit a 
clear fluid smelling strongly of alcohol, and this continued all through 
the night till 9 o'clock on the morning of the 5th, when he complained 
of pain over the abdomen, which was very sensitive to the touch and 
very resistant. Pulse 160 ; very small. I was asked to see him at 
2 p.m., when his condition was practically the same, but there was still 
no local change to be found on percussion. Immediate operation was 
performed, at which a large quantity of sero -purulent fluid was evacuated, 
and a rupture measuring | inch in length in the long axis of the bowel 
was found 12 inches from the ileo-csecal valve. Eight Lembert sutures 
were sufficient to close it. There was a good deal of lymph on the 
surrounding coils. The abdomen was cleansed with sterilised water, 
and a drainage tube passed into the pelvis through a second opening ; 
the upper wound was closed. Ten days later the upper wound yielded, 
two days after removal of sutures, and there was protrusion of small 
intestine. This protrusion was washed and replaced, the wound being 
again sutured. The patient, who had been a heavy drinker and suffered 
from albuminuria, was difficult to manage, having on one occasion got 
out of bed soon after his operation and walked about the ward during 
the night. Following on the second application of sutures, the wound 
suppurated, and he ultimately died on April 30 with lung symptoms. 
At the post-mortem examination the abdomen was almost normal, with 
the exception of a small retro-hepatic abscess on the right side. The 
gut was firmly healed. The lower lobe of the right lung was collapsed. 

C. In a third group the symptoms are rather indefinite ; 
there is a history of abdominal injury, probably of the kind 
which sometimes produces a rupture of the intestine, but the 
shock is trifling ; there is no vomiting, local pain is slight or 
absent, there is little tenderness, no rigidity of muscle, whilst 
percussion shows no change. After a variable time there may 
be a rising pulse, with that change in facial aspect which 
indicates to the experienced eye the presence of grave peritoneal 
inflammation. It may not be easy to say at what moment this 
commenced, but " a change has taken place." It may develop 
after an attack of vomiting, as in the case under the care of the 
late Mr. Walsham. This surgeon, who was patiently watching 
for symptoms, in a case of this kind, found a complete change 
after the patient had vomited, and, operating at once, gained 
a well -merited success. In yet another patient the onset of 



TRAUMATIC RUPTURE OF THE VISCERA 43 

serious symptoms may be sudden and unexpected, caused by 
the giving way of a portion of the contused bowel. 

In some instances, especially where there is a definite history 
of the kick of a horse or mule, it will be judicious to operate at 
once, as recommended by Mr. Bernard Pitts, without waiting 
for symptoms. 

Should the escape of intestinal contents be very restricted, 
possibly in consequence of the smallness of the perforation, the 
symptoms may be limited to occasional sickness, with un- 
easiness in the abdomen, gradual distension and general tender- 
ness, caused by a slowly extending inflammation of the peri- 
toneum, which may become localised, and result in the forma- 
tion of an abscess. It must be remembered that meteorism 
may follow an injury to the abdomen without any rupture of 
the intestine or internal organ. 

A rigid condition of the abdominal muscles is a very important 
sign ; it practically always means serious underlying damage. 
Cases in which it is present may, in rare instances, recover, but 
it is a sign which should be regarded as of great value, and in 
most as an urgent indication for operation, Mr, Croft compared 
it to the protective contraction of muscles round an inflamed 
hip -joint, Hartmann has also shown its value. 

No deduction regarding the value of localised dulness on 
percussion can be drawn from published cases. In the large 
majority the condition of the abdomen on percussion is not 
mentioned, and appreciation of the slighter degrees of abdominal 
dulness is not universal. 

Mr. Bernard Pitts thinks that dulness at the site of contusion 
may be due to collapsed intestine, as a result of a temporary 
paralysis following the injury. It has been ascribed to escape 
of intestinal contents ; this may be so, but it is rare to find much 
feculent fluid present when the abdomen is opened soon after 
an injury, although blood may be found which has come from 
a rupture of the mesentery or a tear of the omentum. An 
extensive extravasation of blood under the peritoneum of the 
anterior abdominal wall will also cause duhiess which does not 
move with alteration of position, but this is a very rare com- 
plication. If there is a history of localised contusion, such as 
that produced by a kick, and in addition to dulness under the 
part struck there is also fluid in one or both flanks, the mesentery 



44 THE ACUTE ABDOMEN 

is torn, and, whatever the opinion as to the state of the gut, 
the indications for operation are evident — first, to prevent 
further bleeding, and, secondly, to repair the injury, which may 
have placed the gut in danger of gangrene by deprivation of its 
blood supply. When the injury has been less localised, such as 
that resulting from a fall or from being run over, it is possible 
that there may be a complication in the shape of rupture of one 
of the solid viscera in addition to damage of the bowel and its 
mesentery. 

It has been observed that local tenderness is usual, but there 
may also be a sharp superficial tenderness extending from the 
rupture towards a dependent part, indicating the direction 
taken by fluid of great irritative properties, in its course to the 
flank or the pelvis.^ In one patient with rupture of the splenic 
flexure this sign was present, and was caused by the escape of 
offensive faecal fluid from an opening behind the bowel through 
minute lacerations in the peritoneum, and its spread down to 
the pelvis along the inner side of the descending colon, and at 
the operation some of it was sponged out of the pelvis. A 
similar tenderness may be found in examples of the recent 
rupture of a jejunal, or of a stercoral ulcer ; it is found some- 
times at the margin of a spreading inflammation started by a 
diseased appendix, and more generally diffused, in acute 
haemorrhagic pancreatitis. Even when other symptoms are 
slight, this alone should indicate caution in prognosis. 

There is another symptom which may possess more im- 
portance than has hitherto been accorded it, and that is a 
marked rise of temperature within a short time of the injury. 
It was present in one patient before the bowel gave way (on 
the second day) ; here 103° was recorded within a few hours of 
the injury, whilst the usual local signs were still absent. There 
is probably some absorption through the lymphatics from the 
lacerated parts of the gut and mesentery, for it is not found in 
many of the cases in which the opening is of large size and the 
escape of feculent fluid presumably greater ; whilst in the case 
to which I have alluded the rupture was a secondary one. 

On October 8th, 1904, a boy aged 14 was admitted at 7 p.m. with a 
history of injury to the abdomen. At 3 p.m. he was walking along a 
row of iron posts, and when stepping from one post to another his foot 

» See p. TjO. 



TRAUMATIC RUPTURE OF THE VISCERA 45 

slipped and lie fell, striking his abdomen on the post in front. H« 
fainted, was taken home, where he was sick several times, and com- 
plained of great tenderness in the abdomen. He could not pass his 
water. When brought to the hospital he was still suffering from shock, 
and complained of pain in the lower part of the abdomen. This on 
examination was found to move fairly well, was not markedly rigid, 
though some rigidity was present about the lower part of the left 
rectus. There was tenderness around and below the umbilicus, but this 
appeared to be rather superficial. There was no area of dulness in 
front and no shifting dulness in the flanks. The liver dulness extended 
from the sixth to the ninth rib. A considerable quantity of clear 
urine was drawn off. Pulse 100, of small volume ; temperature 99°. 

It was stated that for two or three days before the accident the boy 
had had a cough and sweating at night, and had talked of going to the 
hospital for medicine. 

October 9. — He was sick at 9.30 last evening, but since then has not 
vomited. During the night the temperature went up to 103°, and the 
pulse rose to 120. This morning the temperature was 101°, pulse 110, 
and the patient seemed very comfortable. Urine normal. There was no 
diminution of liver dulness, and no increase of rigidity of the abdomen. 
He said that he had no pain unless the abdomen was touched. At 3 p.m. 
he had quite recovered from the shock, and presented the aspect of one 
suffering from reaction. He was flushed, with red lips, bright eyes, 
and dilated pupils ; the pulse was 110, and he was dozing comfortably, 
lying on his back. The thighs were not flexed on the abdomen, but 
were placed straight. His temperature, which had been 103° during 
the night, had fallen to 100°. The pulse was not wiry, he was not rest- 
less, and the vomiting had ceased. On examination of the abdomen 
there was no abrasion or mark to be seen. It was normally distended 
without any visible peristalsis. He could draw a deep breath without 
pain. On palpation there was no rigidity of the muscles, but he com- 
plained of a general tenderness, not excessive. The percussion note 
was normal throughout, the liver dulness being satisfactory ; it was 
thought that the note was less clear in the flanks, but this was put down 
to the greater thickness of the muscle there, for it did not alter with 
position. The opinion given then was that we had no evidence of 
complete rupture of the gut, but that it was quite possible it was severely 
contused, and that it might give, when immediate operation would be 
required. This opinion was founded on the account of the case up to 
3 p.m., not on the local condition. About 5 p.m. he again complained 
of sharp pain in the abdomen, and the pulse rate increased to 136. 
At 7 p.m. the abdomen was rather more rigid, and there was some 
diminution of liver dulness. At 9.30 p.m. he vomited a considerable 
quantity of greenish fluid, and the abdomen was slightly more rigid, 
especially about the upper part of the left rectus. The pulse was 120 ; 
the liver dulness was less evident, but there was no dulness in the flanks. 

Median section was performed at 12 midnight by the resident assistant- 
surgeon, who found evidence of recent peritonitis, with some free fluid 
in the pelvis, which had run down the descending colon. In several 



I 



4G THE ACUTE ABDOMEN 

places the small intestine was distended and showed signs of bruising, 
with small haemorrhages into the mesentery. Near the upper end, 
where the flakes of lymph were most abundant, a small recent perfora- 
tion was found. This was sutured with two rows of Lembert sutures. 
The abdominal cavity was freely washed out with warm saline solution, 
and the wound closed. He improved for a time, but on the 10th was 
restless and vomited considerably during the afternoon, whilst later the 
abdomen was rather distended. 

He died at 5.30 on the 10th, the pulse having become very rapid and 
weak, after a restless night. 

The perforation was situated 57 inches from the commencement of 
the intestine. The sutures had held perfectly, and the post-mortem 
examination only showed localised peritonitis, which had probably 
commenced before operation. 

The absence of liver dulness as a sign of ruptured intestine is 
rarely seen, and if one may judge by published reports of cases, 
much invaluable time has been lost waiting for it to develop. 
It does not require a large amount of gas in the peritoneum to 
produce this symptom, but the contraction of the injured 
section of bowel prevents the escape of intestinal contents 
including gas, the condition of the gut not being quite the 
same as it is in perforation from disease. 

Emphysema of the sub -peritoneal tissue is recognised mostly 
in cases of rupture of the duodenum, during the course of an 
operation for that lesion ; the gas may make its way through 
the inguinal canals, and distend the scrotal tissues when opera- 
tion has been delayed. It is also found when the large bowel 
has been ruptured behind the peritoneum. The crackling 
which is felt by the fingers in these circumstances may assist 
in the locaHsation of the rupture after the peritoneum has been 
opened. The only cases of ruptured gut in which blood was 
found in the vomit were those in which the duodenum had 
been lacerated ; in no instance was there any blood passed by 
the bowel. 

Something must be said about general treatment in cases of 
internal injury, but no hard-and-fast rule can be laid down. 
We must be guided by general principles, and are in a very 
much better position than formerly, because of the recognised 
value as an aid against shock of saline fluid, injected into the 
subcutaneous tissue, passed into a vein, or allowed to enter the 
rectum continuously. We must not forget, however, in 
injuries of the solid viscera that haemorrhage is the chief danger 



TRAUMATIC RUPTURE OF THE VISCERA 47 

to life, hence permit no more delay before the operation to 
arrest it is carried out than is absolutely required. 

It has been recommended by some surgeons that when there 
is rigidity of the abdominal wall warm applications should be 
made to the part, so that if the rigidity is due to injury of the 
abdominal wall alone it may have a better chance of passing 
off and the patient be saved a possibly useless operation. It 
is hardly necessary to say that this treatment should not be 
continued for any great length of time, if there is any possibility 
of rupture of the intestine, because peritonitis is known to begin 
within six hours in many of these cases. 

I may refer again to Messrs. Berry and Guiseppi, who show 
not only that the mortality is less when early operation is 
performed, but that the best results are obtained when it is 
done between seven and twelve hours after the accident. This 
is practically the same conclusion as that to which Siegel came, 
and is explained by the fact that the shock is passing off, and 
peritonitis is still localised, if it has commenced. 

By operation in cases of ruptured intestine is here under- 
stood abdominal section, a search for the injured gut, and its 
repair by suturing. The incision should be a long one to give 
easy access to the intestine, and its central point should be 
placed at the level of the umbilicus. In some it may be 
necessary to excise the contused and lacerated part, and 
perform an anastomosis, but in the majority a double layer of 
sutures, applied as already advised, will suffice. The forma- 
tion of an artificial anus in the small intestine is to be much 
deprecated. In about 10 per cent, there is more than one 
lesion ; forgetfulness of this fact may lead to serious trouble. 
The surgeon had better satisfy himself on this point before he 
begins to apply sutures.^ 

It appears to me that some of the more recently pubUshed 
cases of recovery in this branch of surgery have shown an 
advance in the after-treatment, founded on the principles which 
guide us in perforative peritonitis. The patient has been 
placed in the " Fowler position," drainage employed, and saline 
fluid administered continuously by the rectum. Messrs. G. H. 
Edington, W. Sheen, and W. G. Nash recorded successes in 
1908, whilst Dr. Radcliffe introduced saline into the caecum 

^ See p. 40. 



48 THE ACUTE ABDOMEN 

after appendicostomy at the rate of two gallons in twenty -four 
hours. The effect of this is instructive, as the patient recovered, 
*' perspired, passed urine freely, and at the end of the time had 
some incontinence, passing faeces with a moderate quantity of 
saline fluid. Moreover, there was fluid continuously welling 
up through Keith's tube, so that the pad over the tube had to 
be changed every half -hour." 

A table on p. 52 shows the result as regards actual recoveries, 
but does not show how many were reheved by operation. In 
Mr. Croft's first case the patient died a month later after 
resection of the artificial anus which had been formed in the 
first instance. Another patient, also in the series from St. 
Thomas's, lived for a month, and still another some six days, 
dying ultimately from peritonitis due to the giving way of a 
stitch. 

Rupture of Duodenum. 

Rupture of the duodenum is one of the more rare results of 
injury to the abdomen. The history is nearly always that of 
" run over in the street," caught between a moving and a 
stationary object as in a buffer accident, or struck by an 
opponent's knee during a football match, and it is evident 
that the damage was inflicted above the umbihcus. Occasion- 
ally the peritoneum is torn and intestinal contents escape into 
the peritoneal cavity ; more frequently the tear is in the posterior 
retro-peritoneal part of the bowel, and extravasation takes place 
in and around the rupture to a rapidly increasing extent. As 
this extravasation contains a certain amount of pancreatic 
secretion, there is a swift change in the state of the cellular 
tissue of the part. It may be sufficient to produce a fixed 
dulness continuous with that of the liver if the patient survives 
for a day or two. 

The signs of *' peritonism " are severe, the shock being 
especially great, so much so that occasionally it has been 
necessary to abandon an operation for the relief of this injury, 
because the state of the patient has made it evident that any 
continuation of the exploration would prove fatal before he could 
leave the operating theatre. In addition, there may be board- 
like rigidity of the upper abdomen with great tenderness on 
pressure, emphysema of the abdominal wall, blood in the 



I 



TRAUMATIC RUPTURE OF THE VISCERA 49 

vomit, and on opening the abdomen localised ecchymosis of the 
peritoneum, and sometimes fat necrosis of the kind seen in 
acute haemorrhagic pancreatitis. 

Some of these patients die from the shock, others, and the 
more numerous, as a result of inflammation of the retro- 
peritoneal cellular tissue ; therefore it is well to arrange for 
drainage of this region. The recorded cases of recovery after 
operation are very few indeed. Those of Messrs. Godwin and 
Moynihan were at or near the duodeno -jejunal junction. If it 
is possible to find the opening in the peritoneum, the bowel 
underneath must be examined and treated by suture if this 
opening is small and accessible. Mr. Lawford Knaggs, who 
opened a discussion on this subject at the Royal Society of 
Medicine,^ describes a case in which he sutured the opening, 
which was 1 inch from the pylorus, with a continuous suture 
through the mucous and muscular coats, and applied inter- 
rupted Lembert sutures outside that. At the necropsy twenty- 
four hours later these had held. The drainage was provided 
for in this case by three tubes, one in the right flank to the 
kidney pouch, one into the pelvis, whilst the retroperitoneal 
space was drained through the abdominal incision. In this, 
the second of two cases related by Mr. Knaggs, the patient 
was a man of 20, and operation was performed more than 
twenty -four hours after the injury had been inflicted. 

If there is complete rupture above the entrance of the 
bileduct into the second part of the duodenum, the best method 
of treatment is to close both ends and perform a gastroentero- 
stomy after the method of Mayo, or by the ordinary anterior 
method which takes less time for its performance. Cholecyst- 
enterostomy must also be performed when the complete 
lesion is below the bile papilla. 

When a complete rupture has taken place below the duodeno- 
jejunal junction, a modification of the operation of gastro- 
jejunostomy " en Y." of Roux may be possible, but the 
proximal limb may be very short and require some skill to 
adapt it to the efferent loop. 

These are suggestions of possibilities, but in actual practice 
there is rarely a chance of doipg more than pack and drain, on 
account of the excessive collapse. 

1 See Vol. v., No. 9, p. 243, Transactions. 
A.A. E 



60 THE ACUTE ABDOMEN 

Rupture of the Large Bowel. 

Rupture of the large bowel by force, from within, has been 
occasionally seen. Dr. Andrews ^ has drawn attention to the 
effect of compressed air in causing this accident, and pubhshed 
a most instructive case in which he had to excise a portion of 
the sigmoid and do a lateral anastomosis. He collected fifteen 
other cases from American sources. The air hose which leads 
to the compressed air supply need not be appHed directly to the 
anus, but produces its effect through the clothing. Rupture 
is usually in the sigmoid and may be multiple. All the cases 
not submitted to operation died ; as in other cases, operation 
must be early. In the days when intussusception was treated 
by means of air injections into the bowel, rupture of the gut 
was not unknown. It may be torn also by an attempt to 
introduce the sigmoidoscope or to pass a large bougie through 
a high non -malignant stricture, when the patient is under 
anaesthesia, not from perforation by the bougie, but from 
pushing the inelastic stricture upwards. In cases where 
enemata have been forced into the peritoneal cavity it is 
usually difficult to say whether the damage has been caused by 
the nozzle or from too forcible delivery of the fluid into an 
obstructed rectum. 

Rupture of the Descending Colon, with Lacerations of the 
Overlying Peritoneum. — A woman aged 33 was brought at 12.15 a.m. 
on July 14, 1907, having been run over by a horsed omnibus, the wheel 
of which passed over the abdomen about the level of the lower ribs. 
When admitted she was pale and collapsed with a feeble pulse, 120, and 
a temperature of 97°. 

During the night she was sick once, suffered much pain, and was 
evidently worse in the morning. 1 saw her at 10 a.m. Much of the 
shock had passed off, and she was lying somewhat propped up in bed 
with quickened respiration and pulse. She was complaining of pain in 
the left side of the abdomen over the lower ribs, and the abdomen was 
not moving well with respiration. Tliere was rigidity especially marked 
on the left side, with excessive tenderness extending in a line from the 
site of the injury towards the pelvis. She had passed urine of normal 
appearance, but the bowels had not acted. There was no evident 
bruising of the skin. 

Ten hours after the injury operation was carried out through the 
left rectus sheath with displacement of the muscle inwards. At the 
first inspection there was little visible beyond a scratched appearance of 

> "Surpery, Gynacology, and Obstetrics," January. 1911, N. Y., Lancet, Vol. I. 
1911, p. 524. 



TRAUMATIC RUPTURE OF THE VISCERA 51 

the peritoneum over the situation of the splenic flexure. A bruised 
state of the descending colon was seen, it was not extensive, but 
there was no abrasion or tear of its peritoneum or alteration in the 
normal consistency of the part. Some free gas could be felt in the 
mesocolon, and a mounted sponge passed into the splenic region showed 
a dark fluid with faecal odour. Compression of the descending colon 
between finger and thumb whilst they were moved towards the flexure 
caused some bubbling of gas and escape of a small quantity of faecal 
fluid through the small tears of the peritoneum about the splenic flexure. 
Incision backwards at the angle just below the ribs carried through 
the peritoneum behind the splenic flexure opened up a cavity outside 
the bowel in \^hich there was some solid faecal matter which had escaped 
from a hole the size of a penny, at or below the splenic flexure. This 
cavity extended upwards into the retroperitoneal tissue behind the 
spleen and could hardly be cleansed, for the faeces were ground into the 
cellular tissue. The edges of the rupture were brought together with 
interrupted silk sutures, the margins being inverted. The peritoneum 
was cleansed, and some ounces of offensive blood-stained fluid removed 
from the pelvis. The wound was closed, the peritoneum being sutured 
so as to shut off the septic area behind the bowel which was drained. 

The sutured bowel partly gave, and a faecal discharge appeared from 
the lumbar opening on the fifth day — ^there was also some rise of tem- 
perature, and as this did not subside, 25 c.c. of anti-coli serum was 
injected into the axilla on the ninth day. Improvement was satis- 
factory, but the temperature kept above normal, so on the fourteenth 
day 25 c.c. of the poly-valent serum was injected. Some faecal matter 
with pus continued to come away for nearly five weeks, the amount was 
becoming smaller from day to day, and the wound had quite closed 
before September 7, when she left the hospital. 

The mortality attending rupture of the intestine when the 
patients are placed under the best conditions is shown in the 
table on p. 52. These are all hospital cases — ^ninety- 
seven operations with twenty-one recoveries. In this table 
are included all the cases submitted to operation, whether 
successful or not, but a truer estimate is obtained if only the 
cases for the last ten years are taken. 

I have not made a separate heading of Rupture of the 
Mesentery, because it is usually a complication of the more 
severe lesion, rupture of the intestine. The symptoms are also 
similar, and although a surgeon may be certain there is a 
laceration of the mesentery, he cannot be certain there is no 
accompanying lesion of the intestine. They are serious 
because of the danger of interference with the blood supply 
of the intestine. They may also be the cause of extensive 
hsemorrhage into the peritoneum. Should the separation from 

E 2 



52 



THE ACUTE ABDOMEN 



the bowel be extensive or there is accompanying rupture of 
the intestine, the part must be excised and the ends united 
with sutures. 

Table Showing Results of Operation for Traumatic Bupture of 
the Intestine. 



St. Thomas's Hospital, 1880—1910. 


Berry and Guiseppi 

(London and other 

Hospitals, 1893—1907 

inclusive). 




Cured. 


Died. 


Cured. 


Died. 


Small intestine — 

No operation 

Operation 
T.arge intestine — 

No operation 

Operation 


5 
5 


6 
20 

1 
1 


8 
3 


37 
49 

5 
6 




10 


28 


11 


97 



St. Thomas's Hospital 
Other hospitals . 



31 operations, 10 recoveries. 
66 „ 11 



Rupture of the Pancreas. 

The pancreas is another organ which occupies a protected 
position in the upper abdomen, so it is very rarely injured by 
anything short of a stab or gunshot wound ; still there are a 
few cases on record where such has occurred, and the possibility 
of it must be recognised in cases of contusion in the epigastric 
region. 

A laceration of this organ gives rise to no special symptoms 
beyond those of shock and effusion of blood into the peritoneal 
cavity. When peritonitis supervenes it is apt to be ascribed 
to other causes. 

Should exploration be decided upon in consequence of the 
urgency of the symptoms, which are referred to the region of 
the stomach, a median incision should be used, and after 
examination of the stomach, liver, and spleen, the gastro- 
hepatic omentum should be torn through and the lesser sac of 



^1 



TRAUMATIC RUPTURE OF THE VISCERA 53 

the peritoneum examined. Blood may be seen coming through 
a tear of this omentum, or it may be seen below the greater 
curvature of the stomach. If there is extra vasated blood in 
this sac, the wound should be packed off and the space cleansed 
with sterilised saline. Haemorrhage from a laceration should 
then be arrested by the application of ligatures of catgut to 
the bleeding points. Should this method fail to arrest the 
bleeding, deep sutures to bring the parts together should be 
tried, care being taken to avoid the ducts if they have been 
cut. If the laceration is in the tail of the pancreas, it will be 
well to cut this off beyond a ligature, at the surgeon's discretion. 

Should it be possible to close the rent, additional sutures of 
catgut should be also employed to draw together the peritoneum 
covering the gland so that the damaged organ may be quite 
shut off from the peritoneum. 

The peritoneum must be thoroughly cleansed. 

In every case provision should be made for drainage ; the 
best plan is to close the opening in the gastro -hepatic omentum 
and make one in the gastro -colic omentum, through which a 
strip of gauze the required size can be passed. In more than 
one recorded case a plugging of the wound combined with 
drainage has sufficed. 

A complete rupture of the pancreas was successfully treated 
by Professor Grave.^ 

The patient, a man of 24, had been crushed between the buffers of a 
train. 

There was some little pain after the accident, no vomiting or nausea, 
no shock, whilst the temperature and pulse were normal. The abdomen 
was tense, and there was some tenderness in the epigastrium. Three 
hours later vomiting of coffee-grounds material, later of some blood, 
set in, with severe pain. 

A complete tear of the pancreas was found, the edges of whieh were 
about an inch apart, and sharply cut as if with a knife. 

The torn edges of the organ were brought together with exact apposi- 
tion, and with three posterior and three anterior fine silk sutures through 
capsule and parenchyma the defect was repaired and the haemorrhage 
stopped. Gauze packing was put in and became saturated with 
secretion in two days. This packing was removed after eight days and 
a new loose one inserted. In two weeks a drain was inserted. The 
fistula closed in six weeks. 

Of twenty -four subcutaneous injuries, thirteen died without 

1 ''Beitrage sur Klin. Chir.," 1905. 



H THE ACUTE ABDOMEN 

operation ; eleven were operated on and seven recovered ; 
this operation merely consisted in exposure of the wound and 
drainage, any blood which had been effused being cleared 
away. 

Dr. Randall has obtained success after suture of a laceration 
of some 2 inches in length. He employed drainage. 

Rupture of the Liver. 

Rupture of the liver is an extremely fatal accident, and the 
symptoms which ensue are usually marked and serious. Shock 
is present, frequently passing into collapse and death. Short 
of this there are vomiting, rapid pulse and respiration, pallor, 
etc. In this accident rigidity of the abdominal wall is very 
evident, so that it may appear board-like. Tenderness becomes 
localised to the hepatic region, and there is shifting dulness in 
the flanks with the ordinary symptoms of loss of blood, accord- 
ing to the amount of it which is effused — the man becoming 
restless with a rapid weak pulse, sighing respiration, and what 
is called " air hunger." Jaundice may be a late symptom, and 
is therefore of no use in the early diagnosis, which is so very 
important. 

There is, as might be expected, much variation in the size of 
the rupture, which is usually on the convex surface of the right 
lobe ; the combined statistics of Mayer and Ogston give three 
right lobe to one left lobe as the proportions. 

Shock in this injury may not be evident when the patient 
first comes under observation. 

Fatal Case in which Shock was Delayed. — When leaving the 
Royal Free Hospital some years ago, I saw a woman of 59 brought in, 
who had been run over in the street a few minutes earlier. 

She was excited, and resented examination. There was no mark on 
the abdomen, no dulness in the flanks, or rigidity of the muscles. It 
was difficult for us to induce her to remain in the hospital, yet three 
hours later the abdomen was full of blood, and she did not survive 
for many hours the operation to arrest the bleeding. The liver was 
extensively torn posteriorly and the kidney showed a recent laceration ; 
theie were other injuries also present. 

I must repeat that all cases of abdominal injury should be 
carefully examined^- during their stay in the hospital, for 
secondary symptoms give very few signs which enable them 
to be detected. 



TRAUMATIC RUPTURE OF THE VISCERA 55 

Fatal Case in which the Symptoms were Slight. — In 1911 a 
man who had been injured in a motor car accident was in the hospital 
for about ten days and then went to a convalescent home, apparently 
well. Soon after his arrival there he was transferred to a hospital, 
where it was noted that in addition to jaundice there was a considerable 
effusion in the peritoneum. A large quantity of this was withdrawn 
by aspiration, but the patient died from peritonitis. It was found 
that there had been a rupture of the liver. 

Kecovery after Gauze Packing. — In July, 1912, a boy was 
admitted who had been run over and received fractures of the right 
ribs over the hepatic region. For two days there were no symptoms of 
importance. He vomited on the third day, the abdomen became some- 
what distended and tender, whilst the temperature rose and the pulse 
increased in frequency. No definite dulness could be found on 
percussion, but incision on the right side gave exit to about a pint of 
fluid blood which was becoming septic, and a rupture of the back of 
the right lobe was found from which blood was flowing. He recovered 
after this place had been plugged for thirty-six hours. 

The records of cases which are published give no reason for 
thinking that there is any special disease of the liver that 
predisposes to rupture, although it is stated by a Russian 
veterinary surgeon, Dr. Grymer, that rupture of a lardaceous 
liver is a comparatively frequent cause of death in horses. 
Haemorrhage is the most common cause of a fatal ending, yet 
Dr. Homer Gage considered that 14 per cent, proved fatal from 
peritonitis, caused by the continued presence of blood in the 
peritoneum. Dr. Hogarth Pringle, who contributed a paper 
to the " Annals of Surgery " (a paper which is full of interest 
to the surgeon) on traumatic hepatic haemorrhage, considers 
that, if the severe cases are to be got through at all, the opera- 
tion must be an immediate one for the majority. That some 
of these cases can be saved is shown by the statistics of Ferrier 
and Auvray, and by the cases which are published in the 
literature of this country, though these are few in number. 
He suggests that when the peritoneum is opened, the hepatic 
and portal vessels should be immediately grasped with finger 
and thumb, and held by an assistant whilst the effused blood is 
cleared from the peritoneal cavity and the necessary manipula- 
tions are carried out on the liver. He has practised this in two 
cases, and says that perfect control of the bleeding areas of the 
fiver was obtained and a clear field for operating. 

There can be no doubt that at the operation the first thing 
is to arrest the haemorrhage, which appears to increase directly 



56 



THE ACUTE ABDOMEN 



the peritoneum is opened. In these cases the incision should 
be a large one, the operator quick and decided in his movements, 
and the immediate arrest of haemorrhage the first care. There 
is a difference of opinion as to whether the laceration should be 
closed by means of suture, or whether the surgeon should be 
satisfied with gauze-plugging of the area from which the haemor- 
rhage comes. Dr. Hubbard recommends that in some instances 
the packing of the wound shall be done through the pleura, 

after a flap has been made 
from the chest wall. 

If haemorrhage from the 
area affected cannot be 
arrested, then in the ma- 
jority of cases a long strip 
of aseptic gauze should be 
employed to plug the wound. 
This should be placed in 
position gently, but firmly, 
and its amount proportioned 
to the size of the cavity 
from which the bleeding 
comes Masses of gauze 
should not be employed, 
otherwise adhesions form 
between intestinal coils, 
which may cause obstruction 
later. I have had to operate 
for such a late complication 
Fig. 5. — Extensive Laceration of Liver, of a treatment which was 
Ha'inorrhage : 432, St. Thomas's successful in saving fife in 
Ilospital Museum. , ^ i 

the first place. 

There are some wounds in which it is best to insert stout 
catgut sutures by means of a round -bodied needle which is a 
size or two smaller than the suture. This method of treatment 
should be attempted only when there is ready access to the 
laceration, and the condition of the patient permits of the time 
recfuired. A ready and simple method is to place strands of 
catgut on both sides of the laceration on the surface of the 
liver, otherwise the sutures are apt to cut their way through 
the fiver substance. Intermediate sutures may also be 




TRAUMATIC RUPTURE OF THE VISCERA 57 

inserted in the ordinary manner, on which there is no 
tension. 

Since writing the above the following case under the care 
of Mr. Rutherford Morison ^ has been published which bears out 
what has already been said, and emphasises the possibilities of 
success in the most extensive of these injuries : — 

A miner aged 17, crushed between two objects five hours before 
admission to the Royal Victoria Infirmary, March 17, 1913. He 
felt very faint, and on being released fell down in great pain and very 
ill. The abdominal pain, so severe at first, gradually passed off, and 
he had none when he arrived. His complaint then was of pain over 
the lower ribs on the right side, and he was tender there. The only 
sign discoverable was some rigidity over the right side of the abdomen. 
He looked well, his pulse was 80, and his temperature was normal. He 
was examined by several different authorities, and all agreed that there 
was nothing to indicate a serious lesion or the need for an operation. 
Next morning he had not slept and was in great pain. His colour was 
good, he was sweating freely, his tongue was moist, and his pulse of 
good quality and only 80 to the minute. His abdomen moved very little 
with respiration, it was markedly rigid and tender all over, and there was 
shifting dulness in both flanks and the hypogastrium. Mr. Morison 
continues his account : — 

" It was now evident that some serious intra-abdominal lesion was 
present, and the problem whether this condition was due to ruptured 
intestine with general peritonitis or to intra-peritoneal haemorrhage was 
fully discussed. My view was in favour of peritonitis, as, though 1 
knew a large intra-abdominal haemorrhage might exist with very little 
disturbance, I could not believe that a haemorrhage large enough to 
cause dulness so marked could fail to produce evident anaemia." 

Operation (seventeen hours after the accident). — On opening the 
abdomen blood poured out. This was traced to the liver. Remember- 
ing Hogarth Pringle's valuable hint, 1 passed my left forefinger into the 
foramen of Winslow, and with my thumb in front compressed the 
hepatic artery, portal vein, and bileduct, arresting all haemorrhage at 
once. The wound was found to be in the right lobe of the liver extend- 
ing from the coronary ligament through the free margin and involving 
so much of the whole thickness of the organ that the portion on the right 
seemed to be attached to the left part by only a narrow band. 

The tear was sutured in four tiers with thick catgut. The first line 
of mattress sutures commenced about 1| inches from each side of the 
tear, and caught the bottom of it, the next were introduced about 
1 inch from the edge, the third ^ inch, and a final continuous suture 
brought the fibrous capsule together. Before the sutures were tied any 
relaxation of the hold upon the gastro -hepatic omentum was followed 
by active haemorrhage, but as soon as the sutures were tied the wound 

1 British Medical Journal, Vol. I., p. 8, 1914. 



68 THE ACUTE ABDOMEN 

was quite dry. The peritoneum was washed clean. Intravenous 
infusion on table. 

A drainage tube was left in the hepatic pouch for the first ten days, 
but nothing escaped from it, and the wound healed by first intention. 
Except for a curious rise in temperature every evenmg (up to 102°) the 
patient made a good recovery, and went home well fourteen days after 
the operation. 

Mortality after Eupture of the Liver. 

Mayer . . . Out of 207 cases, 86-6 per cent, fatal. 

Edler(1887) . . „ 547 „ 85-0 

Fraenkel . . „ 31 „ 450 

Tilton (1905) . . „ 25 „ 62-5 

Thole-Dantzig gives the mortality after operation — 

If performed during the first twelve hours, 55 per cent. 
If performed during the second twelve hours, 67 per cent. 
Bej'ond, 78 per cent. 

Ruptures of the Gall-Bladder and 
Biliary Passages. 

Traumatic rupture of the gall-bladder is a very rare accident, 
but is occasionally seen. If the bile is diffused throughout the 
peritoneum there will be evidence of free fluid slowly increasing 
without symptoms of haemorrhage. There may be an injury 
of the liver also, when the symptoms of liver laceration will 
mask those of injury to the gall-bladder. Of the few cases 
which have been published the following is a good example 
in which the effusions became localised.^ 

The patient was admitted into Casliel Union Hospital under the care 
of Dr. T. Laffan. She was a married woman, aged 50 years, who had 
been trodden on by a cow while in the act of milking it. She felt 
something give way inside, and after suffering for some time from all 
the symptoms of acute inflammation was sent to hospital on September 
15. 1898. 

On admission the patient was in an alarming state, being almost 
moribund. She was deeply jaundiced and all the symptoms of peri- 
tonitis were present. The effusion was, however, circumscribed, 
presenting the appearance of a considerable tumour in the epigastric 
and adjacent regions. The patient was put under chloroform, and with 
the assistance of Dr. T. O'-Connell, Dr. G. Cook, and others laparotomy 
was performed. A large quantity of bile, pus, and some liquid faecal 
matter were evacuated. The cavity was washed out with antiseptic 

1 Lancet, I'JOO, Vol. II., p. 1497. 



TRAUMATIC RUPTURE OF THE VISCERA 59 

solution, a drainage tube was inserted, and the wound was sutured, with 
the exception of the opening for the tube. The patient was so weak 
and the parts being so matted as to require a regular dissection to 
unravel the point of rupture, it was deemed more prudent to make it an 
operation de deux temps if necessary. The necessity for a second 
operation, however, did not arise, as after an uneventful period the 
wound entirely closed, all discharge ceased, and the patient made a 
perfect recovery. 

At first there is usually shock with faintness, perhaps local 
pain and vomiting, and a slow accumulation of bile takes 
place in the peritoneal cavity, with production of limiting 
peritonitis and the deposit of much plastic lymph. Jaundice 
may appear early or late, and bile is absent from the faeces. 
There appears to be no indication for immediate operation, 
and when operation is performed, it is usually for the evacua- 
tion of fluid which has accumulated on the right side of the 
abdomen. The abdomen is asymmetrical, for the bile is never 
generally diffused in the peritoneum. 

If the rupture is quite recent the gall-bladder may be 
sutured as in some cases of cholecystotomy. It is usually 
safer to drain it, or, failing this, place a tube down to the 
rupture, packing off the peritoneum after it has been cleansed. 

Ruptures of the bileducts are very rare, and openings in the 
common duct can very seldom be found. Those which have 
recovered have been treated by aspiration of the collection of 
bile which has formed in the peritoneum, and this operation 
has been repeated on more than one occasion ; but, if it is 
considered best to explore, it may be possible to suture the 
duct, at least partially, if it can be found. 

Henlin is said to have recommended abdominal section in 
these cases in 1767. 

If the opening cannot be sutured it would be best to place 
a drainage tube down to the duct, pack off with gauze, and 
perform a cholecystenterostomy. If the patient is very bad 
a temporary cholecystostomy should be done and later the 
junction made with the small bowel ; it would also be well 
to make a lateral communication between the afferent and 
efferent portions of the loop selected. 

Only one example of this injury has come under my immediate 
care, and in this the impression given by the slowly increasing 
collection of fluid was that it was very heavy. 



eo THE ACUTE ABDOMEN 

Traumatic Rupture of the Common Bileduct : Laparotomy} 

A boy aged 6 was admitted to the Royal Free Hospital on August 15, 
1 893, having shortly before been run over by a hansom cab. 

He was a well-developed lad, suffering slightly from shock and 
complaining of spasmodic pains in the abdomen. The only mark of 
injury was t?light gi-azing of the skin on the left side of the chest, running 
downwards and to the right. He vomited soon after admission, but 
did not bring up any blood. Temperature 97-6°. The abdomen was 
not rigid and no special tenderness could be elicited. 

On the 16th beseemed fairly well, but still had spasms of pain in the 
chest, chiefly on the right side. During the night he had been restless 
and fretful and vomited twice. His bowels had not acted and the 
temperature was 98-4°. 

On the 17th, in the afternoon, he was lying on his back with his thighs 
flexed on the abdomen ; there was no rigidity, tenderness, distension, 
or alteration in the percussion note. He vomited twice and his tem- 
perature rose to 101-2°. Urine, sp. gr. 1,020, very red in colour, but no 
blood or albumin present. 

18th. — Still restless, with frequent vomiting : bowels have acted 
normally. Respiration mainly thoracic. Was drowsy in the afternoon. 
Vomited three times and bowels acted three times. Temperature, 

2 a.m., lOr ; 6 p.m., 102-3°. 

On the 19th slight jaundice noticed ; continued restless and looked 
very ill : vomited four times. Less complaint of pain. Highest 
temperature 100-2°. There was more vomiting on the 20th, and only 

3 oz. of urine were passed. Slight dulness noticed on right side of 
abdomen. The temperature did not exceed 98-4°. 

On the 21st there was evident change. He looked very ill, with 
sunken eyes, was deeply jaundiced, vomited frequently in the effortless 
manner of a patient with peritonitis. His pulse was rapid and weak, 
and emaciation was marked. The abdomen, however, was not what 
might have been expected — the impression given was that of " flaccid 
distension," it was larger than normal, moved with respiration, but 
chiefly in the upper part, was but slightly tender and without any 
rigidity. On percussion there was an area of dulness extending from 
the hepatic region into the right iliac fossa ; there appeared also to be 
dulness on the left side in the flank. On the right side the dulness 
extended forwards to the right linea semilunaris, and changed but 
slightly on movement. He vomited in the manner already described 
during the examination, was restless, and gave an occasional deep 
sighing inspiration. The temperature was 97-2°. 

The fluid in the peritoneum was supposed to be extravasated bile, 
with some inflammatory effusion, and it was supposed that there had 
been a rupture of one of the biliary ducts, not a rupture of the liver or 
of the gall-bladder. We could not obtain permission to evacuate this 
until 6 p.m. of the 26th. On incision through the peritoneum, which 

* Transactions of Chnical Society, 1894, p. 144. 



TRAUMATIC RUPTURE OF THE VISCERA 61 

was stained a deep yellowish red, a large quantity of pure, odourless 
bile ran away. The intestines were congested, but there was no 
lymph on them. A drain was placed into the space from which the bile 
had come, but no attempt at fuller exploration was permitted by his 
bad general condition. 

He died on the 28th, apparently from exhaustion. Bile was absent 
from the motions only on the last two days of the illness. At the post- 
mortem examination the whole of the small intestines were found 
injected, and to have on them layers of lymph ; this was especially 
marked on the right side. The liver and gall-bladder were intact, but 
about half an inch beyond the junction of the cystic and hepatic ducts 
the common bileduct was found torn completely across, but the 
aperture was difficult to find. No other traces of injury were discovered. 

Erhardt's experiments are of interest as showing the effect 
of the bacillus coli (which is present in the common bileduct) 
on the peritoneum, when mixed with the bile after its escape 
from the biliary passages, both in the production of a plastic 
peritonitis and the prevention of cholsemia. 

Rupture of the Spleen*. 

Rupture of the spleen is mostly met with in malarious 
districts, where it is so commonly diseased ; it may also occur 
during the course of an attack of typhoid fever. In this 
country it is nearly always the result of a severe injury, and 
none of our recorded cases of operation have been for rupture 
of a diseased spleen, so far as could be ascertained without 
microscopical examination. In one instance which Dr. C. 
Wheen has found in our medical publications there was 
evidence of disease of the blood on examination. 

It is unnecessary to enter to any extent into a consideration 
of rupture of the diseased spleen, for although it would be 
interesting, it would be chiefly so from a medico -legal point of 
view. Much of interest on this subject can be found in papers 
by Dr. D. G. Crawford, in the Indian Medical Gazette (1902 
and 1906). Some of the accounts given by medical men in 
charge of hospitals in tropical countries, or by those attending 
hospitals where patients are admitted from malarial districts, 
are quite starthng. A patient with a large spleen " turns in 
bed," is playfully " dug in the ribs " by a jocular friend, 
someone throws a grain of mustard seed at him or flicks him 
with a cane, and death ensues in a period of time measured 



62 



THE ACUTE ABDOMEN 



by minutes. Playfair gives seven to eight minutes as the 
average duration of Hfe after rupture of a malarial spleen, and 
the late Surgeon -General Coull -Mackenzie said that 68- 9 per 
cent, of his cases died under half an hour. If the abdomen is 
examined after death it is found to have been flooded with 
blood, as if the sac of an aneurysm of the aorta had burst 
into the peritoneum. There is rarely time for more than a 
guess as to the cause of the symptoms — none for treatment. 

Rarely is the rupture of a 
malarial spleen survived even 
for a few days. 

Dr. White Hopkins, who 
spent some years in Sarawak, 
has brought to my notice a 
weapon which I have called 
the " lethal cross," but in 
Malay the real name of 
which is " larang " (meaning 
forbidden). He says it is 
used only in southern China, 
and generally in the Malayan 
countries and islands, Malay 
States, Java, Sumatra, 
Celebes, etc. The weapon 
is unknown in northern 

Fig. 6.-Traumatic Laceration and Con- ^^'""^l ^^^ ^^^ ^^^^^^ ^^^^ 

tusion of the Spleen. Eemoved ^^ enlarged spleen is not so 

during life on account of hremor- common as in the southern 

rhage: 444, bt. Thomas's Hospital ^„ . . i ^. ^ . 

Museum. or tropical portion. It is 

heavy and made of an iron 
bar 16 inches long, with a cross-piece, the ends of which 
turn towards the point. The blunt end terminates in a nut 
which gives it a knobbed appearance. It is carried 
with the shaft up the arm of a long sleeve, clutched between 
the second and third fingers at the cross, leaving the knob 
extending. It cannot be seen in consequence of the size and 
shape of the sleeve. The Chinaman waits for his victim at 
night, and, accosting him, deals him a sudden and unexpected 
blow m the abdomen, not being particular as to the exact 
part which he strikes. The victim without a groan falls dead 




I 



TRAUMATIC RUPTURE OF THE VISCERA 63 

on the spot. His pockets are rifled, and nothing more is 
known of his assailant. 

Dr. White Hopkins adds, " from my experience in Sarawak, 
an enlarged spleen amongst the Chinese is found in about 
90 per cent. I would go further, and say that every China- 
man has an enlarged spleen. But the ratio of enlargement 
would be as follows : — The whole of the abdomen involved 
with a hard nodulous enlargement would be 60 per cent., 
perhaps more ; a partial enlargement, occupying three- 
quarters of the abdomen, would be about 25 per cent., 
and the remainder, from a half to a quarter enlarge- 
ment." If a Chinaman is found with a larang upon him 
he is at once tried and imprisoned, because it is known what 




Fig. T. — ^The Larang. 

intention he has. It is rarely found, except in the case of 
intoxication, or the finding of a Chinaman in close proximity 
to a dead man. 

I do not know of any other instance in the history of the 
peoples of the world in which similar advantage has been taken 
by the criminal of the pathological opportunities of the district 
in which he lives. 

Rupture of a normal spleen is foimd as the result of consider- 
able violence, and is met with clinically under two conditions. 
From its position under the shelter of the ribs, where it is 
well guarded, especially in the adult, it is a comparatively rare 
injury. It is not surprising to find that amongst the published 
cases there is an unduly large proportion of young people, 
whose ribs are more elastic and yielding, no less than fifteen 
out of twenty-three being under 20 years of age, nearly all of 
whom were " run over " in the streets. It was formerly held 
that there must be adhesions between the spleen and diaphragm 



64 THE ACUTE ABDOMEN 

before rupture can take place, but this theory has been dis- 
proved in recent years. Rupture of this organ is not always 
fatal ; healed cicatrices have been found during necropsies by 
Ayres, Neville Jackson, D'Arcy Power, and others. There 
are some cases in which hfe is said to have been much prolonged 
after this injury, but, unfortunately, the condition of the 
abdomen, as given in the report, does not always carry convic- 
tion that the diagnosis was correct. Statistics are, therefore, 
of little value, but Edler computed the mortality at 82* 3 per 
cent, in the uncomplicated cases. 

The symptoms produced may be immediate and alarming, 
or they may be delayed in their development. Barrallier 
summed them up in these words : " peritonisme," " Vhemor- 
rhagie,'' " syncopic,'' but probably referred to the rupture of 
a malarial spleen. Rupture of the malarial spleen may be 
compared to the rupture of an aneurysm, and that of a normal 
spleen to the wound of a large artery. 

The amount of shock varies very considerably when a 
healthy spleen has been ruptured, and does not help in the 
diagnosis, but I am inclined to think it greater as a rule when 
the spleen rather than when the liver has been ruptured, unless 
the laceration of the latter is deep or extensive. There may 
be no local evidence of contusion, but if the injury was to the 
splenic region, more especially if the overlying ribs are broken, 
then the great probability is that the spleen has been torn, 
and the symptoms will be shock, " air hunger," and the signs 
of free fluid in the peritoneum. 

Pain may be severe, but on the other hand it may be absent, 
and there may even be no tenderness. The chief reliance must 
be placed on the presence of blood in the peritoneal cavity 
soon after an injury, and the general effect of the escape of 
this blood on the patient. It is strange that in many recorded 
examples of rupture of the spleen there is no statement as to 
the presence or absence of dulness in the abdomen during the 
progress of the case, or, in fact, any note to show that those in 
charge were aware of the very large accumulations of blood 
which were revealed at the post-mortem examinations. In one 
or two cases, in which operation was performed abroad, it is 
stated there was no dulness, and, a paragraph or so later on, 
that a great deal of blood escaped when the peritoneum was 



TRAUMATIC RUPTURE OF THE VISCERA 65 

incised. In ruptured spleen thete is the shifting dulness of the 
effused blood, whilst the immediate vicinity is occupied by a 
fixed clot which gives the impression of an increase in size of 
that organ. All cases should be closely observed and operation 
performed if there is rapid increase of the effusion or of the 
symptoms of loss of blood. 

Some of the cases which were successfully treated presented 
a less urgent group of symptoms, there being apparently a 
small amount of intraperitoneal haemorrhage at the commence- 
ment, but recurrences during the following days rendered the 
state of the patient precarious. 

The clotting of the escaped blood in and around the lacera- 
tion appears to close the vessels for a time, but secondary 
haemorrhage has been known to prove fatal three weeks after 
the accident. 

If the patient survives, and no relief is afforded during the 
first day or two, to the other abdominal signs and those 
depending on loss of blood are not infrequently added increasing 
distension, vomiting, pain, restlessness, and other symptoms of 
peritonitis, which has for many years been known to follow 
large effusions of blood into the peritoneum. 

It is advisable to remove the spleen, and empty the peri- 
toneum of the blood which has invaded it. The use of a plug 
of gauze is useful in rupture of limited extent, but with such a 
soft vascular organ great pressure may produce sloughing. 
In one case (the notes of which were read before the Clinical 
Society), that of a big, heavy man, where the spleen was very 
adherent to the diaphragm, I passed a ligature round the 
splenic vessels and so arrested the haemorrhage. Saline 
infusion was most useful and bleeding did not recur, but he 
only survived operation four days. Dr. C. Wheen has tabulated 
the successful cases of excision for this injury, done by British 
surgeons, and it is interesting to find that Mr. C. A. Ballance 
not only obtained the first operative success, but has the credit 
of two out of the twenty -three recoveries which have been 
published in this country, and Mr. B. Pitts obtained a third 
success. In all three cases there was marked enlargement 
of the lymphatic glands afterwards, on the surface of the 
body, when the patients had recovered from the immediate 
effects of the loss of the organ. 

A.A. F 



66 THE ACUTE ABDOMEN 

The abdominal incision should, if a diagnosis has been made, 
be placed in the splenic region below the left ribs. An incision 
in the middle line does not give satisfactory access to the 
spleen, although it is very useful if general exploration is 
indicated, because the surgeon is uncertain of the nature of 
the lesion which is present. When it is recognised that the 
spleen is the source of haemorrhage the operator should imme- 
diately secure the pedicle by temporary means. Either a clamp 
should be placed on it or it should be held by the fingers 
whilst the required extension of the incision is made. As a 
rule the laceration is of the hilum and vessels entering by that 
part, and it is easy to increase the size of the lacerations by 
violent dragging on the spleen. 

It is worthy of note that, in the examples of ruptured spleen 
during the course of typhoid fever, operation has mostly been 
performed for supposed perforation of the small intestine. A 
laparotomy of the lower abdomen has been first performed, 
and then a second incision made over the spleen, when it was 
found to be the source of the symptoms. 

In many of the ordinary traumatic ruptures this is done and 
the spleen removed through the second incision. Dr. Auvray 
has advised a long incision in the left side, the upper extremity 
of which slopes backwards over the lower ribs, the cartilages 
of which are excised to give more space. The increased shock 
which such a resection would cause is against its employment 
as a routine practice. 

The pedicle of the spleen should be clamped, the organ 
removed beyond the clamps, and interlocking ligatures applied 
carefully before the clamps are removed. If plenty of tissue 
is left beyond there will be no fear of secondary haemorrhage, 
but if the tissue beyond is possibly inadequate, larger vessels 
in the face of the stump should be secured separately. 

Rupture of the Kidney. 
Contusions of the kidney leading to laceration of that 
organ are amongst the most common of abdominal injuries, 
but on account of its protected position the extent of the 
damage does not often require surgical interference. It is not 
uncommon to find haematuria develop in a patient who has 
been run over in the street and complains of lumbar pain and 



TRAUMATIC RUPTURE OF THE VISCERA 67 

tenderness. There may be some swelling in the region of the 
kidney and slight rise of temperature, but a few days' rest 
in bed enables the patient to resume his work again without 
any disability. A watch must, however, be kept on such cases, 
for serious suppuration may ensue with few symptoms or 
a hydro -nephrosis or urinary cyst develop later. 

The more severe injuries are, however, of considerable 
gravity although retroperitoneal, even when the lesion is 
not accompanied by serious damage to surrounding parts. 
In these the shock may be severe and the pain great, a more 
or less rapid extravasation of blood forms a swelling in the 
peri -renal tissue, and the escape of urine when the laceration 
extends into the pelvis of the kidney renders the occurrence 
of suppuration probable. Suppuration is not an unusual 
complication from the proximity of the large bowel, which 
is itself often bruised. The amount of haematuria varies, but 
is not often an indication for operative interference, unless at 
the same time there is a rapid development of swelling in the 
region of the kidney. 

Tuifier^ found that these contusions of the kidney were 
complicated by other lesions in 20 per cent, of cases which he 
had collected. He also found that the deaths in uncomplicated 
cases were 43 per cent., whilst in the complicated cases death 
followed in 87 per cent. During the ten years 1903 — 12 
inclusive there were forty case 3 of uncomplicated contusions of 
the kidney admitted to St. Thomas's Hospital which recovered 
without operation. 

In five others it was thought advisable to operate and the 
kidney was removed in four ; of these one died ; in one a 
lumbar incision was made and the patient recovered. 

Of the more complicated cases, twelve in number, the liver 
was also ruptured in six (of these two had also a rupture of the 
lung). The spleen was also ruptured in four, one of which 
recovered after excision of both spleen and kidney. In another 
there was also fracture of the skull, whilst in one there was 
rupture of the peritoneum over the kidney and an extensive 
haemorrhage into the abdominal cavity ; the kidney was 
removed and recovery followed. 

It requires considerable force to produce a rupture of the 

1 "Arch. Gen. dt Med.," 1888—9. 

f2 



68 THE ACUTE ABDOMEN 

overlying peritoneum, especially in the adult, and when this 
compUcation is present the symptoms are much the same as 
those produced by a ruptured spleen, there being signs of 
extensive haemorrhage into the peritoneal cavity with evidences 
of injury in the kidney region. There will probably be a 
hsematuria of varying severity, with the general symptoms of 
loss of blood. 

In the case of a man who had been run over, and which proved rapidly 
fatal, under my care in the Royal Free Hospital the peritoneum was 
full of blood and blood-clots. A completely lacerated left kidney was 
found partly displaced through a tear in the peritoneum and was 
removed. The patient died from the rapid and excessive loss of blood, 
the amount being greater than that seen after injury to the other 
abdominal viscera. 

Intraperitoneal Rupture of the Kidney. — A girl aged 8 was 
admitted on March 24, 1911, having been run over about midnight by 
a motor car. It was stated that one of the wheels passed over the 
abdomen. 

On admission she was conscious and looked well, but had a pulse of 
120. The abdomen was tender generally, but there was no definite 
area of tenderness. Pain was referred to the umbilicus. On percussion 
there was slight dulness in the flanks, and the muscles on the right side 
of the abdomen were slightly rigid. 

She vomited soon after admission, at which time the urine was 
normal ; three hours later it contained a trace of blood. 

At 4 p.m. she was pale, restless, appeared to be suffering from shock, 
and had a rapid pulse. There was tenderness in the abdomen, chiefly 
referred to the outer margin of the right rectus. The abdominal wall 
was but slightly rigid. This diminished during the next two hours, 
but the dulness in the flanks had increased, and there was considerable 
tenderness over the kidney region. 

At 6 p.m. an incision was made over the right rectus and the muscle 
displaced inwards. There was a considerable quantity of fresh blood 
in the peritoneal cavity, which came through a rent in the peritoneum 
over the right kidney. This opening was plugged with gauze, the 
patient turned over, and the kidney removed through a lumbar incision. 
In it there was a large rent extending from the hilum three-fourths of 
the distance to the outer side. The peritoneum was cleansed, the 
opening sutured, and the anterior wound closed. The lumbar incision 
was filled with gauze. Intravenous saline was given during the opera- 
tion, and afterwards saline (with brandy) was given per rectum. Two 
days later the lumbar incision was closed with sutures. Five days 
after operation a quantity of sterile fluid was drained from the peri- 
toneum, there being a considerable amount of distension. The tube 
was left in for four days. She left hospital having quite recovered on 
April 20. 

Operation when undertaken for the treatment of a ruptured 



TRAUMATIC RUPTURE OF THE VISCERA 69 

kidney should be by the lumbar route, a pillow being placed 
under the opposite loin ; the incision should be free, so that 
no time is lost in securing the pedicle after the collection about 
the kidney is opened ; there must be plenty of room to carry 
out the manipulations. For this reason some recommend 
an opening which does not follow the usual direction of a 
nephrectomy incision, but extends from the middle of the 
twelfth rib to the iliac crest a little in front of the middle ; 
it is then prolonged to the anterior superior spine. Extra - 
vasated blood is often met with in the muscles, and sometimes 
the effused blood is found making its way to the outer side 
of the spinal muscles. If it is possible avoid opening the 
lumbar fascia until the muscles are clearly divided over it, 
the fascia can be then quickly cut and the kidney pedicle 
compressed with the left hand, whilst with the right accumu- 
lated clot is cleared away. Let the wound be well opened 
up with retractors, and ascertain the origin of the bleed- 
ing, and the exact position of the kidney. It is not well to 
apply a clamp too hurriedly to the pedicle, as the vena cava 
may be injured. If it is possible to apply forceps to the 
bleeding points, do so, and replace them by ligatures if you 
can. Usually it will be best to separate the kidney from its 
capsule and bring it up to the surface as before incision in 
nephrolithotomy ; it is not difficult to pass the finger through 
the lacerated capsule. In some cases it will be found possible 
to pass thick catgut sutures into the substance of the kidney 
and so close the wound and arrest bleeding, but when there is 
a complete transverse rupture, as when there are many frag- 
ments, removal of the organ will be much the safest. Try 
to separate the main part of the kidney quickly with the fore- 
finger, bring it to the surface, and ligature the pedicle with 
catgut in two portions. It will be advisable to use a pedicle or 
aneurysm needle for these ligatures, and pass them so as to 
secure the ureter and vessels separately. The kidney is cut away 
about I inch beyond them. It is sometimes easier to pass them 
after the clamps have been removed, and if the kidney is 
properly under control there is no danger from haemorrhage 
while this is being done. 

If silk is used for the pedicle, then the ligatures must be left 
long. Efficient drainage must be provided. 



70 THE ACUTE ABDOMEN 

When there is reason for thinking that the peritoneum 
overlying the kidney has been ruptured, no time must be 
wasted ; the danger to the patient is the rapid effusion of 
blood into the peritoneum. The abdomen must be opened as 
in the case described and the kidney excised as soon as possible. 
It will be necessary to give much saline during the operation 
and take every precaution to diminish the amount of shock ; 
as haemorrhage is going on internally there is no time to prepare 
the patient ; every minute permits increased loss of blood, and 
the sooner this is arreoted the better the patient's chance of 
recovery will be. 

On completion of the operation in these cases the peritoneum 
should be sutured over the stump of the kidney and the 
abdominal wound closed. If drainage is required, it should 
be carried out through an incision in the lumbar region. It is 
a good plan to leave some saline solution in the peritoneal cavity. 

Intraperitoneal Rupture of the Urinary Bladder. 

Intraperitoneal rupture of the bladder is still a very fatal 
injury, in spite of the fact that surgeons do not fail to operate 
whenever the lesion is diagnosed, or there is reason to fear that 
it has occurred. In 1 886 Mr. Rivington wrote : " No indubitable 
case of recovery after intraperitoneal rupture of the bladder 
is on record.'' In the same year Ullman collected 143 cases, 
and of these only two had recovered, whilst Sir W. MacCormac 
operated successfully in two instances, abdominal section being 
performed and the rent sutured in each case. This was 
nearly one hundred years after Benjamin Bell proposed that 
the abdomen should be opened and the bladder sutured for 
this injury. 

The patient probably presents himself at the hospital with a 
statement that he has had an injury to the lower part of his 
stomach ; that since that time he has been imable to pass 
urine, or has done so in small quantities, and that it is blood- 
stained. I shall always remember the first patient on whom 
Sir W. MacCormac operated so successfully, the " pioneer 
case," when he first came to St. Thomas's Hospital : — 

Going into the casualty department about noon in the pursuance of 
my duties as resident assistant -surgeon, 1 found a big, strong, healthy- 
looking labourer, standing up near a couch readjusting his clothings 



TRAUMATIC RUPTURE OF THE VISCERA 71 

whilst the dresser of the week was turning away with a porringer (con- 
taining urine of normal appearance) and a No. 8 catheter. Noticing 
that the amount of urine which had been drawn off (about IJ oz.) was 
small in quantity for a man applying lor relief of retention, whilst the 
size of the catheter suggested the absence of stricture of the urethra, a 
few inquiries were made, Und we learned that the patient had not been 
able to pass urine since the previous evening, when, running after his 
boy, he had hurt himself against a post in the alley. Throughout the 
night the abdominal pain had been severe ; he had wandered about his 
room, whilst his frequent efforts to pass urine had failed absolutely. 
He partly undressed again and laid down upon the couch for re-examina- 
tion. Percussion showed the presence of such a large quantity of free 
fluid in the peritoneum that in the absence of symptoms of haemorrhage 
it could only be urine which had escaped through a rent in the intra- 
peritoneal part of the bladder. The abdomen was rather distended 
without hypogastric dulness. A catheter was again passed in the ward, 
and 95 oz. of urine came away ; it was obvious that this quantity could 
not have been retained in the bladder, and renewed examination of the 
abdomen now showed great diminution in the amount of free fluid. 
The rent in the bladder measured 4 inches in length. 

I have dwelt on this change in the dull area found in the 
abdomen after an instrument has been passed, and fluid with- 
drawn by it, because it has not received attention adequate to 
its value as an aid in diagnosis. Another useful sign would 
be a contracted state of the bladder, rendering movements of 
the catheter difficult, whilst perhaps only an ounce or two of 
blood-stained fluid is withdrawn. 

Of intraperitoneal rupture of the bladder it must also be 
remarked that shock is most unreliable as a symptom : in 
Sir W. MacCormac's second case, which was also under my 
observation, the patient, a heavy man, who had fallen from a 
height of 20 feet in a sitting position, presented no appearance 
of shock and so few signs of injury that the house surgeon, a 
most able and careful man, did not find justification for his 
admission until he applied again on the following day. Yet 
the rent in the bladder was 2 inches long. This is all the 
more interesting, as this house surgeon had been on duty with 
the first case and recognised the possibility of this lesion. 

The result of injection of sterilised saline in measured 
amount into the bladder, which is allowed to flow out again, 
may be tried, but the forcing of air into the peritoneum may 
give a serious addition to any shock already present, and nothing 
is gained by it. In the majority there will soon be rigidity of 



72 THE ACUTE ABDOMEN 

the lower abdominal muscles, followed by the symptoms of 
peritonitis. At times these symptoms are delayed. Dr. Quick's 
case, which was successfully operated on by Di\ Thompson 
on the eleventh day, is an extreme proof of this. Dr. Quick's 
patient performed his work as a labourer an entire day after 
the injury, which was incurred during intoxication, and was 
not compelled to take to his bed until the second day was well 
advanced. Here the laceration admitted the end of a thumb. 
The symptoms of peritonitis may be very insidious in their 
onset, and in this class of case, more than in any other, the 
pulse will prove an invaluable guide. FaiHng strength, rapid 
pulse, and, later, vomiting, may be the only symptoms of 
extensive mischief. Ashurst states that amongst the patients 
who were intoxicated at the time of the accident the mortality 
was over 43 per cent., whilst amongst the sober it was less than 
28 per cent. 

The shock may pass away during the unconsciousness of 
intoxication and the patient know nothing of any injury 
received when in such a state. There is a record of a series of 
soldiers who died from peritonitis after this injury. The 
men had taken a wrong turning when drunk and fallen from 
a window to the ground outside the barracks when attempting 
to enter a lavatory after return from leave. The cause of the 
accident was discovered by placing a guard over the lavatory. 
Some cases may give less definite symptoms. In both 
patients under the care of Sir W. MacCormac there was a 
normal temperature, no vomiting, and the patients walked to 
the hospital. The second man had little pain, but there was 
no distension of bladder, as there should have been when he 
applied on the second occasion, considering the duration of the 
retention. Tympanites and the presence of urine in the 
peritoneum do not prove the existence of peritonitis. 

A patient with this injury may live for five days, apparently 
improving, and then die quite suddenly. 

Mortality after Operation for Intraperitoneal Rupture of the 
Urinary Bladder. 

1886. Ullman, 143 cases with two recoveries. 
1901. Alexander and Jones, 54. (Before 1893, a mortality 
of 63-5 per cent, after 32 operations ; between 



TRAUMATIC RUPTURE OF THE VISCERA 73 

1893 and 1903, a mortality of 27 5 per cent, after 
22 operations.) 

190G. Ashurst, 110, between 1893 and 1903, a mortality of 
42-72 per cent. 

1907. Quick, 29, between 1893 and 1903, a mortality of 
24' 1 per cent. 

Occasionally a bladder has been ruptured by the injection 
of fluid preparatory to the operation of suprapubic cystotomy. 
Here there is the sensation of something giving way as the 
fluid passes into the cellular tissue around the bladder ; if 
the injection is continued an abnormal swelling may appear 
above the pubes, which gradually diminishes in size. 

An extraperitoneal rupture of the bladder is often associated 
with a fractured pelvis, but is not restricted to such cases. 
There is the history of a likely injury and a complaint of 
inability to pass urine. A catheter if passed goes into a 
contracted bladder and a little urine is found which may con- 
tain blood. No dulness is found in the flanks, nor does a dis- 
tended bladder show above the pubes as time passes. Signs 
of inflammation of the cellular tissue around develop and are 
most marked on the side of the rupture. There is a rapid pulse 
and respiration, with symptoms of inflammation and sup- 
puration as the extravasated urine decomposes. An irregular 
swelling appears above the pubes, which is sometimes tym- 
panitic, and is not diminished when the bladder is emptied. 

Operation is the only treatment permissible ; this must 
consist of coeliotomy, with cleansing of the peritoneum, and of 
the application of sutures to the rent in the bladder, which 
must not penetrate the mucous membrane. It has recently 
been suggested that a plug should be placed over the lacera- 
tion in the bladder without suturing of the rupture, and the 
pelvis drained through a suprapubic opening. There may be 
instances when this would be the only available procedure on 
account of the desperate state of the patient, and it has been 
successfully employed. 

It is necessary to describe more fully the operation in the 
intraperitoneal ruptures. A median coeliotomy is quickly per- 
formed and the peritoneum opened freely. Extravasated urine 
with peritoneal exudation is removed as much as possible, and 
the intestine pushed out of the way with sterilised gauze. The 



74 THE ACUTE ABDOMEN 

Trendelenberg position may be of assistance at this stage. After 
the rent has been locaHsed it may be difficult to reach ; the 
incision must be carried well over the pubes, and should there 
be insufficient room the recti muscles may be detached on each 
side. Silk sutures (No. 1) should be passed by means of a small 
round -bodied needle in a holder after Lembert's method, about 
I inch apart, taking up the peritoneum and muscular coats 
only. The end ones should be placed beyond the rent in 
the bladder, which is usually vertical and about 2 inches 
in length ; all should be passed before aiiy are tied. Their 
introduction is facihtated if the one nearest the abdominal 
incision is passed first. After they have been tied an injection 
into the bladder will show if the line is watertight. Some 
surgeons recommend a double row, one to bring the torn edges 
together, the other to bury the first one in a broad fold. 
The sutures are cut short, and the bladder resumes its normal 
position. The peritoneum is cleansed, especially in the flanks, 
where fluid may have escaped notice ; and the wound closed, 
without drainage. If the patient suffers from retention during 
the after-treatment a sterilised catheter should be passed, 
and it is well to have a supply, prepared by Herring's most 
efficient method of sterilisation, ready for use. 

In cases of extraperitoneal rupture the space of Retzius 
should be freely incised and drained, for sloughing of the 
cellular tissue will follow wherever the urine has gone. This 
cellulitis requires free incisions. It is sometimes possible to 
pass a drainage tube directly to the opening in the bladder 
and so prevent any further diffusion of urine. This opening 
must be left to close by granulation ; it is seldom possible to 
employ sutures. 

Peritonitis is the most common cause of death, and early 
operation is the best preventative ; but even in early cases it 
may occur from extravasation of infected urine ; infection at 
the time of operation ; infection from a dirty catheter ; or from 
an imperfect suturing of the rent. 

THE AFTER-EFFECTS OF ABDOMINAL INJURIES. 

It usually happens that when a patient has survived the 
immediate effects of an abdominal injury his condition rapidly 
returns to the normal, since he is in excellent health at the time 



I 



AFTER-EFFECTS OF ABDOMINAL INJURIES 75 

of the accident, and his vitality has not been sapped by previous 
disease or prolonged ill -health — hence convalescence is rapid 
and recovery complete. Nevertheless, injuries to the abdomen 
are in certain cases liable to leave behind them traces which, 
scarcely noticeable at first, or perhaps not apparent at all, 
later on acquire alarming proportions. The number of patients 
who suffer from such sequelse is no doubt small considering 
the great frequency of abdominal injuries of all sorts, particu- 
larly in industrial communities, but the lesions themselves 
are often of a serious order. Since abdominal injuries are 
nearly always due to the localised impact of violence, and 
not to general contusion, so the lesions produced are local 
lesions, and the nervous system as a rule is spared — hence 
one great feature characteristic of those who suffer from the 
sequelae is their immunity from traumatic neurasthenia. 

In the following sections, the effects of injuries to the 
abdominal wall are considered first, individual viscera being 
dealt with subsequently. 

The Abdominal Walls. — The anterior suffers more frequently 
than the posterior abdominal wall, ventral hernise resulting 
from stab wounds or following exploratory incisions, while 
direct rupture of one of the abdominal muscles is very rarely 
responsible. The muscle which is most liable to rupture is 
the rectus abdominis below the umbilicus, and the fact of its 
rupture may be taken as indicating that the blow was not 
altogether unexpected, the muscle in fact by its violent con- 
traction having broken the force of the impact and thereby 
shielded subjacent viscera from injury. In operations upon 
ventral hernise which arise in this manner, it is often found that 
only the deeper layers of the abdominal wall have given way, 
while the more superficial layers are still intact. Mc Gavin 
has reported a case in which rupture of the rectus took place 
on the left side, a ventral hernia followed, and at operation 
intestine was found lying between the ruptured muscle and 
its anterior sheath. 

Retroperitoneal cysts, apart from those in connection with 
the liver and spleen, have been observed, in which trauma was 
held to be responsible ; most of these have been blood-cysts. 
They probably arise by progressive enlargement of hsema- 
tomata. 



76 THE ACUTE ABDOMEN 

Cases of diaphragmatic hernia due to injury are not common ; 
they are generally due to buffer accidents, severe blows on 
the upper abdomen or lower part of the chest, or to stab 
wounds through the lower intercostal spaces. The signs and 
symptoms are those due to interference with the functions of 
the stomach, the viscus most commonly involved (see pp. 236 — 
238). When the diagnosis is made operation should be 
undertaken for the closure of the defect, as strangulation may 
at any time bring the case to a fatal termination. 

In those cases which follow stab wounds of the chest the 
hernial protrusion may find its way through the diaphragm, 
across the phrenico -costal sinus, and thence through one of 
the lower intercostal spaces. Gerster reports thirteen cases 
of this nature, in only one of which had strangulation taken 
place ; in another a man had been struck three years previously 
on the left side of the chest by a plank, and the hernia had 
appeared shortly afterwards. It had never given rise to any 
inconvenience. The swelhng was easily reducible when the 
patient lay on his right side, but reappeared on coughing. 

The Stomach and Intestines. — The commonest sequelae of 
injuries to the gastro -intestinal tract are cicatricial stenosis, 
external fistula, and intra -peritoneal abscess formation ; and 
of the last two, perforating wounds more frequently lead to 
the former and contusions to the latter. Alexis St. Martin, 
the famous hunter, suffered from gastric fistula following a 
gunshot wound of the abdomen, an accident which earned him 
the right to immortality, since it enabled him to become the 
first subject for direct gastroscopy. Fistulse are formed in a 
similar manner in other parts of the intestinal tract, but 
occasionally they arise somewhat differently. It may happen 
that a viscus has undergone partial rupture, one or more of 
its coats remaining intact, and in such a case an abscess forms 
in the neighbourhood of the lesion owing to emigration through 
the weakened spot of bacteria from its interior. Such an 
abscess may extend till it reaches the surface, when it is either 
opened or else bursts externally, sometimes leaving a fistulous 
track through which intestinal contents leak to a greater or 
less extent. In examining such a fistula it is important to 
observe the condition of the skin round about its orifice, since 
this point affords valuable information as to the portion of 



)f 

I 



AFTER-EFFECTS OF ABDOMINAL INJURIES 77 

intestine involved. Thus a fistula arising high in the intestinal 
tract has a more serious digestive action on the surrounding 
skin than one arising lower down, while the character and 
odour of the discharge should supply confirmatory evidence. 
Occasionally an abscess ruptures into a neighbouring viscus 
and forms an internal fistula ; such fistulse have been observed 
between the stomach and the colon, and may lead to serious 
consequences by short-circuiting long stretches of the intestinal 
tract. External fistulse have a tendency to close spontaneously, 
but they may require operative interference, and then form a 
menace to life by subjecting the patient to the risks of general 
peritonitis. 

In the St. Thomas's Hospital Keports for the year 1904, there is a 
case of faecal fistula following abdomhial contusion. The patient, a 
carman aged 52, was run over by a wagon two months before admission, 
the wheel passing over his abdomen. An abscess formed and was 
incised, when a quantity of stercoraceous pus was evacuated ; the 
wound had discharged faecal matter ever since. As the surrounding 
skin was much excoriated, careful treatment was carried out and 
operation postponed for four weeks. At the end of this period the 
local condition had so far improved that operation was no longer feared. 
The abdomen was accordingly opened in the middle line above the 
umbilicus and the ileum anastomosed laterally to the transverse colon : 
the wound healed by first intention. Eighteen days after operation 
two stools were passed by the rectum, and on the twenty-second day 
the edges of the fistula were freshened and sutured together. Seven 
days later the bowels were acting normally, but there was still some 
discharge from the fistula, and the patient went home relieved, but not 
cured. 

In the light of more recent experience, it seems probable 
that a better result might have been achieved in this case if 
the ileum had been divided and the distal end closed, with 
implantation of the proximal end into the colon. 

Injuries to the stomach are rarely followed by cicatricial 
deformities excepting at the pyloric end, where stenosis may 
occur as the result of previous laceration, the inflammation to 
which it gave rise, or the operation performed for its treatment. 
Such stenosis is liable to cause gastric dilatation with its 
attendant evils, but the prognosis is good if the patient is 
wilHng to undergo operation ; as in this class of case, gastro- 
enterostomy affords certain relief. It is an open question how 
far injury may be responsible for the aggravation of previously 



78 THE ACUTE ABDOMEN 

existing gastric ulcers or for the formation of new ones, but 
it seems more than probable that if injury plays any part at 
all it can be only an exceedingly small one. 

Intraperitoneal adhesions are not likely to be formed merely 
as the result of haemorrhage, since extravasated blood is 
absorbed, and appears to have no other effect than the produc- 
tion of temporary agglutination of peritoneal surfaces ; but 
adhesions are undoubtedly formed whenever denudation of 
peritoneum occurs as the result of injury, and their action is 
protective in that they strengthen an otherwise weak spot 
in the visceral wall. But, their object once attained, they 
cease to be of value and henceforth become a source of danger, 
since they may under suitable conditions be directly causative 
of acute intestinal obstruction. Cases of intestinal obstruction 
are common in which peritoneal adhesions have been respon- 
sible, such adhesions having formed after abdominal injuries 
or their operative treatment ; but it must be confessed that in 
most of these cases the adhesions were due to operation and 
not to the injury itself. 

Simple stricture of the small intestine has been known to 
follow injury, but here again operation plays the greater part, 
since the stricture most frequently occurs at the site of suture of 
a perforation or at the line of an axial anastomosis, but it is 
possible that cicatrisation of a contused wound of the bowel 
may itself be responsible for stenosis. 

Traumatic appendicitis is recognised by some, and if cases 
of recurrent attacks of pain in the right iliac fossa attributed 
to injury may be regarded as due to that injury, then chronic 
appendicitis must be included among the sequelae of abdominal 
trauma. 

The duodenum, owing to its fixed position, is particularly 
liable to contusion, though its depth from the surface renders 
it less likely to suffer in stab wounds. One result of its rupture 
is the escape of bile and pancreatic juice into the retroperitoneal 
tissues with consequent abscess formation, and here again 
fistulse may ensue, or duodenal stenosis and gastric dilatation 
follow. If the peritoneal surface of the duodenum be damaged 
and the case does not immediately prove fatal, the formation 
of a subphrenic abscess is exceedingly likely. 

The Mesentery. — The sequelae of mesenteric injuries are 



AFTER-EFFECTS OF ABDOMINAL INJURIES 79 

few and rare. Laceration of the mesentery may be followed by 
cicatrisation and consequently by kinking of the bowel ; 
destruction of its peritoneum may court the formation of 
adhesions, and extravasation of blood between its layers may 
ultimately form one variety of the mesenteric cyst. But the 
most important of all the lesions, by virtue of its attendant 
risks to life, is mesenteric perforation. Perforations of the 
mesentery due to injury are a perpetual menace, inasmuch as 




Fig. S.-^Opening in the Mesentery of the Small Intestine, which 
caused Intestinal Obstruction: 341, St. Thomas's Hospital 
Museum. 

at any moment they may snare and incarcerate a wandering 
coil of bowel and initiate acute intestinal obstruction. 

The Liver, Pancreas, and Spleen. — Perhaps the most 
characteristic sequela of an abdominal injury affecting the 
solid viscera is the formation of cysts ; if infection occurs 
abscesses result, but, except in the case of the liver, sterile 
cysts are far more common. As in the case of the hollow 
viscera, adhesions are more often due to the operation than to 
the lesion which prompted it, particularly as operations for 
the rupture of solid viscera so often entail the introduction 
of gauze packing into the abdomen. 



80 THE ACUTE ABDOMEN 

A boy was admitted to hospital with signs of haemorrhage and a 
history of abdominal trauma ; at operation a rupture of the liver was 
found and packed with gauze. He made a good recovery, but was 
readmitted a month later with obstructive symptoms. The abdomen 
was opened and an omental band found obstructing the small intestine. 
The case was too far advanced to admit of any hope and the patient 
died. At the necropsy nothing further was discovered beyond the healed 
scar in the liver. 

Perforating wounds of the liver may lead to hepatic abscess, 
while subphrenic abscess occasionally follows ruptures, though 
rarely in uncomplicated lesions. Wounds of the gall-bladder 
sometimes result in biliary fistula and wounds of the ducts in 
stricture with obstructive jaundice. On the whole, the sequelae 
of injuries to the liver are exceedingly rare. 

The pancreas suffers more frequently and presents a greater 
variety of lesions ; among the sequelae may be found lesions in 
the gland itself as well as lesions in the neighbouring tissues. 
Although it may seem incredible, prolapse of the pancreas 
through an abdominal wound has been observed. Inflamma- 
tory sequelae have been recorded by various writers ; thus 
Fitz and Hansemann describe cases of necrosis of the pancreas 
following injury, while Rolleston reports a case of abscess of 
the head of the organ : — 

A woman of 50 received a blow on the abdomen which was followed 
at once by pain, and the next day by severe vomiting, constipation, and 
collapse simulating intestinal obstruction. The vomiting continued, 
and constipation gave place to diarrhoea, though this was not severe. 
Two months after the injury an abscess developed in the right hypo- 
chondrium, and a fortnight later the patient died. At the necropsy 
there was found an abscess in the head of the pancreas with fat necrosis 
in the subperitoneal tissues. 

Cysts of the pancreas due to injury have been classified as 
" true " and " false," the latter arising by closure of the 
foramen of Winslow and cystic dilatation of the lesser sac, and 
the former by dilatation of the lesser ducts behind an obstruc- 
tion of the main duct or of one of its large branches and brought 
about either by direct injury to the duct or its stenosis by 
involvement in scar tissue. Pancreatic fistula is caused 
by the incision of a true cyst or of a pancreatic abscess, and 
rarely by retroperitoneal rupture of the duodenum. False 
cysts or pseudo -cysts of the pancreas are due to the effusion 



AFTER-EFFECTS OF ABDOMINAL INJURIES 81 

of blood and pancreatic juice into the lesser sac after a partial 
rupture. A case of this nature was admitted in 1906, the 
account of which is as follows : — 

On June 13, 1904, 1 saw a master butcher, aged 50, with Dr. Shelswell, 
of Mitcham, for an epigastric tumour. The history given was that 
twenty years before he had had several ribs broken and been severely 
crushed by a cart against a wall, so much so that he was nearly killed. 
For some time he had suffered from pain in the epigastrium and attacks 
of faintness, and three days before, when returning from market, had a 
severe attack of abdominal pain and became so ill that he was taken to 
the house of the medical man from the station. There was also a 
history of strain during lifting a heavy weight four years before. He 
then had pain in the epigastric region, was jaundiced for two or three 
days, and shortly after the strain noticed blood in the motions. There 
had been some swelling in the epigastrium for two years, but beyond 
gradual increase in size it had caused no pain. 

He was a big, heavy man, complaining of pain in the epigastrium 
where there was a considerable prominence dull on percussion, which 
appeared to be due to a swelling as large as his head. It pulsated 
freely, but pulsation ceased when it was lifted off the aorta. There was 
well-marked fluctuation, and the outline was very definite. The cyst 
was punctured where most prominent and 6 oz. of brown fluid drawn 
off. The puncture suppurated and the cyst refilled ; he complained of a 
good deal of pain and lost weight. The fluid was examined, and the 
report stated : " The fluid is red-brown in colour, slightly alkaline and 
coagulates on boiling. Sp. gr. 1,022 : No sugar or ferments : slight 
deposit, with blood cells and granular matter. 

On admission later the sinus was healed and a swelling could be seen 
presenting characters similar to those present when the patient was first 
seen. Distinct movement was observed when he changed his position. 
The cyst was now opened and 7 oz. of offensive fluid escaped ; after 
thorough irrigation it was drained. After operation the temperature 
rose twice, while the discharge became more offensive, and it had not 
settled completely when the patient left the hospital with the wound 
unhealed. The Cammidge reactions A and B were negative. The 
wound continued to discharge for ten months after operation and then 
healed, though the man was too weak to work. In 1906 he was 
readmitted after several attacks of severe epigastric pain with rigors. 
Beneath the scar of the previous operation could be felt a firm mass 
extending transversely across the abdomen, while below, in the 
umbilical region, was a large cystic swelling dull on percussion and 
pulsating. The temperature and pulse were normal, no abnormal con- 
stituents were found in the urine, and the bowels acted regularly. 
The old wound was reopened and a cyst encountered at a depth of 
^ inch from the surface, 24 oz. of the same red-brown fluid being 
liberated. Again the cyst was drained and irrigated daily ; the dis- 
charge was abundant but inoffensive. Convalescence was uninter- 
rupted, and when the patient left the hospital the sinus had almost closed . 

A.A. G 



82 THE ACUTE ABDOMEN 

When first seen in consultation the resemblance of the cyst 
to an aneurysm of the abdominal aorta was very close. The 
stomach appeared to be displaced downwards and the cyst 
came forward to the abdominal wall, to which it appeared 
closely applied. 

Injuries to the spleen are more common in those countries 
where malaria is prevalent. Small lacerations heal, and give 
rise to no symptoms other than such as may be accounted for 
by the presence of adhesions, but if infection occurs, as is more 
likely to happen in stab wounds, then an abscess may result. 
Trauma has long been held responsible for certain cysts of 
the spleen, and not without cause, since there is abundant 
evidence to support the contention. 

In Fowler's series ^ there were no less than five cases of splenic cyst 
in which a definite injury had been received less than one year 
previously. Lejars mentions a case in which a woman was seized 
with severe pain in the epigastrium, with diarrhoea and vomiting, 
three years after an accident in which she was injured ; a cyst was 
found in the splenic region containing 1^ litres of fluid ; the wall of 
the cyst was rough and fibrinous and suggested a haematoma of long 
standing. Heurtaux also records the case of a woman, aged 27, who 
developed a splenic cyst eight years after an injury, and here again the 
cyst had evidently arisen by progressive enlargement of a haematoma. 

While the majority of these cysts thus belong to the category 
of blood -cysts, the view is held by some that certain of the 
serous cysts may also be of traumatic origin by inclusion of 
peritoneum during the healing of splenic lacerations. 

The Kidneys, Ureters, and Bladder. — Though the onset of 
symptoms of nephroptosis is sometimes attributed to injury, 
this factor cannot be held responsible for the condition. It is 
more than probable that in all such cases the condition has been 
latent, and has only been brought into prominence by the 
general functional disturbance and the possible medical 
examination following the injury. Injury is also said to play 
some part in the production of chronic nephritis, but here 
again sufficient evidence is lacking to prove the assertion. 
Stab wounds of the loin, if penetrating the kidney, often lead 
to urinary fistulae, partly owing to the introduction of septic 
organisms from without and partly to the decomposition of 
extravasated urine. Urinary fistulae may also result from stab 

* "Annals of Surgery," 1913. 



AFTER-EFFECTS OF ABDOMINAL INJURIES 83 

wounds of the ureters or bladder or from extraperitoneal 
rupture of the bladder with urinary extravasation ; or, again, 
they may follow operations for the exposure of ruptured 
kidneys. In all cases in which renal fistulse fail to heal under 
treatment, nephrectomy is the only available course to pursue. 
Stab wounds of the ureters are rare, but contusions are less rare ; 
hence numberless examples of their sequelae are on record, and 
in these, in nearly all cases, the ureter has undergone cicatrisa- 
tion at the point of injury and hydronephrosis has resulted. 
While true hydronephrosis may be formed in this manner, 
the so-called " traumatic hydronephrosis " is formed quite 
differently ; this variety of cyst indeed is not a hydronephrosis 
at all, but a cyst of extravasation, an encapsulated collection 
of extravasated urine arising months, or even years, after an 
injury in which the kidney underwent partial rupture. In 
these cysts the kidney may sometimes be felt, of normal size 
and not apparently diseased. Examples may be quoted from 
the St. Thomas's Hospital Reports : — 

A man was admitted having been run over on July 28, 1896. He 
sustained fractured ribs and abdominal injuries, the exact nature of 
which was not evident, but no signs of renal injury were observed. He 
was readmitted on September 3 with an enormous fluid swelling occupy- 
ing the left side of the abdomen and extending beyond the middle line. 
The overlying skin was red, smooth, shining and tense. At operation 
8| pints of urinous fluid were withdrawn ; the kidney and ureter 
appeared normal. The patient made a good recovery. 

Another interesting case was that of a man, aged 24, who was admitted 
as an urgent case under the care of Dr. H. P. Hawkins on November 21, 
1899. He stated that he first felt ill on the 18th, had pain in the left 
side, and was unable to go on duty. Next morning he was worse, had 
an attack of vomiting, and the pain was more severe. The abdomen 
was much enlarged, especially across the umbilical region ; there was 
no movement on respiration in the lower and very little in the upper 
part. On percussion an area of dulness was found all over, excepting 
for a small space in the upper part under the right costal margin. Over 
the whole of this area there was a fluid thrill, but the dulness did not 
change with alteration in the position of the patient. There was much 
tenderness on the right side. The general effect was that of a large 
flattened encysted collection of fluid, and it was not possible with this 
history to give an opinion as to its nature. After the operation, when 
he had recovered from the fever ( 103-6°) and upset of the acute condition, 
he remembered that he had been kicked in the abdomen some twelve 
years before ; the injury was severe, but he could not say anything 
about the condition of the urine at that time. On opening the peri- 
toneum in this case, the same evening, a shining surface having the 

g2 



84 THE ACUTE ABDOMEN 

appearance of intestine presented itself. On exploration with the hand 
it was found that the collection of fluid was retroperitoneal, passed 
down into the pelvis, nearly into the right lumbar region, close to the 
kidney, whilst the spleen could not be felt. The small intestine was 
pushed to the right, and the descending colon crossed the swelling from 
above downwards near the middle line of the body under the median 
incision. A large quantity of brownish urinous fluid, slightly turbid, 
flowed away under considerable tension on insertion of trochar and 
canula. This opening was sutured and the median incision closed. 
Through a lumbar incision the full evacuation of cyst was completed, 
some solid fleshy material commg away with the last pint or two of the 
fluid. Over 8 pints were removed. The wall of the cavity was thin 
and everywhere adherent, so that no attempt was made to remove it. 
A large drainage tube was inserted. The fluid contained urea and a 
little pus, but no crystals. The kidney was not felt. The sinus did not 
close for some weeks after he left the hospital, but he quite recovered 
and resumed duty as a policeman. 

In another case the course of events was much more rapid. A clerk, 
aged 24, was admitted on March 8 and left on April 9, 1901. 

Five weeks before admission he slipped and fell on the pavement, 
striking his right side. This injury was followed by severe and con- 
tinuous pain in the side struck and on the right side of the abdomen, 
which lasted for a fortnight. During this time he had vomited several 
times daily, usually soon after food. At the end of the fortnight he 
felt well and resumed work again. On the third day after going 
out the pams recurred and were much more severe for two days, and 
then disappeared. There had been no hsematuria and he thought he 
was quite well, but a swelling had appeared in the side. 

Nearly the whole of the right side of the abdomen (except the lower 
part) was dull on percussion, the dulness being continuous with that 
of the liver, and extending as far as the umbilicus towards the middle 
line. It did not change with alteration of the position of the patient. 
There was well-marked fluctuation in this area. The left side was 
normal, but over the lower part, near the groin, there was a little 
superficial swelling, and the upper and inner part of the left thigh was 
also swollen and very painful on pressure. The urine was strongly 
alkaline, but in other respects there was nothing abnormal found on 
examination. On March 9 a lumbar incision was made and the cyst 
emptied of about 4 pints of urinous fluid. On the posterior surface of 
the kidney a depression or pit just admitting the tip of the finger could 
be felt. ThLs was regarded as the site of a recent rupture. Drainage 
was employed and the man recovered. 

If the hiotory of a renal injury is suppressed by the patient, 
as it was in another case, the collection of fluid may be mistaken 
for an ovarian cyst. 

An unmarried woman, aged 34, was admitted on October 19, 1900. 
She had been treated in another hospital for the results of a cycling 



AFTER-EFFECTS OF ABDOMINAL INJURIES 85 

accident in April, during which she had been run over by a van. In 
September she had been under my care for malposition of fragments 
at the site of a fracture of the leg. She was under care then for three 
weeks and noticed a swelling in the abdomen, but, not wishing to be 
detained, did not say anything about it. She could not say if her 
kidney had been injured in April, but she remembered that about a 
week afterwards she had a (vague) sort of pain on the right side, and 
a little later noticed a swelling there, which did not change for a long 
time. This cyst was opened and drained through the loin. It contained 
almost 3 pints of dark-brown fluid. The kidney occupied a place on 
the anterior wall of the cyst, which was partly lined with fibrous 
material. She was under treatment for about three months before the 
sinus closed. 

These cases show the necessity for occasional examinations 
after contusions of the kidney region, although no sign of actual 
rupture of the kidney has been found. I remember a man in 
whom, after a ruptured kidney indicated by the usual signs, no 
tumour could be found three weeks afterwards, at the time of 
discharge, but a fortnight later he was admitted to another 
hospital for a cyst which required operation. 



PART II 

PERITONITIS, PERFORATIONS, AND OTHER LESS 
COMMON CAUSES OF THE ACUTE ABDOMEN 

PERITONITIS. 

The acute inflammation of the peritoneum which so fre- 
quently forms a part of the acute abdomen varies greatly 
according to the cause on which it depends, the rapidity of its 
spread, and the part where it has its origin. It also varies 
according to the number and virulence of the particular 
organisms which have found their way into it, the power of 
absorption of the peritoneum, and the resistance of the 
individual. 

In this section it is not necessary to dwell very much 
upon the symptoms of an inflammation which has to be 
considered in almost every part of our subject, whether 
it follows an injury, intestinal perforation, appendix per- 
foration (Fig. 9), intestinal obstruction, or invasion from 
some ascertained external source such as that by the Fal- 
lopian tubes. Here I only wish to mention the general 
symptoms which are met with in peritonitis and refer to 
those varieties in which no gross cause can be found, but 
in which there is an acute bacterial invasion by some 
organism which has probably obtained entrance through the 
blood -stream. 

The patient complains of pain in the abdomen, mostly in 
the umbilical region, becomes feverish, complains of chilliness, 
and probably vomits. The temperature rises and the pulse 
increases in frequency. The position soon assumed by the 
patient who has gone to bed, feeling very ill, is a very charac- 
teristic one, for he lies on his back with arms thrown above 
the head and the thighs flexed on the abdomen. When 
examined a few hours afterwards there is much tenderness 



PERITONITIS 



87 



sometimes amounting to hypersesthesia, especially when there 

is an inflammation which is extending. The complaint of 

pain may be less insistent, whilst its past severity is often 

indicated by the amount of redness, and even vesication of 

the skin which has resulted from the appHcations which have 

been made. The respiratory movements of the abdomen are 

Hmited or almost arrested, and there is still occasional vomiting. 

There is also rigidity of the abdominal muscles ; this may be 

localised at first, but 

may become general. 

The face is flushed, 

there is a furred tongue, 

and usually constipation. 

Percussion may yield 

here little information 

until there is some 

exudation of fluid or of 

lymph. In the former 

instance it may be free 

in the peritoneal cavity 

and vary with the 

patient's position, or it 

may be patchy or 

localised to one spot, 

as in the latter. The 

patient will often be 

restless, and call out 

or groan when the 

paroxysms of pain 

become severe. 

Later the expression 
of his face changes, he is listless, dark lines appear below 
the eyes, which appear to have sunken, whilst the cheeks 
are hollow. The lips become dry, and the tongue dry, 
brown and coated. The breath is offensive. Effortless 
vomiting continues and is now copious, whilst the ejected 
fluid becomes brown -coloured, bad smelling, and even feculent. 
Examination of the abdomen shows an amount of dis- 
tension which is apparently increasing, and the wall of the 
abdomen is moving less than ever. There is, however, no 




Fig. 9. 



Pin protruding through a perfora- 
tion of the Appendix and causing Peri- 
tonitis : St. Thomas's Hospital Museum. 
See also Surgical Diseases of the Appen- 
dix, 2nd ed. 



88 THE ACUTE ABDOMEN 

peristalsis to be seen, and the surface looks smooth ; palpation 
is painful and much resented by the patient. It is still rigid, 
mostly resonant, but in the flanks there may be dulness which 
can sometimes be traced across the middle line above the 
pubes ; if this is so, a fluid thrill may be ehcited. The tempera- 
ture is raised, not necessarily very high, but it may be normal, 
or subnormal, even when the inflammation is of the most 
severe type, with a general diffusion of pus. Such a low 
temperature with a rapid pulse is of very serious import. 
The constipation is probably relieved by an enema, and the 
patient passes flatus without any difficulty until the distension 
of the intestine is due to paralysis of the bowel wall caused 
by the general poisoning which has supervened. 

It is always of bad import in a case of peritonitis to find that 
the patient has lost all pain, and has commenced to hiccough. 
With these symptoms there may be a clearness of intellect 
which disguises the real state of the man from his friends, 
whilst the frequent pulse becoming almost or quite imperceptible 
warns the medical attendant that the clammy, moist hand 
which he took on entering the room was indeed a true witness 
of the patient's state as already indicated by the nurse in 
charge. 

A return of the restlessness and sighing respiration are also 
bad symptoms. 

(Edema of the abdominal wall may indicate a localised 
collection of pus or an extravasation of faeces into the under- 
lying area of peritoneum ; but there is another form of oedema 
of the abdominal parietes to which I drew attention some 
years ago. This may be seen when the general peritonitis 
is very acute. It accompanies an inflammation of the cellular 
tissue, and is caused by an exudation which has passed into the 
subperitoneal cellular tissue and come out along the inguinal 
canals ; it may spread into the scrotum, and laterally towards 
the anterior superior spines, but not into the thighs beyond the 
attachment of the deeper layer of the superficit 1 fascia. 

It may be stated at once that a localised inflammation of 
the peritoneum is not always a dangerous thing, and few 
abdominal operations which are carried out under the most 
perfect aseptic conditions are without a limited peritoneal 
reaction which amounts to an inflammation. In the same 



PERITONITIS 89 

manner all cases of inflammation of the appendix are accom- 
panied by some peritonitis which is a result of the relation 
which that organ bears to the general peritoneum. 

Most attacks of peritonitis can be traced to some form of 
organism or to some definite lesion, but it is not always so ; 
there are some cases in which no organism is discovered on 
examination by the bacteriologist and no gross lesion found 
when the abdomen has been carefully searched. Here the 
symptoms may be so severe and threatening that operation 
is performed, and rightly so ; it is unlikely that a fluid inflamma- 
tory exudate would remain sterile for many hours. Operation 
may save the life of the patient, and should not be delayed. 

N. K., a married woman aged 24, was admitted •)(- March 22 and 
left April 11, 1912. 

She stated that she had not been feeling well for a month ; there had 
been vomiting at intervals, with a slight aching pain in the abdomen. 
For a fortnight there had been intermitting pains and diarrhoea and 
occasional vomiting. Two days before she had suffered from pain in 
the lower part of the back, which in the afternoon had extended all over 
the abdomen, and was chiefly in the middle and right side. It was also 
tender. Vomiting had been fairly constant for twelve hours. 

On admission she had a somewhat distended, rigid abdomen, with 
tenderness mostly to the right of the umbilicus — generally resonant on 
percussion. Pulse, 104 ; temperature, 101-4°. An incision was made 
over the right rectus and the muscle displaced inwards. There was a 
quantity of brown-stained fluid in the pelvis and below the incision, 
which was not offensive. The peritoneal surfaces of some of the coils 
of the small intestine had a good deal of lymph on them. There was 
nothing abnormal found to account for the fluid. A drainage tube was 
inserted into the pelvis and removed on the fifth day as there was no 
discharge. The temperature was normal then and no further rise took 
place. She recovered completely. Dr. Dudgeon reported the fluid to 
be sterile. 

In another case there was no exudation of fluid in the 
peritoneum, but the abdomen was opened and the operation 
gave great relief. 

J. G., a coachman aged 55, was admitted ^ on July 12 and left on 
August 2, 1911. 

There was no history of any previous abdominal attack. Twenty 
four hours before admission he was seized with violent pain in the 
abdomen, which became generalised, not particularly acute in any one 
region. There had been occasional retching but no vomiting. The 
bowels had not acted for two days. 

The face was flushed, features pinched, with an anxious expression. 



90 THE ACUTE ABDOMEN 

Pulse, 100 ; respiration, 18 ; temperature, 99°. The abdomen was 
slightly and symmetrically distended, rigid, and acutely tender all over. 
The percussion note was tympanitic and examination gave no evidence 
of free fluid. 

Incision in lower right half of abdomen showed a normal appendix ; 
a second incision over the stomach revealed nothing abnormal. There 
was no free fluid. During his residence many examinations were made 
of the patient, but no cause for the attack was found. There was no 
continuation of the pain after operation. 

The advantage of early operation was evidenced by th« unsuccessful 
result of a similar line of treatment carried put for a patient, M., 
aged 55, on December 31, 1904.-)f The abdomen was distended, with 
tenderness over the sigmoid. Temperature 98-8° (pulse 96). There was 
no fluid or cause found. The illness had commenced on December 27, 
the day after taking three pints of cider. Abdominal pain, constipation, 
and vomiting. The man, who was very ill, died next day. At the 
necropsy, beyond the peritonitis, which was purulent in the pelvis, 
nothing abnormal was found. Judging from the other cases an earUer 
operation might have saved him. 

Of the varieties of peritonitis which result from an acute 
bacterial invasion through the blood-stream the following must 
be mentioned. 

A. Pneumococcal. — This form of peritonitis is not frequent 
when compared with the peritonitis which follows gross lesions 
of the alimentary canal. As a rule it is not difficult to differen- 
tiate the two unless by any chance the signs of the infection 
are most marked in the right iliac fossa when the patient 
comes under observation for the first time. The patient is 
most frequently a child (Barling gives 73 per cent, girls), whose 
parents tell a history of some recent chest trouble. The 
child was apparently well when a complaint of pain in the 
stomach was made ; vomiting followed, with fever and diarrhoea. 
There are found some of the usual signs of peritonitis already 
mentioned, and the child looks flushed and ill. Distension of 
the abdomen is often present with general stiffness and resist- 
ance of the muscles, and this may be associated with dubiess 
in the flanks. 

Operative interference is indicated, and the appendix 
examined in the first place. A perforation should also be 
sought for in the adult, in the stomach or duodenum. The 
best incision will be one through the right rectus sheath with 
outward displacement of the lower part of the muscle. The 
exudation, which is abundant, should be removed with gauze 



I 



PERITONITIS 91 

strips and soft sponges, and a good -sized drainage tube placed 
in the lower part of the wound to the bottom of Douglas's 
pouch. The child must be placed in the Fowler position and 
saline fluid given per rectum. 

In this, as in all forms of peritonitis, it is well to obtain a 
culture from the fluid (odourless in pneumococcic cases) which 
is present, so that a vaccine may be prepared for future use. 

There may be signs of pneumonia present, and herpes of 
the lips. Barling divides this type of inflammation of the 
peritoneum into three clinical types : — (1) Acute cases present- 
ing marked abdominal features from the first, but with no 
other pneumococcal lesions elsewhere. (2) Cases in which, 
simultaneously, or almost so, with the onset of peritonitis, a 
pneumonia develops. (3) Chronic septicsemic cases. 

It is only right to add that Dr. Hector Cameron is against 
operation excepting in cases of residual abscess. I can but 
think, however, that in the majority it would be wisest to 
drain and so get rid of one source of the toxaemia which is the 
great danger to life. A case which was under the care of my 
colleague Mr. Betham Robinson^ gives an excellent clinical 
picture of primary pneumococcic peritonitis and shows the 
value of vaccine treatment, combined with operation. 

D. W., aged 8, was admitted on April 22, 1908, under the care of 
Dr. Sharkey. 

She had always been a nervous child, subject to bilious attacks. 
Three years before she had measles, and two years before influenza 
with symptoms very similar to those of the present illness, abdominal 
pain, and vomiting. 

On the day before admission she seemingly had been in perfect 
health. At 8.30 a.m. on the 22nd she was suddenly taken ill with free 
vomiting, faintness, and slight abdominal pain centred round the 
umbilicus ; she was very thirsty and feverish. Fifteen hours after the 
onset, she was admitted looking ill and complaining of severe abdominal 
pain and vomiting. The face was very flushed, the eyes bright but not 
sunken, and the tongue furred generally but rather dry at the tip. The 
pulse was 130, regular and of small volume ; temperature, 103-8° ; and 
respirations 36. The chest moved well and equally, and there were no 
abnormal physical signs detected in heart or lungs. Abdominal move- 
ment was restricted below the umbilicus ; there was definite distension, 
but it was everywhere resonant. Palpation proved an almost universal 
tenderness, more marked round the umbilicus and in the right lower 
quadrant ; here there was some increased resistance, but no distinct 

I British Medical Journal, Vol. I., 1909, p. 65. 



92 THE ACUTE ABDOMEN 

lump could be felt. Ter rectum there was a boggy feeling, especially 
on the right side, as if there was something in Douglas's pouch. 

Mr, Robinson saw the child at 11 next morning, her pulse then being 
150 and temperature 103-4°. The abdomen moved fairly well on 
respiration except on the right side below ; here and across the bladder 
region she was tender. There was a little rigidity over the right rectus 
both below and above the umbilicus. An immediate operation was 
decided on, as her condition suggested a perforative peritonitis dependent 
probably on a gangrenous appendix. 

Operation. — The right rectus was displaced inwards. On opening 
the peritoneum a greenish -yellow fluid escaped, of gummy consistency, 
with a few flakes of dirty-white lymph in it. Although this was 
generally diffused through the cavity, and the intestines and omentum 
were smeared over with it, yet they did not otherwise appear to be in 
any way altered from the normal ; the appendix was absolutely 
healthy. A good deal of fluid had collected in the pelvis and in the 
right kidney pouch. There was no sign anywhere of glueing together 
of the intestinal coils by early adhesions. The right Fallopian tube 
was very definitely injected. (Subsequent inquiry elicited no evidence, 
past or present, of any vulval or vaginal discharge.) The glands along 
the iliac vessels and at the bifurcation of the aorta appeared to be a 
little enlarged. The peritoneal fluid was quite odourless. Drains with 
wicks were placed in the pelvis and in the kidney pouch, and the main 
part of the wound was closed in layers. She stood the operation very 
well, and was put back to bed in the Fowler position and given -^-^ grain 
of morphine. Saline was ordered jper rectum. 

After the operation there was a gentle drop in the temperature to 
99° at 8 o'clock the next morning, with a corresponding marked reduc- 
tion in the pulse-rate. She was feeling much more comfortable, and 
there had been very little pain and no vomiting. She was given milk 
and water frequently in small quantities. On April 25 her condition 
was very satisfactory, but both pulse and temperature had again risen 
a little. As her bowels had not acted, she was put on magnesium sulphate 
in the evening. The next morning there was a very slight result after 
an enema. The wicks were removed from the tubes, and a consider- 
able discharge of turbid fluid came away. Calomel, 2 grains, given at 
night, followed by magnesium sulphate in the morning ; this resulted 
in four actions during the day. On this day (April 27) the temperature 
again began to go up, and, as the clinical report showed that the 
peritoneal effusion was a pure culture of the pneumococcus, it was 
decided to use pneumococcic vaccine. On May 5 both drainage tubes 
were removed and gauze drains substituted. The discharge did not 
cease altogether. On May 27 a counter-opening was made in the loin 
and a piece of gauze pulled through from front to back. This soon 
had a marked effect both on the discharge and the temperature. On 
June 6 the front wounds were healed, and on the 10th the drain was 
left out behind. By this date her temperature had been normal for a 
week. She was able to leave the hospital on June 15. 

B. StreptocoQcic. — This is a very fatal variety of peritoneal 

i 



PERITONITIS 93 

inflammation, and is most commonly seen in cases of puerperal 
infection. There is little to be found in our literature which 
enables me to give an authoritative account of it ; most of 
the references are to cases which were treated with vaccine 
but in which the exact bacillus at work had not been proved 
by the usual tests. In a case of streptococcic peritonitis 
published by Dr. Horldidge, of Pinner, the entrance of the 
germ was by way of the appendix, and vaccine was most 
useful when complications arose during the progress of the 
case after operation. This bears out the experience of others 
in appendix cases, but the Streptococcus pyogenes aureus in 
the fluid surrounding an acute appendicitis always makes the 
prognosis grave. Whether a delay of a few hours in the 
examination of peritoneal fluid may give this germ a chance 
of killing off the active bacteria, and so appearing of greater 
importance than it really is entitled to, I cannot say. 

The following is an example of recovery, treated on the lines 
advocated, and I do not think that there can be any doubt 
as to the exact nature of the germ which caused the peritonitis. 

A married woman, aged 60, was admitted -)f on April 21 and left on 
June 30, 1911. 

On the morning of April 15 she woke up at 4 o'clock feeling very ill. 
She had great pain and felt that a cord was being drawn in around her 
body. She had diarrhoea all day, but was not sick. The two following 
days she was better and was able to do a little work in the house, but 
on the 19th she was not so well and went to see a doctor. She was in 
great pain, but did not suffer from diarrhoea. She was advised to come 
to the hospital. 

On examination the patient was lying on her back with her knees 
drawn up, in very great distress. Face pale and anxious, features 
pinched. Tongue furred and dry. Pulse, 108, poor volume and ten- 
sion ; respiration, 28 ; temperature, 102-8°. 

The abdomen moved very badly all over and was noticeably distended, 
with general rigidity of muscles. Tenderness was present all over, 
especially at a spot under the right rectus, just above the level of the 
umbilicus. The note was tympanitic in the umbilical region, but there 
was shifting dulness in the flanks. Liver dulness normal. Pelvic organs 
appeared quite normal. 

^ The same afternoon operation was performed, an incision being 
made through the right rectus, the upper part reaching the area of 
greatest tenderness. On opening the peritoneum a quantity of clear 
fluid escaped, and a great deal more was found in the pelvis extending 
also into the left flank. Scattered about on the surface of the peritoneum 
were flakes of yellow lymph. The appendix was removed, although 



94 



THE ACUTE ABDOMEN 



examination allowed it to be apparently normal. Nothing abnormal 
was found in any part of the abdomen beyond this fluid, etc. Two 
good-sized drainage tubes were placed in the abdomen, one being 
passed upwards under the liver, the other into the pelvis. The wound 
was closed in layers as far as the tubes. A bacteriological report on 
the fluid removed and examined in the clinical laboratory was " Strepto- 
coccus." 

Some discharge continued from the drainage tubes, and later from 
the wound until about May 11, there being gradual general improve- 
ment. About this date an abscess was found in the right buttock which 
was aspirated, the aspiration being repeated more than once ; ultimately 
it was incised. For a long time this discharged, the active germ being 
reported as the Streptocoecus pyogenes. A vaccine was made and used : 



May 16: 11,575,000 cocci. 

19 : 10,000,000 „ ^ c.c. 
23: 15,400,000 „ § c.c. 



Jime 2 : 23,000,000 cocci. 

6 : 23,000,000 „ 1 c.c. 
12 : 23,000,000 „ 



There was nothing special to report on the case beyond continuation 
of fever about 101 — 102° at night until the middle of June and the fact 
that the abdominal wound was very slow in healing, so much so that it 
was again sutured in the lower part on June 12. 

A more general infection of the blood of which the peritonitis 
formed only a part, but was very severe, was the case of a lady, 
aged 50, seen with Dr. A. E. Godfrey on May 7, 1913. 

She visited Dr. Godfrey on May 3, complaining of pain about the 
right shoulder and general feeling of illness. She thought she had 
caught cold. He sent her to bed, and on his visit next day found the 
temperature raised, and a complaint of some pain in the left side of the 
abdomen. In the afternoon she had a rigor. Temperature, 105°. 
There was no vomiting, and examination per rectum showed nothing 
abnormal. On May 6 she had increased and general abdominal pain 
and another rigor. On the 7th, at 11 a.m., she was looking very ill. 
Pulse, 130 ; respiration quick. Tongue dry and furred. She com- 
plained of some pain in the left side. The abdomen was somewhat 
distended ; generally resonant ; very tender, and the muscles hard set. 
The liver dulness normal. 

At 2 p.m. there was some friction in the left chest. Dr. Z. Mennell 
gave anaesthetic and Dr. Godfrey assisted ; the right rectus was displaced 
outwards. A quantity of odourless pus, generally diffused, looking 
like mucopus, escaped. Nothing was found to account for it, the 
internal organs being generally normal. Dr. Dudgeon reported that the 
bacillus present was the Streptococcus pyogenes, and anti-streptococcic 
serum was given next day, but produced no influence on the progress 
of the disease. At 6 p.m. of the 8th she was worse generally, with 
evidence of spreading inflammation in the left lung. The face was 
pinched, pulse very rapid ; temperature still high, but no abdominal 
pain and no return of shivering. She died four hours later. 



PERITONITIS 95 

In a third case which had been sent to a fever hospital as a 
case of typhoid a child of 12 years of age was very ill on 
transfer. Here the appendix appears to have been first 
affected. 

She came ten days after the commencement of symptoms, during which 
time she had been under treatment, with fever and some abdominal 
pain, etc. On admission, April 20, 1905, she was very ill with general 
peritonitis. Pulse, 140 ; temperature, 103°. Operation was performed 
and appendix removed, although it appeared normal ; there was pus 
and lymph all over the peritoneum. Streptococcus pyogenes was found, 
in pure culture, on the appendix and peritoneum near it. The wall of 
the appendix was acutely inflamed, and no mucous coat remained. She 
died from exhaustion next day. There were sheets of very recent 
lymph on the pleura — like those in the abdomen ; lungs congested. 
Evidence of a general infection. 

It is well therefore to remove the appendix in these cases, 
as the source of infection may be in it, but give no proof 
except on microscopical examination. 

C. Tuberculous Peritonitis. — The ordinary forms of tuber- 
culous peritonitis do not demand a consideration from us in 
discussing the acute abdomen in the same manner as do the 
forms of peritonitis which are due to other organisms. The 
manifestations for which the surgeon is called in are, with the 
exception of local suppuration, included under other headings. 

(a) There may be obstruction of the bowels, following 
adhesion of a coil of the bowel to another coil, to the omentum 
or to the abdominal wall. 

(b) Perforation of a tuberculous ulcer (see p. 186). 

(c) The formation of strictures of the bowel. In a case under 
care in 1913, in which the caecum was excised for hyperplastic 
tuberculosis, there were no fewer than eight strictures found 
in various parts of the small intestine which produced no 
symptoms. 

The peritoneum when tubercle is present may, in cases 
associated with abdominal pain and irregularity of the bowels, 
give rise to a suspicion of chronic intussusception from the 
presence of one or more tender swellings. In the neighbour- 
hood of the transverse colon the rolled -up peritoneum may be 
somewhat sausage-shaped. 

Tuberculous glands in the mesentery may not only cause 
trouble by producing adhesion of a neighbouring coil of bowel, 



96 THE ACUTE ABDOMEN 

but when suppuration extends beyond the capsule of the 
gland a localised peritoneal abscess forms, and a fatal peri- 
tonitis may ensue if the pus is not satisfactorily limited by 
adhesions. These glands in the iliac fossa may be mistaken 
for an enlarged and inflamed appendix, and the possibility of 
an attack of acute appendicitis must be remembered where 
tuberculosis of the peritoneum is present already. 

An example of the compUcated abscess of tuberculous 
peritonitis is furnished by the case of A. U., aged 16, who was 
under care from February 12 to March 2, 1910. 

There was a tuberculous family history and she had been under 
treatment for "something wrong with the left lung," during which time 
she had had a feverish cold. Three days before she came in there had 
been a sudden pain in the lower abdomen, and she was very ill on 
admission with a pulse of 132 and temperature 102°. There was sup- 
puration in the lower abdomen not distinctly defined, and a fulness on 
the right side of the rectum. At the operation the intestines were 
found irregularly matted together, and there were intermittent spurts 
of gas and offensive purulent fluid from the deeper parts of the wound, 
showing undoubted perforation of the bowel wall. Whether this resulted 
from ulceration or giving way of the bowel during examination it is 
not possible to say. More searching exploration was not considered 
advisable. A tube was inserted, and for some days there was a feculent 
discharge, but it gradually diminished and the wound closed satis- 
factorily. When she was discharged we could find no evidence of 
tubercle anywhere. 

THE INFLUENCE OF DISEASES OF THE APPENDIX 
VERMIFORMIS ON THE PRODUCTION OF THE 
ACUTE ABDOMEN. 

It is difficult to exaggerate the importance of this part of 
our subject, the cases which come under this heading presenting 
the largest of all the groups which are met with in practice. 
It is of the greatest importance, therefore, that you should 
have a good working knowledge of it from a clinical stand- 
point (Fig. 10). 

In the year 1881 we find few records in the St. Thomas's 
Hospital Reports of diseases of the appendix ; five cases of 
peri-typhHtis were under care and one case of general peritonitis. 
What are the recent records, not of all diseases of the appendix, 
but of the acute inflammations of that small part of the 
ahmentary tract ? Mr. Rouquette, the Surgical Registrar, 



INFLUENCE OF APPENDIX ON ACUTE ABDOMEN 97 



has given me a summary of the cases under treatment in our 
wards from 1903-12 inclusive. 
These are as follows : — 





No. of 
Cases. 


Recovered. 


Died. 




M. 


F. 


M. 


F. 


1903—1907 . 
1908—1912 . 


472 
1052 


208 
546 


128 
353 


102 

98 


34 . 
55 


Total (1903—1912) 


1524 


754 


481 


200 


89 



This shows that of these cases 62-6 per cent, were males and 
37*3 per cent, females, whilst the mortality rate was less during 
the second half of the term— 1903-7, 28-8 per cent. ; 1908-12, 
14-5 per cent. The percentage of 
deaths was always higher in the males, 
but in the second half of the period 
taken it was less than half that during 
the first five years, having fallen from 
32*9 per cent, to 15-2 per cent. This 
may be rightly ascribed to the fact 
that the importance of early operation 
has become more generally recognised 
both within and without the hospital. 
These few figures from one hospital 
out of many will convince you of the 
need for special study of this branch 
of the subject, and no excuse is 
necessary lor treating it somewhat 
fully. You cannot give too much 
attention to the investigation of the 
manifestations of acute appendicitis, 
for it will meet you at every 
turn of your professional career 
unless some discovery is made which will make it less prevalent. 

As students you cannot spend too much time in the wards ; 
more than that, you cannot examine too many of these acute 

A.A. H 




Fig. 10. — Diagram to illus- 
trate by Shading the 
relative Proportions of 
various Perforations of 
the Hollow Viscera : A. 
Appendix. B. Gastric. 
C. Duodenal. D. Bili- 
ary. E. Jejunal. F. 
Typhoid. G. Tubal. 
H. Stercoral. 



98 



THE ACUTE ABDOMEN 



cases. Do not be satisfied that what you are told by the 
physician or surgeon in charge is all that can be learnt of the 
case. Examine for yourselves, and try to draw a conclusion, 
before the abdomen is opened, as to the nature of the lesion 
present. 

You must endeavour to decide, firstly, whether the case is 
one of acute appendicitis ; and secondly, if it is, what is 
the condition of the peritoneum. You must also endeavour 

to estimate its effect on 
the individual, for these 
cases do not die simply 
as a result of the inflam- 
mation — ^they die from 
the toxaemia. Some of 
the apparently mild ones 
are very insidious in 
their progress, and the 
toxins developed produce 
their fatal effects rather 
suddenly and imex- 
pectedly, in spite of 
operation, if deferred too 
long. You should all be 
able to recognise a case 
of acute inflammation of 
the appendix, although 
you cannot always say 
what is the exact lesion 
of the appendix on which 
the symptoms depend. 
In the early stages of a serious injury, acute invasion, or 
marked lesion involving the peritoneum, there will be a com- 
bination of symptoms to which the term " peritonism " has 
been applied. The patient will suffer from local pain, vomiting 
and shock. There is then most usually an interval of varying 
duration, when the resources of the individual are being 
drawn upon to enable him to rally from the shock, repair the 
lesion, and fight the invading bacterial horde. Probably a 
peritonitis will immediately commence, and other symptoms 
be superadded as the inflammation extends and the toxins 




Fig. 11. — Appendix (half size) showing 
localised Gangrene with Perforation 
secondary to a Fsecal Concretion from a 
Child of 3^ years, with General 
Peritonitis, first attack (from " Surgical 
Diseases of the Appendix Vermiformis,'' 
2nd ed.). 



INFLUENCE OF APPENDIX ON ACUTE ABDOMEN 99 

produced by the invading bacteria become to a certain extent 
absorbed. 

To the state which accompanies such symptoms the designa- 
tion "Acute Abdomen " has been appKed, and the intensity 
of the symptoms will vary very much in different circumstances 
when disease of the appendix is the primary cause of them 
(Fig. 11). It may be added that the nature of the lesion will 
also make a difference and the patient will react in a different 
manner according to whether he is old, middle-aged, or a child. 
Then again there will be a difference according to the position 
which the appendix occupies, whether it is pelvic, iliac, retro - 
csecal, or lying to the outer side of the caecum. 

The amount of pain will vary ; it may be severe though 
transient, referred to the iliac fossa, unaccompanied by 
appreciable fever, or more than a temporary increase in the 
pulse -rate. There may be little tenderness, and that of short 
duration, yet at removal of the appendix the surface may be 
coated with recent lymph. 

At other times the patient may call out with pain, having 
been awakened from sleep, and become quite collapsed, so 
that the administration of stimulants is necessary to bring 
him roimd ; this pain may continue for hours and then pass 
off quite suddenly. 

The pain is described differently by patients : all agree that 
it is bad ; usually it is referred to the region of the umbilicus, 
and passes from that region to the right iliac fossa, where it 
becomes localised to the spot in which the individual appendix 
is lying. When it is in the pelvis the pain will be less clearly 
defined, but is said to be low down, and is often increased by 
pressure on the right lower rectus. Vomiting is usually 
present, coming on soon after the onset of the pain ; if it 
continues, the attack is probably of severe character. In many 
attacks of appendicitis there is no vomiting in the early stage, 
but there is almost always a feeling of sickness ; yet even in 
these cases operation is best. 

To these symptoms there are added those of fever, a 
quickened pulse and respiration, with a raised temperature ; 
this is mostly about 101° — 103°, but may be higher. The 
patient looks ill, has a furred tongue and foul breath, whilst the 
bowels are usually constipated ; in severe cases diarrhoea is 

h2 



100 THE ACUTE ABDOMEN 

common. If the abdomen is examined, you find diminished 
respiratory movements, chiefly in the lower part. It feek 
stiff, even rigid, especially about the lower part of the right 
rectus, which is doing its duty, that of guarding the inflamed 
part from all injurious movements or pressure. 

Tenderness may be widely spread, but is most easily elicited 
on pressure over the iliac fossa, or, if the appendix, is in the 
pelvis, on rectal or vaginal examination. Frequency of 
micturition and dysuria are present with the pelvic appendix. 

It is very seldom that one can find any tumour in the iliac 
fossa within twenty -four hours of the onset of the acute 
attack ; the rectus muscle prevents even a distended appendix 
of considerable size from being felt ; there is often a sensation 
of fulness beyond the muscle, and from the rectum a tender 
lump may often be demonstrated. When under an anaesthetic 
an enlarged appendix may be felt in the iliac fossa at an early 
stage. Some inflammations due to the appendix quickly 
subside although they begin very alarmingly, whilst others 
continue, and if untreated cause a spreading inflammation with 
suppuration, which may extend throughout the whole peri- 
toneum. Often the suppuration becomes localised. The 
larger number, luckily, undergo resolution, the pain subsides, 
the temperature falls, and convalescence begins at the end ot 
two or three days. As the rigidity of the muscles is diminished 
a swelling is felt about the appendix, which indicates a localisa- 
tion of the whole process, and the illness is for the time practi- 
cally over. In a few days this swelling has quite disappeared. 

Unless the medical man draws attention to this swelling it 
is very probably not noticed by the patient, and when asked 
in a later attack if there had ever previously been any swelling 
the answer is given in the negative. Although the temperature 
and pulse may be normal, the patient is not well until this 
swelling has quite gone. 

When the symptoms and local signs do not subside but 
increase because the inflammation is spreading, the patient 
often shows signs of increased suffering. He becomes anxious 
looking, the pulse increases in rapidity, the respirations are 
slightly more frequent than normal and more shallow, the 
respiratory movements being chiefly costal. The tendency 
in young people is to throw the arms above the head and keep 



INFLUENCE OF APPENDIX ON ACUTE ABDOMEN 101 

them there. The abdomen is more or less motionless, tender 
on palpation over a larger area, though mostly so in the 
appendix region ; slight percussion is also resented. Exuda- 
tion around often gives a dull note in the appendix region and 
also in the right lumbar region. There is possibly evidence 
of free fluid, shifting dulness in the flanks, which later extends 
across above the pubes. Vomiting is almost invariably present, 
and after that of the onset has passed off a little becomes 
distressing. The tongue is usually furred, and the breath often 
foul ; the bowels are difficult to move, but sometimes an 
offensive diarrhoea is present. When it is a late symptom it 
is called " septic diarrhoea." There is always some disturbance 
of the alimentary canal. The urine is usually scanty and high 
coloured, at first normal ; later it may contain albumin, but 
rarely blood. 

There are, however, hardly any two cases that are alike in 
the exact cause of the illness and in the power of resistance of 
the individual. So that in one patient the general symptoms 
are of the greatest importance, and must be relied upon as 
an indication for treatment, whereas in another the local signs 
indicate the dangerous nature of the illness. 

You will naturally ask, " What are the signs and symptoms 
to be specially noted, after the onset of " peritonism," to which 
importance should be attached ? Make all your examina- 
tions in one routine manner ; in the first place look with 
attention at the patient's face, for you may learn much from 
it. The colour, in a case of acute abdominal disease, will 
vary very much, from that of a healthy person to the dusky 
flush of one whose respiration is embarrassed ; the expression, 
from a placid indifference to that of a man in mortal agony. 
Sunken eyes, with dark circles round them, a pinched face, 
and anxious expression, are very ominous. If the nostrils are 
working rapidly you may be sure that the heart is also going 
too fast, and there is very serious and advanced disease 
present. 

The pulse -rate is a very important indication as to whether 
the case may be safely left, it is imperative to operate, or 
there is no hope. If some hours have elapsed since the 
commencement of the attack, and the pulse -rate is much too 
high, there is nothing to be gained by postponing an operation, 



102 THE ACUTE ABDOMEN 

it must be done. Every hour lost renders the success of it less 
probable. Any acute abdominal case with a pulse -rate of over 
100 should be carefully watched ; if it continues to rise beyond 
this the patient requires surgical aid, although other symptoms 
may be improving. The temperament must be considered 
in estimating the significance of a quick pulse, for occasionally 
a patient may be unduly excited by the medical visit or be 
suffering from a neurosis. 

The temperature is often most misleading ; there may be the 
most widely diffused septic peritonitis, with a normal or sub- 
normal temperature. Usually, as I have said, there is a rise at 
first, but it should begin to fall within forty -eight hours. A 
low or subnormal temperature with a rapid pulse is a very bad 
combination. 

Restlessness is an unfavourable symptom ; so, indeed, is 
a state of manifest indifference and apathy. 

Look for the marks produced by recent applications for 
relief of pain. These will give you some idea of its severity. 
Examine the skin for signs of inflammation or oedema. Find 
out the character of the pain, its most marked seat, and if it 
has moved since the first onset. Gently palpate so as to learn 
the condition of the muscles as regards rigidity, general or 
local ; also the presence of any local swelling or undue resistance 
behind the muscles. Percuss the abdomen throughout, but 
with a light hand, paying special attention to the flanks and 
to the parts above the pubes. If there is any dull area, try if 
it is affected by moving the patient, as the presence of free 
fluid is a sign of importance. Define the liver dulness. Observe 
also the extent of distension of the intestines, the presence or 
otherwise of peristalsis, and whether this is local or general. 
If there appears to be some distension of the bowel, find out 
if this is recent or increasing in amount. A distended fixed 
abdomen without any sound on auscultation and obstinate 
constipation must cause great anxiety. It is a late and 
unfavourable sign in a bad case. It is hardly necessary to 
remind you of the importance of the previous history, especially 
as regards attacks of abdominal pain. You must learn from 
the friends the condition of the bowels, if there is constipation or 
diarrhoea, and endeavour to avoid worrying the patient with 
those questionswhich the friends or nurse are quite capable 



I 



INFLUENCE OF APPENDIX ON ACUTE ABDOMEN 103 

of answering. In most cases your duty is not completed 
until you have learnt the state of the pelvic contents, as proved 
by rectal or vaginal examination. In some instances you will 
find inflammatory swelling on the right side, and in others an 
abnormal amount of tenderness. The extent of these will 
vary much with the nature of the case and the duration of the 
illness. 

The number of acute abdominal conditions w/iich are 
secondary to 'disease of the appendix naturally makes us, 
in the first instance, consider " the acute abdomen " from the 
point of view of that part of the alimentary canal. The 
relative proportion of the various factors in the causation of 
acute abdominal diseases is shown in the. statistics of the cases 
under care in St. Thomas's Hospital during the three years 
1900-2 inclusive. In all there were 456 cases, of which 168, 
or 37 per cent., caused by inflammation of the appendix, formed 
the largest class. 

If to these we add the following table compiled for the years 
1903-12 inclusive, we find this statement much emphasised : — 

Appendicitis and its complications . . . 1,787 

Intestinal obstructions (other than intussusception) 296 
Intussusception .... 
Perforations of the stomach. 

,, ,, duodenum 

Other perforations of alimentary canal 
Acute peritonitis (other causes) 
Acute cholecystitis 
,, pancreatitis 

The acute inflammations of the appendix are therefore 
nearly twice as many as all the others put together. 

The great importance of the role which the appendix plays 
is clearly shown by this table. The first four of the groups in 
this Ust are the most important of the acute illnesses and 
require special attention. They are worth consideration, in 
the first place, from the question of age, for, given certain 
difficulties in diagnosis, the probabilities will be in favour of 
intussusception during the first ten years of life, acute disease 
of the appendix between the ages of 15 and 30, perforations 
of the alimentary tract from 15 to 40, and intestinal obstruc- 
tion from the age of 30 upwards, with increasing frequency to 
a maximum between 50 and 60. 





165 




116 




64 




7 




50 




. 53 




14 



104 THE ACUTE ABDOMEN 

It may be conceded that some cases of acute appendix 
disease are rather difficult to appreciate in their early stages, 
whilst others are so severe that they can be called fulminating. 
The latter cry for operation ; the others do so also, but unless you 
are hstening carefully the cry will be unheard. An indefinite 
pain with a history of indiscretion in diet may make the 
relatives regard the illness as an ordinary stomach ache, for 
which the treatment is in their opinion quite within their own 
competence. 

I remember the case of a girl, aged 7| years, who after repeated 
" bilious attacks " which had come on at long intervals complained of 
another attack, which was apparently similar in character, so far as 
the parents could tell. But she did not improve as they expected, and 
when her medical attendant was asked to see her he found a generalised 
peritonitis. An operation was performed as soon as possible, but the 
appendix was gangrenous, suppuration diffused through the pelvis and 
lower abdomen, and she died in less than a week from toxaemia with 
heart failure. 

Instances of the danger of the domestic treatment of these 
" stomach aches " could be multiplied considerably, if neces- 
sary ; the following case is a good example : — 

A boy, aged 6^ years, was admitted March 30 and left May 20, 1905. 
He first began to be unwell on March 27, about midday, and was sick 
on the 28th and 29th. He had some abdominal pain and constipation, 
but not very much pain. He was thought to have some stomach 
derangement and was given castor oil. Mr. E. T. Whitehead, who saw 
him on the morning of admission, thought seriously of his state, and 
when we saw the boy together about 12 o'clock he had diffuse peritonitis 
secondary to disease of the appendix. The state was as follows : — He 
was a pale lad, with light hair, lying in his bed partly turned to the 
right, and apparently quite comfortable. He did not look very ill, 
smiled when spoken to, and answered questions about his age, etc., 
quite readily. He drew a deep breath when requested to do so, and 
said that his chest did not hurt him ; he admitted that he had had some 
pain in the stomach. When requested to turn round on his face he did 
so easily and with a smile. The abdomen was somewhat distended, 
not rigid, but with greater resistance in the right iliac fossa than in 
other parts. In the right flank, running obliquely into the pelvis across 
the iliac fossa, was a well-marked area of dulness, evidently, from its 
shifting character, due to fluid. His tongue was moist and clean ; he 
had vomited the night before, but not that morning. The bowels were 
confined. He had slept naturally. The temperature was 99°, but his 
pulse was 140. At operation at 3 p.m. we found very offensive pus in 
the right flank and pelvis, quite unlimited by adhesions, and lymph on 
some of the coils of intestine, in the iliac fossa, and pelvis. The appendix 
was large, its walls were oedematous, there was a circular band of gan- 



INFLUENCE OF APPENDIX ON ACUTE ABDOMEN 105 

grene running round it about | inch from its distal end, and in tlie 
mesenteric border of this part there was a perforation. On opening 
the appendix there was a concretion above and another below the 
gangrenous part. The subsequent history was briefly as follows : — The 
bowels acted on the 31st after a turpentine enema, and improvement 
followed in the condition of the abdomen, but he suffered from vomiting. 
Until April 2 he was very ill, losing flesh and strength, with occasional 
vomiting of coffee-ground material. His pulse had come down to 100 
and his temperature was 98°, but he seemed to have " no rally." On 
the 3rd this brown, offensive vomiting ceased at 3 a.m. Later in the 
day five grains of calomel were given with good result, and he began to 
improve. Making steady progress from this time, his condition no 
longer continued to be a source of anxiety to us. 

It is the cases in which there is little pain that often give 
the greatest anxiety, a slow absorption of the poison goes on, 
and the patient appears to be now better, now not quite so 
well, and so the pendulum swings, until perhaps the return of 
vomiting with a rapid pulse shows that the illness is a very 
grave one. 

Some years ago I saw a patient in one of our large public schools who 
was in this condition. A " stomach ache " had been treated for some 
days by the house -keeper with various domestic remedies which she 
considered appropriate. It was only towards the end of the week that 
the medical officer was told of the boy's illness, when he was transferred 
at once to the sanatorium. He had a diffused peritonitis with much 
fluid in the peritoneum. Permission to operate could not be obtained, 
and the patient died next day. This occurred in a school where the 
regulations are very strict and every boy is seen at once on complaint 
of illness being made. 

A more common type of spreading inflammation of the 
peritoneum secondary to appendix disease is shown in the 
following account. It also shows the effect of the toxins on 
the cardiac muscle ; — 

A schoolboy, aged 11 years, was admitted. -X- His illness began four 
days before (January 21) during the night, with acute pain in the right 
side of the abdomen ; on the following day he was much worse. He 
also felt sick, and vomited everything he took. His bowels were 
constipated, and remained so until admission. The vomiting and pain 
in the abdomen continued. On admission he had a pinched, anxious- 
looking face, and complained of pain in the abdomen, chiefly in the 
lower part on the right side. He was lying on his back, with his legs 
drawn up. The abdomen did not move at all in the lower part, and 
there was only a slight movement in the epigastrium and upper part. 
On palpation, great tenderness was found all over the lower part, 
especially in the right iliac fossa. The abdominal muscles were rigid, 
and a swelling was detected in the right iliac fossa, extending upwards 



106 THE ACUTE ABDOMEN 

from Poupart's ligament. This swelling could not be defined accurately- 
owing to the muscular rigidity. On percussion, dulness was present 
over this swelling, and also in the left flank. The rest of the abdomen 
was resonant. The pulse was 100, the respirations were 20, and the 
temperature was 100-6°. This patient was restless, and protested 
vigorously against operation. When the abdomen was opened pus in 
considerable quantities was found free in the peritoneum. There was 
much deposit of lymph on the peritoneum covering the small gut, which 
was generally reddened ; in some places hsemorrhagic patches could be 
seen under this lymph. The purulent fluid filled the pelvis and extended 
into the right flank. The appendix was 3 inches long, thick and fleshy, 
with gangrenous mucosa. There was a concretion in the central part, 
and just below it a minute perforation, plastered externally with 
fibrinous lymph. The peritoneal cavity was washed out with warm 
saline solution ; a drainage tube was inserted, and also a gauze strip. 
After the operation the patient's sickness ceased ; his pulse gradually 
fell to normal, but was still 108 on February 8, fourteen days after 
operation. At first he was peevish and difficult to please, but left the 
hospital quite well on March 17. 

You will perhaps be called upon to give your opinion in a 
case in which, for a time, there has been a very evident 
improvement and the friends of the patient naturally think 
the dangerous stage is passed and recovery assured. "He is 
so much better!" Here you must be guided by various 
considerations. 

We may take as an example the case of a stout strong man, aged 35, 
who had suddenly improved about twelve hours after the commence- 
ment of symptoms. Dr. Yeld asked me to see him because he was not 
satisfied with the general condition. We found him (twenty-four hours) 
without pain, but with a pulse of 120. He protested very strongly 
against operation, and struck his abdomen violently with his closed fist 
to show how well he was and how free from pain. After much persuasion 
we convinced him of the need for operation, and found a perforated 
appendix with commencing suppurative peritonitis (spreading). 

Another way in which acute symptoms arise is by the 
sudden rupture of an empyema of the appendix into the 
general cavity of the peritoneum. 

F. B., a boy aged 11, was admitted under the care of Dr. Acland on 
September 29, 1909. It was stated that the patient awoke at 1 o'clock 
on the day of admission, complaining of severe general abdominal pain, 
worse in the right iliac fossa. There was no vomiting ; the bowels had 
been constipated for thirty-six hours previously. It was reported that 
the boy, who was said to have been always delicate, had been quite well 
on the previous day, and had eaten several apples. Although delicate 
be had had no previous illnesses, with the exception of an attack of 



► 



INFLUENCE OF APPENDIX ON ACUTE ABDOMEN 107 

abdominal pain four weeks prior to admission, which was unattended 
by sickness and localised itself in the right lower abdomen. On admis- 
sion he was a thin, anaemic boy, with a six hours' history of abdominal 
pain. His pulse was 120, regular, of good volume and tension, Kespira- 
tion, 20 ; temperature, 101°. The abdomen was poorly covered, and 
did not move well on respiration. On percussion the liver dulness was 
normal ; dulness was present in the right flank, which disappeared with 
change of position. Tenderness was general, but most marked in the 
right iliac fossa. At 10.30 a.m. when I saw him the pulse-rate was 132 ; 
temperature, 102° ; abdominal pain more acute. There was more 
dulness on the right side of the abdomen with some over the pubes, the 
amount of free fluid having increased. At this time the boy was pale, 
looked anxious and pinched. Operation was performed ten hours after 
the commencement of symptoms. An incision was made in the right 
side of the abdomen through the rectus muscle, the fibres of the muscle 
being separated with the handle of a scalpel. When the peritoneal 
cavity was opened much pus was found in the right iliac fossa and also 
in the pelvis. It was thick, yellow, and without offensive odour. A 
gauze strip was placed in the pelvis and another in the left flank through 
the abdominal wound, so as to absorb pus whilst the appendix was 
removed. Three rows of sutures were applied over the csecal opening. 
The peritoneum in the region affected was dried by means of gauze 
strips, and the wound closed, with a rubber drainage tube passed 
through the lower angle into the pelvis. The greater quantity of pus 
was found in the right flank above the position of the appendix. Anti- 
bacillus coli serum (25 c.c.) was injected subcutaneously into the chest 
wall before the patient left the theatre. He was placed in a sitting 
position, and continuous instillation of warm saline fluid into the rectum 
commenced. The tube was taken out on the third morning and 
shortened, but its use was continued for ten days. 

The appendix was unusually large, and presented a perforation 
towards the tip. When opened a stricture was found about the junction 
of the proximal two-thiids with the distal third, which completely 
closed the lumen of the tube at that point, forming in this way a cavity 
of the distal third, with which the perforation communicated, and from 
which pus was exuding when the appendix was found. The patient 
had had an empyema of the appendix, which had ruptured without 
warning into the general peritoneal cavity. 

The diagnosis of the exact condition depended upon the 
extreme suddenness of the onset, the severity of the symptoms, 
and the large amount of fluid which was noted before the 
operation, although such a short time had elapsed since the 
commencement of the trouble. The history of a former 
attack of pain, as pointing to pre-existing disease of the 
appendix, was regarded as important. 

You must not, however, be misled by a case in which a few 
hours after the onset of " peritonism " the patient appears to be 



108 THE ACUTE ABDOMEN 

better. Always suspect the acute attack which appears to 
have got well quickly ; a rapid improvement in general con- 
dition with entire loss of pain often means the giving way of 
an over -distended appendix. A lull is taking place before the 
septic fluid which has escaped from the appendix produces 
its effect on the peritoneum, but all the time absorption of 
poison is taking place, and the next stage is but a short prelude 
to a fatal ending. 

I have seen a man of 32 in consultation who had a pulse of 80 ; 
respiration, 20 ; temperature, 98-6° ; the local signs but ill marked ; 
a rather rigid abdomen ; some tenderness on pressure over the right 
ijiac fossa, but no distension. He had, however, a marked rigidity of 
the lower part of the right rectus. This was about eighteen hours after 
an attack of pain of a mild character, followed by a sudden severe 
abdominal pain six hours before, then the quiet period during which I 
saw him. A large appendix had perforated beyond a stricture, and 
there were four concretions in it. He had suffered from a previous 
attack, which had been diagnosed as appendicitis two years previously. 

Almost all surgeons who have seen anything of the treatment 
of appendicitis recognise that to save life in the largest number 
of instances you must remove the appendix as soon as possible 
after the onset of symptoms. The public has not yet been 
educated to the need for this, but members of the profession 
recognise its great importance as a routine method of treatment . 

Now that the acute " belly " cases are sent in at once to the 
surgical side, there will be less delay than there was when they 
had to pass through so many hands before they reached the 
operation theatre. I would endeavour to emphasise this 
question of time in the treatment — an hour saved may mean 
the removal of a distended appendix before the poisonous 
contents have escaped and fouled the peritoneum, not only 
in the ca3cal region, but also in the pelvis, where there is such a 
large surface for absorption. There are undoubted records of 
recoveries from a general septic peritonitis, but they are not so 
numerous as pubhshed cases would have us believe. There 
is a difference between " diffused " and " general," which is, 
I am afraid, not always appreciated by those who write and 
talk about the disease. In many it is inadvisable to remove the 
patient to a surgical home ; an operation done on the spot may 
save weeks of illness and pain, especially if the journey involved 
would be a long and possibly shaky one. You can quite 



INFLUENCE OF APPENDIX ON ACUTE ABDOMEN 109 

understand why the extra movement would be bad for a 
distended but still unruptured appendix, the wall of which 
is sometimes like moist tissue paper. 

As a rule you can differentiate an acute appendix attack 
from other urgent affections of the abdominal contents. I will 
return to this subject later ; but this is the essential — to make 
up your mind whether the patient is suffering from a state 
which necessitates interference or not. If you are not certain 
and there is a reasonable probability that you are dealing 
with an appendix trouble, the wisest plan is to operate. Sur- 
geons who see much of this disease can often tell you the exact 
state of the appendix on which the attack depends. This 
may be of great temporary importance, for the surroundings 
of the case may not lend themselves to the probability of a 
successful operation of any kind, especially one involving the 
peritoneum. Or again, there may be urgent private affairs 
to be settled before the risk of an operation is undergone. 

Indefinite or subacute appendix symptoms coming on in 
patients of advanced years should excite the apprehension of 
any one under whose charge the patients may be. The signs 
of disease may be few, whilst the age and weakness of the 
patient make it inadvisable to do any operation excepting one 
of absolute necessity. Yet the most serious disease of the 
appendix may be present, and a fatal result inevitable, unless 
it is removed. Vague abdominal pains, with some rise of 
temperature and perhaps a little sickness, may be the only 
complaint ; perhaps even the medical man is not sent for until 
there is superadded a flatulent distension of the abdomen and 
a running pulse. The following account will show the type 
to which I am alluding : — 

On September 10, 1909, I saw a man, aged 73. During the night of 
the 7th he was awakened by pain in the abdomen, but did not vomit. 
The pain was not severe, but he took some castor oil. Next day, the 
8th, he sent for his medical man, who found him with a temperature 
of 100° and symptoms of a mild attack of appendicitis. On the 9th he 
was much the same, but his temperature was slightly raised ; he had 
vomited on the previous evening, and his tongue was becoming dry. 
Nothing abnormal could be felt per rectum. His condition at 2.30 on 
the 10th, when we saw him together, was as follows : — He was a healthy- 
looking man, with a normal temperature, good appetite, and a pulse of 
88 ; his chief complaint was want of food, and he did not like being kept 
in bed. Th^ only symptoms of anything wrong were a very dry tongue 



no THE ACUTE ABDOMEN 

and some sharp, indefinite, superficial tenderness about the abdomen 
on the left side. The walls of the abdomen moved well, there was no 
rigidity, no tumour, and no abnormal dulness. He had no sickness, 
and his bowels had acted well the day before. Operation was not 
advised, but later vomiting came on, he became much worse, and died 
after an operation on the 12th, at which I was not present. The 
appendix was gangrenous, and two concretions were found outside in 
the pus which had accumulated in the peritoneal cavity. 

It will be noted that there was no swelling in the iliac fossa, 
whilst a sharp general superficial tenderness could be elicited, 
although he had no pain. 

The Diagnosis of Appendicitis. 

The diseases which may be mistaken, especially in their 
onset, for acute appendicitis may be grouped as follows : — 

A. Thoracic, having their origin above the diaphragm. 
Acute inflammations of the lower part of the pleura and of the 
lungs. 

B. Abdominal. — These may be divided into groups : 

1. Pelvic, the most prolific group of all, has its origin in 
the female generative organs : of these we may mention 
salpingitis ; pyo -salpinx ; extra-uterine gestation ; torsion of 
the pedicle of an ovarian cyst ; rupture of an ovarian cyst ; 
torsion of the pedicle of a subperitoneal fibroid, or acute 
necrosis of a uterine fibroid. 

2. Upper abdominal. — Perforation of duodenal ulcer ; per- 
foration of gastric ulcer ; acute pancreatitis ; acute cholecystitis 
and perforations of gall-bladder ; biliary colic. 

3. Mid, abdominal. — Calculous affections of the kidney and 
ureter ; movable kidney, producing Dietl's crises. 

4. Intestinal obstructions. 

5. Acute inflammations of the peritoneum from infection 
through the blood -stream. 

6. Gastro -intestinal affections. — Enteritis and gastro- 
enteritis ; mucous colitis ; intestinal perforations. 

7. General diseases. — Typhoid fever ; " abdominal in- 
fluenza " ; hysteria ; lead colic ; malaria ; the crises of tabes 
dorsalis ; angeio-neurotic oedema ; Henoch's purpura. 

Malignant disease of the caecum and ascending colon. 
Some of these are extremely rare conditions, and it is only 
necessary to remember their occasional occurrence. Others 



INFLUENCE OF APPENDIX ON ACUTE ABDOMEN 111 

only simulate appendicitis when the inflammation has produced 
a localised swelling which can be felt. Moreover, in discussing 
the diagnosis of acute appendicitis, it must be recollected 
that the appendix may be placed as high as the liver, in the 
iliac fossa, or in the pelvis, whilst the pain is often referred to 
the umbilicus in the early stage, only passing to the ihac fossa 
later. 

It would not be advisable to enter into a long discussion of 
this large group of diseases which simulate acute appendicitis, 
but we must say something about the most important from a 
practical point of view, although they are again considered 
when we reach the special sections devoted to them. 

Acute Pneumonia. — There are few surgeons who have not 
been requested to perform laparotomy for abdominal symptoms 
in this disease, which have simulated the acute abdomen. 
The difficulty has mostly arisen on account of sudden pain 
in the upper abdomen with rigidity of the muscles, some 
vomiting, and fever, symptoms found when a perforation of 
a gastric or duodenal ulcer has occurred. In young people 
before the age when gastric and intestinal perforations mostly 
occur, the resemblance to acute appendicitis may be very 
close indeed. 

An instance mentioned by Adams and Cassidy ^ may be referred to 
in which there was not only a rigid abdominal wall, but the site of 
the greatest tenderness was over McBurney's point. 

A careful examination of the chest should therefore be made 
in all cases when there is any likelihood of such condition 
being present, as indicated by the rapidity of the respiration 
in comparison with that of the pulse -rate, which is seldom 
more than 100. The late Mr. Barnard^ in his communication 
on this subject pointed out that direct thoracic signs are often 
almost entirely lacking for twenty -four hours or more. 

He mentions one case in which there were such definite abdominal 
signs that the abdomen was opened, when the pleurisy was associated 
with fracture of the ribs due to a known injury. 

The medical diseases which must be considered here as they 
will not be referred to later are as follows : — 

1 "Acute Abdominal Diseases," p. 555. 

2 » The Simulations of Acute Peritonitis by Pleuro-Pneumonic Diseases," Lancet^ 
Vol. II., 1902. 



112 THE ACUTE ABDOMEN 

1. Typhoid Fever. — The statistics collected by Kelly and 
Hurdon show, from various sources, that amongst 330 cases 
of perforation occurring in typhoid fever, this perforation was 
situated in the appendix in 30. They point out that (1) appen- 
dicitis may be purely accidental, that is to say, appendicitis 
and typhoid fever, both of which are common maladies, may 
by accident be found concurrently in the same individual, 
or a latent and chronic inflammation of the appendix may be 
roused into activity by typhoid fever. {2) An appendicitis 
of a mild or of a severe type may arise from a typhoid affection 
of the lymph glands or from an ulcer situated in the appendix, 
and may even go on to perforation. (3) Appendicitis may 
follow typhoid fever, appearing within such a brief time after 
the subsidence of the fever as to suggest a causal relationship. 

It is a well-established fact that a true typhoid affection of 
the glands of the appendix occurs which may proceed to 
ulceration — and symptoms in the right iliac fossa may induce 
the surgeon to perform an operation for the removal of the 
appendix in the early stage of typhoid before there are any 
definite symptoms of that disease, or indeed any possibility 
of diagnosing it correctly. 

If there are, in addition to fever, the usual signs of appendi- 
citis, ihac pain, tenderness and rigidity of muscles, it would 
be best to operate, for it is far better to remove the appendix 
by an operation, which should not in any way distress the 
patient at this stage, than it is to let him run unnecessary risk. 
Curschmann has described a condition occurring during typhoid 
which he has called " peri-, or para -typhlitis typhosa," in which 
a minute perforation is found in the caecum, or between the 
caecum and colon. In these perforations swellings are found 
which closely resemble those produced by appendix inflamma- 
tion going on to the formation of abscess. 

Occasionally a patient with a concealed abscess or a suppura- 
tive peritonitis due to a diseased appendix comes under 
observation with the diagnosis of typhoid. These are usually 
those cases in which the fever has been sHght and the local 
symptoms somewhat indefinite ; probably the appendix has 
occupied the peMc position, whilst the ihac fossa has been 
free from evident change. The result of absorption of septic 
products may produce a " typhoid state." Widal's test must 



INFLUENCE OF APPENDIX ON ACUTE ABDOMEN 113 

be tried and a careful daily examination made in doubtful 
cases. Examination of the abdomen will usually disclose the 
presence of free fluid in the peritoneum, and a definite general- 
ised rigidity of muscle in the lower part, with tenderness, and 
a rapid, feeble pulse. 

2. Abdominal Influenza. — In more than one instance in 
which I have been requested to see a patient there has been a 
history given of attacks of abdominal influenza. Of the 
manifestations of this disease Professor Osier writes : — 

" The gastro -intestinal symptoms may be marked ; thus, with the 
initial fever, there may be nausea and vomiting. Diarrhoea is not 
uncommon ; indeed, the brunt of the entire process may fall upon the 
gastro -intestinal mucosa." 

He does not mention influenza when speaking of the diagnosis 
of appendicitis. 

During the prevalence of influenza a patient with a slight 
cold may complain of a severe pain in the abdomen, and vomit. 
There will not, however, be the muscular rigidity or localised 
tenderness of appendicitis. Others in the house may have 
similar attacks. They are sometimes alarming, but not 
usually prolonged, and are accompanied with a rise of 
temperature. 

3. Hysteria. — This disease may simulate appendicitis, as 
most of us know, but it should not be possible to make a 
mistake. 

A nurse once came to have her appendix removed ; she had not had 
an attack of appendicitis but had been nursing a boy who died from 
acute suppurative peritonitis, and she was determined to avoid any 
illness of that kind. After the operation she left London and went to 
the seaside for a change. When there she was seized with an acute 
" agonising " pain in the right lower abdomen. Operation was per- 
formed on the spot, and the right ovary and tube removed ; these had 
been normal at the first operation, and she could not tell me of any 
disease of the parts removed. Some months later I was summoned to 
the country to see her for severe abdominal pain, and found every 
preparation made for operation. The symptoms were not quite of the 
recognised type of hysteria, and some surprise was expressed when I 
refused to operate. She lived, however, and developed manifestations 
which convinced all of the nature of the acute attack. Had the appen- 
dix not been removed I think it would have been excised during one 
of the attacks of pain which she had later. 

A.A. I 



114 THE ACUTE ABDOMEN 

Professor Osier ^ says : 

*' There is a well-known ' appendicular hypochrondriasis.' The worst 
cases of this class which I have seen have been in members of our 
profession, and I know of at least one instance in which a perfectly 
normal appendix was removed." 

4. In Lead Colic the pain is general, paroxysmal and relieved 
by pressure. There may be vomiting without any rise of 
temperature. The occupation of the patient, the presence of 
a blue line on the gums, with other symptom's of lead poisoning, 
should prevent any mistake. 

5. In the gastric crises of Tabes Dorsalis there may be 
severe pain in the epigastrium and vomiting, and the attack 
may last for some days. The attacks are variable and may be 
extremely severe. The loss of eye and knee reflexes with the 
history and presence of other symptoms should make the 
diagnosis clear. These attacks more frequently give rise to a 
mistake in the diagnosis of stomach perforations than in 
those of the appendix. 

6. A malarial attack is very uncommon in this country, 
being rarely met with excepting in those who have lived in 
a foreign country or one of the colonies. Severe abdominal 
symptoms in the subjects of malaria may simulate appendicitis, 
and without operation and examination of the appendix it 
will perhaps be difficult to say with certainty at the first visit. 
If the symptoms mentioned above (local pain, tenderness, 
rigidity of muscle and fever) are kept in mind, there should 
not be very much difficulty. 

The Resemblance of Diseases arising in other Organs. 

1 . Of the pelvic causes of the acute abdomen which produce 
a resemblance) to acute appendicitis, the majority are easily 
demonstrated on vaginal or rectal examination, the presence 
of a tumour being readily found. Sometimes a tumour rises 
out of the pelvis. Should a cyst of small size rupture, then 
the exact condition may be difficult to name, but vaginal 
examination should show a tender swelling on the right side if 
the appendix is pelvic and inflamed. 

2. Of all the conditions which arise in the upper abdomen 

1 "Principles and Practice of Medicine," p. 440. 



INFLUENCE OF APPENDIX ON ACUTE ABDOMEN 115 

the one which causes most difficulty is the perforated duodenal 
ulcer, a large number of cases having had an incision made in 
the first place over the appendix. In this group the possible 
history of attacks of pain which have been in the upper part 
of the abdomen, perhaps with vomiting of blood and melsena, 
should be investigated. The subject will be more fully dealt 
with later (see p. 163). 

3. A few words may be said here about the affections of the 
kidney which may produce difficulty in diagnosis from acute 
appendicitis : — (1) Renal colic, pain on the right side which 
shoots down to the iliac fossa, pubes, and even testis, produc- 
ing vomiting and more or less collapse. The pain is very 
severe, can be traced to the right kidney, and there is increased 
frequency of micturition with hsematuria. A calculus may be 
seen with the X-rays. (2) When a stone has been arrested 
at the entrance of the ureter it may cause a condition of 
pyonephrosis, which may simulate the retrocsecal abscess. 
(3) Sudden impaction in the right ureter lower down may 
give great alarm, but rarely reproduces the clinical picture 
of acute appendicitis which we have already given. 

A case of calculus of the left kidney is worthy of reproduc- 
tion, for it shows how very closely a cross transference of 
symptoms may resemble an attack of acute inflammation of 
the appendix (Fig. 12). 

Multiple Calculi in the Left Kidney producing Symptoms 
resembling those of acute appendicitis. nephrectomy. — a 
female patient, aged 30, was seen with Dr. A, E. Godfrey on June 12.. 
1912. She was suffering from an acute abdominal illness and gave the 
following history. About four years previously she had a similar 
attack with pain in the abdomen, and was ill for fifteen weeks. Two 
years ago she had a repetition of the symptoms, and suffered off and on 
for a year. She was under the care of a medical man, who advised her 
to have the appendix removed. On the 7th of June she became ill 
again with pain in the right lower abdomen and vomiting. The pain 
continued, and two days later she vomited again. Dr. Godfrey saw her 
on June 10. On the 12th she was complaining of pain in the same part 
of the abdomen, with resistance to pressure and tenderness. The 
temperature was 102°, and the pulse rapid. On this date there was still 
a temperature varying from 100° to 102°. She looked ill, had a furred 
tongue, with offensive breath, and pulse 100. The abdomen did not move 
well, and she complained of pain which was Umited to the right lower 
part, where there was tenderness and rigidity of muscle. Nothing 
abnormal was found on examination, beyond this, and rectal examination 

I 2 



116 



THE ACUTE ABDOMEN 



was negative. The bowels were constipated. In a day or two the 
symptoms subsided, but returned with severity, so she was sent into 
hospital on the 19th. 

The abdomen was then very tender all over, but not rigid. Nothing 
abnormal could be found. Temperature, 1006^ Pulse 120. Tongue 
still furred and breath foul. Sp. gr. of urine, 1012. Acid, heavy 
deposit of urates, no albumin. The appendix was removed, it was 
normal. Examination of right kidney, ovaries and tubes showed them 
to be healthy, the uterus was retroverted. After the operation she 
vomited a good deal, almost continuously for two days, but the tem- 
perature came down to normal. The Widal test for typhoid was 

negative. On the 26th she was 
examined very carefully by the 
resident assistant physician, who 
found no evidence of disease of the 
chest. The vomiting which con- 
tinued appeared to be functional, 
whilst the temperature, which was 
still irregularly high, might have 
been due to a sore throat of which 
she was complaining. She was 
removed to a small ward in charge 
of special nurses. July 5, the 
patient had ceased to vomit. 
General condition improving. Had 
been complaining of pain in her 
right loin for a few days, and there 
was a trace of albumin in the 
urine, with some pus cells. She 
continued to complain of pain in 
the right loin, so on July 17 she 
was sent to the X-ray depart- 
ment to have the right kidney 
examined. The report was re- 
turned : " There are six shadows 
in the left kidney region. The right kidney is normal." 

This examination was confirmed six days later. She was still complain- 
ing of pain in the right side of the abdomen. The sp. gr. of urine, 1015, 
pus being present with blood corpuscles in large quantities, and also 
epithehal casts. On July 24 the left kidney was excised. It was 
full of stones, and there was very httle secreting tissue left. Its appear- 
ance when cut open is well shown in the illustration (Fig. 12). It only 
measured about 2^ inches in length, the surface was somewhat irregular, 
but smooth, and the capsule non-adherent. The largest stone was lying 
in the renal pelvis and practically filled it. The smaller stones were 
scattered throughout the substance of the organ. At the upper end 
there was a small cystic space containing a rounded stone. After the 
operation she improved quickly, but even on August 3 she still com- 
plained of occasional pain in the right side. She left on August 15. 




Fig. 12.— Atrophied left Kidney 
containing Calculi, which pro- 
duced symptoms resembling 
those of Acute Appendicitis. 



INFLUENCE OF APPENDIX ON ACUTE ABDOMEN 117 



i 



In October she complained of pain along the course of the left ureter, 
and had some fever and sickness. There was tenderness over the 
ureter. Nothing abnormal was shown on examination by the X-rays, 
and the symptoms subsided. 

In his interesting address 

(on reflex pains in diseases 

of the abdominal viscera), 

Mr. A. E. Maylard refers 

to the occasional trans- 
ference of pain in renal 

calculus to the opposite 

kidney, ah occurrence 

well recognised for years 

(Fig. 13). In this case 

there was not only a trans- 
ference of pain, but a state 

of pyrexia, probably due 

to a temporary blocking 

of the renal pelvis, which 

for a time prevented the 

escape of pus into the 

urine. The diseased kidney ^i^- 13.— Diagrammatic representation of 
, n j^ 1 p 1^ Seats of Maximum Keflex Pain in 

was too small to be felt. Disease of Abdominal Viscera. A. 

Stomach and pancreas. B. Small 
intestine and vermiform appendix. 

C. Large intestine, rectum, uterus. 

D. Vermiform appendix, right ovary 
and tube. E. Vermiform appendix, 
both ovaries and tubes. i\ Gall 
bladder, cystic and common ducts, 
and duodenum. E. Kidneys and 
ureters. 1. Gastric ulcer towards 
cardiac end. 2. Gastric ulcer mid- 
way between cardiac and pyloric 
ends. 3. Gastric ulcer at pyloric 
end. 4. Large intestine down to 
splenic flexure. 5. Large intestine 
from splenic flexure to anus. (After 
Maylard.) 




When seen at our first con- 
sultation, had the case 
been one of appendi- 
citis, there should have 
been evidence of swelling 
either in the iliac fossa 
or in the pelvis. In the 
absence of this we did not 
feel justified in recom- 
mending operation. 

Quite recently a female 
patient was sent into the 
hospital for acute appendicitis, in whom we found a very 
movable and painful right kidney. She had complained of severe 
pain in the right lower abdomen a short time before admission. 
There had also been a rise of temperature with sickness. The 
presence of the swelhng, which was very tender, had appeared 



118 THE ACUTE ABDOMEN 

to confirm the diagnosis, which was not rendered easier by the 
nervous apprehension of the patient. Here the extremely 
movable character, position, and shape of the swelUng should 
have given the clue as to its nature, as well as its presence so 
soon after the beginning of symptoms. It is of common 
occurrence. 

4. Intestinal Obstruction. — The sudden onset of pain in cases 
of acute obstruction due to bands, twists, internal hernise, with 
vomiting, locahsed distension and visible peristalsis, without 
fever or signs of localised inflammation, usually make a clinical 
picture which does not very closely resemble appendicitis. 
Again, the pain is relieved by pressure, the muscles are not 
constantly in a state of rigidity, and distension somewhat 
quickly ensues. There is also complete constipation and 
vomiting is troublesome. 

A case which illustrates this occasional difficulty was that of a boy, 
aged 12, previously supposed to have been quite healthy, who had 
complained of pain in the abdomen for two days, and had been very 
sick. This pain was in the iliac fossa, was increased by pressure ; he 
had a temperature of 99°, and a pulse of 130. A shifting dulness on 
percussion was present in the right flank. There was, however, 
occasional peristalsis, complete constipation, and an absence of rigidity 
of muscles. We found a loop of small intestine compressed by a well- 
developed band which passed from the inner side of the ascending colon 
to the mesentery of the small intestine near. It was attached to an 
old tuberculous gland which was one of a group. Strangulation had 
not been complete, and there was an abundance of clear fluid in the 
peritoneal cavity which had exuded from the obstructed loop. He 
has grown into a healthy man and has had no further abdominal 
trouble. 

When a patient is advanced in years, the temperature is 
little, if at all, elevated ; there is early distension and much 
sickness without anything that is definite on examination 
of the abdomen ; a state is present which requires surgical 
interference, unless it is evident that the patient is in a condi- 
tion of collapse and cannot from the nature of the pulse bear 
the necessary manipulation. In these cases in the early stages 
the great iliac tenderness with some rigidity, and the rapid 
pulse, should supply the necessary warning. An extension 
of the area of tenderness (sharp superficial tenderness) is always 
a serious symptom, especially if there is no great complaint 
of pain. 



INFLUENCE OF APPENDIX ON ACUTE ABDOMEN 119 

In a paper recently published ^ I have described cases which 
prove that it is possible for a surgeon to give an accurate 
opinion as to the nature of the pathological process on which 
the symptoms of an acute attack depend. It is not possible in 
every case. Furthermore, I hold very strongly that the 
operator should endeavour to estimate the stage to which the 
disease has already advanced and its relationship to surround- 
ing parts. This knowledge can become of practical value only 
after a considerable experience of operative work in this branch, 
with a careful examination of the appendices removed. It is 
not enough to say that the appendix was gangrenous, we must 
try to come to a conclusion in every case as to why it became 
gangrenous, and whether the gangrene was a general or local 
process. 

The Treatment of Acute Inflammation of the 

Appendix. 

The advantages of cutting short an illness presenting such 
dangers as pertain to an acute attack of appendicitis make 
the importance of immediate removal obvious. The attack is 
arrested, divested of its greatest dangers, a possibly fatal 
result averted, and no weakness of the abdominal wall should 
follow. Moreover, no further attack need be feared. If we 
could stop an attack of typhoid fever by excision of part 
of the ileum I have no doubt the operation would be eagerly 
welcomed, yet a neglected attack of appendicitis is more 
dangerous and distressing than one of typhoid. 

The operation which yields the most satisfactory result is 
that in which a temporary displacement of the rectus is done. 
The wound can be safely extended to any required distance, 
permits of thorough isolation of the parts affected, examina- 
tion of the parts around which should be felt, and is not 
followed by any weakness of the abdominal wall. This wound 
may be closed in the usual way without drainage, unless there is 
pus in the pelvis, the operation being a belated one. 

It is performed as follows in the adult .^ An incision is made 
on the right side of the abdomen, midway between the 

1 Lancet, Vol. L, 1914, p. 1379. 

2 See Battle and Corner, "Surgical Diseases of the Appendix Vermiformis, etc." 



120 



THE ACUTE ABDOMEN 



umbilicus and anterior superior iUac spine, about 4 inches m 
length (Fig. U). The inner Up of this incision is drawn 
towards the middle line, and the anterior sheath of the rectus 
muscle incised for the full length of the wound. The outer 
edge of the sheath is drawn towards the anterior superior 
iliac spine, by means of two pairs of artery forceps which are 
left on for the operation. With the knife the fascial attach- 
ments of the muscle to 
the sheath are divided, 
and the muscle drawn in- 
wards. If there is one 
of the Hnese transversse 
in the part of the muscle 
to be displaced, it must 
be cut where it joins the 
sheath, and a small artery 
will usually require to be 
caught at this point. The 
deep epigastric artery is 
not usually seen, being 
drawn inwards with the 
muscle. Some branches 
of the twelfth intercostal 
may be seen, but division 
of them will do no harm. 
The posterior layer of 
the sheath, fascia trans- 
versahs, and subperi- 
toneal tissue, and peri- 
toneum are lifted up as 
one layer and divided vertically for the whole length of 
the wound. Nothing is much worse than an attempt to 
excise a sloughing appendix through a wound which is of 
inadequate size. Forceps should be placed on the edges of 
the peritoneum so that manipulation shall not displace it 
unnecessarily. Four -inch plugs should now be introduced, 
and if there is any free fluid the first should be passed into 
the pelvis and the second towards the kidney pouch. As 
this method opens the area to be dealt with to the inner side, 
you can fully protect the rest of the peritoneum by gauze 




Fig. 14. — Incision for Appendicectomy by 
the method advised by Author. To 
illustrate the position of the skin 
incision with regard to the rectus 
muscle : A. Line of incision. B. Linea 
semilunaris. 



i 



INFLUENCE OF APPENDIX ON ACUTE ABDOMEN 121 

packing before any search is made for the appendix, unless the 
mischief is already diffused. This is of importance, for 
frequently pus is found under the caput caeci when lifted, or 
escapes from an appendix as its separation is being effected, 
although every precaution may be taken by wrapping it in 
gauze as soon as possible. In every case care must be taken to 
secure the arteries in the meso -appendix, although in some 
instances of gangrene the vessels may be thrombosed. It is 
seldom possible in the acute cases to put a ligature on the 
meso -appendix to include the whole of it ; the thickening 
which has taken place as a result of the inflammation does not 
permit of this ; you must place forceps on the meso -appendix, 
beginning at its distal part and apply ligatures after the 
appendix has been cut away beyond. The separation of the 
appendix from the caecum can be done with the clamp in the 
usual way, but not in every instance ; the coat -sleeve method 
is then employed, a ligature put on close to the caecal origin, 
and the appendix divided between it and the thumb and fore- 
finger of the operator, which prevent the escape of any septic 
material as the division is made. 

This ligature is then buried in the wall of the caecum, and 
in cases where suppuration is present it is advisable to use 
three tiers of continuous Lembert sutures ; a single line of 
enclosing suture may give, and a faecal fistula form. Where there 
has been no escape of pus from the appendix, the area from 
which the appendix has been removed should be cleansed with 
saline and any excess of fluid removed by the introduction of 
a plug into the bottom of the pelvis. Where there has evidently 
been a localised suppuration about the appendix, and it is 
thought possible to close the wound without drainage I have 
thought the application of peroxide of hydrogen (15 vols.) 
useful as a means of destroying septic material which may still 
remain. The wound is sutured in layers from behind forwards, 
in the usual manner. If a drainage tube is placed in the 
wound it should be brought out at the lower end and be of 
adequate size. 

If the disease has been progressing for more than forty -eight 
hours and there are no signs of localisation of the septic 
inflammation, an incision through the rectus muscle is preferred 
by many. In this the muscle is divided about the middle of 



122 THE ACUTE ABDOMEN 

its lower segment and the two halves separated. I think my- 
self that it is better to cut cleanly through the muscle parallel 
to its fibres rather than roll them away from the selected 
line, so often it is found that they refuse to unite when they 
come together again afterwards. In this method the operator 
must tie several vessels in the muscle substance and secure the 
deep epigastric vessels in the lower part of the wound, dividing 
them between ligatures where they cross the line of the incision. 
In these late cases it is well to pass a large plug into the pelvis 
so that it may soak up the fluid which has gravitated there ; 
you will thus get rid of excess of fluid without wasting any time. 
This plug should be changed during the course of the operation ; 
but it is a mistake to wash out the pelvis with fluid of any 
kind, as the manipulation performed will probably tend to 
diffuse the septic material, breaking down defensive barriers 
which are already doing good work. The operation should be 
performed quickly on definite Unes and with a light touch. 
In these cases of more extended mischief drainage should be 
provided, but it is not often that a tube is required elsewhere 
than in the pelvis. If the renal pouch is involved, then a tube 
passed into it may make for greater security, and this may be 
passed in some instances through a separate incision in the loin ; 
but the insertion of multiple tubes is not advised. 

It is good that you should have a standard of what is the 
best to be done in cases of this kind where the septic inflamma- 
tion is becoming generalised. Remember that the danger to 
the patient is due to absorption of toxins by the lymphatics 
of the affected part of the peritoneum, and if you can diminish 
the amount of poison which is there or only check its increase 
you will give the forces on which you must ultimately rely 
to save the patient a chance of coping with the situation. 
Many patients have died as a result of too much surgery — 
the operation has been prolonged beyond endurance because 
it has been felt necessary to take away the appendix, and that 
appendix has possibly been very adherent, awkwardly placed, 
and the bleeding difficult to arrest, or the patient stout and 
intolerant of the anaesthetic, and perhaps the operator short- 
handed. The bruising and disturbance of parts has caused 
an increased local absorption which has been more than the 
already exhausted individual could withstand, and the heart 



INFLUENCE OF APPENDIX ON ACUTE ABDOMEN 123 

has failed. There are many of the late cases which will 
respond to surgical treatment if the intra-abdominal tension is 
relaxed by the introduction of a drainage tube through an 
incision of moderate size and no attempt is made to remove 
the appendix, or give a general anaesthetic . The use of rectal 
infusion of sterilised saline and the Fowler position (Fig. 15) 
should be combined with this treatment. 

In later cases the peritoneum may be converted into an 
abscess cavity containing many pints of pus, and sometimes 
recovery is effected when the aid of the surgeon has been 
refused, for the pus is discharged by the bowel. 

I have known most unfortunate results to follow interference 
when the case is settling down, but has not become quiet ; 
therefore I am strongly against operation under such circum- 
stances. If the case is first seen after four or five days have 
elapsed, the inflammation is localised, and the general condition 
satisfactory, do not interfere unless obliged. It is the spreading 
suppuration that causes anxiety. 

Occasionally the collapse resulting from the attack is so 
extreme that operation is only possible after intravenous 
infusion of sterilised saline. 

Mr. C. P. Childe has written an interesting paper ^ on the 
question of the position of the incision in operations for acute 
conditions of the abdomen, and it is well worth perusal by all 
surgeons. In this he points out that nearly all the diseases for 
which the surgeon is required to operate, which cause the acute 
abdomen, have their origin between two imaginary lines, the 
one on the left drawn from the seventh cartilage, an inch to 
the left of the sternum, to Poupart's ligament ; the one on the 
right drawn from the anterior superior spine perpendicularly 
upwards to the lower border of the thorax. The incision which 
he recommends in cases where the abdominal condition is 
obscure is one which is placed midway between these lines. 
This would, however, come directly over the rectus muscle, 
the outer margin of which (the linea semilunaris) is found at 
the junction of the inner three -fifths with the outer two -fifths 
of a line from the anterior superior spine to the umbilicus. 
The incision through the rectus is not a bad one in acute 

1 The Area of "Acute Abdominal Conflux" and the "Incision of Incidence," 
Lancet, 1907, Vol. I., p. 936. 



124 



THE ACUTE ABDOMEN 



abdominal cases, and I have often used it ; but there must be 
a clear understanding of the line which corresponds to the 
edge of the muscle, if the operator wishes to take that. The 
conditions which most frequently produce the acute abdomen 
vary somewhat at different ages ; but taking an average of 
a large number of patients, a diagram may be drawn which 
expresses fairly well these positions and the frequency of their 
occurrence by means of shading (see Fig. 10). 




Fig. 16. — The semi-recumbent position advised in Acute Abdominal 
conditions, known as "The Fowler Position." 

In Fitz's table of acute intestinal obstructions no less than 
67 per cent, had their origin in the right iliac fossa. 

It is now customary to place the patient in bed in a sitting 
attitude — " the Fowler-position " (Fig. 15). The object of this 
is to encourage the gravitation of fluids towards the pelvis, thus 
limiting the infection to a part where the local resistance 
is high and drainage feasible. The pressure on any barriers 
of defence is also lessened. The maintenance of the position 
may be facihtated by the fixation of a bolster, padded block, 
or stretcher across the bed, just below the level of the buttocks. 
It is kept in place by straps or bandages passing to the 



INFLUENCE OF APPENDIX ON ACUTE ABDOMEN 125 

head of the bed on each side. In any case in which the 
patient's condition is not good at the completion of the opera- 
tion, a pint of warm saline, containing an ounce of brandy, 
should be administered by the rectum before he leaves the 
table. As a routine, after the patient is arranged in bed, the 
continuous instillation of saline is commenced. A perforated 
pewter tube or Jacques' catheter is introduced into the rectum ; 
the end of this is attached by means of rubber tubing to 




Fig. 16. — Simple Apparatus used for the Continuous Administration 
of Fluids jper rectum. 

a reservoir containing the fluid, kept at a temperature of 
105°. The flow is controlled by a screw-clamp on the tube. 
The vessel should be about 1 foot above the level of the 
rectum (Fig. 16). Other more elaborate apparatus can be 
obtained. 

Sometimes the saline is not retained. This may be due to a 
too rapid inflow of the fluid, or to its being at the wrong 
temperature. In other cases the lower bowel must be cleared 
out with a simple enema before toleration to the inflow is 
estabhshed. If this method proves impracticable, subcu- 



126 THE ACUTE ABDOMEN 

taneous infusion must be employed, and may require to be 
repeated. At times the continued flow of saline into the 
subcutaneous tissue may be useful, but a watch must be kept 
on this method, otherwise the tissues become quite " water- 
logged." 

It has been found in practice that much saline can be 
absorbed by the rectum, if the apparatus is introduced at 
regular intervals and kept in position only for a short time. 
This it may sometimes be necessary to commence during the 
performance of the operation. Injections of sterilised saline 
into the axilla through the anterior axillary folds may be 
substituted. When the low condition of the patient is part 
of the primary " peritonism," some reaction from it may be 
expected after a wait of a few hours, but if a collapse is due to 
the action of toxins on the heart muscle, marking the approach 
of the final stage, it is wrong to wait. Every moment increases 
the amount of poison absorbed, and by so much lessens the 
chances of recovery. 

It must not be forgotten that the ultimate course of the 
case is greatly influenced by attention to details in the treat- 
ment after operation. 

In stout patients where the abdominal wall is very thick, 
especially if rapid operation is called for (and it usually is), 
or if the surgeon is short-handed, the incision is better placed 
though the linea semilunaris. It may be more Hable to a 
hernia later, but this consideration must not be allowed to 
weigh against the satisfactory performance of the operation ; 
time is such an important element in these cases that a quick 
operator will gain a success when the slower one will fail. 
The length of any incision should be one which will admit the 
hand of the operator. 

The pelvic organs in the female should always be examined. 

Drainage tubes may be removed in two or three days unless 
the discharge at this time continues profuse or the temperature 
has not come down. At any time it is better to shorten the 
original tubes rather than put smaller ones in. 

It is not usually advisable to give anything by the mouth in 
the first six hours after operation ; the absorption of sahne 
into the circulation relieves the sensation of thirst and increases 
the dilution and rapidity of excretion of toxic products. On 



INFLUENCE OF APPENDIX ON ACUTE ABDOMEN 127 

this account there is no doubt that the steady introduction of 
fluid into the system by one means or another is of great 
value after operation in cases of peritonitis. 

At this stage the question of giving an " anti -toxic serum " 
arises ; the infective process in most cases of appendicitis is 
due to the bacillus coli ; and an " anti "-serum to this organism 
has been prepared. I have employed it in a number of cases, 
but cannot say that it appeared to materially alter the course 
of the disease when comparison is made with instances not so 
treated. The serum should be injected into a pectoral or 
gluteal muscle ; a dose of 20 c.c. is given immediately after 
the operation, and this may be repeated at intervals of twenty - 
four hours for two or three days. Joint pains and fleeting 
rashes not infrequently follow this administration. It is well 
to have a vaccine prepared from the fluid removed at the 
operation, for it is often of value when the progress of the case 
is not as satisfactory as could be wished. Especially when 
the temperature keeps above normal, although there is no pus 
pent up anywhere, and discharge from the wound goes on 
without evident cause. 

For the relief of the pain and discomfort still present after 
the operation an injection of morphine may be given, if a good 
night's rest is not otherwise to be obtained ; but on account 
of its action on the bowel the dose should not be repeated. 

After every operation some vomiting is to be expected, and 
for the first twenty-four to thirty-six hours no definite treat- 
ment is called for to combat it ; if, however, it continues 
longer, becomes more frequent or offensive, an attempt to 
check it must be made. The slighter cases may be stopped 
by the administration of a dose of ^^ gr. cocaine in an ounce 
of water at intervals of an hour ; sometimes minim doses of 
tincture of iodine are successful. If these measures fail, and 
the patient is much distressed, the stomach should be washed 
out with dilute sodium bicarbonate solution ; this will at any 
rate give rest for some hours and probably allow of the proper 
administration of a purgative, which will materially benefit 
the condition. 

In the more persistent cases the prognosis becomes very 
grave, as either a general toxaemia, secondary intestinal 
obstruction or acute dilatation of the stomach is present. 



k 



128 THE ACUTE ABDOMEN 

An attempt to obtain an action of the bowels should be made 
on the second day following the operation. I usually give a 
3 to 5 gr. dose of calomel, followed after four hours by 5ij doses 
of magnesium sulphate or other sahne purgative at hour 
intervals till an action is obtained ; in obstinate cases I have 
found a ^^ gr. ot elaterin very useful, the value of which was 
first demonstrated to me by Dr. John Harold. The diet for 
the first few days should be fluid in character ; if no adverse 
symptoms are present by the third or fourth day, small amounts 
of chicken cream and fish may be given, and at the end of a 
week the patient will be on practically a full diet, if it is 
fancied. 

Meteorism, sometimes very intense, associated with a feeling 
of great abdominal discomfort, appears in some cases. 
Indicating as it does a paralysis of the muscular coats of the 
intestine, its persistence will always give cause for anxiety ; a 
turpentine enema (5i — ^ij turpentine in ^x of acacia emulsion) 
or the action of one of the above-mentioned purgatives may 
reheve the condition. If these fail, and the passage of a long 
rubber rectal tube proves equally ineffective, three or four 
subcutaneous injections of eserine salicylate (yj^ gr.) may be 
given, though in my experience it is of small value in those 
obstinate cases which are due to more or less complete intes- 
tinal stasis, when the necessity of a second operation must 
be considered. Pituitary e-.tract is now used by many (1 c.c), 
repeated hourly for three or four doses. If the obstruction is 
caused by an intense local peritonitis little can be gained by such 
interference ; in cases where it is due to mechanical kinking 
or strangulation of the bowel, operation will afford relief. 

The wound will require at least a daily change of sterile dry 
gauze for some time ; if the discharge is copious and offensive, 
gauze soaked in 1 in 1000 lysol or in 1 in 80 carbolic is to be 
preferred. Any local tension must at once be reheved by the 
removal of skin sutures. Cellulitis or sloughing of the abdominal 
wall may require more radical measures such as incisions and 
the frequent appHcation of hot dressings, but if the wound has 
been well guarded during the operation the local infection will 
be slight if any. 

All degrees of fsecal fistula may develop in the wound ^ 

^ See " Diseases of the Appendix," 2nd ed., p. 282. 



INFLUENCE OF APPENDIX ON ACUTE ABDOMEN 129 

from the second or third day to the eighth ; they may be due 
to the giving of the sutures in the caecum at the point of 
removal of the appendix or to a sloughing of part of the bowel 
wall where involved in the inflammation. They tend to 
spontaneous healing in practically all cases ; the diet in these 
circumstances should be readily digestible or such as to leave 
little debris ; violent purging should be avoided ; the dress- 
ings must be frequently changed, and an outside pad of 
carbolised tow, wood-wool, or peat moss will confine the 
offensive odour and prove an economy. 

The onset of black vomit is never a satisfactory symptom, for 
it indicates a severe degree of toxaemia, and must cause con- 
siderable anxiety to those in charge. Other signs of toxaemia 
are present, frequently associated with constipation and dis- 
tension of the abdomen. Washing out of the stomach, with 
the administration of turpentine enemata may prove very 
useful. Should turpentine fail, the administration of a pint 
of molasses or common treacle, or yeast, will not infrequently 
cause an action of the bowels and a rapid general improve- 
ment. It is advisable to protect the skin by means of oint- 
ment, and of these Wallace's ointment, vaseHne or zinc are 
most useful. 

A serious amount of cardiac weakness leading to rapid 
pulse, breathlessness, and dropsy of the legs may develop 
during convalescence, due to the toxaemia, of which we have 
already spoken ; it requires energetic treatment with digitalis, 
strychnine, and other cardiac stimulants, diet, etc., and careful 
nursing, over a period which may be prolonged, and demands 
much patience, even when the wound (usually in an adult) has 
done well. 

Should there be dilatation of the stomach as a compHcation, 
the state of the patient may give well-founded cause for alarm. 
Improvement follows gastric lavage, position, enemata, etc. 
If washing out is not tolerated, it is sometimes possible to 
make the patient wash the stomach out himself. He should 
be given a large quantity of warm water and induced to reject 
it again. In a case which I saw with Dr. Noyes, of Worthing, 
the patient did this most successfully.-^ 

1 See Lancet, Vol. I., 1914, March 21. 
A. A. K 



130 THE ACUTE ABDOMEN 

LOCALISED SUPPURATION. 
Appendicular Abscess. 

Localised suppuration is much more common than is generally 
believed ; inflammation of the appendix, being of a septic 
nature, frequently terminates in suppuration, and one of the 
dangers of the disease is the latent character which some of 
the abscesses assume. Sometimes pus is found about an 
appendix long after the temperature has become normal and 
all pain and tenderness gone. As a rule, however, some 
thickening may be felt in the region of the appendix or an 
abnormal resistance to pressure. If an attack of appendicitis 
of more than average severity has been experienced, and a 
swelling has formed in the iliac fossa, there is usually suppura- 
tion present, but a sudden fall in the temperature, which had 
continued high, and improvement in the general condition, 
may indicate the escape of the pus into the bowel. 

In other cases, after the temperature has become normal, 
or almost normal, it rises again, and with that there is an 
increase in the size and tenderness of any inflammatory mass, 
the position of which varies with that of the individual appendix. 
There are localised suppurations secondary to disease of the 
appendix which are found in other parts of the body, but these 
are treated of elsewhere. If, however, the local signs of 
abscess are not found in the iliac fossa or loin, a vaginal or 
rectal examination should be made (Fig. 17). 

The rigidity of the lower part of the right rectus usually 
persists, but no longer conceals the swelling beneath ; indeed, 
the muscle is often pushed forward. This swelling is tender, 
especially where most prominent, but fluctuation is rarely found 
unless the case has gone so far that the abdominal wall is being 
penetrated or the purulent collection unusually large. Per- 
cussion over it shows a change from the normal, and where the 
parietal peritoneum has become adherent the note is evidently 
dull ; should the abscess contain gas then hyper -resonance 
will be found, with some duLiess varying with the position of 
the patient. 

When the abscess has been permitted to penetrate the 
abdominal wall, there will be redness and oedema of the skin, 



LOCALISED SUPPURATION 



131 



with bulging, fluctuation, and possibly a tympanitic area when 
gas has accumulated. 

Occasionally the thigh is flexed, everted and abducted, and 
as a child with an abscess walks badly and complains of pain 
when examined, such are occasionally sent to hospital with the 
diagnosis of " hip disease." 

In the diagnosis of some cases a blood count is of great 
importance, and is referred to on p. 151. 

A good instance of a retroperitoneal abscess of large size 
which it was difficult to diagnose, as 
for a long time it was concealed, is 
shown by a case seen with Dr. Wilson 
Stoker. 

The patient, an unmarried girl of 23, became 
ill and feverish in June, 1908, and this con- 
dition became worse in August. There was 
no vomiting and no local pain, but a general 
weakness with fever. Dr. Stoker, who was 
consulted towards the end of August, had 
her carefully nursed, and in September a 
swelling was found by him in the lower 
abdomen. The fever was of a hectic type, 
and night sweats with loss of flesh occurred. 
She had had two similar attacks of fever, the 
first when 7 years of age and the second 
seven years before the present illness. The 
periods were paiuful and irregular. On 
September 17, the lower abdomen appeared 
somewhat fuUer than normal, and there was 
resistance to pressure. On percussion no very 
markedly dull area was present, but under 
the lower part of the left rectus the note was 
tympanitic as if from a gaseous abscess ; it was not tender, and the 
upper limits of the swelling were fairly defined and higher on the right 
side. Exploration on the 20th showed the pelvis covered in as by a 
cloth with a yellowish -white membrane, and the only thing recognisable 
was the sigmoid flexure, which passed down in its usual position. The 
small intestines were displaced upwards and to the left. The uterus, 
ovaries, bladder, etc., were quite hidden, and the appendix was also 
concealed. Incision gave release to a large quantity of yellow pus 
without characteristic odour. A drainage tube was put in. Consider- 
able shock followed, from which she recovered in a few hours. 

A sinus formed and would not heal, so in June, 1909, the appendix 
was excised. There had been some fsecal discharge for a few days and a 
bullet probe passed in for several inches. The appendix was turned 

k2 




Fig. 17.— Clinical Diagram 
with the regional per- 
centages of Appendix 
Abscesses (from Surgical 
Diseases of the Appen- 
dix Vermif ormis, etc. , 
2nd ed.). 



132 



THE ACUTE ABDOMEN 



round an enlarged and cystic ovary, and was much thickened, strictured, 
and adherent. She made a satisfactory recovery. 

When these abscesses are watched from the commencement 
there is as a rule Uttle difficulty in ascribing them to their 

right source (Fig. 18). 
But when seen for the 
first time some days 
after the onset of an 
illness' there are other 
conditions which must 
be remembered which 
may cause similar ap- 
pearances. Of these 
may be mentioned — 
(1) Pyo -salpinx ; (2) in- 
flamed or suppurating 
ovarian cyst ; (3) acute 
pyo - nephrosis ; (4) 
tuberculosis of the peri- 
toneum ; (5) actino- 
mycosis ; (6) abscess 
secondary to malignant 
disease of the bowel ; 
(7) malignant disease of 
the caecum or ascend- 
ing colon. 

In Pyo -nephrosis the 
tumour is in the right 
loin and is distinctly 
outlined. It has pro- 
jected gradually from 
the kidney region, 
moves on deep inspira- 
tion. Occasionally a 
calculus can be seen 
with the X-rays. There may have been renal cohc with pus 
in the urine. 

Inflamed or Suppurating Ovarian Cyst.— The change in 
the cyst may arise in various ways, frequently from twisted 
pedicle, and is difficult to diagnose when seen after a few days' 




Fig. 18. — Diagram of the paths of Peritoneal 
Infection in relation to Appendicitis. The 
primary form is in the right iliac fossa. 

1. Right-sided subdiaphragmatic abscess. 

2. Eight-sided subhepatic abscess. 3. 
Right-sided ante-renal abscess. 4. Left- 
sided ante-renal abscess. 5. Pelvic 
abscess. 6. Abscess in the left iliac fossa. 
7. Left-sided subdiaphragmatic abscess. 
Between 4 and 7, a left- sided subhepatic 
abscess may be found. Between 6 and 7, 
a subsplenic abscess may occur. (From 
• ' Surgical Diseases of the Appendix, etc.," 
2nded.) 



LOCALISED SUPPURATION 133 

illness, should the cyst be entirely intrapelvic . In the beginning 
of the ilkiess a swelling would be found of a size too large for 
any recent inflammatory condition to have reached ; later 
it may still retain its definite outline. Where it is above the 
pelvic brim it has probably been recognised before the onset 
of the inflammation. 

In Pyo -salpinx there is a tumour present on vaginal examina- 
tion, possibly on both sides, though the side which is causing 
the trouble is the more tender. There may be a history of 
dysmenorrhoea, menorrhagia, backaches, vaginal discharge, 
and possibly feverish attacks. I have known a patient certified 
and treated for tuberculosis when suffering from this disease 
before the pyo -salpinx ruptured. 

Abscess secondary to malignant disease of the bowel may be 
due to the giving way of a stercoral ulcer, which has formed 
secondarily to a carcinoma of the lower part of the large 
intestine or rectum. It is a very serious complication, and in a 
stout subject might be mistaken at its commencement for an 
attack of appendicitis. There is usually a history of obstruc- 
tion, obstinate constipation, or diarrhoea for some time before 
the complication shows on the right side of the abdomen. 

Occasionally a Growth in the Csecum undergoes a change, 
possibly from necrosis of tissue, and suppuration takes place 
around it ; it is a very distressing complication, because an 
incurable faecal fistula forms after the pus is evacuated. Here 
again it is possible to get a history of illness with the presence 
of a localised swelling before complaint was made of the more 
acute condition. 

The resemblance between an appendix abscess and a tumour 
may be very close. A case seen with Dr. Arthur Browne is 
a good example of this difficulty. 

A man of 50, stout and previously healthy, had an attack of abdominal 
pain and vomiting five weeks before. The pain was severe and in the 
right iliac fossa. For about three weeks a definite swelling had been 
noticed, tender on pressure, and painful when he was moving about. 
He had not felt ill enough to keep altogether in bed, and occasionally 
walked about the room. There was a hard swelling, the size of a large 
fist, with rounded outline on the right side of the abdomen, between the 
umbilicus and anterior superior spine, dull on percussion, very tender, 
but without fluctuation and movable on the deeper parts. It came 
forward and, at the outer margin of the rectus muscle, was adherent to 
the abdominal wall. The temperature was normal. About eighteen 



134 THE ACUTE ABDOMEN 

months before he had had an attack of pain on the right side of the 
abdomen but it was not of long duration, and no swelling had been 
noticed. The operation was done in two stages — (1) incision of abscess ; 
(2) removal of appendix twelve days later. The appendix, which was 
large with very thick walls, was adherent to the parietal peritoneum 
under the right rectus. The abdominal wall was very thick from fat 
deposit and the muscles and fasciae very much degenerated. 

In these cases the previous history is very important, and as 
a rule a new growth is more prominent, clearly outlined, and 
less tender. Still the diagnosis will occasionally be very- 
difficult in fat patients. 

I have elsewhere^ published the account of a case of large 
Colloid Growth of the Ascending Colon 

in which there had been an attack of appendicitis for which a female 
patient had been treated in a provincial hospital, and dismissed when 
the inflammatory symptoms had subsided. She was aged 59. The 
growth was excised and an ileocolostomy performed, from which great 
benefit was obtained, the woman being in good health when seen 
several months later. Here there was a large swelling left when she 
had recovered from the acute illness, the importance of which was not 
recognised as there was no obstruction of the bowels. The growth 
probably obstructed the appendix. 

Hyperplastic Tuberculosis of the caecum is a chronic disease, 
and at first presents no evidence of swelling ; later this may be 
found in the iliac fossa, or even above the iliac crest, but as 
time advances it surely becomes evident, whilst there are 
increasing signs of tuberculosis in other parts, especially the 
lungs. The tumour is more or less cylindrical, somewhat 
nodular, and rather fixed ; it may be tender. It is of slow 
development, and irregular abdominal pains merge into the 
symptoms of obstruction. Excision is indicated if the general 
state of the patient permits. 

In Actinomycosis a swelling forms and increases gradually 
with a brawny infiltration of the tissues, followed by the 
formation of sinuses, the purulent discharge from which 
contains granules of a yellow ^colour and hyphge, which show 
clearly the nature of the disease. Some ameh oration may be 
obtained by repeated incisions and the administration of 
potassium iodide. 

The vast majority of abscesses of the appendix diminish in 

J " Surgical Diseases of the Appendix, etc.," p. 273, 



LOCALISED SUPPURATION 135 

size and become absorbed or disappear by discharge into the 
bowel, probably through the appendix ; therefore it is unneces- 
sary to interfere, unless (1) the abscess has become chronic; 
(2) increases in size ; (3) gives rise to much pain. Operation 
should then be performed whether there is reason to think it 
has become adherent to the parietal peritoneum or not. A 
rapidly increasing abscess is a source of danger. 

When an abscess is pointing, having made its way through 
the muscular wall of the abdomen, a simple incision is all that 
is required, with provision for drainage. 

If the pus is covered by peritoneum in the iliac fossa, the 
McBurney operation by separation of muscular fibres should 
be done, the first incision being made parallel with the fibres 
of the external oblique. If the covering omentum or intestine 
is adherent to the wall, all that is then necessary is to pass the 
finger in between this coil of gut or omentum limiting it and 
the parietal peritoneum downwards towards the appendix. 
The pus will then come away easily. If the abscess is not 
adherent, a strip of gauze should be passed around with the 
end of a blunt -pointed pair of scissors and the abscess opened 
in a similar way with the finger. In both a large tube should 
be inserted. In the latter the gauze plug may be removed 
in thirty-six hours. 

A pelvic abscess may be opened after displacement of the 
rectus muscle inwards and ligature of the deep epigastric 
vessels, but it is usually best to open it through the rectum in 
the male and young female, or through the vagina in the 
married woman. 

The patient having been placed in the lithotomy position, 
and a duck-bill speculum introduced into the rectum, a 
longitudinal incision is made over the most prominent part, 
dividing the mucous membrane ; the deeper parts are then 
opened up with a director, along which a closed pair of forceps 
is passed, opened and withdrawn. This will suffice to make an 
opening large enough for the escape of pus and the necessary 
drainage. After the evacuation of the pus and cleansing of 
the parts as much as possible, a strip of antiseptic gauze is 
introduced and left in the opening for forty -eight hours, when 
it probably comes away during an action of the bowel. 

Where the abscess is opened through the vagina, it is best to 



136 



THE ACUTE ABDOMEN 



shave the vulva and douche the vagina with sterilised saline. 
The cervix uteri is seized with a vulsellum, which is given to an 




Fig, 19. — Sagittal Section of a female body, with a rubber tube inserted 
in the Vagina and through the Posterior Fornix to illustrate the 
vaginal drainage of the Pouch of Douglas (from " Surgical Diseases 
of the Appendix Vermiformis, etc." 2nd ed.). 



LOCALISED SUPPURATION l57 

assistant. The parts are well retracted and an incision made 
behind the cervix with the point of the knife directed upwards 
and towards the posterior surface of the uterus (Fig. 19). It is 
advisable to go deeper than into the rectal wall as the vagina 
is the thicker. The pus is then evacuated in a similar manner, 
the finger introduced to make the opening large enough for a 
good -sized tube. This should be long enough to project from 
the vulva, gauze is carefully packed round the tube in the 
vagina, and an external pad applied with a T bandage. The 
gauze is changed every day and the vagina douched, but the 
tube is not disturbed for a week or so, when it may be 
removed if the condition is satisfactory. Recovery may be 
delayed by some pelvic cellulitis, in which case there will be an 
irregular temperature for some time. 

If the abscess rises directly from the pelvis and the supra- 
pubic position is chosen for drainage, the position of the bladder 
must be defined, and operation only done when that viscus 
is empty and out of the way, as shown by the insertion of an 
instrument into it. It is sometimes held up by the abscess 
and cannot fall into position when emptied ; it then lies well 
above the pubes and would be in danger. 

I think it is rarely permissible to attempt to take away 
the appendix when the abscess is opened, and that a much 
better result in a large series of cases of varying severity will 
be obtained if it is removed when the inflammatory mischief 
has quieted down.^ It must be removed if you wish to make 
the patient safe. 

Sudden Diffusion of the Pus from Rupture of an Abscess 
into the Peritoneum. 

A most serious condition may arise through the bursting of 
an appendix abscess into the peritoneal cavity, and formerly, 
in the experience of most, this accident was a fatal one. In 
appendix suppuration there is an attempt made by nature to 
localise the pus ; occasionally for some reason this is only 
successful for a time, and there is a further extension of the 
pus and involvement of more of the peritoneum. This takes 
place slowly and is not accompanied by the definite signs 

^ See " Surgical Diseases of the Appendix Vermiformis and their Complications," 
2nd ed. 



138 THE ACUTE ABDOMEN 

which we have spoken of as "peritonism." A very different 
clinical picture is presented by the patient in whom an abscess 
containing a large amount of pus has suddenly burst, distri- 
buting its septic contents throughout the abdomen. 

Examples of this complication which were treated within 
two daj^s are instructive, and have been selected as most 
typical. 

A ward maid at a fever hospital, aged 19, was admitted ^ on Novem- 
ber 3, 1904. Her illness commenced with pain in the right iliac region 
seven days before admission. She was obliged to go to bed, but resumed 
work on the following day and did her usual duties as well as she could 
until about fifteen hours before she came into hospital, when a sudden 
acute pain attacked her and she was obliged to return to bed. There 
had been diarrhoea for two or three days. When I saw her with Dr. 
Hector Mackenzie she was propped up in bed, her nostrils were working 
rapidly, and she was breathing with some difficulty. Her face was 
dusky and anxious -looking, she was restless, but quite clear in her 
mind, and able to answer questions. The respiration was 32, thoracic 
and shallow, the tongue furred and dirty, the pulse 100, and tempera- 
ture 100-6°. The lower abdomen was distended and did not move at 
all on respiration ; the upper half moved moderately. On palpation 
there was a marked resistance in the lower half of the abdomen, especi- 
ally over the right iliac fossa, where there was a definite swelling. There 
was great tenderness here ; the abdomen was generally tender. On 
percussion extensive dulness was found in both flanks, but not in the 
middle line. The liver dulness was obliterated. At the operation an 
abscess was found to have given way on its pelvic aspect, and the pelvis 
was filled with offensive, semi-purulent fluid, which was generally 
diffused throughout the lower part of the abdominal cavity. Lavage 
with warm saline solution was carried out, and drainage through the 
openings made in the abdominal wall. The patient made a good 
recovery, and later on the appendix was removed. 

Another case which presented similar symptoms, and also 
ended in recovery, was that of a man aged 33 years, who was 
sent to the hospital by Mr. Hallam, and admitted the day 
following the admission of the patient whose case I have just 
recorded.-)(- 

The patient had had an attack of pain in the abdomen on October 31, 
chiefly on the right side, but did not give up his work. During the 
night of November 3 an attack of intense pain was experienced, and he 
came to the hospital in the morning sixteen hours later. When examined 
he was found to be perspiring freely, his face was pale and anxious - 
looking, respirations were shallow and diaphragmatic. An attempt to 
breathe deeply caused him much pain in the abdomen. The pulse was 
104, temperature 101-2°. There was no vomiting, the bowels were 



LOCALISED SUPPURATION 139 

confined, the abdomen did not move on respiration, and was very- 
tender on examination, especially in the right iliac region and in the 
loins. There was dulness in the flanks and the liver diilness was 
obscured. The abdominal muscles were rigid, this rigidity being most 
marked on the right side. In the right iliac fossa there was an ill-defined 
swelling. At the operation two incisions were made, one through the 
right rectus muscle and the other through the middle line below the 
umbilicus. Offensive, semi-purulent fluid was generally diffused 
throughout the peritoneum ; the intestines looked very congested and 
oedematous ; the abscess had ruptured to its outer side. Lavage with 
saline fluid of a temperature of 110° was thoroughly performed, the 
hepatic and splenic regions being carefully irrigated. Drainage was 
employed from both wounds. These were healed by December 17, 
and later on the appendix was removed. 

In this case, as in the former, suppuration had followed 
perforation of the appendix beyond a stricture. It will be 
noted that in both these cases there was a definite fixed 
swelling in the iliac fossa, in addition to the free fluid, the 
history of a recent abdominal pain which subsided to some 
extent, then a sudden and alarming return of pain and 
vomiting. 

OTHER ABDOMINAL SUPPURATIONS. 
Hepatic Abscess. 

It is not often that we see the large abscesses of the liver 
which used to come under observation some years ago. They 
were frequently so very large that the patient was not only 
reduced to a skeleton by the accompanying fever, night 
sweats, and possibly diarrhoea, but he had little chance of 
surviving the shock and subsequent drain which the release 
of such a large amount of pus and closing of such a large 
cavity entailed on his resources. I have seen such abscesses full 
of thick chocolate -coloured pus opened, and the result has been 
a haemorrhage into the cavity in some or a high hectic fever 
which proved fatal in a short time in others. 

The training of the members of our profession, whether civil 
or in the Services, is so much improved, and their ability as 
operators so high, that these cases no longer progress to such 
a dangerous extent. They are wisely treated in the colonies 
and not sent home for treatment, with the possibility of serious 
complications during a voyage of uncertain duration. 



140 THE ACUTE ABDOMEN 

Mr. Cantlie has suggested that hepatic abscesses should be 
treated by means of trocar and cannula followed by siphon 
drainage ; he gives excellent reasons for the operation which 
he advocates, but I do not know of any statistics which enable 
us to compare his method with those in general use. It would 
be well if he could give his exact results. The majority of 
surgeons, I take it, are more comfortable as to the results of 
operation for such abscesses if they feel that there is nothing 
to interfere with the free escape of the pus through an opening 
which they consider more adequate. 

The early evacuation of these abscesses is to be desired, as 
it is in the case of abscesses in other parts of the body. The 
majority are situated in the upper and back part of the right 
lobe of the liver, but there are no reasons why suppuration 
should not commence in any part. Those which begin within 
the liver, or which are in the most common situation, may 
possibly be permitted to attain a size large enough to enable 
them to be searched for with a probability of success. Those 
which develop on the anterior surface should be opened quite 
early, and a long illness cut short. We no longer have that 
fear of the peritoneum, which formerly acted as a deterrent to 
operation before the wall of the abscess was adherent to the 
parietal peritoneum. A plug of gauze can be placed to shut 
off the peritoneal cavity and the operation expeditiously con- 
cluded at one sitting. It is not necessary to use sutures. The 
cavity does not require to be scraped out neither does it need 
syringing ; both may cause haemorrhage. 

G. H., an ex-soldier, aged 35, was admitted -X* on June 6, 1905. 

He stated that on May 30, about 9 a.m., he had a sudden attack of 
vomiting : he had no breakfast that morning. On June the 1st he had a 
dull aching pain in the lower part of the back on the right side, extending 
in front to about 2 inches below the margin of the ribs and 2 J inches 
from the middle line. He vomited several times during May 30 and 31, 
and June 1. He had been feverish. 

This patient had been previously under the care of Dr. Mackenzie in 
1904, from November 8 to December 31, and on November 11 an 
abscess of the liver which had been causing symptoms for ten days was 
opened and drained. The abscess was a small one containing greenish 
pus, which was sterile on examination in the clinical laboratory. 

The surface of the liver was dark-red in colour, and the abscess 
was not bulging, nor the liver adherent, but the area underneath 
which the pus had collected was softened. The point of a pair of 



OTHER ABDOMINAL SUPPURATIONS 141 

artery forceps was pushed into it, the forceps opened, withdrawn, 
and replaced by a rubber tube. 

The man had been in India, Malta and South Africa, and had suffered 
from dysentery in 1897, and on more than one occasion since. He had 
also had enteric in South Africa. 

On his second admission the man looked ill and his breathing was 
hurried. Deep inspiration caused sharp pain. There was the scar of the 
previous operation in the right hypochondrium. The liver edge could 
not be felt because of the extreme resistance of the right rectus, much 
tenderness was complained of, on even light pressure, over this area. 
There was no friction to be heard. A dragging pain was caused when 
he turned on the left side, and he was usually found lying on the right. 
The liver dulness extended vertically downwards to 1 inch below the rib 
margin, from the fifth rib. Pulse, 80 ; respiration, 44 ; temperature, 
100-2°. There was nothing abnormal found in other parts. 

His symptoms did not improve. On June 10 he was unable to sleep 
because of paia. On the 14th an incision was made through the right 
rectus ; on passing the finger along the anterior surface of the liver, an 
area of bulging was found towards the summit, the upper part of which 
was soft, whilst the part at the base of the projection was unduly 
resistant. This area was isolated with gauze packing, a trochar put 
into the swelling, along which a pair of forceps was passed and exit 
given to about 3 oz. of yellow pus. A drainage tube was placed in this 
and the area shut off from the general peritoneal cavity with a strip of 
gauze. The temperature became normal at once ; in three days' time 
there was hardly any discharge, and the wound had healed ten days 
after the operation. 

This abscess was nearer the middle line and less accessible than the 
former one. 

Perigastric and Subdiaphragmatic Abscess. 

Perigastric Abscess. 

In cases of localised suppuration secondary to perforation of 
a gastric ulcer, the opening is usually a small one and the 
abscess forms gradually. There is a history of gastric ulcer, 
with an increase of any pre-existing epigastric tenderness and 
pain ; swelling in the stomach region, which increases from 
day to day, and a feverish attack. Although we do not find 
any of the food contents of the stomach in these abscesses, 
the smell of the evacuated fluid is so characteristic that no 
one can have any doubt of its origin when the pus is released. 
It is often impossible to find the perforation. There is some- 
times bulging, fluctuation, and the presence of free gas in 
these abscesses. The smaller abscesses are rarely diagnosed 
and have not infrequently proved fatal from secondary rupture, 



142 THE ACUTE ABDOMEN 

whilst the larger collections are likely to cause death from 
exhaustion, filling as they may do the upper abdomen. When 
these abscesses spread downwards they more generally run 
along the left side of the spine, and along the side of the 
descending colon, than behind the peritoneum. 

In one case treated with Dr. S. West at the Koyal Free Hospital that 
was the course taken, and the abscess had attained a large size at the 
time it was opened in the left iliac fossa. The patient, a woman, 
recovered. 

The possibiUty of a need for counter -openings must be 
considered and a careful watch kept for signs of involvement 
of the pleura. 

An abstract of a case described in a communication to the 
St. Thomas's Hospital Reports is of interest^ : — 

A married woman of 26, admitted -X- October 23, 1902. She had 
been confined on August 6, and about seventeen days later began to 
complain of pain in the lower chest, which extended down to the front 
part of the abdomen. This was very severe, generally came on after 
taking food, and frequently caused vomiting, which gave great relief. 
On admission there was a swelling in the umbilical region which was 
rounded and smooth. Above it was a very hard nodular mass the size 
of an orange, which appeared fixed and did not move well with respira- 
tion. Continuous with this, but deeper in the abdomen, was a smooth 
rounded mass, which extended 1^ inches below the umbilicus from the 
middle line to the line of the right nipple. This also appeared fixed. 
The rounded prominence in the epigastric region was recognised as a 
dilated stomach, the greater curvature of which reached 2^ inches below 
the umbilicus, and to the left nearly to the middle line. The lesser 
curvature was just below the most prominent part of the tumour. 
Peristalsis was poorly marked. The swelling was extremely painful 
on pressure, and she complained of a more or less continuous aching at 
all times. 

On November 5 the epigastric swelling had increased in size, but the 
temperature was normal. On the 8th the pain had become acute, and 
was not relieved by vomiting. The temperature was again elevated. On 
November 11, 24 oz. of pus were evacuated through a median epigastric 
incision. The fluid was first of a yellowish watery appearance, and 
then pus-like matter escaped, afterwards blood-stained fluid. The 
cavity was situated in front of the stomach under the liver, being shut 
off by adhesions of the omentum to the abdominal wall. A drainage 
tube was inserted. For a few days progress was good, but there was 
again complaint of abdominal pain, and on the 18th another fluctuating 
swelling was found extending down towards the left iliac fossa. An 

1 '♦Chronic Perforation of a Gastric Ulcer," by William H. Battle (Vol. XXXI., 
p. 385). 



OTHER ABDOMINAL SUPPURATIONS 143 

incision was made about 2^ inches above the left anterior superior spine, 
and a large retroperitoneal abscess opened ; it contained several ounces 
of sour-smelling pus. The peritoneum encircling the two openings was 
stitched together and a drainage tube put in. At the same time an 
offensive whitish slough, resembling sloughed omentum, was taken out 
of the higher incision. Ten days later a slough of similar character was 
removed from the lower incision, evidently derived from the cellular 
tissue. About December 1 she began to pass clay-coloured stools, and 
the discharge from the lower wound stained the dressings green and 
yellow ; it continued for a few days, and then ceased. Kectal feeding 
was commenced after the second operation and continued for ten days, 
but she was permitted to take some fluid nourishment by the mouth. 
Eecovery was complete. 

It was noticed that the patient had an unusual amount of tenderness 
about the epigastric swelling when she was admitted, but until the 
occurrence of the sharp attack of pain on November 8 there was nothing 
very marked to indicate a complication of the kind which ensued. 

In some cases perigastric abscess is formed more rapidly. 
In nearly all much ilkiess may be saved by early incision. 
Should the pus make its way behind the stomach, or have 
originated in an ulcer placed on its posterior wall, especially 
if the perforation is large, the process of suppuration may be 
very tedious and even fatal. Pin-point perforations are 
responsible for a large number of these abscesses. Care has 
to be taken when the peritoneum is opened lest the stomach 
wall (if it is adherent) be mistaken for the wall of an abscess. 

Subdiaphragmatic Abscess. 

A localised collection bf pus which is in contact with the 
under surface of the diaphragm. When perforation or suppura- 
tion occurs in connection with the stomach, duodenum, liver 
and bile passages, pancreas and spleen, the pus will probably 
have some relationship to the under surface of the diaphragm. 
Suppuration may also extend from the lower part of the 
abdomen. The late Mr. Barnard analysed the causes in 
76 consecutive cases which occurred at the London Hospital : 
21 were due to perforation of gastric ulcer, 12 to appendicitis. 
Leith, who collected 212 cases, says that 74 were due to gastric 
ulcer and 20 to appendicitis. The proportion given by the 
former is probably the more correct. To the affections of 
the organs mentioned are included, in Mr. Barnard's list, 
parturition, pyaemia, splenic infarct, extension of thoracic 



144 



THE ACUTE ABDOMEN 



disease, acute periostitis of transverse process of lumbar 
vertebra,^ resection operations, typhoid, pyo-salpinx, ruptured 
gut, congenital cystic kidney, and injury. 

There will usually be a history of some cause such as gastric 
ulcer for the formation of an abscess in the upper abdomen — 
pain, reheved by vomiting and increased by taking food ; 
hsematemesis. An attack of dysentery, typhoid, malaria. The 
onset may be sudden or quite insidious and pain is the first 
symptom. Vomiting is very common, especially in cases 





Fig. 20. — Diagram of the 
Anatomical Relations of a 
Right-sided Subdiaphrag- 
matic Abscess (from " Surgi- 
cal Diseases of the Appendix, 
etc.," 2nd ed.). 



Fig. 21 . — Diagram of the Anato- 
mical Relations of a Left- 
sided Subdiaphragmatic 
Abscess (from "Surgical 
Diseases of the Appendix, 
etc.," 2nd ed.). 



where perforation has occurred. Amongst the general symp- 
toms is pyrexia, which varies much in severity, is frequently 
accompanied by sweating at night, and gastro -intestinal 
disturbance. Rigors are of bad prognosis. Leucocytosis 
was found in all the cases in Barnard's series which were 
examined for it. 

As regards the abdominal signs and symptoms. In most 
there is an abdominal sweUing caused by the purulent collec- 
tion, or the bulged liver substance over a tropical abscess. It 
does not move on inspiration, and varies according to the 
particular anatomical variety present. There may be bulging 



See also Major Haddock, British Medical Journal, Vol. I., 1914, p. 862. 



OTHER ABDOMINAL SUPPURATIONS 



145 



and fluctuation with dulness on percussion, unless gas is present, 
when an area of tympanitic resonance will be found, varying 
with the position of the patient. The parts bounding the 
abscess towards the abdomen will be tender and dull. A 
peritoneal rub has been heard. 

When the pus is between the liver and diaphragm, the 
liver, being adherent at the margin of the abscess, does not 
descend on inspiration. 

Changes at the bases of the lungs may indicate extension of 
inflammation through the dia- 
phragm, or a compression of the 
lung. Barnard records the presence 
of basal signs on the opposite side 
in two cases of perigastric abscess. 
The measurement of the affected 
side is often increased, whilst bulg- 
ing may be easily seen, or the inter- 
costals are pressed outwards and 
the tissues feel oedematous over 
these muscles. 

Subphrenic abscesses should be 
treated as such collections are 
treated in other parts of the 
abdomen ; if they are left to become 
very large the chances of recovery 
are much diminished ; still it is sur- 
prising how rapidly a young patient 
may improve even after months of 
delay, when the abscess has been 
emptied and drained. In 23 out of 
Barnard's 76 cases the abscess ruptured — ^into a bronchus, 4 ; 
right pleura, 2 ; left pleura, 3 ; peritoneum, 1 ; stomach, 8 ; 
intestine, 2 ; colon, 1 ; through the skin, 2. 

In the diagnosis of these abscesses X-rays are useful if the 
state of the patient makes it possible to apply them and there 
is any obscurity in the case. The use of an exploring needle 
is not advocated ; it may be a very dangerous weapon and 
very misleading : there is more than one case on record where 
the needle failed to find the pus, and others where it caused a 
fatal result. 




Fig. 22. — Clinical Diagram of 
Incision for exploring the 
Eight Subdiaphragmatic 
Eegion (from ** Surgical 
Diseases of the Appendix, 
etc.," 2nd ed. 



A.A. 



146 THE ACUTE ABDOMEN 

The subphrenic abscess may be satisfactorily treated by one 
of two methods — 

(1) Exposure and drainage from the front when the abscess 
tends to pass in that direction. If the abscess has not reached 
the margin of the ribs, but is situated between the upper and 
anterior part of the hver and the diaphragm but is not under 
the hne of incision, the peritoneum is packed off, a finger passed 
upwards into the abscess and replaced by a large rubber 
tube. The abscess is washed out gently with saline solution, 
and a layer of fresh gauze placed to prevent escape of any 
pus into the general peritoneum. This can be removed in 
thirty-six hours. 

(2) If the abscess is behind and above the liver or above 
the spleen, a section of a rib (the ninth is probably the most 
commonly selected) should be made and the pleura opened. 
If the diaphragm, which is often oedematous, is adherent to the 
pleura, an incision of 1| to 2 inches should be made in the middle 
line of the wound, and the upper margin of this sutured to the 
pleura. If the pleura is not adherent, a line of sutures should 
be passed all round, shutting off the pleural cavity. Whilst 
these sutures, which maj^ be continuous, are passed it is well 
to have the diaphragm which is exposed held up with forceps. 
The incision is carried through to the surface of the liver ; if 
the peritoneum is not adherent, then a plug should be passed 
and packed into the lower part of this space before further 
exploration is carried out. The forefinger is then passed along 
the surface of the liver in the direction in which the abscess 
is supposed to be, a bullet probe being substituted if nothing 
is found. Where there is a probability that the suppuration 
is in the liver, whether tropical abscess or suppurating hydatid, 
a trochar and canula is passed into it, the opening enlarged, 
and a drainage tube inserted. In any operation of this kind 
it is well to make certain that the peritoneum is quite shut off 
before the incision is closed. 

Drainage will be required for some time, and the surgeon must 
not be hurried into shortening the tube or diminishing its 
size. 

Suppuration in the splenic region is usually secondary to an 
attack of appendicitis with spreading inflammation of the 
peritoneum some time after an operation has been satisfactorily 



OTHER ABDOMINAL SUPPURATIONS 147 

performed for the arrest of the mischief so far as the lower 
part of the abdomen is concerned. Captain F. E. Wilson, 
I.M.S., has recently drawn attention to perisplenic suppuration 
in cases of malaria with cachexia ; he gives three instances in 
which he opened such abscesses. He writes : ^ 

" The points on which I rely in making a diagnosis in such cases are : 

(1) Continuance of fever under thorough quinine treatment and after 
the disappearance of all forms of the parasite from the peripheral blood ; 

(2) local evidences of softening, pain, or adherence to the abdominal 
parietes ; and (3) leucocytosis. What probably occurs in the spleen is 
the necrosis of areas of hypertrophied splenic tissue, this being followed 
by infection from the blood-stream. Unfortunately I have not had the 
laboratory facilities at my disposal to determine the infecting organism 
in each instance." 

Suppurative Perisigmoiditis in Childhood. 

Professor Ransohoff has pubHshed in the " Annals of 
Surgery " ^ two cases of perisigmoiditis in children which went 
on to suppuration. 

The first was a child of 6 with a seven days' history of anorexia and 
constipation. Strong purgatives were given and the sixth day sharp 
abdominal pain ensued, with repeated vomiting, rise of temperature, 
and meteorism. The abdominal muscles were rigid, bowels distended, 
with persistent fever and leucocytosis. In three days' time an infiltra- 
tion was found in the left side of pelvis, and on operation an abscess was 
opened ; this was closely connected with a patch of necrosis in the wall 
of the sigmoid. This was inverted, fixed with sutures, and covered with 
omentum. Drainage and recovery in three weeks. In a second child, 
aged 9 months, there was an abscess in the meso -sigmoid. This child 
had been suffering from entero -colitis for some months, fever, diarrhoea 
with occasional passage of blood, and great rectal tenesmus. 

The exact causation in these cases must remain doubtful ; 
it was suggested that there might have been a diverticulum 
of the sigmoid, but such is unknown in children. An alterna- 
tive diagnosis before operation was left -sided abscess due to 
appendix disease. No foreign body was found. 

Concealed Abscesses. 

It is not necessary to enter into a description of the other 
varieties of abscess which are seen in the abdomen : there is 
nothing that requires special mention ; the principles of treat- 

1 Lancet, 1913, p. 1913. 

2 1913, Vol. II,, p. 218. 

l2 



148 THE ACUTE ABDOMEN 

ment should be carried out as indicated in what has been said 
about other abscesses. Those in the kidney region may be 
mistaken for suppuration due to appendix disease, but this 
will be ascertained at the operation, for the odour of the pus 
is characteristic. 

At the Children's Hospital, Shadwell, it was not unusual to 
see cases in which abscesses were pointing, or already discharg- 
ing, at the umbilicus ; these were usually regarded as probably 
tuberculous in origin : there is no doubt that in many instances 
they are caused by the pneumococcus, and in such the prognosis 
is good. 

There are, however, many instances of concealed abscess 
met with in practice, the position of which is not easily ascer- 
tained, nor the cause discovered, when they have been found and 
successfully treated. Some of these are residual abscesses 
following on suppurative appendicitis ; some are of tuberculous 
origin ; others originate in the pelvis the result of tubal 
disease ; whilst others have their origin in the liver, or possibly 
in connection with a mahgnant growth which is of itself too 
small to give localising symptoms. Pain is not a characteristic 
symptom, but the patient becomes feverish, listless, loses 
weight and strength ; his complexion is pale and muddy. 
The tongue is furred, the bowels constipated ; he has no 
appetite, and sleeps badly ; whilst in the morning his clothing 
is wet with perspiration. The pulse is increased in frequency, 
but there is nothing abnormal found on examination of lungs 
or abdomen. Examination of the pelvis in women may show 
evidence of suppuration about the uterus, but there may be 
nothing abnormal discovered. Typhoid fever is suspected, 
but the tests for that and tubercle are negative. The blood 
is examined and leucocytosis is found, indicating the presence 
of suppuration somewhere ; the difficulty is to locate the 
abscess. The surgeon may suspect that it is in the subphrenic 
region by exclusion of other places as a result of examination 
and the history of the particular case, but it may still be 
impossible to point to any one localising sign. Here the 
X-rays may be of use, and comparison of the measurements on 
the two sides of the chest should be made. 

The following cases will illustrate this part of our subject. 
In the first, under the care of Dr. Box, it was thought that the 



OTHER ABDOMINAL SUPPURATIONS 149 

patient might have had appendicitis as a cause for the disease, 
though this was not proved. 

The patient, a youth of 18, was admitted on August 11, and left on 
November 15, 1911. He gave a history of pain in the abdomen on 
August 1 and complained of headaches, and for three days before that 
had epistaxis on and off. The pains were short and sharp in character. 
He walked about for four or five days ; his doctor then sent him to 
bed and afterwards to hospital. 

On admission he had a temperature of 102-4° and a pulse of 104 ; 
and nothing could be discovered on examination of the abdomen, nor 
of any region of the body. The temperature continued at 102° to 103° 
every night until the end of August, and all the tests for paratyphoid, 
typhoid, tubercle, and syphilis were negative. The pains in the 
abdomen disappeared. On the 26th it was reported that the percentage 
of polynuclears was 73-25 and that of small lymphocytes 19-75. 

Examination with the X-rays on September 29. " Eight side of 
diaphragm moves less than left. Some opacity of right base seen on 
screen examination." There is an area of definite tenderness on 
pressure over the lower ribs on the right side behind. Four days later 
he was complaining of pain there. Area of liver dulness increased. 
During the greater part of September the temperature was better, 
and from the 13th to the 24th it did not rise above normal. After this, 
however, it became high again, and with the symptoms which now 
developed, increased pain and tenderness in the hepatic region, there was 
no doubt of a collection of pus under the diaphragm, and on October 4 
this was opened by a transpleural operation with resection of part of a 
rib. The diaphragm was incised and the peritoneum opened ; at this 
point it was not adherent, so a gauze plug was inserted shutting off the 
peritoneal cavity below. The finger passed upwards between the liver 
and diaphragm entered a large abscess cavity. A drainage tube was 
inserted and the gauze plug left in situ. The bacteriological examina- 
tion showed the presence of the staphylococcus aureus. Recovery was 
now rapid. 

In a second case there could be no doubt that the opera- 
tion clearly proved the hepatic abscess to have been the cause 
of the symptoms. 

A patient, aged 29, was seen on August 4, 1904, at Brighton with Mr. 
W. H. Bowring and Drs. Hobhouse and Sanderson. When on a voyage 
some eighteen months previously he had suffered from an attack of 
dysentery, but had apparently completely recovered from the illness 
and its consequences until April, when he complained of pam in the 
right shoulder and feverishness. These feverish attacks have con- 
tinued since, without any long intermissions, but signs of any local 
trouble have been slight, excepting for two attacks of pain of rather 
sharp character, which in one instance was followed by jaundice of 
short duration. The patient had been under observation and treatment 



150 THE ACUTE ABDOMEN 

since April, and the temperature had shown a very marked range 
from 105° at night to 98° and even 97° in the morning. If kept strictly 
to his bed, the temperature would become normal, only to resume the 
previous course on his return to a more active life. On July 24 the 
gall-bladder and ducts were explored by a surgeon who had suggested 
the possibility of a gall-stone impaction in the cystic duct. Nothing 
abnormal had been found, however, and the progress oi the case had 
been but temporarily interrupted. 

On August 3 a localised dulness had shown itself at the right base, 
and on the insertion of a trochar and canula, clear fluid had come away. 
This dull area was recent and not of large extent. There had been some 
tenderness along the ninth interspace since the tapping. 

The patient was a tali man, much emaciated. He had a rapid pulse, 
the tone of which was not good. It was explained to him that there 
was an abscess of the liver, between the posterior aspect of that organ 
and the diaphragm, and that it was necessary to open it through the 
chest wall. 

Part of the ninth rib on the right side was excised, the pleura sutured 
to the diaphragm, and the incision carried through that muscle. Several 
large veins were visible in it, and it was somewhat oedematous and 
adherent to the liver. A trochar was passed into the liver, upwards and 
inwards and pus found. The opening into the abscess was enlarged, 
and about 15 oz. of yellow pus evacuated. Two drainage tubes were 
inserted. The added drain from the abscess was too much for the 
patient, who died exhausted a few days afterwards. 

In the case of a young lady of 16, who had been under 
treatment for some weeks for typhoid fever, the cause of the 
symptoms was a tuberculous pyo -salpinx. 

I was asked to operate by Dr. Mackenzie, who had seen the patient 
in consultation. The distended tube extended upwards into the posterior 
part of the left iliac fossa and fluctuated. She had fever and was much 
emaciated. Operation confirmed his diagnosis ; the swelling was very 
adherent and difficult to separate, being very closely attached to the 
upper part of the rectum, and although no opening could be found at 
the time of operation, in view of the density of the adhesions and 
difficulty of separation, it was considered advisable to put in a drainage 
tube. A faecal fistula formed but closed in a few days, and the patient 
recovered. Some years later she married and has had children. There 
has been no further manifestation of tubercle. 

Another abscess, the cause for which was obscure, whilst the 
localisation of the pus was difficult, was the following : — 

R. W. R., a man of 33, was admitted "^ on July 12 and left Sep- 
tember 10, 1913. 

Patient, who was formerly in the army, left China six years ago. 
Whilst there he had malaria and an attack of jaundice, but not dysen- 
tery. He also contracted syphilis, for which he underwent two years' 
treatment. 



OTHER ABDOMINAL SUPPURATIONS 



151 



Six weeks ago, when apparently in good health, he had a sudden 
attack of pain in the epigastrium, which doubled him up. This lasted 
for five hours. Next day he returned to work and continued his occupa- 
tion for another week, but at the end of that time felt so weak that he 
saw a doctor, who sent him to bed, where he was kept for a fortnight. 
He has had some breathlessness on exertion, slight cough, and pain 
over the liver, where he has noticed some swelling. 

A sallow -complexioned man with pyorrhoea. There is swelling over 
the liver region, especially laterally. The hepatic dulness extends 
from the fourth rib to about 3 inches below the costal margin and well 
beyond the middle line to the left. No tenderness : no complaint of 
pain. Behind over the right lung there is dulness almost to the apex, 
and the breath sounds are almost inaudible. Temperature, 98° ; 
pulse, 108. 

On July 30 it was noted that there was considerable swelling. The 
result of the hydatid complement fixation test was returned as negative. 
The X-ray examination showed fluid in the right pleura. On this day 
the abscess was opened by transpleural incision from behind after 
excision of 3 inches of the ninth rib. The pleura was sutured to the 
diaphragm round an area through which a trochar was passed and then 
an incision made. Thin purulent fluid was evacuated to the extent 
of several pints ; it was not offensive. The report of the clinical 
laboratory on this fluid was "few pus cells, much debris, no organisms 
seen. No evidence of hydatid disease." 

Before operation the highest temperature record was 99°, and an 
examination of the blood gave the following : — 

per cent. 



Polynuclear neutrophils . 


. 57 p€ 


„ eosinophils . 


. 7 , 


Small lymphocytes .... 


. 21 , 


Large lymphocytes .... 


. 6-5 , 


Large hyaline cells .... 


. 7-5 , 


Coarsely granular basophilic cells 


. 1-0 , 



PAKT III 

PERFORATION OF ULCERS OF THE DIGESTIVE 

TRACT 

In considering the perforation of ulcers of the digestive 
tract that give rise to the " acute abdomen " I do not propose 
to include those which take place at the site of a malignant 
growth, but only those which are known as " simple," the 
sudden giving way of an ulcer of the stomach or bowel into the 
general peritoneal cavity. 

Gastric Ulcers. 

In the autumn of 1894 Sir Alfred Pearce Gould opened a 
discussion at Bristol on the surgical treatment of simple 
ulcer of the stomach and duodenum and typhoid ulceration 
of the ileum and colon. The influence of this debate in Great 
Britain did a great deal to encourage surgeons in their treat- 
ment of these emergencies, and defined the steps of the opera- 
tion which are essential when one of these ulcers has perforated. 
There is no doubt the profession has been much indebted to 
that eminent surgeon for the manner in which he brought 
forward this subject. At that time the introducer of the 
discussion only knew of seven cases of successful operation 
for the closure of the perforation in a gastric ulcer. At the 
present time the diagnosis and main principles of treatment are 
so well understood that no surprise is expressed when recovery 
follows operation. Success is often attained. 

The first operation for perforation of a gastric ulcer in 
St. Thomas's Hospital was done in 1892. This was not 
successful, but in August, 1896, a success was obtained for the 
first time. Forty -nine cases had been submitted to operation 
up to 1904, the ulcer being treated by suture and the peritoneum 
washed out : 58" 1 per cent, recovered. The average time 



PERFORATION OF ULCERS, DIGESTIVE TRACT 153 



in the successful cases t at had elapsed between perforation and 
operation was 23 hours ; in the fatal cases 32-6 hours. 

The results of operation in the second half of the period 
mentioned are better than in the 
first. Cases are recognised and 
sent into hospital earlier, and 
operation is more quickly and 
surely performed. 

During the year 1910 the 
operative mortality after suture 
of perforated gastric ulcers was 
three out of fourteen, or 21 per 
cent. In all the anterior surface 
was affected, and the perforation Fig. 23.— Acute Perforation of a 
was closed with sutures. The Gastric Ulcer (A) (St. Thomas's 

Hospital Museum). 
cause of death in the three cases 

which did not recover was peritonitis, perisplenic abscess, 
and gastric haemorrhage. Three cases which were admitted 








Fig. 24.— Stomach Perforations. Diagram to illustrate most 
common positions of Perforation. The dark circles indicate 
Anterior, and the clear circles Posterior, Perforations. 

too late for operation died from general peritonitis. 1903-1912 
inclusive, 116 cases, with 70 cures and 46 deaths. 

In these perforations (most commonly occurring in women 



154 THE ACUTE ABDOMEN 

under 30 years of age) the symptoms which are grouped under 
the term " peritonism " are usually very marked, the sudden 
onset of pain causing signs of distress which are unmistakable. 
There is considerable variation as regards the amount of shock ; 
sometimes it is so excessive that nothing can save the patient. 
Shock is followed by collapse, and the patient may die in a 
few hours without response to medical treatment. 

In the autumn of 1905 a girl was admitted "tv with a history of sudden 
seizure of pain in the region of the stomach so severe that she sci earned 
out, and had to be carried home from the tram from which she had just 
alighted. When seen at the hospital half an hour later the diagnosis 
of gastric perforation was confirmed, but the state of shock was so 
profound that the most vigorous treatment, including saline infusion 
into the veins, failed to overcome this, and the patient died within six 
hours. She was quite unconscious, made no resistance to abdominal 
examination, nor did she complain of pain. There was a large perfora- 
tion about the size of a penny in the anterior wall of the stomach near 
the pylorus. A curious fact, noted at the necropsy, was the presence 
of extensive gaseous emphysema of the body a few hours after death. 

As a rule the patient rallies from the shock, and other 
symptoms develop which resemble those met with in perfora- 
tions of other parts of the digestive tract. In gastric and 
duodenal cases, perhaps more than in others, the previous 
history is important, especially if morphine has been given 
recently to relieve pain. It is not wrong to give morphine when 
the diagnosis has been made and the course of action decided 
upon, but there must be no subsequent going back because the 
patient " appears better." 

In a large percentage there is vomiting soon after the 
perforation has occurred, but the absence of vomiting is not 
against the diagnosis of perforation. 

Probably there is no form of the acute abdomen in which 
there is a greater amoimt of fluid to be fomid free in the 
peritoneum. At operation, only a few hours after the onset 
of symptoms has been noted, one has been surprised to find 
the flanks and pelvis quite full of a thin greenish fluid, acid 
and sour-smelhng. This statement applies to cases in which 
the stomach was comparatively empty at the time, as well as 
to those in which the perforation occurred soon after a large 
meal. Much of it is doubtless of a protective character, 
thrown out from the peritoneum covering the bowels and 



PERFORATION OF ULCERS, DIGESTIVE TRACT 155 

omentum in response to the irritation of the acid contents of the 
stomach. In this respect it resembles very closely the con- 
dition which obtains soon after the sudden rupture of the wall 
of an abscess, hydatid or other cyst, where the escaped fluid 
floods the peritoneum. 

Rigidity of the recti muscles in the upper part of the abdomen 
will be present, with great tenderness in the epigastric region. 

In any case where there is a difficulty in diagnosis between 
a perforated gastric ulcer and an acute diffuse peritonitis 
secondary to a gangrenous appendix, the presence of much 
free fluid, as determined by percussion within a few hours 
after the commencement of symptoms, should compel a strong 
leaning towards the stomach as the site of the lesion which 
has caused the illness. A tympanitic note over the liver 
region in an abdomen which is not distended may be an impor- 
tant additional proof, and is not infrequently observed in 
gastric perforations soon after the sudden onset of pain. Its 
absence, however, must not be regarded as a reason for post- 
poning operation in a case otherwise calling for it. It was not 
present in the following instance of large perforation, in which 
the accident occurred although the patient was under excep- 
tionally advantageous conditions, the stomach having had rest 
for two days. 

A groom, aged 45, was admitted "tv on September 30, 1904, with 
symptoms of gastric ulcer. The history of the case was that he had 
often been sick in 1902 and 1903. Vomiting occurred about hall an 
hour after food, and the vomited material was very acid. In January, 
1904, he vomited a large amount of blood, which was quite black ; 
this vomiting recurred a few days later. In July he had a similar 
attack of hsematemesis. 

When admitted he was suffering a good deal from pain in the epi- 
gastric region, and was obliged to lie on the left side. The abdomen 
was normal in appearance, and with the exception of tenderness in the 
epigastrium was without evidence of disease. He was sometimes 
unable to keep down milk. 

During the next few days he complained at times of the severe pain, 
and hot fomentations were required for his relief. Vomiting also 
occurred at intervals. On October 22 it was decided to put him on 
rectal feeding and give nothing by the mouth. 

At 2 a.m. on the 24th he had a severe attack of pain, perspired very 
freely, and his pulse rose to 120. 

When seen with Dr. Mackenzie twelve hours later he was evidently 
suffering acutely. Lying on his back, with head and shoulders raised. 



156 THE ACUTE ABDOMEN 

he looked pale, agitated, and intensely anxious, whilst his face and fore- 
head were covered with sweat. His respirations were hurried, painful, 
shallow, and iiregular, the pulse rapid, and he complained much of pain 
in the abdomen ; he was unable to take a deep breath on account of the 
pain, and on examination of the abdomen it did not move much with 
respiration. It was generally tender, rigid, and rather distended. The 
liver dulness had not disappeared ; there was dulness in both flanks, 
also across the lower abdomen above the pubes. He had vomited. 
The temperature was 100-6°. 

Operation was performed as soon as possible. On opening the 
peritoneum there was a flow of greenish thin sour-smelling fluid. The 
stomach was somewhat adherent to the under surface of the liver, and 
when they were separated by the finger there was a gush of free gas. 
The finger was passed to the pyloric region at once because of the diag- 
nosis of perforation of ulcer in that situation, made by Dr. Mackenzie. 
A sharply-cut ulcer, large enough to admit the forefinger, was found on 
the anterior surface of the pyloric end of the stomach. The stomach 
wall round this perforation was much thickened. The hole was closed 
with interrupted sutures. The peritoneal cavity appeared to be filled 
with the greenish fluid, there being large collections in the pelvis, the 
flanks, the subhepatic and splenic regions. A counter-opening was 
made above the pubes and the abdomen thoroughly washed out with 
normal saline. The intestines were not much distended. 

The deposit of lymph was limited to the parts around the perforation. 
Normal saline to the amount of two pints was passed into the median 
basilic vein during the operation, as the pulse became very feeble and 
rapid. The stomach was a good deal dilated. The upper wound was 
closed and a glass drain placed in the lower one. Recovery was slow 
but satisfactory, and he left on December 7, 1904, for his home in 
Devonshire. The induration surrounding the ulcer compelled the 
infolding of an unusual amount of stomach wall. 

[ do not think authors of text-books, when writing of the 
diagnosis of gastric perforations, have paid sufficient attention 
to the valuable information to be obtained by percussion. 
In nearly every case the amount of free fluid present is con- 
siderable, and it can be detected quite early, accumulating 
in the flanks. It should not be possible for any case of acute 
abdominal pain to be introduced to the surgeon with the 
peritoneum full of fluid and no statement of its presence made. 
This excess of fluid helps us to place out of court such con- 
ditions as pneumonia, diaphragmatic pleurisy, thrombosis of 
the superior mesenteric vein, various kinds of poisoning, and 
acute dilatation of the stomach. There are four or five states 
of the acute abdomen in which we get an excess of fluid — 
perforated gastric (or duodenal) ulcer, rupture of an abscess 



PERFORATION OF ULCERS, DIGESTIVE TRACT 157 

(usually appendicular), rupture of extrauterine foetation, 
ruptured pyo- salpinx, or the rupture of a large cyst. As a 
rare occurrence it is seen after the rupture of a large empyema 
of the appendix. A case in which there is reason to suspect 
gastric perforation, but about which you are not sure, should 
be carefully examined for the signs of free fluid, not only at the 
time when first seen, but every hour afterwards, for there 
are few emergencies that better repay prompt surgical attention. 
Contrast with the case just described the following and the 
importance of what I have said will be evident : — 

A nurse, aged 20, was admitted on November 28, 1913, having been 
sent up by Dr. Lock, of Ux bridge, for perforated gastric ulcer. 

She had suffered from very bad indigestion at intervals during the 
past three months, and, having been on night duty, was in bed on the 
26th in the afternoon, when she had a sudden severe pain in the epigas- 
trium. She was very sick. The pain was better on the 27th and 28th, 
but she still had tenderness. 

A somewhat chlorotic woman with flushed cheeks, and without any 
sign of anxiety. A pulse of 124, and respirations, 28 ; temperature, 
100°. She complained of some pain in the abdomen, but of no great 
severity, and the sickness had not recurred. Her general condition was 
good. The abdomen was somewhat distended, generally tender, but 
not very markedly so, yet the muscles were rigid, and there was shifting 
dulness in the flanks. The tongue was furred and the bowels confined. 
There was a difference of opinion as to the absence of liver dulness, but 
the diagnosis was " a small perforation of the anterior wall of the 
stomach and considerable effusion in the peritoneum." It was some- 
what difficult to convince the patient that she required immediate 
operation, because she did not feel very ill. 

It was not easy to find the perforation, for no gas or fluid escaped 
during the search, and it was only by examination of a small patch of 
lymph with a small probe that it could be found ; even then it was not 
possible to force fluid through it from within the stomach by any kind 
of pressure. This opening was in a patch of thickening about the size 
of a florin to the left of the middle line near the lesser curvature and was 
covered in by interrupted Lembert sutures. The fluid in the general 
peritoneal cavity was purulent, especially in the pelvis, and generally 
diffused, but contained no traces of food. It was washed away with 
sterilised saline, through a drain in a suprapubic opening. The upper 
opening was closed ; a drainage tube was left in Douglas's pouch. 
Uninterrupted recovery. 

The operation for perforation of a gastric ulcer may be 
divided into three parts : — 

(1) The abdominal incisions ; (2) the finding and treatment 
of the ulcer ; (3) the cleansing of the peritoneum. 



158 THE ACUTE ABDOMEN 

In preparation for the operation it may be necessary to do 
a great deal to combat the shock and bring the patient into 
a condition to bear the required manipulation. The usual 
preparation of the skin with iodine is advisable, and the 
surgeon must remember to have the hair of the abdomen and 
suprapubic region shaved. This part of the preparation is 
apt to be overlooked. The upper incision is made first, should 
be about 4 inches or more in length, and is made in the epigas- 
trium, from the left costo -xiphoid angle downwards to the 
left of the middle line. Before the peritoneum is opened it 
may bulge irregularly into the wound from the gas which has 
collected behind it, which bubbles up when this layer is 
incised. There may be none if the case is an early one and 
the perforation small. The amount of fluid is very variable, 
usually of a mawkish smell from gastric juice, and acid in 
reaction ; there are frequently particles of half -digested food 
in it, according to the size of the perforation, the character 
of the last meal, and the time which has elapsed since it was 
taken. In cases where there is much fluid it is a good plan 
to pass the hand through the upper wound to the under surface 
of the hypogastric region, cut down on it, and place a tube in 
the pelvis ; the fluid can then run away under an aseptic pad 
whilst the necessary manipulation of the stomach is being 
carried on. 

As the perforation is most commonly on the anterior surface 
near the lesser curvature, this is the part which should be 
examined in the first place. The stomach should be firmly 
but gently pulled downwards, whilst the fluid is mopped 
away as it comes from the opening, that already in the peri- 
toneum being kept back and partly absorbed with wide strips 
of gauze. Sometimes the opening is temporarily blocked by 
a particle of food, but as a rule there is an increasing flow of 
fluid with bubbles of gas as a result of the increased tension 
when it is pulled upon. 

If the opening is small or concealed by lymph, a more 
careful search may be necessary, but the injection of air into 
the stomach by means of an oesophageal tube as an aid to 
locaUsation is not either advisable or necessary. Abnormal 
redness of the surface, the presence of a patch of lymph, or 
the discovery of a hard plaque of tissue, when the perforation 



PERFORATION OF ULCERS, DIGESTIVE TRACT 159 



is small, may indicate it. Any recent adhesions between the 
stomach and liver should be separated and folds opened out. 
If the stomach is much dilated, filling up the epigastric region, 
it should be emptied, either through the perforation or through 
an oesphageal tube. If distended intestine causes difficulty 
it may be punctured with a trochar or the point of a knife and 
the puncture closed with a stitch. The sutures to close the 
perforation should be of 
silk, interrupted, sero- 
muscular, and passed 
after the method of 
Lembert. If escaping 
contents cause embar- 
rassment a stitch or two 
may be inserted across 
the opening. As a rule 
No. 1 silk is satisfactory 
for the sutures, but if the 
stomach wall is softened 
No. 2 should be used. I 
have found a single row 
of these sufficient, but 
they should penetrate as 
deeply as the submucous 
layer and extend well 
beyond the perforation. 
As a rule they should be 
passed from side to side, 
especially in the region 
of the pylorus, to avoid 
narrowing of the outlet. 
AU should be inserted 

before they are tied, and if there is any doubt of their hold on the 
stomach wall reinforcing sutures should be put over them. In 
small perforations a continuous Lembert suture may be used ; 
whenever this is feasible the suturing should be performed 
with the viscus outside the wound, resting on sterilised gauze 
moistened with warm saline. When the perforation is in a 
fixed part, suturing must be done with the stomach in situ ; 
here the wound must be well opened out with retractors, and 




Fig. 25. — Perforation of Gastric Ulcer. 
Insertion of sutures where there is 
much thickening of the base (1). 
Sutures bringing a ridge of sero- 
muscular tissue across the ulcer with- 
out tension. 



160 THE ACUTE ABDOMEN 

it may be found necessary to cut the left rectus, although 
this should not be hghtly done. Where there is an opening 
in an indurated area which will not hold stitches you must 
bring a fold of stomach over it from the cardiac side and suture 
that securely to the parts beyond the induration. 

When the condition of the patient, the position of the 
ulcer, or the large area of induration makes it impossible 
to close the perforation as advised, there are various courses 
open to the operator. 

A drainage tube may be passed down to the opening and 
gauze packing placed round it for some thirty -six hours. It 
may be possible to cover the opening by suturing some omentum 
over it, or the liver may be utiUsed in this manner. 

A gastrojejunostomy may be performed to diminish the 
leakage from the wound, but it must be remembered that 
although the amount in the upper abdomen may seem 
small, there may be a considerable quantity of fluid in 
the pelvis. 

So far I have spoken of the perforation of ulcers on the anterior 
surface of the stomach, for perforation is most commonly 
met with as a complication of these anterior ones. The 
posterior rarely perforate into a free portion of the peritoneum, 
owing to the tendency of adhesions to form between the 
surface of the stomach and the pancreas. If the history of 
the case points to a perforation, and none can be found on 
the anterior surface or along the lesser curvature, you must 
examine the posterior surface. Here there will probably be 
little fluid present in front of the stomach when the abdomen 
is opened, but search may reveal small bubbles of gas under 
the peritoneum as it leaves the greater curvature of the 
stomach. This perforation can be attacked through — (1) the 
gastro -hepatic omentum, which readily yields and gives direct 
access to the area usually aifected, or (2) by tearing through the 
gastro -colic omentum. The route chosen will depend on the 
difficulties of the individual case and the position of the ulcer ; 
in many the route above the stomach will give the easier access. 
The finger pressing on the anterior wall readily brings the 
lesion into view. 

The following is a case of perforation of an ulcer on the 
posterior surface of the stomach. 



PERFORATION OF ULCERS, DIGESTIVE TRACT 161 

M. J., aged 25, engaged in a laundry, was admitted -X* January 2 
and left on February 10, 1911. 

She gave a history of three to four years indigestion, pain and dis- 
comfort after meals. On three occasions during the past three years she 
has had acute attacks of pain similar to the present, and has been ill in 
bed for some time afterwards. During the last three weeks she has had 
more pain than usual and has " had the wind " badly. About 9 p.m. 
the day before admission the pain was so bad that it doubled her up 
and she had to go to bed. There was much shock. She did not vomit 
until the morning of admission ; and the symptoms when she came in 
were probably influenced by morphine, which had been given before her 
journey to hospital. 

She was drowsy and her general expression placid ; the pupils were 
small. Pulse, 128; temperature, 101-6°. The tongue was very dry and 
coated. The abdomen was moving poorly, was generally distended and 
rigid. It was extremely tender all over. On percussion there was an 
area of dulness in the left flank below the spleen, which shifted on 
movement. Friction could be heard over the left chest in front ; liver 
dulness present at the side. On making an incision over the stomach 
a little gas escaped, but not much fluid. Nothing abnormal was seen on 
the anterior surface, but as fluid with flakes in it and small bubbles of 
gas was coming through a small hole in the gastrocolic omentum this 
opening was enlarged and the posterior surface explored. A perfora- 
tion was found near the lesser curvature towards the pyloric end ; it 
was surrounded by an indurated area the size of a sixpence. It was 
shut in by means of two rows of silk Lembert sutures. The lesser 
sac was washed out as well as the general cavity, and tubes were left in, 
one being passed into the lesser sac, the other into Douglas's pouch. 
Convalescence was retarded by an attack of pneumonia in the left lung. 
There was some discharge of a purulent nature from the lower wound 
for a fortnight. 

We have placed considerable stress on the need for careful 
suturing ; it is now necessary to emphasise the need for thorough 
treatment of the peritoneum. The pelvis must always be 
examined, for although the amount of fluid is small in the 
upper abdomen, there may be a considerable accumulation 
in the pelvis. Irrigation is required in most cases of gastric 
perforation, because of the partly -digested food producte 
which have escaped and the irritating effect of the fluid with 
which they are mixed. Without this it is almost impossible 
to get rid of the various particles which have been swept into 
the outlying parts of the peritoneum. The fluid used should 
be sterilised saline (sodium chloride 5j., boiled water Oj.) at a 
temperature of 105°. If no irrigator is at hand a glass tube, 
or the end of an oesophagus tube, attached to indiarubber 

A. A. M 



162 THE ACUTE ABDOMEN 

tubing (recently boiled) arranged as a syphon or attached 
to a funnel, will serve the purpose. Failing these an ordinary 
Higginson syringe worked by an assistant, whilst the surgeon 
performs the needful manipulation of the parts. If, however, 
the case is quite early and the extravasation hmited, irriga- 
tion may be unnecessary and a hmited cleansing by means of 
moist swabs suffice, but as a rule, in my opinion, a combina- 
tion of the two is required if there are many food particles 
in the peritoneum. Try to cleanse the peritoneum from above 
downwards, and make certain that the hepatic and splenic 
regions are cleared early ; the amount of fluid *in those parts 
is often very large, and trouble may arise there from septic 
infection after the operation. 

Some pints of sahne will be required and irrigation should 
be continued until the fluid comes away clear. There is no 
need to dry the peritoneum ; it does good to leave clear fluid 
of this nature to be absorbed. The necessity for drainage 
depends upon the particular case : if operation has been 
early, and the amount of extravasation is small and Hmited, 
the abdominal wound may be closed ; in the majority of cases 
it will be advisable to drain. 

The "Fowler position" should be adopted as soon as the 
patient has recovered from the anaesthetic. 

Before the patient leaves the operation table a rectal injec- 
tion of sterilised saline with an ounce of brandy should be 
given, and the use of continuous saline per rectum should be 
commenced a short time afterwards. 

There is no objection to the administration of sips of tepid 
water by the mouth, but nothing else should be given for the 
first forty-eight hours. If there is much complaint of pain, 
and the patient is very restless or unable to sleep, a sub- 
cutaneous injection of morphine may be given, but it is to be 
avoided if possible. 

The treatment above advised is best calculated to prevent 
the more common causes of death after this accident — 
peritonitis, shock, subdiaphragmatic abscess. There are 
two comphcations which cannot be guarded against : — 
(1) Perforation of a second ulcer, stated by Finney to be 
present in 20 per cent, of the cases. The occurrence of 
a second perforation in the same ulcer when it is large. 



PERFORATION OF ULCERS, DIGESTIVE TRACT 163 

(2) Haemorrhage may occur from the same ulcer, or another 
near it. 

Subacute Perforations. — By this is meant the occurrence of 
a very small perforation so that only a little fluid escapes, 
which may be walled off by adhesions. This may happen in 
gastric and duodenal ulcers, the pus forming around the 
perforation. The abscess may gradually extend if untreated 
and eventually attain a large size. If in connection with a 
duodenal perforation, bile may appear in the discharges. 
Should they rupture into the general peritoneal cavity, the 
result will probably be fatal, as it is almost impossible to find, 
or isolate, the leaking point (see Perigastric Abscess, p. 141). 

Perforations of Duodenal Ulcers. 

These ulcers are far less frequently met with than the 
gastric, and it is not always possible to diagnose the one from 
the other. They are far more common in males over 30 than 
in females, but Mr. J. W. Struthers^ had to operate for this 
perforation under the age of 20 in two instances, and only 1 in 
27 was a female. Osier says they may be distinguished by the 
following definite characters : — 

" (a) Sudden intestinal haemorrhage in an apparently healthy person, 
which tends to recur and produce a profound anaemia. Haemorrhage 
from the stomach may precede or accompany the melaena. (b) Pain 
in the right hypochondriac region, coming on two or three hours after 
eating, (c) Gastric crises of extreme violence, during which the 
haemorrhage is more apt to occur. Certainly the occurrence of sudden 
intestinal haemorrhage, with gastralgic attacks, is extremely suggestive 
of duodenal ulcer." 

Unfortunately, in many cases, there is no history of local pain 
preceding the attack. 

It is advisable to speak of this variety of perforation 
separately from the gastric, because it is often difficult to 
distinguish perforations of these ulcers from acute disease 
of the appendix with peritonitis, especially if the appendix is 
situated to the outer side of the caecum, or has never attained 
its proper position in the iliac region. 

When the perforation is that of an ulcer of the stomach, 
the symptoms are those of a general peritoneal invasion ; when 

1 EdlQburgh Medico-Chirurgical Society, LancetyYo\. II., 1912, p. 1371. 

M 2 



164 THE ACUTE ABDOMEN 

the perforation is in the duodenum, the escaping fluid, which 
rarely contains sohd particles, flows down the right side, 
external to the colon, into the pelvis. In these cases, there- 
fore, the resemblance of the attack to one of acute perforative 
appendicitis is very close, and a mistake in diagnosis has been 
made by the most experienced. Mr. Struthers,^ ' in relating 
his series of 27 cases, says that in three of them the pain 
was referred chiefly to the right iliac fossa, and the maximum 
tenderness and resistance was below the umbihcus on the 
right side, but the temperature and pulse-rate were not 
markedly raised. 

Moynihan states that in 51 cases collected by him a correct 
diagnosis was only made in two, whereas the primary incision 
was made over the appendix in 19. 

At the time of operation the appendix may be found 
surrounded by an area of inflamed peritoneum, and may be 
itself so inflamed that the surgeon is misled. It would be 
well, therefore, always to examine the duodenum in its first 
part, when disease of the appendix is not manifested by gross 
naked -eye change, such as gangrene or perforation. 

Do not forget to examine the pelvis for extravasated fluid ; 
failure to do so in any case of perforation may prove fatal, 
whether the ulcer be of the stomach (anterior or posterior 
surface) or other part of the digestive tract. 

The following case is typical : — 

A cabman, aged 39, was admitted ^ on June 13, 1907, complaining 
of much pain in the abdomen. He had suffered from pain in the 
epigastrium for ten years, coming on about an hour after food ; also 
from a feeling of distension and flatulence, but had never had any 
vomiting. The attacks had come " off and on." Six weeks before 
admission he had noticed that his motions were black. At midnight 
on June 12 he had taken a glass of beer, the drinking of which was 
followed immediately by violent pain in the abdomen. This was 
especially severe over the pubes. He vomited one and a half hours 
afterwards, was in great pam all night, and had constant aching pain 
in the right shoulder. 

On admission he was in a condition of collapse, with a pulse of 140 
and temperature of 99°. There was marked tenderness all over, but 
more especially down the right side, and dulness in both flanks. The 
muscles of the abdomen were very tense. Sixteen and a half hours 
after perforation an epigastric incision gave exit to a gush of fluid and 
gas. whilst another incision over the hypogastric region gave freedom 

^ Edinburgh Medico -Chirurgical Society, Lancet, Vol. L, 1912, p. 1371 . 



PERFORATION OF ULCERS, DIGESTIVE TRACT 165 

to much more. The ulcer was found in the first part of the duodenum. 
Saline infusion was required during the operation, and had to be repeated 
later in the day. On June 29 a subdiaphragmatic abscess was opened, 
after resection of part of a rib. He left hospital quite well on July 31. 

There was the sudden onset of abdominal pain (which is 
usually most severe above and to the right of the umbiHcus), 
with marked shock, followed by vomiting. He had had no 
latent interval, but the symptoms which precede the onset 
of a peritonitis were definite. Bile -stained fluid may be found 
in these cases, and the sutures (of No. 1 silk) should be put 
in by Lembert's method in the axis of the canal. A limited 
irrigation should be employed, a drainage tube placed in the 
pelvis, and saline commenced at once, by the usual method of 
administration per rectum. Mr. Struthers does not consider 
irrigation required, but advocates drainage for the first twenty- 
four hours or more. As it is advisable to put a drainage tube 
into the pelvis, no harm is done by making the preliminary 
incision in the lower abdomen to examine the appendix. A 
diagnosis of intestinal obstruction has been made, but the 
rigidity, fixation and tenderness (especially evident on the 
right side), and the incompleteness of the constipation may 
serve to prevent this error in most instances. 

The advisability of performing a gastro -enterostomy must 
be considered whenever operation for perforated gastric or 
duodenal ulcer is performed, but the number of cases in which 
this addition to the gravity of the other operation can be 
made is limited. To do it in some would be to ensure the 
death of the patient, and there are few in which it can be 
said to be required " there and then " to save life. A secondary 
operation can be performed with safety later, should symptoms 
demand it. It is the ulcer of, or near, the pylorus which 
is most likely to lead to contraction, but the suturing of a 
perforation should never diminish the passage to such an 
extent as to render a gastro -enterostomy a matter of urgency. 

At the present day there is perhaps a tendency to do too 
much, for the surgeon naturally wishes to place his patient 
in the best position for complete recovery, and that without 
further operation. Much will depend on the condition of 
the patient, the duration of the illness, and the way in which 
the anaesthetic is tolerated. 



166 



THE ACUTE ABDOMEN 



Should the surgeon think it right to perform a gastro- 
enterostomy the anterior method will be the one chosen. It 
can be quickly performed and does not involve nmch disturb- 
ance of parts. The anastomosis should be made towards the 
pyloric end, and near the greater curvature of the stomach. 
Let the communication between them be fully two inches in 
length, and about 18 inches from the commencement of the 




Fig. 26. — To Illustrate the Relations between Jejunum and Stomach 
in the Operation of Anterior Gastro-Enterostomji 

jejunum. The clamps should be applied obliquely so that the 
opening slopes from the left downwards to the right, and it is 
advisable to apply the outer suture for some distance above 
the inner row to prevent kinking of the loop, although the 
application of one or two extra sutures to hold the left 
extremity of the curve of the loop in position will answer the 
same purpose. This anastomosis is performed in a manner 
similar to that described under entero- anastomosis (p. 280). 
It is not necessary to impress upon the reader the value of 



PERFORATION OF ULCERS, DIGESTIVE TRACT 167 

muscular rigidity in the acute abdomen as a proof that a 
grave lesion has occurred within. This rigidity is a very 
important sign of perforation, the abdomen being often 
literally as hard as a board, and in the diagnosis from other 
acute states it must be specially looked for and its variation 
in different areas noted. 

The acute diseases which are likely to be mistaken for 
perforations of the stomach and duodenum are mainly the 
following : — 

(1) Acute pancreatitis resembles perforation of a gastric or 
duodenal ulcer very closely at times ; there is the same onset, 
with severe pain, vomiting, and collapse. If this is soon 
followed by exudation into the peritoneal cavity of a large 
quantity of fluid the resemblance is very great. Usually, 
however, the pain remains very intense in the upper abdomen, 
dulness on percussion is patchy, and there is a general superficial 
tenderness without very marked rigidity. A rise of tempera- 
ture is frequent. The patient is usually a male, stout and over 
middle age. 

As showing the difficulty occasionally encountered the 
following case may be quoted : — 

A motor-cab driver, aged 33, was sitting on his cab outside one of the 
large cricket gronnds waiting for a fare, when he was suddenly taken 
with a severe pain in the upper abdomen and vomited. He was 
subject to indigestion and had taken food shortly before. He was a 
stout man. On admission twenty-four hours later he was evidently 
very ill, suffering from severe pain and tenderness in the epigastric 
region ; had a pulse-rate 68, laboured respiration, and temperature 97°. 
The abdomen was moving badly, and there was abnormal resistance 
to pressure ; in addition there was slight dulness in the flanks. 

Operation was performed shortly after admission, but the fluid, of 
which there was a large quantity, was blood-stained, and after a search 
fat necrosis of the omentum was found. The abdomen was washed out, 
and a drainage tube packed off with gauze was passed down to the 
pancreas through an opening in the gastro -colic omentum. He was 
relieved of his pain, but died suddenly the fifth day of illness, with 
temperature 103°, rapid cardiac failure and delirium. 

No tumour could be felt before operation. Cammidge's reaction 
was positive. 

(2) Acute Intestinal Obstruction. — Here there is vomiting 
which continues, complete constipation, and paroxysmal 
pain, with a peristalsis which can be seen or felt. Distension 



168 THE ACUTE ABDOMEN 

soon comes on, but between the paroxysms of pain there is no 

rigidity. 

In the sudden onset of gall-stone obstruction due to a large 
stone in the duodenum, there may be difficulty for a time, 
for the pain is high up and not accompanied with intestinal 
peristalsis. There is no free fluid. 

(3) Ruptured Extra-uterine Gestation. — ^The following case 
will illustrate clearly the difficulty sometimes caused by 
this mischance. 

E. S., a married woman aged 31, was admitted -X* on December 1,1913, 
and left St. Thomas's Hospital January 2, 1914. She had suffered from 
indigestion for many years, with pains coming on about fifteen minutes 
after taking food. She had never brought up any blood. It was 
between seven and eight weeks past the last period. At 7 a.m. on the 
day of admission she was seized with violent pains in and across the 
abdomen, chiefly in the epigastrium. These pains were of a shooting 
character and reached right up to the shoulder region behind. She was 
sick twice during the day, and the pains became worse every hour. 
The woman looked ill, but not distressed ; the cheeks were pale, but 
the lips not blanched. Her pulse was small, 108 ; respirations, 36 ; 
temperature, 98-2°. She still complained of pain in the abdomen. This 
was distended, did not move well on respiration, and there was general 
but not very marked rigidity. She had diffuse tenderness, especially 
on the left side of the abdomen, where there appeared to be some greater 
distension. There was greater resistance to palpation in the left loin, 
but no tumour. On percussion there was dulness in both flanks, but 
this was more marked on the left side, and extended into the splenic 
region, and also across above the pubes. The tongue was furred ; 
breath offensive ; bowels not open. She complained of great thirst, 
but was not particularly restless. There was no vaginal discharge ; but 
the uterus was larger than normal. 

Dr. Wilson Stoker was present at the operation, which took place 
about midnight. An incision was made in the lower abdomen to the 
left of the mid-line and the rectus muscle displaced to the left. The 
pelvis and lower abdomen were full of blood, and large clots were 
removed from the pelvis. The tubes on both sides were quickly lifted 
and examined, but showed no evidence of disease or change of any kind. 
The uterus was somewhat enlarged, and just beyond the attachment of 
the left Fallopian tube was a depression which would admit the tip of a 
forefinger, from which arterial blood was trickling into the pelvis ; this 
was removed with the tube and ovary after ligature of the attachments 
close to the uterus. The blood continued to come from above after the 
pelvis had been emptied, and there was a large quantity about the 
spleen which had not clotted and looked quite fresh. With this large 
amount in the upper abdomen where, according to the patient, she had 
first felt pain, it was considered advisable to make certain that there was 



PERFOKATION OF ULCERS, DIGESTIVE TRACT 169 

no source for the bleeding in the stomach region. An incision was 
quickly made in the middle line above the umbilicus, and although 
there was much blood and blood-clots still about the spleen, nothing 
was found in addition to the small opening in the Fallopian tube to 
account for it. During this epigastric examination the pulse failed and 
it was necessary to rapidly close both incisions with interrupted sutures 
of strong fishgut. There was no time to wash away all the blood which 
had accumulated, but some saline was left in the peritoneum, which was 
drained through both wounds. The blood seemed to have penetrated 
everywhere. Sterilised saline was passed into the median basilic vein 
during the operation, and, although very little blood escaped from the 
ruptured tube, after the abdomen was opened she seemed to rapidly 
fail as blood which had previously got into the peritoneum was removed. 
The foot of the bed was raised, the limbs bandaged with flannel, and 
warm water-bottles applied. Saline 'per rectum with some brandy was 
given. The pulse gradually improved and she made good progress. A 
vaginal discharge appeared in a day or two and required treatment. 
Little came away from the drainage tubes, which were soon removed, 
but the temperature was irregularly raised for nearly three weeks. 

(4) Acute Appendicitis. — The usual symptoms of an acute 
attack of appendicitis have already been given somewhat 
freely, so it is unnecessary to refer fully to this part of the 
subject again. 

A history of previous attacks with pain in the usual situation, 
and accompanied by fever, would indicate that there has been 
a diseased appendix, but the variety which is most likely to 
simulate the perforation of a gastric ulcer is that of a first 
attack with gangrene secondary to a concretion in an adult, in 
which there has been an unsuccessful attempt to localise the 
pus. Even here the amount of fever would probably contra - 
indicate gastric perforation. The age of the patient and the 
position of greatest tenderness and greatest degree of muscular 
rigidity are helpful, yet it is possible that the appendix has 
never descended into the iliac fossa but is still subhepatic. 

When it is a first attack of appendicitis, there is also a history 
of gastric ulcer, a distinct statement that the pain began in 
the epigastric region, and much free fluid, the diagnosis is 
impossible. 

E. W., a married woman, aged 33, was admitted on February 20 and 
left for a convalescent home on April 9, 1914. 

On February 18 she was suddenly seized with severe pain in the 
epigastric region when lying in bed in the early morning. She vomited, 
and the vomiting was repeated three times, whilst the pain did not 



170 THE ACUTE ABDOMEN 

greatly improve and was also bad in the right lower abdomen. The 
bowels had acted after an enema. 

For two years she had suffered from pain in the upper part of the 
abdomen, coming on about half an hour after meals and followed by sick- 
ness, which relieved it. There had also been hsematemesis on occasions. 

When first seen she was in a condition of collapse and required 
stimulation to restore her. She looked very ill. The abdomen was 
motionless on respiration, not much distended, but rigid all over, more 
especially on the right side, with marked general tenderness. There was 
considerable dulness in the flanks and on the right side this extended 
up to the liver. The temperature was 102° and pulse 96 (small). 

As there was the history of gastric idcer, and the pain commenced in 
the gastric region, whilst with general rigidity and tenderness there was 
much fluid, it was decided to explore the stomach for possible perfora- 
tion. On opening the peritoneum very little fluid was seen ; the 
anterior surface of the stomach was normal, but as a hard patch could 
be felt on the posterior surface below the lesser curvature, this was 
examined by turning the stomach up. Through an opening below the 
greater curvature the congested base of an ulcer the srae of a sixpenny 
bit was exposed, but there was no perforation. It was covered in with 
some Lembert sutures, but the posterior sac was empty. Exploration 
in the gall-bladder region gave exit to a large quantity of watery- 
looking pus with some flakes of lymph, but without offensive odour. 
The hand passed into the appendix region did not find any induration, 
but the pelvis was full of pus, which passed into the left flank. The 
intestines were not distended and the pelvic organs were normal. 
Although there was no thickening in the region of the caecum, it was 
possible to feel some irregularity of surface, and exploration made 
through a suprapubic drainage incision (extended for this purpose) 
showed a gangi-enous appendix which had given way. This was about 
3^ inches long and gangrenous in the distal two-thirds. A ligature was 
applied, but the peritoneum was not sutured over it. Dr. Gardner 
reported that the bacillus fyocyaneus was the principal organism 
present in the pus removed. Operation relieved her pain and she 
looked much better next day. On March 10 a note was made to the 
effect that the temperature had continued high (about 102° in the 
evening) with a pulse of about 100 to 120. Suppuration had occurred 
in both incisions, and an investigation of the pus showed the bacillus 
pyocyaneus. A vaccine was made and given on February 25 and again 
on March 2, with a sUght effect on both occasions. On March 8 the 
lower wound began to discharge more freely. There was evidence of 
pleuritic effusion at the left base. 

A fortnight later there was still some fever, although the wounds 
had closed for some time and nothing abnormal could be found any- 
where, except at the left base. No signs of mischief remained at the 
end of another week. 

(5) Hysteria. — An attack of hysteria may simulate perfora- 
tion sufficiently near to mislead. At p. 233 is the account of 



PERFORATION OF ULCERS, DIGESTIVE TRACT 171 

the case of a young nurse who was operated on for epigastric 
pain and vomiting, supposed to be due to perforation. In a later 
simulation we found no rigidity of muscles, a moderate pulse - 
rate, and a smiling face, although she had " great agony " 
and vomiting. Dr. Beddard has recorded somewhat similar 
attacks in chlorotic women, in two of whom operation had been 
performed twice. 

(6) Perforation of the gall -bladder closely simulates perfora- 
tion of gastric and duodenal ulcer. Here there will probably 
be a history of gall-stone colic, sometimes with jaundice. 
The tenderness would be in the region of the gall-bladder, 
and incision would be required over that part. I have known 
an acute biliary colic due to gall-stones in a young chlorotic 
female resemble perforation very closely at its onset. 

(7) In lead-colic there would be other symptoms of lead 
poisoning, and may be a history of previous attacks, but the 
first attack, as also the first of the gastric crises of tabes 
dorsalis, might present some difficulty. 

(8) Rarer conditions which require mention but need not be 
particularly discussed are acute dilatation of the stomach, 
thrombosis of the mesenteric vessels, irritant poisoning, and 
pneumonia. Of these the only one which requires a special 
notice is the last ; we have already referred to it in speaking 
of the resemblance of acute pulmonary inflammation to an 
attack of acute appendicitis. An illustration of this close 
resemblance may be given. 

A. S., aged 20, admitted -X- February 8 and left March 12, 1913. 
The day before he was feeling bad with general pains about the body, 
vomited, and could not breathe properly. He gave a history of a 
month's dyspepsia, and complained of acute pain in the abdomen which 
had commenced ten hours before. He had been treated for an attack 
of appendicitis ten years before. He looked very ill, his lips were white, 
and he appeared almost collapsed. He complained of right-sided 
abdominal pain ; had a pulse 130, and temperature 103*8° ; respirations, 
20. 

The abdomen was quite motionless on respiration. The recti on 
both sides were very rigid. On palpation tenderness was present, 
confined to the right side ; in the upper abdomen it was very pro- 
nounced, whilst there was some shght tenderness in the right ihac fossa. 
Nothing could be felt in the abdomen on account of its extreme rigidity 
and tenderness. There was no distension or abnormal dulness. The 
respiratory movements were almost entirely thoracic and rather shallow. 



172 THE ACUTE ABDOMEN 

Some pain was complained of on the right side of the abdomen on deep 
inspiration. No abnormal signs were present anywhere over the lungs. 

An epigastric incision was made and both surfaces of the stomach 
examined. The appendix was then removed, it was kinked, but 
showed no other evidence of disease. A large round worm could be 
felt in the small intestine. There was no free fluid in pelvis or in 
flanks, but a small quantity was found between the stomach and anterior 
wall of the abdomen. On the following day he still had some pain in 
the abdomen, but had passed a fair night. The pulse had improved. 
At 11.30 it had changed and was now 160, but improved after injection 
of camphor and rectal saUne. At 3.30 p.m. the pulse was 146 and 
respirations 44, and he coughed up some rusty sputum. At 11.30 p.m. : 
" there are now definite signs of inflammation at the lower part of the 
right lung posteriorly. " 

On the 24tli he succeeded in bursting open the wounds as a result of 
his violent coughing, and it was necessary to resuture. 

Both lungs became affected, but no further abdominal compUcation 
ensued. The temperature became normal on the twelfth day. 

Perforations of Gastro -Jejunal and Jejunal Ulcers. 

The knowledge that an ulceration of the jejunum is one of 
the causes of the acute abdomen which must be considered 
by the surgeon of the present day was due in the first place to 
Brauns. In 1899 he met with a case in which an ulcer of that 
part of the small intestine perforated and produced a fatal 
peritonitis eleven months after a gastro-jejunostomy for pyloric 
stenosis in a man aged 25. In this instance the operation had 
been by the posterior method, and the ulcer was found at the 
necropsy. Since that time there have been recorded many 
cases in which ulceration of the jejunum has required surgical 
treatment, and in all of them the operation of gastro -enteros- 
tomy had been performed for the relief of some form of gastric 
ulceration, or a result of it. From a chnical point of view 
they may be divided into two classes — the chronic and the 
acute perforative. In the former we are most likely to get 
an ulcer which will produce local symptoms before perforation 
into the peritoneum, if it does perforate ; in the latter no 
warning is given, but if the patient has previously had a 
perforation of a stomach ulcer he thinks that a similar accident 
has occurred again. I have purposely refrained from using 
the term " peptic " as applied to these ulcers, for it is not 
proved that they are all of them due to hyperacidity of the 
gastric juice ; indeed, in more than one the state of the gastric 



PERFORATION OF ULCERS, DIGESTIVE TRACT 173 

juice has been definitely described as normal. The appearance 
in three out of the four perforations of this kind that have 
been under my personal notice was similar to that of some 
acute perforated gastric or duodenal ulcers. They also 
resembled the ulcer in two cases of perforation of the ileum 
during the course of typhoid fever,-^ to which I shall refer 
later (see p. 182) ; the naked -eye appearances were quite 
similar. Some of these ulcers are probably due to an acute 
bacterial invasion, but I do not think the term " peptic " 
should be used. It is an interesting fact, however, that they 
are only met with after the operation of gastro-jejunostomy, 
and chiefly after the anterior operation — ^for example, out of 
some 77 cases 52 followed anterior gastro-jejunostomy.^ In 
the paper here referred to a collection of 100 cases has been 
made. 

The most startling complication of jejunal ulcer is acute 
perforation when the patient is apparently quite well in health, 
and in this, as in other compHcations, it resembles simple 
ulcers of the other parts of the digestive tract. This accident 
happened in 21 patients, but inasmuch as in two of them it 
occurred twice at considerable intervals, 23 instances are now 
known. Operation performed at the earliest opportunity 
was successful in saving life on nine occasions (Goepel, 2 ^ ; 
Hybrinette, 1 ^ ; Maylard, 2 ^ ; Battle, 4). This improved 
record of results for operation makes it appear that operation 
for that accident has rendered it less dangerous than the slow 
extension of an ulcer which is shut off from the peritoneum 
by means of adhesions. The formation of a localised abscess 
is known to follow at times, and may lead to an intestinal 
fistula, but it may be necessary to operate for the local ulcera- 
tion, on account of the troublesome symptoms which it causes. 
This has involved resection of the ulcerated bowel, the jejunal 
end being placed into the stomach and the duodenal end into 
the side of the jejunum lower down. 

The cases which have been under my treatment are as 
follows : — . 

1 Lancet, 1903, Vol. II., p. 863. 

2 Universal Medical Record^ Moynihan, January, 1912. 
* " Kongress bericht," 1902, p. 10. 

^ Revue de CMrurgle, 1906, p. 30. 
« Lancet, 1910, Vol. I. 



174 THE ACUTE ABDOMEN 

A clerk, aged 30, was admitted July 15, 1904, for acute abdominal 
distress. He stated that about four hours before admission he had been 
seized with violent pain in the abdomen, vomiting and hiccough. 

On admission the abdomen was moderately distended and did not 
move on respiration. A rounded prominence was visible in the epigas- 
trium, and immediately below this another and smaller prominence, 
the latter being situated immediately above the umbiUcus. Distension 
was most marked in the epigastric and umbiUcal regions, and there was 
obvious fulness of the flanks. There was no hyperaesthesia of the skin, 
but considerable, yet not intense, tenderness. No definite tumour 
could be felt. The resonance was impaired in both flanks, but no fluid 
thrill could be felt, nor was the dulness a shifting one. Elsewhere the 
note was of a tympanitic character, this being especially marked in the 
epigastric region. The liver dulness was obliterated, the note over the 
region of the Hver being decidedly tympanitic. The general condition 
of the patient was good. Temperature, 98° ; pulse, 100 ; respira- 
tions, 20. 

The presence of a scar in the abdominal wall caused questions to be 
asked about previous operation, and the following history was obtained, 
some of which was subsequently verified. He had suffered from 
indigestion after he became 16 years old, and three years before was 
much troubled with vomiting from a quarter of an hour to two hours 
after food, and on one or two occasions he brought up blood. Twenty- 
two months previously he had undergone an operation in Birmingham, 
for pyloric obstruction after gastric ulcer. Anterior gastro-enterostomy 
was performed, a Murphy's button being used to approximate the 
parts. His progress after this operation was uninterruptedly good 
until March 4, 1904, when he was seized with pain in the abdomen, and 
had to go into the hospital again for " obstruction " ; at this operation 
the Murphy's button was removed. 

At the operation, which was performed about five hours after the 
commencement of the symptoms of perforation, an incision was made 
to the left of the middle hne above the umbilicus through the rectus 
sheath, the muscle being displaced outwards. There was a rush of gas 
when the peritoneum was opened and a greatly distended coil of bowel 
presented ; this was punctured to diminish its size and gain more room 
and emptied of much gas. The opening was closed with Lembert silk 
sutures and the coil returned. The stomach, which was much distended, 
was drawn into the wound ; the point of attachment of the small 
intestine to the gastric wall was defined, and a small round perforating 
ulcer, about ^ inch in diameter, located in the anterior part of the 
jejunum at a distance 1^ inch from the point of attachment of the 
latter to the stomach. The stomach and the upper part of the jejunum 
were as far as possible emptied of gas through the ulcer, and this was 
then turned in with a single row of Lembert sutures. The coils of 
jejunum in the immediate neighbourhood of the perforation were greatly 
distended, tliiokened, and of a dull red colour. A small amount of free 
purulent fluid was present in the abdominal cavity, with patches of 
lymph on the intestinal coils. A second incision was made in the 



PERFORATION OF ULCERS, DIGESTIVE TRACT 175 

middle line above the pubes and the peritoneal cavity thoroughly 
irrigated with normal saline solution. A Keith's drainage tube was 
then inserted into the pelvis through the lower incision, and the upper 
wound closed. The man's general condition at the end of the opeiation 
was satisfactory. 

There is not much to record in the after progress of the case. He 
was sick three times during the night following the operation, bringing 
up each time large quantities of greenish fluid. In the morning a 
turpentine enema was administered with a very good result. Sulphate 
of magnesium (two teaspoonfuls) was given every four hours. The 
abdomen was very shghtly distended and not very tender, it moved to 
some extent with respiration, though not freely. Pulse, 104 ; respira- 
tions, 20. 

The bowels acted on the following day, the abdominal distension 
subsided, he became much more comfortable, and towards night the 
sickness ceased. The Keith's tube was replaced by a rubber one of 
smaller size, there being very httle discharge. Two days later this was 
removed altogether. He left the hospital on August 8, having com- 
pletely recovered. 

The second case was a very interesting one, being almost 
unique from the course of the various conditions for which 
operation was required. 

An unmarried woman, aged 37, was admitted -X* on March 25, 1903,^ 
with symptoms of perforated gastric ulcer, which had commenced four 
and a half hours before. Operation was performed at 11.15 p.m., and 
an ulcer near the pylorus and on the anterior surface was found and 
sutured, the peritoneal cavity washed out and the pelvis drained. At 
the operation it was noted that there was already a good deal of narrow- 
ing of the pylorus. She left hospital on May 12 and continued well 
until October, after which gastric pains recurred. She was readmitted 
in April, 1904, and anterior-gastro-jejunostomy performed. The 
stomach was dilated, the lower border reaching the level of the umbilicus. 
The pylorus was much constricted. The operation \\ as on the 8th, and 
she left hospital on April 28. 

She regarded herself as cured until May 5, 1905, when she was again 
sent to the hospital by Dr. J. Scott Battams. 

About six hours before admission she had a severe attack of pain, 
especially on the right side of the abdomen, with vomiting. The bowels 
had acted twice that day. 

In the ward the abdomen did not appear distended and moved freely 
on respiration. The resonance was normal in all parts. Pulse, 72 ; 
temperature, normal. There was shght tenderness all over the abdomen, 
more evident above and to the left of the umbilicus. 

She vomited two or three times during the night. On the morning 
of the 6th the temperature had been up to 99*4°, and a distended coil 
of small intestine was seen above and to the loft of the umbihcus. There 

^ .Transactions R. See. Med., June, 1909. 



176 THE ACUTE ABDOMEN 

was tenderness as before, but it was more marked over the distended 
coil. 

When seen by me at 2 p.m. the condition was much as above de- 
scribed, but the distension of the small intestine in the umbilical region 
was greater, and there was visible peristalsis. 

Operation was performed twenty-three hours after the first onset of 
pain, the abdomen being opened through the left rectus sheath about 
an inch from the middle Hne. A red and distended coil of small intestine 
presented which, traced upwards, led to the old gastro-enterostomy 
junction ; from this a greatly distended coil passed downwards, on the 
anterior aspect of which, 1 ]^ inch from the line of junction, was a rounded 
opening from which gas and intestinal contents were escaping. The 
coils near were inflamed, oedem^tous and distended, there being lymph 
on the surfaces near the perforation. A knife was introduced through 
the ulcer and a cut made upwards, so that the hne of junction between 
the stomach and intestine could be explored ; the finger passed easily 
into the stomach and then into the jejunum beyond the line of junction. 
There had been no contraction of the opening. After the distended 
coils had been emptied, the incision was closed with Lembert silk sutures 
and the intestine washed with sterihsed sahne. A second incision was 
now made in the middle Une above the pubes through the old scar and 
the pelvis emptied of a small amount of purulent fluid, which was not of 
offensive odour. It was cleansed with steiihsed saUne, and both wounds 
sutured, without drainage. Shock was counteracted by the administra- 
tion of half a pint of sahne per rectum every two hours. The patient 
recovered and left a month later. 

She came again for operation^ in 1906 on account of symptoms which 
she herself diagnosed as due to " perforation." She had not been 
feehng very weU for a fortnight, but there had been nothing very definite. 
There was, however, some pain in the abdomen on March 12 which she 
could not locahse. At 9 a.m. on the 14th she had felt a sudden increase 
in pain, which was now in the upper part of the abdomen, and she 
vomited. 

At 3 p.m. she was lying on her back, with eyes sUghtly sunken, but 
not at all anxious-looking. Her pulse was 85 and temperature 100' 6°. 
The abdomen was moving fairly on respiration. On examination it was 
tender, especially to the left of the umbilicus, and still more so near the 
lower end of the scar representing the site of the previous operation for 
perforated jejunal ulcer. In that region the muscular rigidity was most 
marked, and there was distinct swelling. There was impaired resonance 
towards the left flank. No visible peristalsis ; the hver dulness was 
not changed. 

Incision was made through the left rectus sheath and the muscle 
displaced inwards. A thin purulent fluid was present on opening the 
peritoneum ; and a coil of distended small intestine of a dull red colour, 
having some patches of lymph on its surface, presented immediately 
under the opening. Two or three patches of yellow lymph were espe- 
cially evident on the line of junction of the stomach and small intestine ; 

1 Clin. Soc. Trans., Vol. XL., p. 250. 



PERFORATION OF ULCERS, DIGESTIVE TRACT 177 

one of them, of rounded shape, covered the ulcer, which had perforated, 
and the probe passed directly through it into the gut. It was about 
^ inch below the line of junction on the jejunum, and about the size of a 
crow quill. The tissues around it were indurated. A suture was put 
across it, and this was infolded with a row of interrupted Lembert silk 
sutures. The pelvis was cleansed from purulent fluid and lymph 
through a second incision. Both openings were closed and healed 
without difficulty, and she left on April 12. No adhesions were found 
within the peritoneal cavity at this operation, and when she was shown 
at the Clinical Society some months later there was no ventral hernia. 

The fourth perforation was in a patient under my observa- 
tion in 1910. 

He was a man of 35 who had undergone an operation in 1907 by a 
surgeon in Glasgow for a perforated gastric ulcer, and two months later 
a gastro -enterostomy by the anterior method, with entero -anastomosis, 
for the relief of pyloric obstruction. He had enjoyed good health until 
the morning of August 26. That morning about half-past 8, when 
having his breakfast, he had been seized with a sudden pain in the upper 
part of his abdomen in the splenic region and had felt sick. He had 
not, however, vomited. Feeling himself that his symptoms were some- 
thing like those whch he had experienced at the time of perforation of 
the gastric ulcer, he immediately sent for a medical man, Dr. Currie, 
who recognised that something serious had taken place. He called in 
a surgeon, who, in consultation, considered that the condition was a 
temporary one of colic and that the patient would soon improve. He 
did not advise operation. So strongly did Dr. Currie feel that some 
perforation had taken place that he thought it well to get another opinion. 
When first seen by Dr. Currie there was comparatively little dulness in 
the region of the stomach to the left side, where most of the pain was, 
but by 11.30, three hours after the commencement of symptoms, a dull 
area was evidently extending from this spot, and from the great tender- 
ness whch existed down the left side of the abdomen and the rigidity 
of the left rectus, it was considered that fluid was escaping and gradually 
diffusing itself along this side of the abdomen towards the pelvis. I 
thought at the consultation that the patient had a perforated jejunal 
ulcer because the symptoms were similar to those in the other cases 
which had come under my notice, and from the fact that he had under- 
gone the two operations mentioned. Operation in this case was 
performed at 1 o'clock, as soon as he could be got into a surgical home. 
There was some free fluid, thin and without odour, on the left side of the 
abdomen, running down to the pelvis. A perforation was found at the 
junction of a coil of intestine with the anterior wall of the stomach, 
being on the intestinal portion of the junction. There was induration 
round this perforation, and the coil of intestine, which came up to the 
stomach and formed the loop, was a good deal distended and much 
congested. The opening itself was comparatively small and was only 
defined on pressure of the intestine so as to force gas through it It 
was closed with silk sutures, the left side of the abdomen thoroughly 

A.A. N 



178 THE ACUTE ABDOMEN 

cleansed, some fluid mopped from the pelvis, and the wound closed 
without drainage. The patient made a good recovery. The amount 
of fluid in this case was comparatively small and of a greenish colour, 
without odour, but gave definite evidence of its presence and extension 
downwards, firstly by the increase in the dull area noticed by Dr. Currie, 
and secondly by the spread of the tenderness. The operation was 
performed so soon after perforation that no lymph had formed, and I 
consider that the case reflects very great credit on Dr. Currie. 

There are various points in these cases which are worth 
recapitulating : — 

(1) The ulcers gave no intimation of their presence until 
perforation occurred. 

(2) The symptoms were very much like those resulting from 
an obstruction by a band, there being localised distension 
and, in one instance, peristalsis of the bowel near the perfora- 
tion. 

(3) The distension of the bowel when exposed was found to 
be considerable, but it was relieved by forcing the contained 
gas through the perforation, after which, manipulation was 
easy. It was not easy to find the perforation in all. 

(4) In no case was it necessary to excise the ulcer. 

(5) In two instances a counter -opening was required for the 
satisfactory cleansing of the pelvis, but both wounds were 
closed without drainage in the second case. 

The proportion of recorded cases of simple ulcer of the 
jejunum to the cases of gastro -enterostomy appears very 
much against the anterior method of operation ; but this 
tells as an argument less forcibly than would appear, because 
it is very probable that the anterior operation has been per- 
formed more frequently than the posterior. I formerly 
considered that the anterior operation possessed advantages 
which were likely to make it the more favoured operation of 
the two in a general way, and that the danger of the formation 
of this kind of ulcer was so slight that it might be neglected in 
considering the question. The introduction of the posterior 
" no loop " operation by the Mayos has, however, given us 
even better results, which in my opinion constitute it the best 
of the numerous methods before the profession. Since the 
account of it was published, I have invariably performed the 
posterior operation in cases requiring gastro -jejunostomy, if 
the state of the parts involved permitted. 



v. 



PERFORATION OF ULCERS, DIGESTIVE TRACT 179 

Perforations of the Small Intestine met with during 
THE Course of an Attack of Typhoid Fever. 

Although the fatal character of a perforated typhoid ulcer 
was fully recognised long before 1884, it was only during that 
year that Professor Leyden suggested operation for it and, 
during the same year, that Professor Miculicz operated for the 
first time. 

This group differs from most of the others which we have 
been considering, inasmuch as " the acute abdomen " develops 
during the course of an illness which may have already severely 
tried the strength and endurance of the patient. It has been 
calculated by Dr. Hector Mackenzie that 3-3 per cent, of 
all cases of typhoid fever 
(Buizard gives 3*73 per 
cent.) die from this com- 
plication ; and, further, 
that 696 per cent, of them j^ 
occur during the second, 
third, or fourth weeks of 
the illness. His lecture in 
the Lancet of September 
26, 1903, is both interest- j^iq. 27.— Perforation of Typhoid Ulcer, 
ing and instructive and A. Other Ulcers are shown, B. 

will well repay perusal. ^^- ^^"^^^'^ ^^^P^^^^ ^^^^^^• 

Dr. E. W. Goodall found perforation in 35*9 per cent, of 
fatal cases at the Homerton Fever Hospital, and of the total 
number of cases only two recovered — one after operation, the 
other after doubtful perforation. Perforation may occur in 
the ambulatory form of typhoid or before the patient has 
felt ill enough to go to bed, but it is very rare before the ninth 
or tenth day of the disease. It is most frequent towards 
the end of the third week. 

" Peritonism," the result of a perforation of the ileum, is 
often not very marked, and unless some such series of rules as 
those suggested for the nurse by Osier in cases of typhoid be 
enforced its occurrence may be overlooked. As a rule these 
patients are under skilled observation ; therefore there is a 
chance for them which is not afforded many of those in our 
other groups. They are watched from the beginning, and 

n2 




180 THE ACUTE ABDOMEN 

preparation should be made for operation at the earliest 
moment if there is any serious change in the abdominal 
symptoms. 

Whilst in ambulatory cases and cases of a mild nature the 
symptoms are definite, they may be ill -marked in a man who 
is in a condition approaching the typhoid state. 

Then again the contents of the ileum in this disease are 
frequently scanty, and the perforation may not allow of the 
immediate escape of much fluid ; at all events, the sensitive 
peritoneum is not flooded at once with a highly irritating acid 
compound, the amount of which rapidly increases from minute 
to minute, as in perforation of the stomach. 

The account of two cases on which I operated at the request 
of my colleague. Dr. Hector Mackenzie, will show to some 
extent the conditions which may be met with when the general 
state of the patients is favourable. 

In the first, perforation occurred on the tenth day of the 
first relapse, and symptoms of perforation had been noted 
twelve hours before the operation, which took place on 
December 4, 1901, when he was under treatment for the 
fever. The history was as follows : — 

The fever had lasted about thirty days ; there was then a period of 
normal temperature lasting eight days, followed by a relapse, and on 
the tenth day of this he complained of a sudden and severe pain in the 
abdomen which woke him up. After an action of his bowels he went 
to sleep again and slept for nearly two hours, being again awakened by 
the pain. He did not vomit until seven hours after the commencement 
of symptoms. 

He was a man aged 22. At the time of operation he had pain, 
distension, shifting dulness in the flanks, extreme tenderness in the 
right iliac fossa, and a complete absence of dulness in the liver region. 
The pulse was 95 ; respirations, 26 ; temperature, 102-4°. The 
temperature fell rapidly to 97° after operation, but soon rose again. 

At 10.30 a.m. incision in the median line below the umbilicus showed 
a collection of thin yellowish fluid under the peritoneum, with some 
lymph on this surface of the small intestine. Coming from the upper 
angle of the wound was a thin tongue of omentum adherent at its 
extremity to a coil of the small bowel, which appeared paler and more 
contracted than the other coils around. On pulling on this piece of 
omentum the portion of intestine to which it adhered rotated and 
showed a perforation from which the same kind of fluid was coming. 
This perforation was rounded and sharply cut, measuring about ^ inch 
across. A silk suture was placed across this opening to draw the 
edges together, and the ulcer invaginated with Lembert silk sutures 



I 



PERFORATION OF ULCERS, DIGESTIVE TRACT 181 

(size No. 00). The lower abdomen was washed out with sterilised 
saline and a drain left in the lower angle of the wound. On February 22, 
1902, an abscess was opened which was under the right rectus, which 
appeared to have resulted from an indiscretion in diet. The pus from 
this abscess was sterile. 

The second case was in some respects similar. 

A man aged 28 was admitted on July 7, 1902. On June 30, after 
a heavy day's work, he had been suddenly taken ill with pains, some 
shooting across the forehead and others of a stabbing character in the 
back. On July 2 he was at work, but had to return home. On the 
morning of the 3rd he awoke feeling very chilly, shivered and then 
sweated profusely, and the pains continued during the day. On the 
4th he had several rigors and vomited after food. On the 5th he was 
able to go out and see his doctor. On the 7th, when going to the 
hospital, he became giddy and fell. He was a well-developed man, 
with flushed perspiring face, and slightly sunken eyes. The abdomen 
was well covered and moved well. There was slight distension in the 
left iliac fossa, which, as well as the epigastrium, was slightly tender to 
pressure. No spots ; spleen felt ; tongue dry and brown ; chest 
normal. Pulse, 80 ; respirations, 36. Bowels confined. The Widal 
reaction was absent on the 8th. For the first four days the temperature 
varied from 100° to 103°. On the morning of the 11th it was noted : 
" Pain in the epigastric region on coughing, where there is some tender- 
ness on pressure. Tongue cleaner. Bowels well opened after enema. 
Temperature 100-6° ; pulse 68, good tension ; respirations, 26." At 
1.30 p.m. there was a sudden onset of abdominal pain, referred princi- 
pally to the region of the umbilicus, but also to the right iliac region. 
Vomiting occurred soon after the onset of pain. He was seen at 
2.15 p.m. ; and then the abdomen moved poorly on respiration, the 
right side being especially rigid, resistant and tender to palpation. 
The pulse was 84 and the temperature 102-6°. At 4.30 p.m. he looked 
much worse. His expression was anxious, and eyes sunken. He lay 
with the knees drawn up, and complained much of the abdominal pain, 
which was most severe about the umbilicus, and was aggravated by 
coughing or drawing a deep breath. The abdomen, which did not move 
with respiration, was held rigidly. The resistance and tenderness were 
very marked, especially in the right iliac region. There was no dulness 
in the flanks and the liver dulness was not encroached on. The pulse 
was now 104, and smaller than before, but the temperature was un- 
altered. Operation was performed at 7.15 p.m., five, and three-quarter 
hours after the onset of the acute pain. The anaesthetic was ether, 
preceded by gas. A 4-inch median incision below the umbilicus was 
made, and some thin, light yellow pus-like fluid containing some small 
yellowish masses, without faecal smell, was seen between the nearest 
coils of intestine. On tracing a coil downwards towards the caecal 
valve there was soon found a round, clean-edged perforation about 
I inch in diameter, with a slough adherent to it on its inner side. The 
opening was closed with Lembert sutures. After the lower abdomen 



182 THE ACtJTl: ABDOMEN 

had been washed out the abdomen was closed without drainage. The 
patient's condition at the end of the operation was good. On the 1 4th 
the Widal reaction, which had been negative before the operation, was 
now positive. The abdominal wound did not close satisfactorily for 
some time, and he only left on September 10. This man was readmitted 
on September 18 of the same year for periostitis of the femur. He was 
readmitted on January 3, 1903, for abdominal pain, which had come 
on after a slip when he was carrying a sack of coals. This was very 
severe, and was probably the result of rupture of some adhesions. 
Next year he came under observation again for abscess of the thigh, 
which closed under treatment. The pus contained typhoid bacilli, and 
the bone was bared but not necrosed. 

I may mention here, as a curious addition to this history, 
that the thigh wound reopened after he left the hospital, and 
as recently as December, 1904, the pus contained typhoid 
baciUi on bacteriological examination. It is sad to relate that 
his wife, who dressed his wound for him, caught typhoid about 
August, 1910, and died soon after admission to the hospital as 
a result of the severity of the attack. 

Influence of Perforation of TypTioid Ulcer on the Temperature. 

The chart (Fig. 28) illustrates the rapid fall to 96-8°, rebound 
to 102-8° on evening of operation ; then a gradual return 
to the previous run of temperatures mitil, on the seventh day 
after the perforation, the records were much the same as 
before it. This patient had a second relapse in January and 
a third in February of the following year, but recovered. 

In both instances the ulcers were single and of a punched - 
out character, with surrounding healthy tissue, and did not 
suggest that they resulted from the spread of the necrotic 
process seen in the Peyer's patch of an ordinary typhoid 
patient. 

There may be more than one perforation, but as a rule 
(in 88 per cent.) it is sohtary and small. The incision should 
therefore be made near the middle line, rather than over the 
iliac fossa. 

Messieurs Dujarier and Matthiew ^ state that it is found in 
the last 60 centimetres of the lower end of the ileum in 93-51 
per cent., and it is almost always on the free border of the gut. 

Another perforation may sometimes be found co-existing 

* Le Journal Medical Frangais, October, 1912, p. 426. 



PERFORATION OF ULCERS, DIGESTIVE TRACT 183 



l90!.December 

I 23 456789 10 



with the one in the ileum, and this may be in any part of the 
digestive tract below the diaphragm. 

The amount of shock was not excessive in either patient 
whose case has been related. The rate of the pulse in the 
first case was increased in frequency from 68 to 84, forty- 
five minutes after the perforation, and to 104 three hours 
afterwards. In the second it was more constant at about 
95 for from two to ten hours after the onset of acute 
symptoms. 

In neither instance was there any history of shivering, which 
is described by Dr. 
Goodall as an initial 
symptom in at least 
26 per cent, of his cases. 

The diagnosis of these 
perforations in the 
course of enteric fever 
is not always easily 
made. Patients suffer- 
ing from this disease 
frequently complain of 
abdominal pain. This 
has occasionally been so 
severe that an explora- 
tory operation has been 
performed, but without 
any lesion being found 
to account for the 
symptom. 

The signs on which chief reliance should be placed in making 
a diagnosis are local pain and tenderness, with rigidity and 
fixation of the abdominal muscles and disappearance of the 
liver dulness. 

If there is a doubt about the presence of a perforation it 
might be well to percuss the hepatic region on each examination . 
A gradual diminution in the normal liver dulness would be 
very significant. In one of our patients the latter sign was not 
evident five and three-quarter hours after the perforation had 
occurred, and you must not wait for it. 

A sudden drop in the temperature in the absence of 



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Fig. 28. — The Temperature after Perforation 
and Operation for Typhoid Perforation. 

Perforation during relapse (tenth day), 
10.20 p.m., December 3; operation, 
10.30 a.m., December 4. (Case 
p. 180.) 



184 THE ACUTE ABDOMEN 

hsemorrhage is suspicious, but there may be no change in 
this respect for some time. 

Rarely peritonitis develops during the progress of typhoid 
fever and no evidence of perforation has been found, whilst 
in some instances this inflammation has evidently preceded 
the symptoms of perforation, for which an operation has been 
undertaken. 

I do not think there is now any real difference of opinion 
amongst surgeons regarding the necessity for operation in 
cases of perforation occurring in the course of typhoid fever. 
It is hard to beHeve that there is any amongst physicians of 
the present day. The fact that exploration has not revealed 
a perforation in every instance in which the abdomen has been 
explored is not against exploration ; a fatal ending is assured in 
practically every case if a perforation is not treated by operation. 

As a rule the incision should be made through the right 
rectus muscle or to its inner side. Suture of the perforation 
should always be carried out if possible ; this undoubtedly 
gives the best results when the bowel will hold sutures without 
producing too much constriction of its lumen. 

A French surgeon, Duval, speaks rather highly of the 
formation of an enterostomy done by bringing the perforation 
to the skin, and in 22 collected cases gives 10 cures to 12 deaths, 
a better result than has been obtained by any other method. 

Owing to the mortality of enterostomy for other conditions, 
I can but think that the surgeon should be very loth to perform 
this operation in a disease like typhoid, as it must interfere so 
seriously with nutrition. 

In a limited number of cases excision of the area involved 
might be necessary, but, as you will quite understand, such 
an operation is a severe one, more than most typhoid patients 
could possibly undergo with any prospect of survival. 

Professor Buizard gives a summary of 664 operations : — 
Cures, 182 (27-41 per cent.) ; deaths, 482 (7259 per 
cent.). 
Examination of his statistics shows that the improvement 
continues as regards results of operation for typhoid perfora- 
tion, and the mortaHty diminishes yearly. 

Taking five -yearly periods : — 

1884—1889, 90 per cent. ; 1889—1894, 86-36 per 



PERFORATION OF ULCERS, DIGESTIVE TRACT 185 

cent. ; 1894—1899, 75-63 per cent. ; 1899—1904, 697 
per cent. ; 1904—1909, 64-63 per cent. 
From a study of cases operated on we learn that recovery 
may follow — 

(1) In spite of the desperate condition of the patient ; 

(2) In spite of the supervention of complications necessitating 
other operative assistance ; 

(3) In spite of one or more relapses of the fever. 
Operation, to be successful, must be early. You must not 

wait too long for recovery from collapse. Armstrong says that 
in ten operations performed during the first twelve hours there 
were four recoveries ; but that in ten done during the second 
twelve hours success was only once obtained. All those diecf 
which were operated on twenty -four hours or more after the 
onset. 

Ashurst states that two out of 31 cases recovered in the 
third twelve hours, and 18 out of 55 when more than thirty -six 
hours had passed. 

A curious clinical observation has been recorded by 
Dr. Poynton,^ who discovered much fluid in the peritoneum 
of a typhoid patient in the early stages of the disease. 

The attack was acute, and Widal's reaction had proved negative. 
An operation was performed, as it was thought it might be a case of 
acute perforation of the appendix. On opening the abdomen no 
disease of the appendix or perforation of the bowel was found. The 
whole of the peritoneum appeared to be much congested, no lymph was 
present, but a considerable quantity of almost clear fluid escaped 
through the incision. The wound was closed, and the patient recovered, 
after a typical attack of typhoid fever. The bacillus typhosus was found 
in the fluid. 

This finding of a large quantity of fluid in the peritoneum of 
a typhoid patient is very unusual, but its possible occurrence 
is a thing to be remembered, as a somewhat similar condition 
was found in a patient subjected to an operation for typhoid 
perforation by Mr. Gordon Watson. 

A female aged 11 — the twenty-sixth day of the disease. Operation 
about an hour after the first symptom. Dulness in flanks when first 
examined, and " the abdomen absolutely full of fluid " when opened. 
Ulcer 18 inches from the valve ; closed with suture. Peritoneum 
everywhere injected, but quite glossy. 

1 Transactions of the Medical Society, London. 



186 THE ACUTE ABDOMEN 

It is evident that this effusion had been present before the 
signs of perforation were manifested. The septic fluid from 
the bowel would therefore be considerably diluted directly 
it entered the peritoneum. 

Tuberculous Ulcer of the Small Intestine. 

The occasional perforation of a solitary tuberculous ulcer 
of the small intestine is sometimes encountered in an operation 
for peritonitis, the nature of the ulceration being proved by 
microscopical examination after removal by excision. In 
some of the cases there is no history preceding the perforative 
symptoms, and nothing can be found at the operation pointing 
to the causation of the disease. Cruise^ gives an account of 
thirteen instances of intestinal perforation found in 475 
necropsies on patients who had died from chronic pulmonary 
tuberculosis. Ten of these were complete, into the general 
peritoneal cavity, and in the majority the symptoms were 
characteristic, commencing with sudden violent pain and shock. 
The shock may be quickly fatal, or an acute peritonitis may 
develop. Cruise says that in five the symptoms were most 
indefinite, two having absolutely no abdominal symptoms ; he 
came to the conclusion that perforation of the intestines occurs 
most commonly in chronic tuberculosis in from 1 to 5 per cent, 
of the cases. It is never possible to diagnose with certainty a 
partial perforation, and the existence of a local abscess due to 
perforation can only be diagnosed when the mass can be felt. 

In any case, when the symptoms and history point to a 
perforative peritonitis, special attention should be given to 
the ileo-csecal region, for here we find not only the perforation 
in cases of latent typhoid, but also in tuberculosis. If the 
perforation is not found close to the caecum, follow the small 
intestine upwards, and go slowly, looking for any change from 
the normal and for the presence of fluid, which may be seen 
flowing from the direction of the opening. 

If nothing is found in the small intestine, examine the 
sigmoid. Professor Lejars ' mentions a case in which he closed 
a fistula remaining from an enterostomy for acute obstruction, 

^ American Journal of fhe Med. Soc, 1911. 
2 " Urgent Surgery," p. 544. 



PERI^ORATION Ot ULCERS, DIGESTIVE TRACT 187 

and two days afterwards the patient died from acute peritonitis 
due to perforation of a solitary tuberculous plaque low down in 
the sigmoid. It is in this region that perforations of intestinal 
diverticula are found. 

Mr. Lionel Norbury showed a patient before the Clinical 
Section of the Royal Society of Medicine ^ for whom he had 
operated for perforated tuberculous ulcer of the small intestine, 
and I am indebted to him for the accompanying illustration 
(Fig. 29). 

The patient was a man aged 39, who gave a history of occasional 
attacks of epigastric 
pain. He was admitted 
eight hours after the 
onset of an acute abdo- 
minal pain, chiefly felt 
in the lower abdomen, 
which doubled him up ; 
he vomited later. On 
examination, after ad- 
mission to St. Thomas's 
Hospital, there was 
tenderness and rigidity 
of abdomen, chiefly in 
the lower half. Tem- 
perature, 100° ; pulse, 
100 ; respirations, 20. 
Abdomen otherwise 
normal. Operation nine 

hours after onset of symptoms. There was a small amount of free fluid 
and lymph in the abdominal cavity, but no free gas. The appendix and 
stomach were normal. A hard sweUing was found which involved the 
small intestine 2 feet from the caecum ; this narrowed the lumen of the 
bowel considerably, and there was a small perforation in the wall of 
the bowel in this situation. Four inches of the ileum with the ulcer 
were resected, and an end-to-end anastomosis performed. Dry spong- 
ing of the pelvis and closure of the wound without drainage. The 
patient recovered without any adverse symptoms. Microscopical 
examination proved the ulcer to be tuberculous, but no other evidence 
of intra-abdominal tubercle could be found at the time of operation. 

The state of the parts around an ulcer such as this does 
not permit of the simple application of sutures ; it is necessary 
to excise and then perform anastomosis, in order to obtain the 
best result. The surgeon will, however, be guided by the 

1 See Vol. IV., 1911, No. 3, p. 50. 




Fig. 29. — Perforation of Tuberculous Ulcer of the 
Small Intestine. Probe placed in the opening. 
Mr. Norbury's case. 



188 THE ACUTE ABDOMEN 

local condition and general state of the patient ; he might 
find it impossible to do more than place a tube in the intestine, 
attach it to the abdominal wall, and drain the peritoneum. 

The Perforation of Diverticula of the Large 
Bowel. 

During recent years the attention of the profession has been 
drawn to tlie formation of diverticula mostly in the sigmoid 
colon. These diverticula are of varying size and number, and 
changes which take place in them are responsible for some of 
the cases of the acute abdomen which require surgical treat- 
ment. The larger number of them are in stout males over 
50 years of age. Dr. Telling has written a very full account of 
this disease, for which the profession is much indebted to him. 
He points out that as the diverticulum increases in size it 
becomes atrophied, until there is frequently only a layer of 
peritoneum between perhaps a hard dried lump of fsecal matter 
or a foreign body and the general peritoneal cavity. It will be 
readily understood, therefore, that such patients will be hable 
to chronic inflammation with thickening and other changes to 
which the appendix vermiformis is liable, there being a very 
close resemblance between one of these pouches, placed as it 
frequently is in an appendix epiploica, and the appendix. It 
is also evident that the result of anything like a perforation 
into the general peritoneal cavity will be a very serious thing 
for the patient. Nothing but early operation will be of avail 
to prevent a rapidly fatal ending, these perforations taking 
place at a time of life when the power of resistance is not always 
at its best. An abstract from a paper pubhshed by Mr. Gordon 
Taylor ^ will illustrate the chnical character of such a case, and 
indicate the treatment which it demands. 

The patient, a man aged 57 years, markedly obese, after a four-mile 
walk in the morning was suddenly seized with very severe pain in 
the abdomen while taking his mid-day meal. He became somewhat 
collapsed, and required help to reach his bedroom. Almost immediately 
after the onset of the pain, which was accompanied by vomiting, a 
loose motion was passed. About seven hours after the commencement 
of the attack the patient was lying on his left side with his knees drawn 
up on the abdomen. There was great tenderness on pressure over the 

1 Lancet, 1911, Vol. I., p. 495. 



PERFORATION OF ULCERS, DIGESTIVE TRACT 189 

left iliac fossa, and most marked cutaneous hypersestliesia was present 
in this region ; the rest of the belly wall was soft. The liver dulness 
was normal, and there was no evidence of free fluid in the abdominal 
cavity ; the temperature was subnormal and the pulse was 100. The 
symptoms strongly suggested appendicitis and the possibihty of a left- 
sided appendix was considered. 

There is generally a history of pain commencing on the left 
side of the abdomen, and as most of the pouches develop in the 
sigmoid this is to be expected, and that region, in a doubtful 
case, should be examined first. In the paper from which the 
above case is taken another is described, in which the pouch 
was situated in the ascending colon. 

The patient, a man of 70, did not get medical advice until a week had 
passed, and at that time his condition was desperate from diffuse 
peritonitis. 

When considering the localised suppurations which are met 
with in the abdomen we referred to these diverticula ; their 
presence probably explains many conditions which were 
formerly obscure. The cases of successful operation for this 
perforation are not very numerous, but, with the improvement 
which has taken place in our recognition of the causes and 
treatment of peritonitis, the list will doubtless increase, as 
early operation becomes recognised by the profession at large 
as the only satisfactory treatment. 

Perforation of Stercoral Ulcers. 

As recently as 1896 the late Mr. Grieg Smith wrote about 
stercoral ulcer : " Although no special description of this 
disease has, so far as the writer Imows, been written, and 
although it is not of frequent occurrence nor of great import- 
ance, yet its undoubted existence and real gravity may justify 
its being classed under a separate heading." He then mentions 
a few instances of intra-abdominal abscess, in which a foreign 
body was found, but admits that some of them were most 
probably due to disease of the appendix. He writes : " The 
condition as I have met with it is simply a diffuse subperitoneal 
cellulitis," and he evidently regarded it as always dependent 
on the irritation of a foreign body. 

Sir J. Bland-Sutton has given examples of fsecal abscess, 
associated with small but sharp foreign bodies, in the large 



190 THE ACUTE ABDOMEN 

intestine ; and Dr. H. D. Rolleston, in a paper on " Pericolitis 
Sinistra," gives instances in which ulceration developed in 
a diverticulum of the colon, and produced suppuration 
around. These ulcerations were not, however, like the variety 
Avhich is under consideration here, but come under the 
heading of " Abscess Secondary to Diverticula, of the Large 
Bowel/' 

Stercoral ulcers behave much in the same way as ulcers in 
other parts of the digestive tract ; they may perforate suddenly 
and produce general peritonitis, or extend gradually and give 
rise to a localised intraperitoneal abscess. When it is recog- 
nised that they are usually secondary to a condition which of 
itself is seriously threatening the patient's Hfe, it will be 
appreciated why they prove so fatal. The patient, who is 
most frequently suffering from chronic intestinal obstruction, 
caused by carcinoma of the large intestine low down, appears 
to have his last chance of recovery taken away if a stercoral 
ulcer, perforating suddenly, floods the peritoneum with the 
very septic contents of the bowel above the obstruction. In a 
patient already weakened and distressed by the obstruction, 
this additional attack is usually more than can be successfully 
combated, and proves fatal in a few hours. 

In May, 1912, I saw a young and strong-looking man with Dr. A. E. 
Godfrey, of Finchley, for a swelling of the liver which we considered to 
be secondary to a carcinoma of the large bowel, which was producing 
few symptoms beyond constipation. We advised the patient to have 
nothing done in the way of operation unless more urgent symptoms 
developed. A day or two later another medical man was called in by 
a relative. He gave the patient a small white powder (? calomel), and 
within four hours after taking this acute peritonitis with collapse 
developed suddenly and death occurred within twenty-four hours. I 
have no doubt that a latent stercoral ulcer had burst probably as the 
result of a violent purgative. 

When any one the subject of chronic intestinal obstruction 
of a mechanical kind complains of sudden increase in abdominal 
pain and has a rise of temperature, not necessarily a very high 
one, the possibility of the giving way of a stercoral ulcer must 
be remembered. This possibihty is increased if there is, in 
addition, an excessive sensitiveness to palpation, previously 
absent, but perforation may give no immediate sign of its 
occurrence, as in the following instance :— 



PERFORATION OF ULCERS, DIGESTIVE TRACT 191 

Some years ago I was asked by the late Mr. C. Mortimer Lewis, then 
of Steyning, to see a lady with him, who had carcinoma of the rectum. 
She was over 80 years of age, and had only sent for him that morning 
because her bowels had not acted for a week. He examined the abdo- 
men, found it much distended and tympanitic, whilst the rectum was 
completely blocked by a carcinomatous growth. When we saw her 
together a few hours later she was much the same, but without any 
vomiting. Her temperature had been 100°, the pulse was good, but 
the tongue was brown and dry. Incision was made to perform colostomy 
in the left iUac region, but when the peritoneum was opened it was 
found to be flooded with black hquid faecal matter, which was still 
escaping freely from two ragged openings in the immensely distended 
sigmoid flexure. These openings (with thin and irregular edges) were 
situated one above the other in the anterior part of the bowel, which 
passed down behind the middle hne of the abdomen. Pints of this offen- 
sive fluid came away before it was possible to secure the sigmoid flexure 
to the abdominal wall. The peritoneum was cleansed as well as 
possible, but the patient did not rally from the operation. 

In this case it is possible that the bowel had given way in 
the morning, when the patient sent for her medical adviser. 
Up to that time she had for some days gone on, taking dose 
after dose of medicine without relief, whilst the immense 
accumulation of fsecal matter above the constriction had 
caused excessive stretching and local injury to the bowel, which 
had ended in acute bacterial necrosis. The necessary removal 
from the bed to the operating table may have given rise to a 
further escape and diffusion in the peritoneum. 

Treatment of this most unfortunate complication should be 
directed to the cleansing of the peritoneum, the insertion of a 
Paul's tube in the opening from which the fsecal matter is 
escaping, and the suturing of the damaged bowel to the part 
of the abdominal wall most easily reached. Strain on the 
wall of the bowel, usually softened and easily torn, must be 
avoided. By this means the opening will serve as a colostomy 
opening and the obstruction be relieved. The difficulty in 
cleansing satisfactorily the fouled peritoneum will render the 
prospect of recovery doubtful. Yet success may occasionally 
be obtained. 

On March 27, 1901, I saw a patient in consultation with Dr. S. 
Faulconer Wright, of Lee. He was 7 1 years of age, and stated that he 
had always been healthy until the 21st of that month, when for the 
first time he experienced abdominal pain. This was accompanied by 
vomiting and constipation. Since that time the pain had continued 



192 THE ACUTE ABDOMEN 

with occasional vomiting, and the bowels had not acted. The abdomen 
was much distended and tympanitic, the note around the umbilicus 
being high pitched. There was no diminution of the liver dulness, and 
no evidence of free fluid in the peritoneum. The tenderness was not 
extreme, but he winced when touched. His general condition was fair, 
and the temperature was normal. An incision was made in the middle 
hue below the umbiUcus, and when the peritoneum was opened free gas 
escaped, and fluid faecal matter was seen covering the intestine in the 
region of the caecum and extending into the pelvis. This had come, 
and was still escaping, from a stercoral ulcer on the anterior surface of 
the distended caecum, which had recently given way. It was large 
enough to admit the little finger, and its outUne was somewhat irregular, 
with a thinned edge. Into this a Paul's tube was passed and secured, 
the caecum being sutured to an incision in the right ihac region. After 
the bowel and peritoneum had been cleansed as thoroughly as possible, 
a long drainage tube was passed into the pelvis and the median wound 
was sutured. The small intestine was generally adherent, coil to coil, 
and fixed in the posterior part of the abdomen, evidently the result of 
an old attack of peritonitis, the cause for which was not ascertained. 

Under the skilful management of Dr. Wright the patient recovered, 
and was able to go daily to the City to business for several years after- 
wards, when he died from an attack of bronchitis. The artificial anus 
never closed completely, and gradually, as time went on, this opening 
became more important, until hardly any faecal matter found its exit 
by the natural anus. The patient wore a flat, circular indiarubber bag, 
containing a large flat sponge, fitting accurately to the abdomen over 
the artificial anus. The dieting had to be very carefully arranged, on 
account of occasional stoppages, which, when they occurred, caused 
considerable pain, only reUeved by the escape of faecal matter by the 
artificial opening. His general health was afterwards excellent. What 
the nature of the obstruction was in this case it is impossible to say ; 
the fouhng of the peritoneum and the condition of the patient made it 
inadvisable to explore. The comphcation of perforation was such a 
serious one that the clear indication was to deal with that, more espe- 
cially as its treatment was calculated to give reUef to the obstruction 
which was responsible for it. The cleansing of the peritoneum was no 
doubt aided by the Kmitation of the fouled area in consequence of the 
old intestinal adhesions. The after history of the case is instructive, 
inasmuch as the obstruction often recurred, and a " safety-valve " 
action permitted of reUef on each occasion. It was thought at the 
time of operation that the obstruction was caused by a ring carcinoma 
of the sigmoid flexure, the growth of which is sometimes very slow ,• 
anyway, the case is a most instructive and encouraging one. 

It may perhaps be possible to suture the perforations, and 
afterwards majke an artificial anus in a more favourable part 
of the large bowel. 

Perforation of Stercoral Ulceration associated with 
Obstruction of the Large Bowel. — A case was admitted on 



I 



PERFORATION OF ULCERS, DIGESTIVE TRACT 193 

March 18, 1913, and successfully operated on by Mr. Stewart 
Kouquette. 

G. C, a man of 61, complained of pain on the right side of the abdomen 
for six weeks, but three days before it was worse and he was doubled 
up by it. He had vomited and was evidently suffering from obstruction. 
The abdomen moved well on respiration ; was more or less tympanitic 
on percussion ; rather tender in the right lower half, with some rigidity 
of the rectus. Temperature, 99*8° ,- pulse, 64. Nothing could be felt 
per rectum, and the bowels were not acting. Mr. Kouquette, who made 
an incision through the right rectus mascle, found free gas in the 
peritoneal cavity which had escaped through two openings in the 
anterior part of the caecum. The caecum was much distended, the 
openings small, with thin edges ; very httle faecal matter had escaped. 
The wall of the caecum around the openings appeared normal. The 
openings were closed with silk sutures. The appendix was removed. 
A carcinoma of the upper rectum was found, and a colostomy performed 
on the left side. 

The right incision permitted a discharge with faecal odour for about 
seven days, but the patient left on April 24 in a very fair condition with 
the colostomy wound acting quite satisfactorily. 

It appeared probable that the caecum had given way during removal 
from bed to theatre. 

" Stercoral ulcer " is one of the most serious complications of 
chronic intestinal obstruction, even when the peritonitis pro- 
duced is purely local in its character. If there is an ill -defined 
area of dulness in the csecal region, with tenderness and a sense 
of resistance, whilst rectal examination shows an apparent 
thickening on the right side of the pelvis, this complication 
should be suspected. Fluctuation may be found if the case is 
seen at a later stage. Should the patient be fat and nervous 
the diagnosis may be very difficult ; even with the assistance 
afforded by the administration of an anaesthetic it may be hard 
to say that there is much wrong with the side really affected. 
There is nothing like the definite induration which is found in a 
case of localised inflammation or suppuration secondary to a 
disease of the appendix which it resembles closely in some other 
respects. It comes on in a person suffering from intestinal 
disturbance ; the pain is in the right iliac fossa, and is accom- 
panied by increased distension of the abdomen and a rise of 
temperature. Tenderness is more marked in the right iliac 
fossa than in other parts of the abdomen. Yet there are 
differences — a stercoral ulcer, giving rise to a localised extravasa- 
tion and abscess, is specially met with in elderly females who 

A.A. O 



194 THE ACUTE ABDOMEN 

give a history of chronic constipation, recently more obstinate, 
and associated with "wind in the stomach." The rise of 
temnerature is not great, and the area of tenderness is not so 
easily locahsed as in appendicitis. 

The collection of fluid faeces which forms in the peritoneum 
has a tendency to spread laterally, for it is not easily locahsed, 
as it escapes readily, and it may be the operator will find it 
up to or beyond the middle line should he make an exploratory 
median incision to find out the exact site of the obstruction 
when there is a doubt. Whether he thus discovers it by 
accident, or makes direct or intentional incision into the 
abscess, a counter -opening and the insertion of a large drainage 
tube will generally be required. If the opening in the caecum 
be found, a tube sliould be passed into this, so that the contents 
of the bowel, which rapidly come away, may be conducted 
beyond the abscess cavity. These contents, pus mixed with 
fluid faecal matter, are extremely offensive, more so than most 
abdominal collections of a purulent character, and that is saying 
a great deal. 

Under the best conditions the prognosis is bad ; the discharge 
of large quantities of faecal matter, with an increasing admixture 
of pus, causes much local irritation, and may end in rapid exhaus- 
tion. Should the inflammation subside and an artificial anus 
form, it is not placed in a convenient position, and may lead 
to all the disadvantages of an opening on the right side — that 
is, if the obstruction becomes complete. The case under the 
care of Dr. Wright suggests the possibility of a more satis- 
factory course of events, the opening acting as a safety valve 
when required by the temporary stoppage beyond, and causing 
but httle inconvenience in the intervals. Another danger in 
these perforations is the tracking upwards of the pus and the 
formation of a large collection in the sub -hepatic or sub-phrenic 
regions ; a second incision would be required for the better 
drainage of this extension, but exhaustion from the discharge 
would not unhkely prove fatal. It will be evident that 
recovery from these collections will take some time, during 
which the original cause of the trouble — probably a mahgnant 
growth — is increasing in size and becoming more difficult to 
treat radically. 

The estabhshment of a short circuit between the small 



I 



PERFORATION OF ULCERS, DIGESTIVE TRACT 195 

bowel and the large beyond the stricture would be the ideal 
operation, but it is not often that the septic state of the 
abdomen allows this to be done. You cannot do it at the first 
operation when the condition of the patient is bad and the 
complication a very serious one, perhaps of considerable and 
ill -defined extent. Later the result of a prolonged septic 
discharge makes it very unlikely that the sutures required. 
would hold after the junction had been effected ; but you must 
judge each case on its merits. 

Messieurs Challiet and Thomasset ^ say that when the large 
bowel gives from softening of its coats in cases of obstruction, 
the rupture is found at the junction of the ascending colon 
and caecum to the outer side of the longitudinal band. The 
second variety, or gangrenous perforation, is found in the left 
portion of the colon ; it is generally solitary, of small size, 
with gangrenous eroded edges. 

1 Arc/i. Gen. de Ckir., 1911. 



o 2 



PAET IV 

ACUTE CONDITIONS HAVING THEIR ORIGIN IN 
THE FEMALE GENERATIVE ORGANS 

Salpingitis. Pyo -Salpinx. Extra-Uterine Gestation. 

Several conditions of the female generative organs may be 
rightly considered under the heading of the " acute abdomen " : 
The spread of an infection through the Fallopian tubes, the 
rupture of a pyo-salpinx, the giving way of the sac of an 
ectopic gestation, necrosis of a subperitoneal uterine fibroid or 
the twisting of its pedicle ; also accidents attending the growth 
of an ovarian cyst. 

(1) Infection through the Tubes, etc. — An acute, urgent, and 
occasionally fatal illness is sometimes produced by the spread 
of a gonococcic inflammation from below. The tubes not 
having been occluded by a pre-existing inflammation, it is 
possible to see purulent fluid coming from one or both of them 
when they are lifted for examination. 

This was the case in a young married woman seen with Dr. Fitz- 
gerald. Acute abdominal symptoms had commenced three days 
before and the patient was very ill with quick pulse, abdominal pain, 
and distension. She had suffered from a vaginal discharge for three 
weeks. At the operation there was purulent peritonitis in the pelvis, 
with acutely inflamed tubes. The pelvis was cleansed and a drainage 
tube put in afterwards. Both tubes had to be removed, but part of 
one ovary was left. She made a satisfactory recovery. The origin of 
the disease and its nature were easily proved. 

If the symptoms are severe and cause anxiety, in these cases 
it is better to operate, for, although the inflammatory condition 
settles down in most, a chronic disease of the tubes will remain 
and repeated inflammatory attacks be the rule. There are 
many more hves crippled and spoilt by chronic salpingitis than 
is usually acknowledged. It is not advisable to remove the 
ovaries, nor is it always necessary to remove both tubes. 

In other infections by bacilli, such as puerperal, strepto- 



DISEASES OF FEMALE GENERATIVE ORGANS 197 

coccal, or influenzal, the symptoms will be similar and require 
prompt treatment. 

In puerperal peritonitis the most active of the organisms 
present is the streptococcus pyogenes, which finds entrance 
through some breach of surface in the genital tract or passes 
directly by way of the Fallopian tubes, the infection being 
only too commonly conveyed in the first place by the attendant 
at the confinement. If it finds access to the pelvis by way of 
the Fallopian tubes, a peritonitis of great intensity quickly 
commences ; luckily the nature of " child-bed fever " is generally 
recognised, and the precautions now taken render the disease 
a comparatively rare one. 

The invasion of the system by the streptococci in this disease 
is usually marked by an attack of shivering, or a rigor and 
rapid rise of temperature, with much increased pulse-rate. 
Any discharge which may be present becomes offensive. There 
is abdominal pain in the hypogastric region of varying severity, 
sometimes vomiting and usually offensive diarrhoea. 

Tenderness in the hypogastric region spreads and is some- 
times very acute. The abdomen becomes distended ; rigors 
recur ; the temperature becomes of a pysemic type, there is 
profuse sweating and complete anorexia ; the diarrhoea is 
troublesome ; delirium is present at night ; and evidences of 
secondary mischief in the lungs, pleura or pericardium or other 
remote parts develop, and the patient dies exhausted. Dulness 
may be found in the flanks as a result of the collection of free 
fluid in the peritoneal cavity or a considerable exudation in 
the subperitoneal cellular tissue, especially if the inflammation 
has spread by way of the lymphatics. 

The treatment should be in the flrst place to disinfect the 
uterus and vagina, to take away remaining debris of placenta 
and decomposing clots, to remove infective fluid which has 
accumulated in the pelvis, and possibly in the flanks, and to 
provide good pelvic drainage. 

It is wise to begin the administration of anti -streptococcic 
serum at once (the usual stock " polyvalent " preparation) and 
continue this treatment with a vaccine prepared from fluid 
removed from the peritoneum at the operation. 

In cases where the uterus has been ruptured, perforated, or 
is extensively infiltrated, it may be advisable to remove it. 



198 THE ACUTE ABDOMEN 

These cases are always most serious, and require energetic 
treatment from the commencement. They are not all of them 
of the fulminating variety, but it is important that the milder 
cases should be treated with decision. In performing the 
needful dressings after operation, and in douching, etc., the 
attendant should use sterihsed rubber gloves. 

A careful watch must be kept for the development of secon- 
dary abscesses, which should be evacuated as soon as they are 
found. If possible a local anaesthetic should be used, or gas 
and oxygen ; they must not be permitted to attain any size. 

(2) Rupture of a Pyo-salpinx. — The following case will illus- 
trate this accident. It is the account of a patient admitted for 
acute abdominal symptoms. It will be noted that there is a 
certain amount of similarity between the symptoms caused by 
a ruptured pyo-salpinx and those due to a ruptured ectopic 
gestation. 

L. S., aged 21 years, was admitted -X- February 20, 1906, early in the 
afternoon. Tlie history was that she had been suddenly seized with 
abdominal pain during the night of the 19th. This pain had been very 
severe in tlie upper part of the abdomen, and she had vomited. She 
had had a meal of pork during the previous evening. At 4 o'clock in 
tlie morning a medical man was sent for, who gave her some medicine, 
which she could not keep down. In her previous history there was an 
account of indigestion of indefinite character some years ago. There 
had been profuse vaginal discharge for some months, and the menstrual 
period was a fortnight overdue. There had been no action of the 
bowels for two days. 

When seen with Dr. H. Mackenzie late in the afternoon the patient was 
lying on her back, looking very ill and anaemic, and seemed collapsed, 
drowsy, and apathetic. There was a small circular flush on each cheek. 
The skin was dry. The respirations were somewhat quickened (24), 
and the pulse was 110. The temperature was 101-4°. She complained 
of pain in the abdomen, which was found to be moving quite well in the 
upper half, but was less mobile than usual in the lower part. On 
palpation there was much complaint of tenderness, especially in the 
left iliac region and right up towards the liver. Nothing abnormal was 
found ; the abdominal wall was quite without rigidity, and offered no 
resistance to palpation. On percussion the note over the whole ab- 
domen, including the hver, was normal. At 5.30 abdominal exploration 
was carried out ; an incision was first made in the epigastric region, and 
the stomach and duodenum examined. The hand was then passed 
downwards to the iliac fossa and appendix region and onwards to the 
pelvic organs. A tumour was felt to the left of the uterus. This was 
recognised as a pyo-salpinx, and it was thought that a rupture of this 
would account for the condition. A second incision was made in the 



DISEASES OF FEMALE GENERATIVE ORGANS 199 

middle line above the pubes, and when the peritoneum was opened, 
thin, somewhat viscid, odourless pus was found, extending from the 
pelvis into the flanks. The intestines were packed off with strips of 
steriHsed gauze, and the pyo -salpinx was removed after the application 
of three (No. 4) silk ligatures. There was no inflammation of the peri- 
toneal coat of the intestine, and no lymph was seen. The area of 
infection was cleansed with moistened sponges, and drainage was 
provided by a rubber tube and a strip of gauze. The right ovary was 
somewhat fixed by adhesions, which were freed, but it appeared to be 
healthy, as did also the tube on that side. The upper wound was 
sutured in layers by Mr. Bletsoe, the house surgeon, whilst the pelvic 
condition was being treated. The pyo -salpinx formed a tumour of the 
size of a hen's egg, the walls of the Fallopian tube were much thickened, 
and there had been a rupture not far from the ostium abdominale, which 
itself had been closed by adhesion to the broad ligament. The ovary 
formed part of the inflammatory mass removed, and could only be 
distinguished on dissection. The plug was removed on the 24th ; 
there was a small amount of clear discharge. The bowels had acted 
twice. The pulse was 76 and the temperature was normal. Pain was 
quite relieved. She progressed satisfactorily, and left hospital on 
March 13. 

Pyo-salpinx is recognised as the most important condition 
giving rise to peritonitis having its origin in the pelvis, repeated 
localised attacks being common. As a source of diffuse spread- 
ing peritonitis it is less frequent, for the thickened tube does 
not often rupture as it did in this case and allow the purulent 
contents to become diffused. There can be little doubt that 
tlie gonococcus is extensively spread by the rupture of a tube, 
and although Dr. Dudgeon^ and Mr. Sargent conclude that it 
possesses a slight pathogenicity when introduced into the 
peritoneal cavity, it does produce a peritonitis which may be 
ultimately fatal. We must endeavour to operate before 
peritonitis becomes extensive. The prognosis is thereby im- 
mensely improved, and the duration and severity of the 
illness diminished. 

None of those who saw the extent to which purulent diffusion 
had taken place in this patient doubted that general peritonitis 
must have ensued had operation been delayed. It was the 
aspect of severe illness, with the history, which induced Dr. H. 
Mackenzie to suggest the desirability of exploration, for local 
signs of the gravity of the attack were absent. There was no 
trace of protective rigidity of muscle, whilst the tenderness 

1 " The Bacteriology of Peritonitis," p. 53. 



200 THE ACUTE ABDOMEN 

found was not in any way remarkable. Nothing indicated the 
probable origin of the symptoms, and although the epigastric 
region was explored this was in deference to the former history 
of indigestion, with a recent heavy meal, rather than to any 
idea that stomach ulceration had really given way, for there 
were no locahsing signs. I have stated that the appendages on 
the right side appeared to be healthy, and were therefore not 
removed. It was probably right to leave them ; but the result 
of so doing, in a case formerly under my care, in which a pyo- 
salpinx had given rise to intestinal obstruction, has made me 
less confident of this than I might otherwise have been. The 
appendages on the left side appeared normal, and were therefore 
left, but in the following year the patient returned with 
peritonitis, the result of a rupture of the remaining tube. 

A woman, aged 26, was admitted •)(- January 31, 1903. She stated 
that she had been quite well until the 25th, when she was taken ill with 
pains all over her. The attack passed off, but came on more severely 
at 4 a.m. on the 26th, and was accompanied by severe pain in the right 
hip which spread all over the abdomen. On admission the abdomen 
was distended, did not move well on respiration, and the patient looked 
ill. The abdomen was not tender ; it was easy to examine, but nothing 
abnormal was detected on palpation. Examination 'per rectum showed 
notliing unusual. The temperature was 100-6°, and the pulse was 104. 
On February 3 she had an attack of abdominal pain with vomiting, there 
being visible distension of small intestine and peristalsis. The bowels 
acted well just before the attack. Operation was advised because it 
was recognised that she had recurring attacks of obstruction due to a 
mechanical condition, but she refused consent until February 6, when 
another more severe attack of pain and vomiting induced her to think 
more seriously of her illness. 

Incision was made through the right rectus sheath and the muscle 
temporarily displaced. On opening the peritoneum a coil of small 
intestine was found to be distended and to pass down into the pelvis, 
which seemed unusually full. At first it appeared as if the uterus was 
very large and smooth-waUed, but further examination showed the 
sweUing to consist of two parts, a softer one to the right, and when the 
finger was passed into Douglas's pouch a groove could be felt marking a 
division between them. The pelvis was isolated with sponges and a 
large pyo-salpinx, which ruptured during the process, was brought 
outside, separated from its attachments, and removed. The pus was 
very offensive. The ovary was included in the mass removed. The 
left side appeared to be normal. The loop of obstructed gut was found 
adherent to part of the boundary wall of the pyo-salpinx which had 
been left behind — ^it was kinked from before backwards ; another loop 
also adhered to this part, but was not obstructed. These were freed 



DISEASES OF FEMALE GENERATIVE ORGANS 201 

and some omental adhesions were also separated or divided between 
ligatures. The pelvis and lower abdomen were washed out with warm 
saline solution, and a tube was left in which extended into Douglas's 
pouch. On the third day some distension of the stomach was present, 
and this was followed by a more or less general meteorism which 
gradually subsided under appropriate treatment, although the patient 
was for a time seriously ill. The tube was removed on the seventh day 
after operation. She left the hospital on March 14, 1903. 

On October 20, 1904, the patient was readmitted with symptoms of. 
diffuse peritonitis. She had enjoyed good health since leaving the 
hospital until three weeks before her return ; she then had a menstrual 
period, followed a week later by haemorrhage from the vagina which 
lasted for three or four days. This was followed by acute pain on the 
right side of the abdomen which spread to the left side. This pain 
continued for a week, and then for the three days previously to her 
coming up it increased considerably, and was again accompanied on the 
first and third days by haemorrhage. She had vomited four times only 
and on the day of admission. The abdomen was sUghtly distended but 
scarcely moved with respiration. The left rectus was rigid, and the 
lower half of the left side. Great tenderness was complained of all over 
the abdomen. The flanks were resonant. The pulse was 120, and the 
temperature 102°. A tender swelUng could be felt per vaginam in the 
left fornix. Mr. Sargent, who successfully operated, found that the 
pelvis contained pus, whilst a sero -purulent fluid invaded the lower 
abdomen. The left Fallopian tube was of the size of a thumb ; its 
walls were much thickened and distended with pus. The ovary con- 
tained a large cyst in which was a blood clot of the size of a tangerine 
orange. The lower abdomen was washed out with saline solution. 
From the history of disturbed menstrual function it was thought that 
the blood clot might represent the remains of an ovarian gestation, 
but careful examination in the clinical laboratory did not confirm 
this idea. 

(3) Ectopic Gestation. — ^Another part of this subject — that of 
ectopic gestation and its rupture as a cause of the " acute 
abdomen " — introduces us to additional symptoms : those 
caused by the increasing accumulation of blood in the peri- 
toneum and the effect of its loss from the circulation on the 
general state of the patient. The rapidity with which it is 
poured out and the effect of this are so great that the patient 
may die as suddenly as if a deadly poison had been taken. 
Luckily, most of the victims of this accident are not so quickly 
overwhelmed, and time is given for attempts at a rescue. It 
is not my intention to enter into a discussion of extra-uterine 
gestation, its varieties, diagnosis, modes of ending, etc., but 
simply to introduce the subject as it occurs in actual practice 



202 THE ACUTE ABDOMEN 

as a surgical emergency, so that you may be able to recognise 
and successfully treat it. 

Of instances of the milder type when the hsemorrhage is not 
excessive but recurs, the following recent case may be quoted : 

M. C, aged 32 ; seen in consultation with Dr. Bulger, November 7, 
1913, and transferred to the hospital for operation. 

Her menstrual periods had been regular until the beginning of 
September ; between that date and the middle of October there had 
been no period. On October 14 a discharge commenced, which had 
persisted, of thin blood-stained fluid. There had been slight pelvic 
pain from time to time for a month. A week before there had been 
an exacerbation of this pain, and again on November 4, the pain 
causing the patient to perspire profusely. The day before admission 
the pain came on again and at midnight was very intense, lasting for 
three hours. This pain was in the pelvis and both groins, and there was 
great tenderness of the lower abdomen. She became very faint and 
white-faced. 

Dr. Bulger, who had been called in, diagnosed ectopic gestation with 
haemorrhage, and found an enlarged uterus with fulness in Douglas's 
pouch. There was also distension of the abdomen with some tender- 
ness in the lower part. On admission she was much the same, but had 
a temperature of 98-4° and a pulse of 128. 

At the operation later in the day we found scattered blood-clots over 
the omentum, and Douglas's pouch was partly filled with black coagu- 
lated blood. The left Fallopian tube was very congested and dilated, 
especially near the fimbriated extremity. Here there had been a 
rupture of the tube and hsemorrhage was still proceeding. A piece of 
amnion was found in the removed clot. The other side was normal. 
The tube and ovary were removed. The peritoneum was sutured 
with catgut, the sheath of the rectus with silk, and the skin with 
fishgut. Convalescence was interrupted by a troublesome attack of 
celluhtis. 

Of the more severe cases of hsemorrhage I have selected one 
of rupture of a sac situated in the wall of the uterus in which 
symptoms were very urgent and the state of the patient some- 
what desperate. It is a rare position for the sac to occupy, but 
there is no means of ascertaining this before the abdomen is 
opened, and the indications for operation are the same as 
in examples of the much commoner rupture of a tubal 
gestation. 

A married woman, aged 35 years, was admitted -X- April 23, 1903. 
Her history was as follows : — She was treated in a London hospital nine 
years before for " peritonitis " after a confinement. She had had five 
children. The youngest was eighteen months old. The last menstrual 



DISEASES OF FEMALE GENERATIVE ORGANS 203 

period was six weeks previously ; one should have come on about a 
week before admission. She had always suffered from leucorrhoea, but 
during the past few weeks this had been worse than ever. About a 
month previously she began to suffer from attacks of vomiting which 
came on especially after food, which she was unable to retain. There 
was also some indefinite pain in the abdomen. A fortnight previously 
she attended the out-patient department and was treated for gastritis. 
The abdominal pain got worse, and at 4 o'clock on the day of admission 
she had a very severe attack which doubled her up and later completely 
prostrated her. She vomited several times and became very cold, pale, 
and collapsed. During the afternoon she fainted. She was brought 
to the hospital thirteen hours after the onset of the severe pain. 
On admission she was blanched, emaciated, and in a state of collapse. 
The abdomen was held rather rigidly, and was generally tender, 
especially in the lower part. In the left iliac region there was a 
rounded elastic swelling, and there appeared to be fluid in the lower 
part of the abdomen, and to a less extent in the flanks. The pulse was 
120 and feeble, the respirations 26, sighing, and the temperature was 
97-2°. At 8 p.m. a median incision in the lower abdomen about 4 inches 
in length was made, and the dark colour of the blood could be seen 
before the peritoneum was incised. When the abdominal cavity was 
opened there was an immediate gush of blood mixed with clots, and the 
hand was at once passed to the uterus and tubes. The left one was 
enlarged, and so was brought to the surface. The enlargement was found, 
however, to be due to a hydro -salpinx, so the uterus and right tube 
were drawn up for inspection. The former was ruptured at a point on 
the fundus to the inner side of the place where the right tube joined it. 
It was larger than normal ; the opening was about 1| inches in length 
and placed transversely. Fiom it there protruded a fluffy mass of 
deHcate moss -like tissue which filled the opening and bulged over the 
edges. This was evidently placental tissue. From this place there 
was a constant oozing of blood. This tissue was removed with a curette 
and the cavity from which it came scraped out. The opening was then 
closed with a continuous Lembert suture. This arrested all bleeding. 
The left tube was then removed. The intestines appeared pale, almost 
bloodless, and contracted. The peritoneal cavity was carefully cleansed 
of clots and free blood by saline irrigation and gentle sponging, after 
which the abdomen was closed. Four pints of saline infusion were 
injected into the left median basilic vein during the operation with 
evident benefit. The patient slowly recovered. On the third day she 
complained of abdominal distension and pain in the epigastric region due 
to acute dilatation of the stomach, for which the stomach tube was 
employed, with lavage. Some distension of the abdomen continued for 
about three days, but the temperature remained normal, and the pulse 
about 100. Convalescence was slow, and she did not leave until 
June 29. 

In another patient the diagnosis was rendered unusually 
difficult, there being a diseased appendix present, also because 



204 THE ACUTE ABDOMEN 

of the history of the illness and the absence of clotting in the 
blood which had escaped into the peritoneum. 

A woman, aged 31 years, was admitted ■)(- April 14, 1904. There was 
history of irregular periods, and a white discharge on and off between 
the period^!, but general good health until April 8. She was then 
seized with internal pain, which was so bad that on the following day 
she was obliged to go to bed ; it improved, but recurred severely on 
the 12th. It was most marked on the right side, running up to the right 
breast, and affected the right leg so that it was very painful to move. 
This pain started with the period, which was a fortnight overdue. 
When the discharge ceased the pain went, but came on again when the 
discharge returned. Almost fainting, on admission she appeared a pale, 
anaemic woman. The abdomen, slightly distended and tender, was 
difficult to examine satisfactorily, as the patient held herself very 
rigidly. There appeared, however, to be more dulness in the right 
flank than in the left. On vaginal examination the uterus was normal, 
freely movable, and a httle retroverted ; there was no fulness in 
Douglas's pouch or abnormality of the uterine appendages. The 
tongue was furred, but the bowels were acting. The pulse was 112 and 
the temperature 99°. On the 18th she was again seized with pain in 
the right ihac region. The vaginal discharge recommenced, being of a 
red colour. She felt very faint. The pain passed oft' during the night, 
and on the next morning her temperature was 100-2°, and on the 
following evening 101°. The history, character, and duration of the 
pain, with the rise of temperature, made it very probable that the 
appendix was diseased, whiLst the account of the menstrual irregularities 
induced Dr. W. W. H. Tate to suggest the possibility of an extrauterine 
gestation which was leaking into the peritoneum as a result of some 
rupture of the sac. On the 29th the operation by temporary displace- 
ment of the rectus was performed, and a diseased appendix removed 
after the application of the clamp. As free blood was present in the 
peritoneum when it was opened, and there was some in the pelvis, the 
opinion expressed by Dr. Tate was confirmed, and rapid incision in the 
median hne low down gave access to the pelvic organs. The right tube 
was thickened at one part, and from the ostium abdominale haemorrhage 
was still proceeding. This was ligatured and removed with the ovary. 
A tumour about the size and shape of a pigeon's egg was attached to 
the left broad hgament. This was excised, and proved to be an intra- 
hgamentous cyst with papillomatous growth inside it. The appendix 
wa« catarrhal, and strictured near its base. The right Fallofian tube 
was enlarged and thickened ; the ostium abdominale admitted a little 
finger, and its mucous membrane was rugose. The uterine end of the 
tube for a distance of 1 inch was normal ; beyond this it was dilated, 
and contained a large clot which was attached to the upper and posterior 
part of the interior. No foetus was found. The right ovary was cystic, 
and contained a recent corpus luteum, besides several old ones. A 
pedunculated cyst containing blood-stained fluid was attached to the 
right broad hgament. The incisions in the abdominal wall were closed 



DISEASES OF FEMALE GENERATIVE ORGANS 205 

after the pelvis had been sponged and flushed with warm sahne solution. 
A week later she complained of pain in the left side of the pelvis, and a 
hsematocele gradually formed and suppurated, being opened per vaginam 
about thr >e weeks after the operation. She left hospital quite recovered 
on June 4. 

This was, then, a case of tubal abortion, the loss of blood 
coming from the open mouth of the tube, whilst the unusual 
character of the pain was explained by the condition of the 
appendix. There was no sudden seizure, as in the case of the 
patient with intramural gestation ; but the result would have 
been fatal ultimately, and I have quoted it as a contrast to the 
former example. In all operations for haemorrhage the uterine 
appendages should at once be brought out of the wound and 
examined. No attempt to clear away blood-clot must be 
permitted until the source of the haemorrhage is found and its 
flow arrested. No case is beyond surgical aid until actually 
dead. Examine both sides, tor there may be a ruptured sac 
in each tube. As a temporary measure it is advisable to apply 
clamps to the uterine end of the tube and to the broad ligament 
beyond. 

The sudden onset of an appendix suppuration may simulate 
the bursting of the sac of an extrauterine gestation, if men- 
strual irregularity and no marked rise of temperature are 
present. A further sudden access of symptoms due to bursting 
of the abscess, with collapse, simulates a similar condition with 
renewed haemorrhage. 

Some years ago I was called upon to go into the country at night to 
see a lady with an acute abdominal illness. The history was that ten 
days before, when the period was a week overdue, she had had a severe 
attack of abdominal pain, with faintness and sickness, from which she 
had gradually ralhed. This had been regarded by her medical attendant 
as probably due to the rupture of an extrauterine gestation, but as she 
slowly improved he did not think that operative interference was called 
for. On the morning before I saw her she had been again suddenly 
seized with a similar attack of abdominal pain, and became collapsed. 
The condition of collapse continued when I arrived, and was extreme. 
The pulse was imperceptible, the temperature was subnormal, the ex- 
tremities were cold, and the patient restless. On the following morning 
the condition was not improved, and, in fact, for four days she was so 
ill that it was not thought worth while to take her temperature. As a 
result of careful tending she recovered, so that on the seventh day after 
I had iirst seen her it was possible to open a large collection of pus which 



206 THE ACUTE ABDOMEN 

had been known to be present in the lower abdomen for the week, and 
which had not much increased in size. There was no blood-clot in this, 
and, although the appendix was not found, it was regarded as the 
probable cause of the suppuration. During the gradual closing of the 
abscess an extension of it to the left of the umbilicus was especially slow 
in recovering, and pus could be expressed from this part when every- 
where else the condition appeared satisfactory. In this region adhesions 
formed between coils of small intestine, and I operated for acute 
intestinal obstruction due to them later in the year. Still later in the 
same year an attack of appendicitis made it advisable to remove the 
appendix. A good recovery ensued. 

Important Changes complicating Tumours of the Uterus 
AND Tumours of the Ovaries. 

We will consider in the first place some of the complications 
arising from changes in ovarian growths because of their greater 
prevalence : 

(1) Torsion of pedicle causing haemorrhage into the cyst, 

acute inflammation, suppuration, or gangrene of a 
cyst. 

(2) Rupture of the cyst, due to intracystic pressure, softening 

of the wall, or injury. 
(1) In torsion of the pedicle the tumour becomes rotated to 
a varying extent, and according to the amount of obstruction 
to the blood supply of the cyst will be the urgency of the 
symptoms. In all cases of sudden and complete torsion 
" peritonism " is present ; sometimes the pain is so severe that 
the patient completely collapses. A careful examination at 
this period of the illness will often show the presence of the 
tumour either in the pelvis or in the lower abdomen, or the 
patient may have been treated for an abdominal swelhng which 
had caused httle or no discomfort, and therefore the question of 
operation had been postponed, if it had been considered. If 
the case is comphcated by abdominal distension, then it may 
be difficult to find the cause of the urgent symptoms, for the 
rounded outhne of the tumour will be obscured or completely 
hidden. Here there should be no hesitation before exploration 
is carried out and the state of affairs adjusted, and in the more 
acute cases the patient does not object, for she is suffering so 
much that she cannot hide the extent of her sufferings ; more- 
over, the relatives can see how ill she is. 



DISEASES OF FEMALE GENERATIVE ORGANS 207 

As the symptoms of " peritonism " pass off they are replaced 
by those of (a) haemorrhage, (b) peritonitis, or (c) obstruction. 

(a) Patients have been known to die quickly as the result 
of intraperitoneal haemorrhage, as in the well-known case 
described by the late Sir Spencer Wells. In this the haemor- 
rhage had been previously into the cyst, which had burst, giving 
rise to an enormous extravasation in the peritoneum. In 
nearly all of the torsions about which we are speaking there is 
haemorrhage into the tumour, but should leakage take place 
into the peritoneum, of a gradual character, possibly inter- 
mittent, the usual symptoms of loss of blood will become 
evident, with an increase of dulness in the lower abdomen and 
flanks. 

The clinical appearance after haemorrhage from a cyst which 
has become more or less filled with blood as a result of torsion 
of the pedicle resembles very much that presented after a 
ruptured ectopic gestation. The treatment is similar and the 
urgency as great. 

(6) The vomiting may continue as the shock passes away, and 
the character of it change. Pain continues, with great tender- 
ness in the lower abdomen. In addition there may be disten- 
sion, with constipation and retention of flatus. It is possible 
in these cases that the obstruction is real and caused by the 
pressure of the tumour, which, owing to a shortened pedicle 
and increase in size, can no longer accommodate itself to 
ordinary intestinal movements. This is, however, not so 
common as in those cases where the constipation is incomplete, 
fl.atus is passed, the vomiting irregular, but rarely urgent. 
Here the symptoms may be those of localised peritoneal 
irritation with distension and a temperature, pulse, and 
general condition indicative of septic poisoning from some 
intra-abdominal source. 

(c) When a suppurating cyst ruptures, well-marked peri- 
tonitis will develop and prove fatal unless operative procedure 
is quickly resorted to under favourable surroundings. The 
importance of early attention to a cyst which is causing pain 
and a rise of temperature following on a sudden bout of pain 
is therefore evident. Although after some attacks of this land 
it is common to find omental adhesions at a subsequent opera- 
tion, showing that recovery may follow, there is always the 



208 THE ACUTE ABDOMEN 

risk that an infection of the cyst has commenced which will 
terminate in gangrene, which no effort on the part of the 
patient or medical attendant can locaUse. It is very dis- 
heartening to find an acute peritonitis in the late stage caused 
by a gangrenous cyst with twisted pedicle,which is surrounded 
by lymph and stinking purulent fluid, where operation has 
been repeatedly postponed. 

The history of attacks of a painful character in the lower 
abdomen is given in a proportion of the cases of cyst which 
ultimately show torsion of the pedicle, but such attacks are 
Hkely to be misinterpreted and may be due to suppuration. 
Vaginal examination should not be neglected. 

Suppuration of Cysts secondary to Infection from the Diges- 
tive Tract. — A married lady of 41 was under my care in February, 
1907. Her previous history was good ; but for four years she had 
complained of pain in the lower abdomen, especially on the left side, 
when walking and during the catamenia, which were, however, quite 
regular. In July, 1906, she had an attack of diarrhoea, following pain 
of greater severity than usual, across the lower abdomen. Vomiting 
lasted for three days and she was kept in bed for a week. Some swelUng 
was said to have been present on the left side. Three weeks afterwards 
she had another attack of pain and diarrhoea and was kept in 
bed for ten weeks. On this occasion the pain was on the right 
side, which was very tender. The temperature rose to 101-2° and 
remained there for nearly the whole of the time. She was evidently 
very ill. 

On examination the abdomen was normal generally, but there was a 
complaint of tenderness in the lower part to the right of the rectus 
muscle. At the position of greatest tenderness a rounded swelhng 
could be felt. The uterus was rather fixed ; nothing else abnormal was 
discovered. At the operation a multilocular ovarian tumour the size 
of a cricket ball was found. It was adherent to the side of the pelvis 
and broad ligament, and had a short pedicle. The appendix was 
adherent to it, as was also a coil of small intestine. The former was 
removed, the small gut was separated, a denuded place being covered 
in with a peritoneal flap from the surface of the cyst. During its 
removal the cyst emptied itself of very offensive pus and altered blood. 
The smell of this was so very faecal in character that the large intestine 
in the i>elvi8 was searched for a possible opening, but it was uninjured. 
The main cyst was bound down by very firm adhesions, which required 
very considerable force to separate them. The solid gauze packing was 
removed, and the area involved cleansed with sterilised saline. Another 
small cyst (not adherent) the size of an egg was removed from the other 
side. Drainage. There was an offensive discharge for a fortnight. 
The wound closed in three weeks. 



DISEASES OF FEMALE GENERATIVE ORGANS ^09 

A suppurating ovarian cyst is not uncommonly found in 
cases where the appendix is removed after locaUsed suppura- 
tion. The spread of an appendix inflammation to a cyst may 
produce adhesions to the surrounding parts so extensive as to 
render its excision quite impossible. 

This was seen in a patient recently sent to me by Dr. Kinloch, of 
St. Albans. It was necessary to drain the cyst, because its firmly 
adherent walls were so thin that they separated in flakes with much 
haemorrhage. 

(2) Rupture of an ovarian cyst may take place quite early 
after its formation, as in a case brought to me by Dr. White- 
horne Cole. 

An unmarried lady had consulted him for some shght symptoms of 
iU-health, and when leaving his house on her way home was seized with 
a sharp pain in the abdomen, and became so faint that she was helped 
to a chemist's. Here she soon recovered and on the following day was 
apparently quite well. 

We thought that the symptoms might have been produced by 
rupture of a small ovarian cyst. An exploration showed that this had 
been the cause of her symptoms ; a ruptured ovarian cyst the size of a 
large egg was found on the left side and removed. 

When the patient has a larger cyst the symptoms of rupture 
may be more acute, whilst, on the other hand, in the absence 
of sepsis, it may be impossible to say when the wall of the 
cyst gives way. 

J. B., a married woman, aged 60, was admitted under the care of 
Dr. Culhngworth and transferred on April 27, 1903. She left May 17. 

For twelve months she had noticed increase in size of abdomen, but 
rapid increase during two months. The pain at first was rather inde- 
finite, but more troublesome of late, dragging and tearing in character, 
worse at night. She had been losing flesh lately. No vomiting, no 
difficulty with micturition. There was a large swelling of irregular 
outline in the lower abdomen ; more on the left side. It extended above 
the level of the umbihcus and to the costal margins laterally. There 
was marked vermicular movements of the intestines in front of the upper 
part of the swelhng. There was some tenderness over the right side of 
the swelling. Fluctuation could not be obtained. There was resonance 
on percussion over the greater part of the swelhng, the only area of 
dulness being immediately above the pubic ramus on the left side. 
Uterus small, and movable independently of the swelling. 

When the peritoneum was opened on April 28 a large amount of 
yellow jelly-hke material (hke Brand's essence) exuded. When thif» 
had been washed away a pedunculated ovarian adenoma the size of a 

A.A. P 



210 THE ACUTE ABDOMEN 

footbaU was removed from the right side. In this there Was a large 
rupture with everted edges, evidently of some duration. In the cyst 
with wliich this communicated was viscid yellow jelly, and the wall was 
lined with adenomata containing similar jelly, but a few of these were 
calcified. The cystoma was not adherent. The gelatinous material 
was diflScult to wash away, and left the surface of the intestine quite 
woolly in appearance. Other structures were normal, and the wound 
was closed. 

If the patient was known to have had a tumour there will 
probably be a change in its outline and evidences of free fluid 
which were previously wanting. If the opening is compara- 
tively small and the leakage slow, very little urgency may be 
shown at first, a somewhat rapid increase in size of the abdomen 
being the most evident change. To this will be added a diffi- 
culty in lying with a low pillow or in moving about, and a 
swelling of the legs. Examination inay give the physical signs 
of a very large cyst, for the fluid, being of high specific gravity, 
compresses the intestines against the spine ; resonance is found 
over the colon on both sides and dulness elsewhere. 

Excessive Abdominal Distension due to Ruptured Ovarian 
Cyst (treated successfully under adverse circumstances). — Some years 
ago I was asked by my friend Dr. A. J. Southey, of Colnbrook, to see a 
patient with him in a village not far from London who refused to leave 
her home and go to a hospital. She was a single woman of 30 who had 
noticed an abdominal enlargemcDt for some months which had increased 
rather rapidly for a few weeks, so that he feared the case would have a 
fatal ending if he could not induce a surgeon to go and reUeve her. After 
talking the case over it was arranged that we should meet at the house 
prepared to do ovariotomy if the diagnosis which appeared most 
probable proved correct. Mr. Carter Braine, the eminent anaesthetist, 
kindly agreed to accompany me. On arrival we found the patient in 
the front room of a row of cottages, the window of which came quite 
up to the pavement. The patient, who was greatly distended, had some 
dyspnoea, and considerable oedema of both lower extremities which 
extended on to the abdominal wall. The surroundings were most un- 
favourable for operation, there being a Umited supply of Unen, of soap, 
and only a low table that would bear her weight. The only other 
person in the house was a woman of the working class whose acquaint- 
ance with modern ideas of cleanhness appeared very Umited. The 
supply of boiled water was very inadequate, but we kept this assistant 
engaged in preparing more. 

The abdomen was very large and of rounded outUne, dull all over 
excepting in the flanks. A fluid thrill was felt throughout. 

She did not hke lying on her back, and when she was under the 
anaesthetic it was necessary for her to be held in position whilst the 



I 



DISEASES OF FEMALE GENERATIVE ORGANS 211 

incieion was made. Many pints of fluid were taken away, and an 
ovarian tumour, one of the larger cysts of which had ruptured, was 
removed from the left side. Another and smaller multilocular growth 
was found in the pelvis, adherent to the right side and posterior aspect 
of the uterus ; to free this required the aid of strong scissors. The 
intestine remained flattened against the posterior wall of the abdomen, 
and the abdominal wall in front seemed very thick, heavy, and alto- 
gether too large. The remaining fluid was cleared away with gauze 
swabs and the incisioD closed. She made a good recovery. Dr. 
Southey gave most valuable help, and through his devotion to the 
welfare of the case without any coDsideration of his own interest, the 
life of this woman was preserved, for she had made up her mind that 
she would " die at home ! " 

The air which is left in the peritoneum in such cases may 
take three to four weeks before it is absorbed, as was shown 
in a case where there were hernial sacs in the groins, which 
had been overdistended before operation.^ 

Occasionally the remaining tumour can be made to trav^el 
from side to side in the fluid, if the pedicle is of adequate 
length. Again, an infected cyst may become adherent to the 
bowel and discharge its contents into it. In this way a patient 
may progress with fair comfort for a long time, excepting for 
occasional inflammatory attacks in the cyst and the increase in 
size of the rest of the tumour. 

There are two conditions affecting subperitoneal uterine 
fibroid which may give rise to an acute abdomen, the first is 
the twisting of the pedicle, the second is acute necrosis. Both 
are rare compared with the frequency with which the complica- 
tions of ovarian tumours obtrude themselves on our notice. 

Torsion of the Pedicle of a Subperitoneal Fibroid of the 
Uterus resembling Acute Appendicitis. — ^An unmarried woman, 
aged 40, was admitted for " appendicitis " on October 30 and left 
November 21, 1913. 

So far as the patient knew, she had always been well, with the excep- 
tion of troublesome constipation, until October 26, and her periods had 
been normal. 

On that day she was suddenly attacked with pain in the lower 
abdomen, not more one side than the other. This pain continued all 
day, and in the evening she noticed that the abdomen was swollen. 
The pain was worse after food, but she did not vomit ; it was also 
increased by micturition, and there was some difficulty at the com- 
mencement of the act. 

On admission the pain was chiefly on the left side, but easier. Later 

1 See Trans. Med. See. Lond. 

p2 



212 THE ACUTE ABDOMEN 

in the day there was distinct tenderness on the right side, with some 
distension of the lower abdomen, and an ill-defined swelling to the 
right of the middle Une. The temperature was 100-6° and pulse 108. 
Vaginal examination was negative. 

She was kept in bed, and the distension diminished so that a swelling 
in the right lower abdomen could be defined. Its upper boundary was 
rounded, and the whole swelling gave the impression that it was the 
size of an ostrich egg and arose from the pelvis, but it was not possible 
to ascertain whether there was any fluctuation in it or not. As the 
inflammatory symptoms were quieting down, operation was postponed 
until November 7. The incision was made to the right of the middle 
hue and the rectus displaced outwards. The tumour was a sub^ 
peritoneal fibroid, growing from the right posterior aspect of the 
fundus, the size of an orange, the pedicle of which was twisted. This 
was clamped and the fibroid cut away. The left ovary was cystic, so 
this and the tube were removed with the uterus by supra-vaginal 
amputation. The uterus presented many fibroids of different sizes in 
and about the body, but the one which had been removed was the 
largest. This was inflamed, and on section showed extensive haemor- 
rhage into its substance. The appendix was long and contained concre- 
tions, so it was excised ; it had not been recently inflamed. Recovery 
was uneventful. 

After the tumour was definitely outlined on lessening of the intestinal 
distension, she said that she had noticed swelling there before the 
present attack. There had been no menorrhagia. 

When the rotation has been more gradual in its progress we 
may find adhesions to the surrounding parts, which in their 
turn as they become organised may produce obstruction of 
the bowels. 

In 1903 Dr. Fairbairn^ made a valuable contribution to 
the study of one of the varieties of necrotic change, the so- 
called '' necrobiosis " in fibro-myomata of the uterus. Although 
this is well recognised amongst gynaecologists it is not often 
met with, nor does it necessarily demand immediate operation. 
Still, there are cases in which urgent symptoms arise, commenc- 
ing with an attack of acute pain in the lower abdomen. Pain 
was present in 16 out of 23 cases which Dr. Fairbairn collected, 
and in all it was the reason for the patients seeking advice. 

The following is a good example of the more acute process : — 

A married woman, who was four and a half months pregnant, was 
admitted in 1903. Five days before she had been suddenly seized with 
an attack of violent pain in the lower abdomen, and the pain and 
vomiting continued when she came in. For four days a swelling had 

^ Journal of Ohstetrlci and Gyncecology^ 1903. 



DISEASES OF FEMALE GENERATIVE ORGANS 213 

been noticed. The abdomen was enlarged, presenting two tumours 
rising from the pelvis. The one on the right was the size of two fists ; 
that on the left was the pregnant uterus. The temperature was 99° 
and pulse 118. 

At the operation a necrotic fibroid was removed from the anterior 
and right aspect of the uterus. The attachment of this tumour to the 
uterus was easily separated with the finger, but it was difficult to stop 
the bleeding from the raw surface left, as the tissues were very soft and 
sutures easily pulled out. Pressure with sponges soaked in hot saline 
solution appeared to answer most effectively. The wound was closed, 
and she recovered without miscarriage, although a low temperature and 
quick pulse continued for some days. 

The attachment of the tumour to the uterus, which was pushed to 
the left, was in this instance very sUght, and it was not possible to bring 
flaps completely over the raw surface. The tissues around the attach- 
ment appeared to have undergone inflammatory softening and would 
hold neither sutures nor ligatures. 

Similar cases are referred to by Dr. Fairbairn in his 
paper, notably those under the care of Bland-Sutton, Doran, 
and Mackenradt. Bland-Sutton has pointed out the liability 
to mistake these cases for axial rotation of an ovarian cyst. 
In either case operation would be required, and therefore the 
mistake would not have any serious consequences. Most of 
the patients were pregnant and there was no history of 
menorrhagia. 



PART V 

OTHER CAUSES OF THE ACUTE ABDOMEN 

At intervals one meets with cases showing acute abdominal 
symptoms, such that a diagnosis of one of the diseases already- 
described may be wrongly arrived at ; yet on opening the 
abdomen the appendix, intestines, and stomach do not show 
any of the expected lesions, there is no obstruction of the 
bowels, and search must be made for other possible causes of 
the symptoms. Acute pancreatitis or acute cholecystitis are 
perhaps the most likely of these. Very occasionally an acute 
dilatation of the stomach may have given rise to the symptoms. 

Acute Hemorrhagic Pancreatitis. 

In this disease the onset is sudden and associated with severe 
abdominal pain, located usually in the upper abdominal and 
umbihcal regions. The signs often suggest acute intestinal 
obstruction ; at other times perforation of an ulcer of the stomach 
or duodenum, or acute bacterial invasion of the peritoneum, 
such as that by the streptococcus, may be suspected. A 
history suggesting previous inflammation of the gall-bladder or 
ducts is occasionally obtained. The following case is that of a 
patient who recovered after operation : — 

A widow, aged 57, was sent to my care by Dr. G. Brebner Scott, of 
Brixton, for an acute abdominal illness, on February 23, 1909. At 
6 o'clock on February 22 she complained of great pain in the abdomen. 
She said that it began on the right side and spread rapidly to the left, 
and also extended upwards to the right costal margin. She was sick 
at the same time, and could keep nothing down subsequently. Her 
bowels had acted naturally the previous morning. 

There was no history of biliary colic or of injury, and she had been 
quite well until this illness. She was a well-nourished woman, who 
still complained (at 6 p.m. on February 23) of abdominal pain. This 
was now general all over the abdomen. She looked ill, had a pulse of 
1 10, and a temperature of 101°. The abdomen was distended, generally 



OTHER CAUSES OF THE ACUTE ABDOMEN 215 

hard to the touch, and very tender, but not specially so in the ihac 
fossa. On percussion there was patchy dulness, both in front and on 
the lateral aspects of the abdomen, but not in the flanks. No abnormal 
sweUing could be felt, but the wall of the abdomen, which was fat, was 
also distended and resistant. Her tongue was dry and bowels not 
acting. At the operation, which was performed about twenty-four 
hours after the beginning of symptoms, an incision was made on the 
right side through the rectus muscle. When the peritoneum was 
opened a good deal of blood-stained fluid escaped. There was no 
lymph on the peritoneum, but the omentum appeared somewhat thick ' 
and infiltrated, whilst in more than one spot there was fat necrosis. 
The pancreas appeared harder than usual, and enlarged. The gall- 
bladder was normal ; no stone could be felt either in it or in the biliary 
passages. The small intestine on the right side was distended. The 
peritoneum was washed out with normal saUne solution and the incision 
was closed. She was relieved by the operation, but on the following 
evening her temperature rose again to 100° and pulse to 136, so the 
incision was reopened, the presence of fat necrosis confirmed, more 
fluid evacuated and a drainage tube put in. The following day Cam- 
midge's test C was reported as positive. The patient was very ill for 
some days, and at one time appeared very weak, flushed and despondent. 
Drainage was continued until March 10, after which she gradually 
improved. It is not necessary to give any further details. She left 
hospital on April 20, having quite recovered. 

A more acute case, but one which came under treatment 
eight hours after the commencement of symptoms, was that of 

Gr. L., aged 39 ; admitted January 25 and left March 3, 1914. For 
about a fortnight he had had a feeling of sUght iUness, but never any 
abdominal pain or special symptoms. At 3 p.m. on the day of ad- 
mission he had gone to bed to rest, when he was seized with violent pain 
in the epigastrium. This continued and he vomited till he came up 
five hours later. He was a big, strongly-built man who looked very ill, 
had a respiration of 28, pulse of 72, and temperature 97°. The abdomen 
moved very badly with respiration and was rigid all over with areas of 
well-marked dulness in the flanks, in the left iUac fossa, and in the middle 
line of the umbilical region. There was general tenderness and rigidity, 
the tenderness being most marked over the stomach region. 

The man was sent in for supposed perforation of a gastric ulcer, but 
in discussing the case before operation we came to the conclusion that 
he had acute pancreatitis. About eight hours after the onset of the 
pain an incision was made in the epigastric region to the left of the 
middle hne, the rectus sheath opened and the muscle displaced to the 
left. As soon as the peritoneum was opened there issued a quantity of 
thin watery blood. More of this fluid was found in the flanks and iliac 
fossae, and in the lesser sac of the peritoneum. 

The peritoneum over the pancreas was softened and felt rather 
shreddy, and it was possible to expose the gland by using a pair of 



216 THE ACUTE ABDOMEN 

dressing forceps. It felt hard, was enlarged and somewhat lobular. 
A tube was passed down to the gland and packed off from the peri- 
toneum : it was in contact with the gland at its lower end, and in 
consequence of the size of the patient was of unusual length. A supra- 
pubic puncture was also made and the peritoneum flushed with saline 
solution (temperature 110°). There was a suspicion of fat necrosis 
about the duodenum, but nothing definite. Fatty material came away 
in the irrigating fluid. Tubes were left in both wounds. 

Dr. Dudgeon reported : " January 30, 1914. Cammidge's reaction 
test C after fermentation. Negative." 

For the first five days there was free drainage of serous fluid from the 
upper wound, but after that a thick purulent discharge from both 
wounds. For some days he complained of a great deal of epigastric 
pain, and there was fever with a pulse of 100. But his expression was 
good and the strength of the pulse satisfactory. The drainage tube 
was removed on March 4. The discharge gradually ceased, but the 
wounds were slow in healing. 

Acute pancreatitis is most commonly seen in adults, especially 
males of more than 40 years of age, well -nourished and even 
fat ; possibly the patient is a free liver who has been in good 
health until seized with a sudden attack of severe abdominal 
pain and urgent vomiting. On examination the abdomen has 
been more resistant generally than it should have been, but not 
rigid. The epigastrium has been most tender, but there has 
been a difihised superficial tenderness, especially on unexpected 
light palpation, in other parts. The general resonance over 
the abdomen has been rather patchy in character, whilst the 
movements during respiration have been good. In all the 
pulse has been rapid, the temperature elevated, 101° to 103° : 
there has been anxiety, and not infrequently a flushed face. 

If the abdomen is opened within twenty -four hours the 
amount of blood-stained fluid will usually be small, but some- 
times may be in sufficient amount to cause dulness in the 
flanks, and may be supposed to have come from the wound ; 
again, at this stage, it may be difficult to find any points of fat 
necrosis. In any case, in the adult where nothing is found in 
the more usual places to account for acute abdominal symptoms 
search should be made for these patches, which are yellowish - 
white in colour, and of small size (Fig. 30). If nothing is 
discovered to account for the state of the patient, then it may 
be well to put in a drainage tube for a few hours at all events, 
for a discharge of a red colour will soon come away, odourless at 
first, but later, and when in larger quantity, having a peculiar 



OTHER CAUSES OF THE ACUTE ABDOMEN 217 



mawkish smell, which, so far as I know, resembles nothing else. 
There may be no evident swelling of the pancreas. Many cases 
will only be diagnosed when the opened peritoneum shows the 
presence of spots of fat necrosis in the omentum, the escape of 
odourless blood-stained fluid having first attracted attention. 
This fluid may, however, be 
thought to have run into 
the deeper parts from a cut 
vessel in the wound, unless 
it appears flaky, and the 
operator is prepared to 
find it. 

The previous history may 
be of the greatest import- 
ance, pointing to the 
presence of gall-stones or 
ulcer of the stomach or duo- 
denum. Sometimes there is 
a history of an acute abdo- 
minal illness of doubtful 
causation. 

The principal abdominal 
catastrophes with which 
this disease is liable to be 
confused are — the perfora- 
tion of gastric and duo- 
denal ulcers ; in the male 
the resemblance to the latter 
is very close, if there has 
been a history of former 
attacks of pain and there is 
much fluid in the peritoneum 
within a few hours after the 

acute onset. If the vomiting continues and there is a rising 
temperature with patchy dulness and general hypersesthesia of 
the abdomen in a stout adult with previous good health, 
there is less difficulty, but even then a small perforation 
might mislead the inexperienced, although there is a great 
difference in the appearance of the two patients and in the 
state of the lower abdomen. 




Fig. 30. — Fat Necrosis, from a Specimen 
in the Eoyal College of Surgeons 
231, 1, General Pathology. 



Museum 



218 THE ACUTE ABDOMEN 

In intestinal obstruction high up in the small intestine there 
is the same kind of initial peritonism. The symptoms are 
severe, vomiting troublesome, and constipation marked. 
There is no distension at first and but little peristaltic move- 
ment visible. If the patient is a female over middle life, 
without any history of gall-stone colic, the diagnosis may be 
difficult in the first few hours after onset, but as time passes 
the symptoms in this form of obstruction change, the pain is 
more definitely of a paroxysmal character, the site of the chief 
pain becomes more umbilical, whilst peristalsis is seen. In 
thin people a lump may be felt which is neither in the position 
of the gall-bladder nor of the pancreas. Distension comes on 
in the later stages as the gall-stone approaches the ileo-csecal 
valve, and the symptoms show a considerable change as the 
stone is passed along. If the patient gives a history of opera- 
tion for an abdominal condition, or has had an illness which 
might indicate the possibility of internal adhesions, this must 
be fully discussed. 

The presence of the tumour in cases of acute distension of 
the gall-bladder, with its rounded outline, and the localisation 
of the pain and tenderness to the parts under the right upper 
rectus, with the rigidity of that muscle, will suffice to indicate 
the nature of the mischief. There may be no jaundice. A 
tumour is rarely felt in acute hsemorrhagic pancreatitis. 

In a case seen at a later stage it may be very difficult to 
say that the illness is not due to an attack of acute appendicitis. 
This is so in hospital work more than in private. To give an 
example : 

A deaf woman, by no means intelligent, over 50 years of age, who 
applied, with pain after three or four days' illness ; a distended abdomen, 
with dulness in the flanks and general tenderness. Rapid pulse, 
temperature 100°, and continued vomiting. With these symptoms and 
signs, an inability to say where the pain began, and no history of 
previous illness. 

Still, even in such a case as this, that of a woman admitted in Decem- 
ber, 1913, there were signs which pointed to the appendix as the origin 
of the trouble 

The muscular wall seemed more rigid in the right lower abdomen, 
the dulness was more evident in the right flank and iliac fossa, whilst 
the acute tenderness, indicative of spreading peritonitis, was most 
marked on the left. The epigastric region was without rigidity or 
special tenderness. 



OTHER CAUSES OF THE ACUTE ABDOMEN 219 

She had a general peritonitis secondary to a gangrenous appendix, 
and died in the following month, when convalescent after the operation, 
from haemorrhage from a gastric ulcer. 

These patients are not good subjects for an abdominal 
operation, and I believe you will get better results in most 
cases from simple incision with the insertion of a large drainage 
tube down to the pancreas with gauze packing, than from a 
more elaborate operation. Most of them will not stand a 
prolonged manipulation, with the larger amount of ansesthetic ; 
it is possible, however, to do much more if the patient is in fair 
condition and not too fat. The ideal operation is to incise the 
tissues over the pancreas, with due regard to the duct and 
main vessels, and establish a direct route for drainage, packing 
off the tube with gauze ; unfortunately the action of the 
secretion from the gland, if much escapes, on the tissues with 
which it comes in contact is very destructive, and if the flow 
is profuse you will find it difficult to prevent actual digestion 
of parts. 

Mr. Barker^ suggests that when the operator finds in an 
early case that the acute process is mainly or entirely retro- 
peritoneal, it will be advisable to drain the affected area by a 
large tube passed from the flank along a track partly made 
by the forefinger. In this way he may close the anterior 
wound without drainage, and avoid possible complications 
from adhesions in later life. 

If the condition of the patient permits the time required for 
the removal of any gall-stones that may be discovered, they 
should be removed and the gall-bladder drained. Should a 
stone be present in the common duct, it should be extracted, a 
drainage tube passed down to the opening, and isolated by 
gauze. Sir Berkeley Moynihan recommends that access to the 
pancreas should be obtained by making an opening through the 
gastro -hepatic omentum ; others that the deeper opening be 
made through the gastro -colic omentum ; this is the more 
accessible route of the two, and better placed for drainage. 

A stone in the common duct may be left until the state of 
the patient is less critical ; the drainage of the gall-bladder will 
effect the immediate improvement required. 

1 Lancet, Vol I., 1914 p. 1594. 



220 THE ACUTE ABDOMEN 

You need not place a drain in the pelvis, for after cleansing 
the peritoneum, either by sponging or lavage with steriUsed 
sahne, the plugs which are placed around drainage tubes should 
be sufficient to prevent further escape into the general cavity of 
the peritoneum. Strong fishgut sutures passed through all the 
layers of the abdominal wall to close the wound are the best, 
provided they do not obstruct the rubber drains. A firm 
many-tailed bandage should be apphed with plenty of absorbent 
dressing. You must trust to drainage by the anterior wound 
in severe cases and not prolong the operation and incur 
further risks by making a posterior opening. 

If it is necessary to drain for a long period, a ventral hernia 
will certainly result, and it will be well to explain this to the 
friends during the course of the illness. It cannot be avoided. 

The plugs should be removed after thirty -six hours, gradually, 
according to the amount of pain which the adhesion may 
cause. If the wound becomes septic the administration of 
gas and oxygen, and the early removal of the plugs, is 
indicated, and the insertion of others after a cleansing of the 
wound with an antiseptic solution. 

Acute Dilatation of the Stomach. 

This is a rare condition, the cause of which is often doubtful ; 
at other times it follows an operation or injury involving the 
peritoneum, and it is with these that we are most concerned. 

An attack starts with copious fluid vomiting, epigastric pain 
and distension, which becomes general ; the action of the bowels 
is irregular ; signs of extreme collapse are present. Towards 
the end of a severe case complete atony of the stomach may 
lead to cessation of the vomiting. 

Of physical signs, the most valuable, when it is present, is 
succussion, but it is important to remember the possibility of 
the occurrence of such a condition in the acute abdomen. 

Unless relieved by evacuation of the stomach contents it 
usually proves rapidly fatal. The extreme distension of the 
abdomen and generally severe condition may lead to a diagnosis 
of acute peritonitis, or if there is constipation intestinal obstruc- 
tion may be thought to be present. A few notes of a case 
will bring this condition more fully before you. 



OTHER CAUSES OF THE ACUTE ABDOMEN 221 

On January 21, 1903, I was asked to see a girl of 15, who had been 
under care for two days, in consequence of an acute pulmonary affec- 
tion, but there had been a sudden change in her symptoms. She was 
the subject of angular curvature of the dorsal spine, the result of old 
tuberculous disease. 

On the 21st she began to vomit about 7 a.m., the vomited material 
being of a bihous character, and yellow in colour. The bowels acted 
at 8 a.m. The pain in the side of which she had complained was 
much better, but the constant vomiting masked all other symptoms. 
Temperature, 99° ; pulse, 80. Nothing reheved the sickness. The 
abdomen was retracted, dull all over, and without tenderness on 
pressure. At 6 p.m. she was rather collapsed, the vomiting continued, 
and now she was bringing up a black, tenacious fluid. She had com- 
plained of no pain since the vomiting came on, but the abdomen was 
becoming distended. About 1 1.30 p.m., when I saw her with Dr. Bulger, 
the abdomen was somewhat distended but not markedly so, dull on 
percussion all over the front and down the left flank to Poupart's Uga* 
ment. No dulness was present in right flank. A well-marked thrill of 
fluid could be felt in the lower part, and to the left. There was no 
rigidity. Her pulse was rapid, face pale and sunken, tongue black and 
dry, whilst there was frequent vomiting of a black, tarry fluid. 

An incision in the middle hne showed a greatly distended stomach, 
the lower margin of which passed down to the pubes ; it was bluish in 
appearance and flattened with very thin flaccid walls. All the intestines 
were empty. There was no free fluid. Distension apparently ceased 
at the third part of the duodenum, and no pressure could empty the 
contents of the stomach along this part. A tube was put in, and the 
opening sutured to the abdominal wall. Much black, blood-stained 
fluid was drained off from the stomach by this tube, and vomiting 
ceased ; but otherwise httle rehef was afforded, and the patient died on 
the following day apparently from exhaustion. 

Here with acute symptoms we find dulness along the middle 
line for the first time in the acute abdomen. 

As an example of the disease following an abdominal opera- 
tion a case ^ may be given, as it illustrates many important 
points which may develop during the course of such an illness. 

A woman, aged 27, came under my care from the late Dr. Heath, of 
St. Leonards-on-Sea, on November 7, 1901, for a swelhngin the abdomen 
which had been noticed to be increasing for the previous nine years. 
On November 12 a coehotomy was performed, the diagnosis of ovarian 
cyst confirmed, and a large tumour removed in the usual manner. 

On the first and second days after the operation the patient's pulse 
was about 110, and temperature rose from 101° to 103°. The abdomen 
became increasingly distended ; there was no vomiting beyond that 
directly following the anaesthetic. A week after the operation there was 

I See Lancet, 1903, Vol. I., p. 1031. 



222 THE ACUTE ABDOMEN 

evidence of slight suppuration in the abdominal wound, and some pus 
was evacuated with a director. There continued to be great distension 
of the abdomen and much discomfort. 

On November 21 Dr. C. R. Box saw her with me. The epigastric area 
was then very prominent and a ringing coin sound could be obtained 
over this area and extending downwards to the iliac crests ; marked 
succussion was ehcited on shaking the patient ; there was no vomiting. 
Lavage of the stomach was commenced and carried out twice daily from 
this time. Twenty-six days after the operation parotitis developed, 
associated with a septicaemic temperature and severe diarrhoea, and for 
some days this was uncontrollable. Antistreptococcic serum was given ; 
a marked rash followed two days after its administration, but it was 
without apparent effect on the disease. The distension of the abdomen 
did not appreciably diminish, and with a high temperature and the 
diarrhoea it continued for about three months ; much oedema of both 
legs and the lower part of the abdominal wall supervened. Some 
peristalsis in the region of the umbihcus was occasionally seen, and the 
stomach still showed the physical signs of dilatation. 

On August 12, 1902, the gastro-intestinal functions had become 
practically normal, the oedema in the lower part of the body, due 
presumably to thrombosis of the inferior vena cava, was still present 
and the patient left the hospital. Seen again in January, 1903, her 
general health was good, though evidence of thronfbosis persisted, there 
being some oedema of the ankles with dilatation of the veins over the 
lower part of the abdomen. 

The subsequent history of this case is very interesting. She was 
readmitted under my care on November 19, 1907, for another abdominal 
sweUing. It was stated that her general health had been good until a 
fortnight before, but that during that time she had suffered from pain 
in the stomach and sweUing but no vomiting. The abdomen was a 
good deal distended and tense on admission, the superficial veins 
dilated, chiefly in the lower part, and there were numerous hneae albicantes 
in the same region. A dull rounded area was present reaching almost 
to the umbihcus from the pelvis. This was fluctuating and tender, 
whilst around it the intestines were distended and tympanitic. Her 
temperature was shghtly raised. She was kept in bed for some time in 
order to give the inflammatory state a chance of quieting down, but the 
distension did not appreciably diminish. On December 4 an incision 
to the left of the middle hne was made, and an inflamed ovarian cyst 
removed. The pedicle was long and had been twisted three times from 
left to right. The cyst was very adherent to the omentum, but not 
suppurating. It was an ordinary multilocular cyst. The gut was very 
much distended, the sigmoid being about 5 inches in diameter when 
examined in the wound. It was not punctured, as the condition was 
regarded as temporary in character. 

Much flatulent distension of the abdomen continued not involving 
the stomach ; many remedies were tried, but until the employment of 
the interrupted current late in December no definite effect appeared to 
have been produced by them, but the distension suddenly subsided on 



OTHER CAUSES OF THE ACUTE ABDOMEN 223 

the 25th of that month. There was no suppuration or rise of tempera- 
ture after the operation. 

The unusual amount of distension of the intestines present at the 
time of the second admission, and the difficulty in getting rid of it after 
operation is especially interesting in a patient with this history. On 
this occasion there was no suppuration either before or after operation, 
yet the distension was extreme, and suggested that the nervous element 
was an important factor in its causation. The rapid recovery on the 
use of the interrupted current confirms this view. We know how 
marked the "reflex" effect may be sometimes of an injury to the. 
abdomen unattended with obvious lesion, also the great distension 
which may ensue on the mere appUcation of a ligature to the neck of a 
hernial sac in the operation for radical cure. In one patient a condition 
of rapid distension of the abdomen with pain, vomiting and a tempera- 
ture of 103 "6° ensued with a collapse which excited alarm. Appropriate 
remedies soon produced a change for the better and the case ran the 
usual aseptic course. 

These cases are both of them examples of acute dilatation of 
the stomach but present many points of contrast. In the first 
the stomach had become a mere fluid -containing sac with a 
thin wall, which at the time of the operation was lying over the 
front of the intestines and gave a dull note on percussion across 
the middle line, an area which is resonant in all other conditions 
of the acute abdomen. There was most certainly no gaseous 
accumulation, and until quite the last stage there was no disten- 
sion of the abdomen. It is difficult to account for it, unless we 
accept the suggestion that it was a paralysis due to some toxic 
condition associated with the patch of inflammation of the left 
lung found by Dr. Bulger, when he first saw the patient. Spinal 
deformity has been noticed in other cases of acute dilatation, 
but when not associated with the application of a plaster jacket 
it is difficult to understand how it could have much influence 
on the production of such an acute and fatal affection. 

Dr. W. B. Laffer ^ collected a series of 217 reported cases, and 
of these 38*2 per cent, followed operations, usually one on the 
abdomen. The notes of the second case were published by 
Dr. Box and myself on account of its rarity, and as an encour- 
agement in the treatment of such desperate conditions. We 
are incHned to put its occurrence down to some toxic absorption 
from the wound, although the amount of suppuration was 
neither acute nor extensive. It is probable that she owed her 

1 '' Annals of Surgery," Vol. II., ]908. 



224 THE ACUTE ABDOMEN 

recovery to the fact that her distension was general and not 
absolutely confined to the stomach and duodenum. 

As regards the causation of acute dilatation of the stomach, 
the following opinion may be quoted ^ : — 

" This cause we found, after experiments on the cadaver, to be the 
pressure exerted by the superincumbent and dilated stomach on those 
parts of the duodenum which Ue in contact with the front and left side 
of the spinal column. AVe learned later that a somewhat similar 
suggestion had been made by Meyer in 1889, and by Schultz in 1890. 
Our hypothesis is that in the production of the train of symptoms, 
associated with acute dilatation of the stomach, a vicious circle came 
into play ; first a paralytic dilatation of the viscus occurred, and then 
distension, due to duodenal obstruction, induced by the weight of the 
superincumbent stomach." 

Although the insertion of a tube after abdominal section into 
the stomacli has been successfully tried, your main reliance 
should be on position, and the washing out the stomach with the 
stomach pump or siphon. The patient must lie on the right 
side with the head low. 

Embolism and Thrombosis of the Mesenteric Vessels. 

This is very rare. The results which follow obliteration of 
the vessels in the mesentery are the same whichever vessel 
becomes first affected. Gangrene of the gut invariably follows. 
A man between 30 and 60 years old has an abrupt onset of 
sudden intense pain in the abdomen, followed quickly by 
vomiting and collapse, peritonism is well marked. If diarrhoea 
is present the motions are frequent and blood-stained ; if 
constipation, then nothing, not even flatus, is passed. The 
abdomen is distended, rigid and tender. Sometimes free fluid 
is present. The temperature is often subnormal, the pulse 
rapid and of bad quahty. In the second smaller group the 
origin is insidious and the progress varies. A diagnosis of 
intestinal obstruction may be made, but the true condition is 
only found at the post-mortem examination. Gerhardt gives 
the following as necessary for a diagnosis : — (1) The presence 
of a source for the embolus ; (2) copious intestinal haemor- 
rhages, not to be explained by disease of the wall of the bowel, 

» C. R. Box and C. S. Wallace, "Acute Dilatation of the Stomach." Lancet, 
Vol. II., 1911, p. 215. 



OTHER CAUSES OF THE ACUTE ABDOMEN 225 

or by impediment to the portal circulation ; (3) a rapid and 
marked fall of temperature ; (4) colicky pain in the abdomen ; 
(5) the simultaneous or previous occurrence of embolism in 
other parts ; (6) the occasional presence of a tumour in the 
abdomen, due to the infiltration of the mesentery with blood. 
All of these signs are not, however, present in every case. 

The operative treatment consists in a resection of the part of 
the bowel that appears involved in the process of gangrene, and • 
the placing of an opening in the bowel at a convenient spot 
above. This is done (1) because in resection of a portion of 
gut, the line of suture, if anastomosis of the bowel is to follow, 
must be in sound tissue, and it is always doubtful in these cases 
if the gangrene will not spread ; (2) the full operation would 
in most instances take too long when consideration is paid to 
the grave state of the patient.^ 

Perforations of the Gall-bladder and Bile-ducts. 

Symptoms of peritoneal involvement of variable extent arise 
either from perforation of the gall-bladder, or from its being in 
a state of phlegmonous or gangrenous inflammation. A history 
of previous attacks of biliary colic, perhaps associated with 
jaundice, may very likely be given. 

The pain in typical cases will be localised in the gall-bladder 
region, but it may extend to the umbilicus, to the appendix 
region, or become generalised, in accordance with the extent of 
the infection. Referred pain in the right shoulder is uncommon. 
Confusion in diagnosis with acute appendicitis or perforation of 
a duodenal ulcer is likely to arise. The following is an example 
of the former type of case : — 

On the evening of November 17, 1903, 1 was requested to see a patient, 
aged 58. Two days before he had been taken with severe paroxysmal 
abdominal pain accompanied with vomiting. 

He had had three other attacks of abdominal pain, the first two years 
previously. None of them had been followed by jaundice, although the 
pain was always in the region of the gall-bladder, and they were regarded 
as biUary cohc. The present attack began during the night of Saturday, 
the 16th, and resembled the other attacks. On the 18th he felt so much 
better that he went into the City to business. In the evening he came 
home earUer than usual, and sent for Dr. Godfrey, who found him again 
complaining of pain in the abdomen, with a temperature of 101°. On 

1 Moynihan, Abdominal Operations. 
A.A. Q 



226 THE ACUTE ABDOMEN 

the following morning he was worse, and during the day he had occa- 
sional vomiting; the abdominal pain continued to be severe and 
gradual distension came on, whilst liis expression became changed to 
that associated with serious abdominal disease. 

AVhen I saw him about II p.m. he had a greyish look and appeared 
distressed. There was occasional vomiting. His pulse was 84, of fair 
strength. The abdomen was distended and did not move well with 
respiration. It was tender on pressure, especially on the right side 
below the ribs, the area of most marked tenderness being midway 
between the ribs and the ihac fossa. The liver dulness was not increased, 
but there was some dulness below in the right flank difficult to define, 
as the man was very fat. The bowels had acted twice during the day. 
He was evidently suffering from peritonitis, but we could not decide 
where the origin of the trouble was. Incision over the ihac fossa 
showed that to be healthy, whilst there was pus along the colon coming 
from above where the intestine was covered with lymph. A second 
incision over the gall-bladder showed a recent peritonitis around it 
with pus, not definitely locahsed. The area affected was cleansed, 
and the gall-bladder examined. It was small, not distended, but 
presented a small perforation near the fundus. No stone could be felt, 
but the condition of the patient under the annesthetic was bad, and it was 
imperative to finish the operation as soon as possible. The gall-bladder 
was therefore packed off with gauze, and a tube introduced above the 
plug down to the opening in the gall-bladder. The patient recovered 
and has had no acute abdominal attack since. 

The cases may be very acute in their course, and early 
operation affords the only chance of success. The peritoneum 
fills rapidly sometimes from this source, and as a rule there is 
little in the previous history to point to the presence of gall- 
stones in the gall-bladder, as they are usually of large size, 
giving very little inconvenience to the possessor until ulceration 
has taken place over them and extended through into the 
peritoneum. Occasionally the symptoms may not be of this 
acute character. 

It is possible to get large accumulations of fluid in the 
peritoneum after perforation of the gall-bladder without the 
production of much disturbance. This is well known where 
there has been a traumatic rupture of the gall-bladder or bile- 
duct, but a rapidly fatal peritonitis is the usual consequence 
when the contents of the gall-bladder have escaped through a 
breach of the wall in disease of that viscus, when micro- 
organisms are very active. 

The condition of the patient will not often give the oppor- 
tunity for an excision of the gall-bladder. You are usually 



OTHER CAUSES OF THE ACUTE ABDOMEN 227 

restricted to drainage of the gall-bladder and peritoneum. Do 
not forget the tendency of escaped fluid to run down into 
the pelvis. 

Perforations of the gall-bladder or bile-ducts, though by no 
means frequent, form an important class in the production of 
abdominal catastrophes. Mc Williams has collected 108 cases 
from general medical literature. 

In a series of 3,180 operations on the biliary system there 
were only 29 cases of perforation, or less than 1 per cent. 

Dr. C. Campbell Horsfall has recorded ^ the case of a woman of 45 on 
whom he operated for a perforation of the common bile-duct the day- 
after its occurrence. The patient had gall-stones. It was not possible 
to see the opening, but drainage was provided to the part from which 
bile was coming, and tubes placed in the right kidney pouch and over 
the pubes. He says that McWilUams collected four similar cases 
amongst the series of 108 perforations of the biliary passages. 

(1) Kehr. — Female, 51 ; symptoms four days ; perforation of common 
duct ; cholecystectomy. 

(2) Biedel. — Male, 56 ; symptoms three days ; perforation of 
common duct and gaU-bladder ; cholecystotomy. 

(3) Eoutier. — Female, 56 ; symptoms one day ; perforation of 
common duct, free bile ; cholecystotomy. Recovered. 

(4) Neupert. — Female, 42 ; symptoms fourteen hours ; perforation 
of common duct at juncture with cystic duct, free bile ; cholecystectomy. 
Recovered. 

The above five cases show in a very graphic way the import- 
ance of early operation in these cases. In two the symptoms 
had been in progress for four and three days respectively, and 
both died. The other three were operated on within thirty -six 
hours after perforation, and all recovered. 

Occasionally the symptoms may not be of this acute character. A 
patient under my care in 1908 was admitted for supposed intestinal 
obstruction. He was a feeble old man, who had been losing flesh and 
strength for some time, whilst the abdomen had gradually become 
distended for a week or ten days before admission, during which time 
he had also had a little vomiting and constipation. The abdomen was 
distended, it contained a large quantity of fluid, and the man was 
emaciated and rather yellow in appearance. He appeared apathetic, 
had no pain, and at this time was not vomiting, but from the history it 
was supposed that he might have incomplete malignant obstruction of 
the large bowel with secondary growths about the peritoneum and in 
the liver. Nothing abnormal could be felt per rectum. His pulse was 

1 British Medical Journal, 1913, Vol. II., p. 118. 

Q2 



228 THE ACUTE ABDOMEN 

not more than 70; his temperature was normal. An exploratory 
operation was done and the peritoneum found to be fuU of bile-stained 
fluid. Search was made for a possible cause of obstruction, but the 
intestine was nowhere distended and no growth could be felt. Some 
lymph was seem in the region of the gall-bladder, and amongst this 
lymph was an opening which led into the gall-bladder, in which there 
were some gall-stones. The patient did well for a few days after the 
operation and then rapidly sank and died. 

Enterospasm. 

By this term is now recognised a condition in which there 
is a spasmodic contraction of the muscular wall of some part of 
the intestines ; there is no obvious structural change in the 
bowel, and the phenomena are usually regarded as being 
dependent upon some abnormal action of the nervous 
mechanism. 

The spasm may give rise to symptoms of var3ring intensity, 
from those of chronic constipation to such as simulate acute 
intestinal obstruction. 

Dr. Hawkins drew attention to the condition in 1906,^ and I 
will give some of the conclusions he then set down. 

Symptoms usually manifest themselves in patients during 
the active period of life ; they appear with about equal fre- 
quency in the two sexes. The individuals affected are usually 
of a neurotic type and often of sedentary habits. 

Opportunity for direct observation of the spasm of the bowel 
does not often occur, but Dr. Hawkins thinks that the colon 
is more often affected than the small intestine. The pain in the 
subacute cases is sometimes locahsed in the right ihac region 
and so appendicitis may be simulated. 

In one case under my care some years ago the patient, a man of 60, 
rather stout and very neurotic, had a swelhng in the left iliac fossa, with 
occasional haemorrhage from the rectum. These conditions were due 
to spasm of the sigmoid associated with internal haemorrhoids. 

I need here only consider the severe cases giving rise to 
symptoms which suggest the necessity of immediate operative 
interference. Sometimes the resemblance of the condition to 
intestinal obstruction of organic origin or even to general 
peritonitis may be so close that the mind of the observer is 

1 British Medical Journal, January 13, 1906. 



OTHER CAUSES OF THE ACUTE ABDOMEN 229 

left in doubt as to the right diagnosis, and exploration of the 
abdomen will be the only sound course to pursue. 

Points which will be helpful in arriving at a decision are the 
presence of the trouble in highly -strung, nervous individuals, 
with a history of previous attacks of abdominal pain similar 
in character which have passed off without operation. 

In a case operated on for me in St. Thomas's Hospital by 
Mr. L. Norbury : . 

The patient was a woman of 40, for whom I had removed gall-stones 
about two years previously. Her symptoms were those of acute 
intestinal obstruction, and the spasmodic contraction affected much of 
the small intestine. She was a typical neurotic in appearance. 

I have met with the condition as a localised affection of the 
splenic flexure in more than one instance. Here the patients 
have been overworked and anxious men of over 45 years of 
age. Unless abdominal exploration has been carried out in 
any case of abdominal pain, it is impossible to say that it is 
of neuralgic character. I have known severe attacks of 
recurrent pain put right by the division of a band. 

Torsion affecting other Abdominal Structures. 

Many other examples of torsion of a pedicle have been 
recorded in medical literature, such as the spleen, the gall- 
bladder, the appendix, Meckel's diverticulum, and, more 
frequently, tumours with a movable attachment, such as simple 
growths of the small intestines, cysts of the mesentery. In 
hydro -salpinx (or pyo-salpinx) the tube occasionally becomes 
twisted. 

Torsion of the great omentum is a lesion to which Mr. E. M. 
Corner has drawn attention in the St. Thomas's Hospital 
Reports. It is rather more commonly met with than most 
of those conditions which we have mentioned in the last 
paragraph. Not infrequently it has been diagnosed wrongly 
as appendicitis, but usually there is a history of inguinal hernia 
on the side of the swelling or a hernia may be present. The 
size of the swelling, which is mostly situated under the right 
rectus, and the slight nature of the symptoms considering its 
somewhat rapid formation, are against an inflammation of the 



230 THE ACUTE ABDOMEN 

appendix. It is also more movable on the deeper structures 
and gives the impression of a solid mass. 

An incision should be made over the inguinal region and 
carried upwards as high as necessary along the front of the 
rectus sheath, the muscle being displaced inWards and the 
peritoneum divided with the posterior layer of the sheath. 
The upper part where the twist has taken place is not very 
broad and is easily secured with ligatures. Early operation is 
desirable because of the danger resulting from gangrene of the 
omentum involved, but successful removal of the mass, which 
is sometimes as large as the adult head, has been effected after 
the condition has been in evidence for a long time. This has 
usually been during an operation for irreducible hernia. It is 
interesting to note that many of the subjects of omental 
torsion have been sufferers from attacks of abdominal pain the 
origin of which has been unrecognised. 

Vignard's Case. — A man of 31 had attacks of pain in the right side 
of the abdomen for nine years. These attacks lasted four to five days, 
and there were four or five attacks yearly. In this patient a diagnosis 
of appendix abscess with inflammation spreading to a hernial sac was 
made. 

In more than one the position of the pain with rise of tem- 
perature and presence of a swelhng has led to the diagnosis of 
appendicitis, or partial obstruction has appeared a likely 
explanation of the symptoms. It is extremely likely that 
minor degrees of torsion are frequently present in omental 
hemiae. 

HEMORRHAGE FROM GaSTRIC AND DuODENAL UlCERS. 

Few surgeons have any doubt that operative treatment 
is sometimes absolutely necessary in haemorrhage from these 
ulcers. It may be the only means of saving hfe, but the 
indications for its performance must be clear and definite. 
It is certain that in a large number of cases which have appeared 
to be absolutely hopeless the haemorrhage has ceased and the 
patients recovered under appropriate treatment, such as 
complete rest in bed, the administration of morphine, sahne 
solution given intravenously or subcutaneously, with, in addi- 
tion, a continuous supply 2)er rectum. Nothing should be given 




OTHER CAUSES OF THE ACUTE ABDOMEN 231 

by mouth. No visitors or business worries should be per- 
mitted. 

Some of the pubKshed cases do not lead one to think that 
operation was really necessary, and that the patient would 
not have recovered without the operation. In addition it 
should be noted that in more than one instance no lesion has 
been discovered by the operator. 

If, however, the character of the bleeding makes it appear 
that an artery has been opened up by the ulcerative process, 
the rules of treatment must be adhered to in the stomach as 
in the case of similar lesions in other parts of the body. 

The need for. quick and steady operative procedure will 
be apparent ; the surgeon must lose no time, whilst the deeper 
manipulations must not be hampered by an inadequate opening 
in the abdominal wall. The patient must be prepared as 
usual in abdominal cases where much shock is expected, whilst 
the preparations to replace some of the blood which has been 
lost are completed. If the loss of blood has been considerable, 
intravenous infusion of sterilised saline should be commenced 
at once and continued during the operation. 

A free incision is made in the middle line to fully expose the 
gastric area ; the intestines must be packed off with gauze 
strips, and the stomach examined with the view of locating the 
ulcer. If nothing is found anteriorly, then it is advisable to 
explore the posterior surface through an opening in the gastro- 
colic omentum. The stomach, having been brought outside, 
must be partly emptied, with a trochar and canula if very full, 
if not very full through an incision. This incision is made 
through the anterior wall of the stomach parallel with the 
greater curvature and nearer to it than to the lesser curvature. 

This stomach opening is held stretched with retractors and 
the interior examined in detail, commencing with the areas 
in which ulceration is most common. The whole of the 
interior should be explored when the fluid contents have been 
cleared away, because of the possibility of the presence of 
more than one ulcer. The use of any one of the various means 
used for arresting the haemorrhage will depend on the size of the 
ulcer, its position, attachment, and the general state of the 
patient. These include : — 

(1) Excision of the .ulcer, and suture of the resulting opening. 



232 THE ACUTE ABDOMEN 

(2) Under -running the tissues round the ulcer with catgut 
sutures, or applying a Hgature to the artery which goes to the 
ulcer. 

(3) Suture of the mucous membrane over the bleeding 
point when this is small, as in the closure of a perforation on 
the serous surface. 

(4) Gastro -enterostomy, taking advantage of the opening 
already made. 

Pylorectomy, which has been advised for some cases of 
ulceration with thickening, is seldom possible ; the operation is 
too severe and prolonged for cases of such urgency. 

I do not advise the application of the actual cautery ; 
its effect on the tissues is to produce a slough, which when 
it separates may give rise to renewed haemorrhage and septic 
trouble. 

Sir Berkeley Moynihan^ writes : 

" Gastro -enterostomy, it was found, led, in all my cases, to an 
instant cessation of the bleeding and to the speedy and complete 
heahng of the ulcer. The explanation ot this was, it seemed to me, as 
follows : In all cases of haematemesis or melaena, the tendency to 
Bpontaneous cessation is known to be remarkable ; the cause of the 
continuance of the haemorrhage in certain cases, I concluded, after an 
examination of several cases during operation, must be distension of 
the stomach." ..." My own practice has justified my advocacy of 
this method ; in no case have I found reason to regret having adopted it. 
In all, the arrest of the haemorrhage has been complete, and permanent." 

This is a very important statement coming from such an 
authority. 

One of my cases of gastro -jejunostomy died a few days after- 
wards from haemorrhage from an ulcer in the duodenum, one 
of two which were present, but this was evidently because the 
ulcer had extended into an artery, the influence of the opera- 
tion being brought into play too late to arrest the process. 

It may be the wiser plan, when possible, to perform the 
operation of gastro -enterostomy although the local trouble 
has also been directly treated. 

In deahng with these cases it is advisable to remember that 
the haematemesis may be of hysterical origin, for such a 
condition is always amenable to medical treatment, and 

1 " Abdominal Operations," \\ 162. 



. S 



OTHER CAUSES OF THE ACUTE ABDOMEN 233 

should not be submitted to operation under any circumstances. 
The history of the case given below not only helps to prove 
this, but shows in a marked degree the ills that may follow 
such ill-advised interference. 

A nurse, aged 29, was sent to me by Dr. Frank Boxall, of Kudgwick, 
in September, 1902, for varicose veins of the left leg, which were causing 
her pain when standing. She was admitted to St. Thomas's Hospital, 
and Trendelenberg's operation with excision of some of the more 
prominent veins in the calf performed. 

In her past history it was stated that she had been in another hospital 
a short time before for symptoms which were regarded as indicating the 
presence of a gastric ulcer. One night she developed acute symptoms, 
which were supposed to have been due to perforation of the ulcer, and 
an exploratory incision was made in the epigastric region by a surgeon, 
who found nothing but a normal state of the stomach ; there had been 
no perforation. 

From the history this was supposed to have been hysterical. During 
her stay with us this opinion was confirmed by the fact that in the 
earUer days after her admission, when she was looking somewhat 
anxious in the face, she again gave an exhibition of perforation. She 
complained of acute pain in the epigastrium, the upper abdomen 
became suddenly distended, and the muscles appeared tense. There 
was, however, no change in her facial expression ; the pulse-rate, or 
temperature, and other symptoms were not in agreement with perfora- 
tion ; we had also the history to go upon. 

This patient left St. Thomas's about a fortnight after the operation 
for the varicose veins, but returned in 1904 on account of hsematemesis. 
She was vomiting daily large quantities of fluid, in which there was a 
good deal of blood of dark colour, evenly diffused. In spite of the fact 
that this continued for a month without cessation, she showed no signs 
of anaemia, and always presented a smiling face to the world. No 
particular drug was given to arrest the bleeding, which was regarded as 
of hysterical origin. When the hsematemesis had ceased for a few days 
and she had become bright and cheerful she was sent home. 

In about three months' time she was sent back to the hospital with 
another attack of hsematemesis of similar character, from which she 
recovered in from three to four weeks, and returned to her home 
quite well. 

It was some months before anything further was heard of her, but 
she had not been altogether idle. It appeared that she had again 
developed hsematemesis when the influence of the hospital had passed 
off, and this time her friends sent her to a hospital " where there was a 
surgeon who would operate." 

Her next admission to St. Thomas's was on July 19, 1905, when she 
was found to have a fsecal fistula, which communicated with the 
transverse colon and was situated at the lower part of a scar, through 
which, it was stated, her stomach had been operated on. We were 
informed by letter that although no ulcer or cause for the hsemorrhage 



234 THE ACUTE ABDOMEN 

was found at the examination, it was thought by the surgeon that there 
was an ulcer in the duodenum. She said that after the operation she 
did very well until the tenth day, when it was found that the milk 
which she was taking came through into her dressings. A second 
operation was done and the milk no longer came through the wound, 
but in ten days' time faecal matter appeared when she took medicine, 
and fsecal fluid came through if she had an enema administered. 

The abdomen was opened in the middle hne below the old scar and a 
lateral anastomosis of the large bowel above and below the fistula done. 
There were many adhesions. Kecovery from this operation was quite 
uneventful, the fistula was allowed to close and, when she left the 
hospital, was about the size of an ordinary wooden match. She left at 
her own request. 

Readmission was sought January, 1906, because she said that the 
escape of gas from the fistula was troublesome and caused offence to 
patients when she was nursing them. 

There was now a fistula about the size of a cedar pencil, and as the 
bowels were acting well there appeared no reason why this should not 
be permitted to close. Accordingly a dressing was placed over it, and 
secured in position by means of broad strips of rubber strapping. The 
fistula closed to some extent, but we could not feel sure that it was not 
kept open in some way by mechanical means at the command of the 
patient. A smaller dressing was then applied, and this was covered 
and held in position by means of collodion. After this was appHed she 
complained of " excruciating " pain and said that she could not possibly 
bear the agony of it. It was not, however, removed for a week, when 
the fistula had completely closed. I may perhaps mention that the 
fistula was found to have become distinctly larger after she had had a 
bath without the presence of a nurse : this was before the collodion was 
applied. 

We were for a time under the impression that the case was now 
completed, but in March, 1909, she again came into the hospital during 
the cleaning of a charitable institution to which she had gained admis- 
sion. A fsecal fistula had formed at the site of the former one, and she 
refused to have anythirg done with a view to closing it. When ques- 
tioned as to the formation of this fistula she said that an abscess had 
come and burst, leaving the fistula behind it, but there is a possibility 
that it did not form in this manner. If it had been closed, and this 
would soon have occurred under simple treatment, for there was a free 
normal passage for the faeces, she would no longer have been eligible 
for the institution in which she had now been received. 

I may add that her expression was that of a neurotic, and the 
diagnosis of hysteria was confirmed in many ways. 

It was surely unnecessary to perform a gastrotomy for the 
relief of hsematemesis in a case with this history. 

Gardini ^ has given the account of a case of similar origin. 

» Clinica A/oderna, May, 1905 ; British Medical Journal, Epitome, August, 1905. 



OTHER CAUSES OF THE ACUTE ABDOMEN 235 

A girl of 22 had suffered from gastric symptoms for six years, and 
almost daily vomiting of blood for five months or more ; in that 
instance the mucous membrane of the stomach is said to have been 
tinged, hypertrophic and of a red colour, but there was no evident cause 
for the haemorrhage. The patient was apparently cured by the opera- 
tion. Gastric haemorrhage has sometimes a purely nervous origin ; 
sometimes it is simply a form of vicarious menstruation, and has a 
relationship to the menstrual periods, as well as to emotional and 
constitutional disturbances and injury. 

It is advisable to exclude the possibility of cirrhosis of the liver as a 
possible cause. 



PAKT VI 
OBSTRUCTIONS 

STRANGULATION OF THE STOMACH. 

This rare condition is only met with when the stomach has 
formed part of a hernial protrusion through the diaphragm into 
the chest. It is well illustrated by the case described, where 
the symptoms were entirely due to obstruction (practically 
total) of the stomach alone. Nothing could pass into it from 
the mouth, and the result was shown in the distress, frequent 
vomiting, excessive thirst, diminished excretion of urine, rapid 
emaciation and boat-shaped abdomen. The stomach was 
accompanied in its escape from the abdomen by the transverse 
colon, but this was not obviously obstructed. The patient was 
practically dehydrated, and the effect of saline infusion was such 
that operative treatment, although delayed, was made possible. 

A Spaniard, aged 30, journalist, "^ was admitted April 15, 1901. 
He was then very ill and emaciated, with sunken, eyes and hollow 
cheeks. He complained of pain in the upper abdomen ; there was 
constant vomiting of thin fluid, and he had a feeble pulse. The 
abdomen was retracted and boat -shaped ; there was some tenderness 
in the epigastrium, especially to the left of the middle line. His thirst 
was great. On admission he was so ill that an intravenous saline 
solution to the extent of three pints was given. He did not look as if 
he could live through the night. ^ 

The history of the case was as follows : — He had in the course of his 
professional duties in Spain, as a journalist, encountered successfully 
on some five occasions rivals in the political world, using a rapier as his 
weapon. When he again had a difference of opinion, which was referred 
to the arbitrament of the sword, his opponent thought it wiser to 
prevent an encounter which would very possibly have disastrous conse- 
quences to himself. He therefore hired a bravo who took an opportunity 
of stabbing our patient in the left side with a knife before the date of 
the duel. The doctor who treated him for this wound, which was 
received about six years before the man came under our care, said that 
'* he saw the lining of the stomach." After recovery it was three years 
before any serious symptoms developed, and he then had an attack of 

1 Lancet, Vol. N., 1901, p. 1582. 




STRANGULATION OF THE STOMACH 237 

vomiting, with severe pain in the region of the wound, from which he 
recovered in a few days. He had suffered occasionally from attacks of 
discomfort in the stomach and vomiting, from which he obtained reUef 
by passing his fingers down his throat to make himself sick. A week 
before admission he crossed from France to England, and was violently 
sea-sick. The vomiting had continued and there had been complete 
constipation for six days. When seen the day after admission with 
Dr. Mackenzie, the vomiting and thirst continued, he was excited and 
restless, placed his fingers in his throat to make himself more sick, and 
asked for a large quantity of water to aid the vomiting. The reason 
why he did this was because he had found that in the less severe attacks 
of pain and sickness the use of the finger in this way with the effect 
produced would usually result in reUef. The temperature was 96° and 
the pulse was hardly perceptible. There appeared to be some fulness 
under the left lower ribs, but no dulness. The chest was well formed and 
the ribs showed prominently owing to the great loss of flesh. There was 
a scar over the left hypochondrium in the left axillary line. The note 
on percussion was resonant all over and the breath sounds normal. 
There were a few crepitations at the base. The cardiac dulness began 
at the fourth rib and did not extend to the right beyond the left edge 
of the sternum. The apex beat was in the fifth intercostal space, 1 inch 
internal to the nipple Une. The sounds were normal. The urine was 
scanty. The tongue was fairly clean, having a slight white coating. It 
was necessary to give another three pints of sahne before we could 
operate, and this improved his pulse. 

On opening the abdomen through an incision below the left costal 
margin, a quantity of collapsed gut was found. The descending colon 
was traced upwards to an oval aperture in the left side of the diaphragm 
about 2J inches in greatest diameter. The stomach had also passed 
through this into the left pleura, and was gradually withdrawn by 
traction on parts as they presented. Some of the transverse colon and 
omentum were adherent and could not be withdrawn. The stomach 
was marked by the edge of the aperture and had evidently been tightly 
nipped. 

Nothing could be done to repair the diaphragmatic opening ; he was 
too ill. 

The effect of the operation was to relieve both pain and vomiting, 
but he still had much thirst. On the 18th it was necessary to put on 
a special nurse, he was so very excitable. During the day he frequently 
" practised dying," and during one of these practices he passed away. 
The temperature did not rise to normal at any time whilst under 
treatment. 

At the post-mortem examination, which was made by Dr. J. J. 
Perkins, a large loop of transverse colon and omentum was still in the 
left chest and quite irreducible. There was no sac over the protrusion, 
but a spurious one had been formed by the omentum ; this was, how- 
ever, very incomplete, but shut off the pleural cavity. The left lung 
was pushed up and there was pleurisy on both sides, chiefly on the left, 
and the lower lobe of the left lung was sohd from septic pneumonia. 



238 THE ACUTE ABDOMEN 

There was localised peritonitis, probably caused by the passage of 
organisms through the wall of the stomach at the point where it had 
been nipped after it had been freed at the operation. The opening in 
the diaphragm was in the muscular part 1 inch posterior to the limit of 
the pericardial sac, so that the hernia was in direct relation to the 
pericardium. 

Mr. Lawford Knaggs, who has given an important contri- 
bution to this subject,^ reminds us that protrusion of the 
stomach in these herniae may be complete or partial, and 
therefore the signs will vary. The symptoms may be spread 
over a number of years dating from a sudden strain or injury : — 

(1) Attacks of dyspnoea, due to the tumour in the left chest. 

(2) Discomfort, pain, and vomiting after meals. (3) Obstruc- 
tion and strangulation, as in the case described. (4) Tetany, 
as in a case under the care of the late Sir Russell Reynolds. 

A woman of 29, in whom the hernia followed a stab inflicted seven 
years before death from tetany. The stomach, transverse colon, and 
omentum were found in a hernial swelling the size of two fists, in the 
left chest. There was no tight constriction. 

The signs which are of importance in the diagnosis are the 
following : they assist very much when present, but they are 
not always present : — (1) Stomach or intestinal noises in the 
chest. (2) Intestinal or stomach peristalsis seen through a 
thin chest wall. (3) Displacement of the heart to the right. 
(4) A sound produced by the forcing of air from the thoracic 
part of the stomach into the abdominal part. Other signs of 
less importance are absence of breath sounds ; alterations in 
resonance ; changes in shape and deficient movements of the 
chest ; sinking in of the epigastric region ; inability to lie on 
the opposite side. Mr. Knaggs considers that in some instances 
the strangulation of the stomach may be the result of volvulus 
of the stomach or torsion of the small omentum. Few cases 
have been submitted to operation, but should operation be 
performed, and the condition of the case give opportunity, it 
may be possible to do something with the view of preventing 
recurrence of the hernia— (1) by suture ; (2) covering the 
opening by the liver (Berry) ; (3) " anchoring the stomach 
and omentum to the parietes in such a way as to prevent other 
abdominal contents finding their way into the opening" 
(Lawford Knaggs). 

> Lancet, Vol. II., 1904, p. 358 



INTESTINAL OBSTRUCTION 239 



INTESTINAL OBSTRUCTION. 

In considering obstructions of the intestines, I have thought 
it best to present it from the cHnical side and to avoid as 
much as possible the more purely pathological part. It is 
hoped that you may find what is essential in the diagnosis and 
so be able to cope with these cases although comparatively 
inexperienced and perhaps short-handed. It is at all events of 
the greatest importance that you should be able to " appreciate" 
a case when it comes before you, for the sufferer from acute 
intestinal obstruction requires prompt surgical assistance if his 
life is to be saved. 

The arrangement which appears to me most practical is that 
of the comparative frequency of the various kinds of obstruction 
as met with in practice. 

A. Acute obstructions other than intussusception. 

B. Intussusception. 

C. Acute supervening on chronic obstruction. 

A. Acute intestinal obstruction is responsible for about 24 
per cent, of all cases of the '' acute abdomen," without includ- 
ing the cases of intussusception, which constitute about 16 per 
cent. The onset of the attack, with the symptoms of 
*' peritonism " — abdominal pain, shock and vomiting — much 
resembles that in perforations of the hollow viscera ; and 
the same careful examination of the abdomen and analysis of 
symptoms will be required. The character of the pain is of 
little value, but it is much increased by percussion in peritonitis, 
more so than by palpation, whilst in obstruction percussion 
causes Httle or no pain, whilst palpation is less readily tolerated. 
The vomiting is severe, and changes its character as the case 
progresses, becoming very foul-smelling later. Shock may be 
profound, but varies greatly. The abdominal wall in obstruc- 
tion is mobile and soft excepting during a paroxysm of pain, 
whilst in peritonitis it is rigid. Peristaltic movements are more 
commonly seen in obstruction, but may be found in peritonitis 
when the inflammation is localised, as I have shown in cases 
of perforated simple ulcer of the jejunum. In obstruction 
peristaltic waves can frequently be excited by friction of the 
abdominal wall. The bowels are confined, neither faeces nor 
flatus being passed. 



240 THE ACUTE ABDOMEN 

In the severely toxic form, or the last stages of peritonitis, 
the abdominal wall, previously rigid, becomes soft and pliable 
again. As a rule, in the perforations leading to peritonitis the 
patient lies quiet, with flexed thighs ; in obstruction he moves 
about in bed, altering his position to that which appears for 
the moment to be most comfortable, and complains of almost 
intolerable griping pain, usually referred to the region of the 
umbiUcus. In all a careful search should be made for any 
abnormal swelling, which in acute obstruction may be found in 
various parts of the abdomen. As the case progresses, general 
distension of the abdomen supervenes and increases, and any 
locaUsed swelUng will be gradually merged in the general 
enlargement. Septic absorption and inflammation are super- 
added and the case practically becomes one of peritonitis of the 
most grave nature. If seen for the first time at this stage a 
diagnosis of the exact cause of the inflammation is impossible, 
but prompt measures may yet prevent a fatal termination. 
Luckily patients do not often permit things to progress to this 
extent before applying for relief. 

In those cases in which obstruction is not so acute in its 
onset you not infrequently find, before it becomes complete, 
complaints of griping pain and can see and feel local hardening 
and swelling of the abdominal wall, with gurgling as gas is 
forced past the obstruction. 

An example of one of the most easily diagnosed (and 
remedied) forms of obstruction, both from its nature and the 
short time which elapsed before operation, may be given. 

A married woman of 38 was admitted April 15, 1914, with a history 
that on the previous evening she had felt some stomach-ache, but it was 
not bad until she had gone to bed. It then became very severe and she 
had troublesome vomiting all night. At the time of operation (1.30 p.m.) 
she was stiU suffering from pain and was vomiting at intervals, the pain 
was paroxysmal and situated in the lower abdomen. The abdomen 
was somewhat distended, with shifting dulness in the flanks ; the pain 
was referred to the under surface of the lower end of the left rectus. 
Some of the coils of small intestine were very clearly outlined, and there 
was occasional peristaltic movemeDt. Nothing abnormal was felt on 
vaginal examination. She had never had any previous illness. Al- 
together the evidence appeared to be in favour of volvulus of small 
intestine as a cause for the obstruction, although there was no tumour. 

The right rectus was displaced outwards, and when the abdomen was 
opened a large quantity of clear fluid escaped. The small intestine was 



INTESTINAL OBSTRUCTION 



241 



generally distended and the largest coil passed into the pelvis, from 
which a contracted ileum emerged. At the point where these met, about 
2 feet from the ileo-csecal valve, the dilated bowel was twisted and 
overlapping the contracted portion from left to right. When drawn 
to the surface, the end of the dilated bowel felt heavy and contained 
some irregular particles of undigested food. In view of the nearness 
of Easter Monday, it was suggested by one of the dressers that this might 
be part of an undigested cocoa-nut. The contents of the bowel were 
easily passed on, and the obstruction was reUeved without any special 
manipulation. The wound was sutured in layers and the patient had 




YiG. 31. — End-to-End Anastomosis after Excision. — Oblique Section of 
Bowel after application of Clamps : 1. Small intestine. 2. Clamps. 
3. Oblique section of bowel. 4. Cut mesentery coming well beyond 
edge of section. 5. Wedge-shaped removal of mesentery of limited 
extent. The points of the clamps should be nearer to the cut edge of 
the mesentery. 



an uninterrupted convalescence. Portions of cocoa-nut were passed 
with the first action of the bowels. 

The obstruction was not complete, therefore there was an 
exudation of free fluid into the peritoneum. No localised 
swelling could be felt, partly because the twist was in the 
pelvis, and the coil affected was not distended with much gas. 
Early operation was allthat was required to put things right. 

As an example of volvulus producing a more severe form of 
obstruction in which early operation is most desirable the 
following case may be given : — 

A.A. R 



242 



THE ACUTE ABDOMEN 



K 



G. D., aged 28, was admitted"^ on November 7, 1904, with acute 
iutestinal obstruction. At 4 p.m. on the day before admission he was 
suddenly seized with pain in the lower abdomen ; since that time his 
bowels had not been opened, neither had he passed flatus. There had 
been vomiting off and on since the onset. The pain had been continuous 
in character, with paroxysms. On admission it was stated : " The 
patient's face is drawn with pain, he continually moans and pants. 
He complains of pain in the abdomen, which does not move at all in 
its lower part during inspiration, and movement is poor in the upper 
part. There is a marked prominence in the hypogastric region in the 
middle Hue, looking hke a much distended bladder. The percussion 

note over this area is resonant and 
the part very tender. The Uver 
dulness is not diminished and the 
abdomen appears to be normal in 
other parts." The pulse was 120 
and the temperature was 100-6°. 
Catheterism did not diminish the 
size of the swelhng. When seen 
with Dr. C. K. Box, under whose 
care the man had been admitted, 
the local signs had become less 
acute and there was less complaint 
of pain. Acute intestinal obstruc- 
tion was diagnosed, due to vol- 
vulus of small intestine, or 
strangulation by a band. The 
patient was a strong, healthy- 
looking man, without any history 
of previous attacks of abdominal 
pain. 

At 5.45 the abdomen was opened 
below the umbiUcus to the right 
of the middle hue, the rectus being 
displaced outwards. When the 
peritoneum was incised a very 
black coil of small intestine pre- 



*r 



iili 



j1 1 



Fig. 32. — End-to-eiid Anastcmosis 
of Small Intestine. — The inner 
suture completed. 1. The outer 
suture continued. 2. On com- 
pletion it will be tied to 3, which 
18 the same thread left loDg for 
this purpose. 4. Sutures closing 
mesentery. 



sented ; this was very tense and hard and could not be drawn up through 
the wound. It was therefore punctured with a trochar, and a quantity 
of fluid, which consisted almost entirely of venous blood, escaped ; this 
had a faecal odour. This coil was then brought outside and found to 
be the ileum immediately before its junction with the caecum. Another 
coil then presented itself and was also tapped and emptied of similar 
fluid contents and flatus ; it was now possible to hft the whole of the 
affected gut out of the abdomen. This was quite black, and when 
emptied of its contents without resihency, although the peritoneal 
covenng was not without pohsh. The twist which had occurred was 
one on the mesenteric axis from right to left, but when this had been 
reduced no improvement occurred in the circulation of the affected 



INTESTINAL OBSTRUCTION 243 

portiou of small intestine ; it was necessary therefore to resect the 
whole of this, and to include an inch or two beyond. Altogether 
43 inches of gut were removed from close to the ileo-csecal valve upwards, 
Doyen's clamps being placed on the bowel above and below and the 
mesentery ligatured after the rapid apphcation of artery forceps to each 
section before it was divided. The upper end was then joined to the 
part left at the ileo-csecal opening with two rows of continuous sutures, 
an inner including all the coats, and a continuous " Lembert " outside 
that.i The tipper part of the divided mesentery was also sutured. The 
pelvis contained dark blood-stained offensive fluid. There was no 
lymph present on any part of the peritoneum that came under observa- 
tion. After washing out the pelvis and cleansing the parts involved in 
the operation with sterilised saUne solution the wound was closed with 
deep and superficial sutures. Chloroform was administered, and during 
the operation two injections of 5 minims of Uquor strychninse were given 
hypodermically and, later, 15 oz. of saUne solution per rectum. The 
operation was well borne. 

Beyond the fact that a localised abscess, probably due to a bacillus 
coli infection, formed in the wound and discharged a fortnight after the 
operation, there was nothing of moment to record in the after-progress 
of the case. Kectal feeding was employed for three days. A good 
abdominal wall without hernial protrusion was obtained. 

We had in this case a formidable compHcation — gangrene of 
the gut, one which required very prompt measures in dealing 
with it. Not many hours had elapsed since the onset of 
obstruction, but the strangulation of bowel had been absolute ; 
luckily it had not given way into the general peritoneal cavity. 

Dr. C. L. Gibson, of New York, collected 1,000 cases of 
intestinal obstruction (including 354 cases of strangulated 
hernia), and amongst these there were 121 cases of volvulus. 
These were taken from various medical publications and 
included those affecting the large intestine, which are by far the 
most common, constituting practically the only form of acute 
obstruction of the large bowel. This variety of obstruction 
when affecting the large intestine has a mortality of 46 per 
cent. When affecting the small intestine the mortality is 
70 per cent. This is accounted for by the fact that the small 
gut is of far greater importance, whilst the vitality of its walls 
is probably less. When the small intestine is the subject of 
volvulus the symptoms are more acute, manifestations of shock 
are more marked, and possibly its mobility allows of a tighter 
twist. Knowing the tendency there is to pubhsh only successful 
cases, it is very probable that Dr. Gibson's statistics are more 

1 See Fig. 32. 

r2 



244 



THE ACUTE ABDOMEN 



favourable than they should be. He found only one record 
of successful resection for gangrene due to volvulus of small 
intestine, and this was performed by Riedel on the second day 
of obstruction. 

A somewhat similar clinical picture is presented by obstruc- 
tion by Meckel's diverticulum, the symptoms of which are 
practically those produced by any kind of band. There is 
less frequently a history to guide you as to the actual cause of 
the obstruction in these cases ; no account being given of a 
previous inflammatory attack or of injury, although you may 




Fig. ;33. — Obstruction produced by Meckel's Diverticulum, A. 
(St. Thomas's Hospital Museum.) 



at times hear of occasional " stomach-aches." Gibson gives 
42 cases of obstruction by Meckel's diverticulum, as against 
186 by bands of various other kinds. This seems to me to be 
much too high a proportion as compared with actual practice ; 
obstruction due to a Meckel's diverticulum is not often seen 
in our hospitals. 

The symptoms produced by the compression of small intes- 
tine by a band are practically the same as those described when 
the cause is a twist — viz., " peritonism " — ^with the formation of 
a locaUsed swelHng in the lower abdomen, which is resonant on 
percussion. Any swelHng of this kind should be regarded as of 
importance and as an indication that notliing but operative 



INTESTINAL OBSTRUCTION 245 

treatment is possible. The friends must be at once informed 
of this ; they will probably protest and the patient demand 
morphine for the relief of his pain, but you must be firm. 

It is most important that abdominal operations should be 
performed before any general distension sets in ; operation is 
far more difficult in the face of distension, whilst the result is 
likely to be much less satisfactory. 

In a stout man of 46 who had strangulation of gut by this 
diverticulum I found it necessary to excise some 46 inches of 
the small bowel, but the stitches gave way, because I probably 
placed them in damaged bowel. It is possible that a wider 
removal of the gangrenous gut would have had a better result, 
for I lost my patient. 

In both these cases of gangrene the progress of events. was 
rapid, the gut having become gangrenous in a few hours from the 
onset of symptoms. In dealing with volvulus it is only neces- 
sary to empty the involved intestine, and after drawing it 
from the abdomen twist it round in the required direction. 
In diverticulum, after the band has been found (not always an 
easy thing, if one may judge by recorded cases), it requires to 
be divided and the ends afterwards dealt with. Let me remind 
you of the necessity of examining carefully any band that may 
be divided during the progress of an operation for intestinal 
obstruction. I have known the careless division of a Meckel's 
diverticulum to allow of the escape of intestinal contents into 
the peritoneal cavity, which occurrence resulted in a rapidly 
fatal peritonitis. 

In these cases we were met by a very formidable complica- 
tion which requires special consideration. More or less exten- 
sive gangrene of the intestine may confront you in any acute 
abdominal case in which operation is performed, and you must 
be able to deal with it on the spot. It is of vital importance 
that the safe passage of the intestinal contents along the canal 
should be made possible. There will be no time to send a 
hurried messenger for button, bobbin, special forceps, or any 
one of the scores of suggested mechanical aids on which you 
may have decided to pin your faith ; in the presence of this 
complication you must immediately act, if you wish to save 
the life of the patient. The faith which was formerly placed 
in the special instrument should be put in an accurate method 



246 THE ACUTE ABDOMEN 

of suturing, after a judicious selection of the points of section 
of the gut. and in the precautions against sepsis, which are now 
a part of the usual technique. 

There are many cases of localised gangrene in Avhich it is 
found that a part of the gut does not look sound, but of 
which it is not possible to say that it will not recover if placed 
in favourable circumstances. When the portion of bowel 
affected is very localised, as when the pressure of a band 
has produced a transverse lesion, it may be possible to invert 
this by a row of Lembert sutures, as suggested by Professor 
Caird. I have clone this with satisfactory results in early 
ciises of strangulated hernia and pressure by band. 

The treatment of gangrene of the small intestine when the 
entire circumference is affected will depend on the general 
condition of the patient, and the circumstances of the case, 
rather than on the extent of the gangrene, for the procedure 
will be nnich the same whether you resect 1 inch or 1 yard. 
In favourable circumstances excision should be the method 
adopted in the case of gangrenous intestine. Dehvery of the 
affected part from the abdominal cavity, examination to define 
the extent, not only gangrenous but changed beyond this, 
cleansing of the part, careful packing off of the healthy area 
with sterilised gauze, covering of the gangrenous part with 
gauze to prevent possible contamination of the wound, 
resection, and subsequent joining of the ends. 

In the resection of the gut in both cases which I have recorded 
Doyen's clamps Avere used and answered their purpose well. 

1 used them because they were handy. In other cases of 
resection pieces of drainage tube passed through the mesentery 
and secured by tying or by forceps have answered equally well. 
Strips of gauze would answer in case you had no drainage tube 
available. The proximal and distal clamps should be placed 

2 inches above or below the hne of proposed section in a healthy 
part. I lay very special stress on this point, because in the 
case of obstruction by a Meckel's diverticulum it appeared 
that the suturing failed because the stitches could not hold 
in tissue which had been stretched and which underwent 
afterwards an inflammatory reaction and softening. The 
bowel seemed healthy, and one was naturally not anxious 
to excise more than was necessary. It is often advisable to 



INTESTINAL OBSTRUCTION 247 

cut the bowel a long distance away ; for instance, in January 
1905, I resected 16 inches of small intestine with good result 
in a case of strangulated femoral hernia, although the part 
alfected by gangrene was only about 1 inch in length. The 
bowel close to this was not in a healthy state. As each end 
of the bowel is separated it should be cleaned and wrapped in 
gauze until wanted. One or two vessels may require ligature. 
You need not excise a wedge-shaped portion of the mesentery, 
as in the removal of a new growth of the bowel (see Fig. 32). 

The junction of the two ends should be made by careful 
suturing with a double row of silk sutures. These should be 
continuous, for they are more rapidly applied than the inter- 
rupted, and are equally efficient. According to the thickness 
of the intestinal wall should be the size of the suture material. 
As a rule. No. 1 is right for the adult. The first should include 
all the coats of the bowel ; the second will take only the two 
outer, as a rule. In applying this, you must see that the 
suture has a good hold. If you are satisfied on this point, it is 
not advisable to dip the needle more deeply, for if you pass your 
outer thread into the lumen of the bowel, in the endeavour 
to get a stronger hold, your patient will probably do badly. 
When applying the deeper stitch hold the two portions of bowel 
with forceps, one pair applied at the mesenteric point of attach- 
ment of each half, the other to a corresponding point opposite. 
If a pair of forceps is also placed half-way between these, closely 
applying the cut edges, the suture can be introduced still more 
rapidly. The mesentery should then be sutured, so as to present 
no raw surface to which adhesions can form ; the parts involved 
in the operation are cleansed, and the abdominal wound closed 
without drainage. 

The amount of intestine resected in these cases appears 
large ; 43 inches in one case, and 46 inches in the other. But 
greater lengths have been excised. Mr. A. E. J. Barker, 
in a very instructive paper on the limitations of enterectomy, 
mentions a case in which Mr. Hayes, of Dublin, successfully 
excised 8 feet 4| inches of intestine for injury in a boy aged 10 
years. Another paper by Mr. Barker will repay perusal. It 
is on enterectomy for gangrenous hernia. Many practical 
points are brought out. He also shows that the amount of 
shock is much less than is beheved from such an extensive 



248 THE ACUTE ABDOMEN 

operation. I have mentioned these excisions of large pieces 
of intestine to show what can be done, so that you may not 
be intimidated should you meet with one of these extreme 
cases, remembering that if the gut at the point of union is 
sound, and you take proper precautions in following the various 
steps of the operation, you may gain a success, even in desperate 
circumstances. 

The effect on the patient of the removal of a large portion 
of the small intestine is apparently very slight. In the former 
of the two cases of which I have just given details, there was, 
for a time, a tendency to looseness of the bowels ; but this 
passed off, and he regained good health, excepting for occasional 
*' indigestion." The effect on the intestine has been recorded 
by Mr. Barker in two cases in which he had an opportunity 
of looking at the bowel during life some months (in one case 
five years) after operation. In both, the line of union was 
sound and mthout contraction, but the bowel on the proximal 
side was somewhat larger than that on the distal side, and 
showed smaller power of muscular contraction. 

In the cases of volvulus the probable cause and position of 
the obstruction was known and the incision was made to give 
most direct access to it, due regard being paid to the anatomical 
arrangement of the muscles of the abdominal wall. 

What is the best incision to use in cases where the cause 
of an acute obstruction is unknown, and what steps should be 
undertaken to find and remedy this when it is found ? 

I think that an incision through the right rectus sheath to 
the inner side with displacement of muscle outwards is the 
best ; it should be of a size large enough to admit the hand, 
far too much time is lost in making a small incision and then 
enlarging it : you may make a small opening through the 
peritoneum at first, for it may be possible to quickly discover 
the cause of the symptoms. Anyway an extension of the 
incision in the peritoneum is very quickly effected. I have 
already pointed out the importance of operating before the 
onset of distension ; where the bowel is but sUghtly distended, 
manipulation within the abdomen is easy, for the hand can 
be passed from point to point without difficulty. 

Where the small intestines are obstructed you should first 
examine the ileo-caecal region, and if there is empty gut there 



INTESTINAL OBSTRUCTION 249 

follow it upwards to the obstruction ; but it is better to empty 
distended gut at more than one point where there is much 
distension rather than add to the danger of the case by bruising 
with your hand the already damaged wall of the gut. This 
not only enables you to explore the abdomen with greater 
rapidity and sureness, but gets rid of a large amount of toxic 
material, the absorption of which adds much to the dangers 
which the patient is facing. A loop of gut should be drawn 
out, placed over a sterilised vessel, and punctured opposite 
the mesentery with the point of a knife ; it is not needful 
that the opening be of large size. It is closed by means of 
a Lembert suture of silk (continuous), or by a purse-string 
stitch. The surface of the bowel is cleansed and the loop 
returned. It can be repeated with other coils. In examining 
the abdominal contents with the hand, search should be made 
for bands, which may be of various kinds, and these should be 
traced to their attachments if possible and cut short ; if there 
are adhesions which are too strong to be separated, it will be 
necessary to resect the bowel, do a short circuiting operation, 
or in a bad case open the bowel above after attaching it to the 
abdominal wall (enterostomy). 

The operation of enterostomy must be regarded as a very 
unsatisfactory operation unless performed as a purely temporary 
measure for the relief of distension in advanced obstruction of 
the bowel or paralytic ileus. It is sometimes possible to save a 
life by this procedure when an injudiciously prolonged operation 
would cause a fatal ending. A local anaesthetic is required, 
and the opening should be made in the right iliac region, the 
caecum or some presenting coil of small bowel being selected 
for the insertion of the tube. In an adult of ordinary size the 
incision should be about 3 inches in length. The part of the 
bowel to be opened is brought to the incision and sutured there 
by means of silk sutures placed in such a position that it will 
be possible to put a tube in the centre of the area brought up. 
A small -sized Paul's tube, or failing that a piece of rubber 
tubing with side openings near the extremitj^, or a Jacques 
catheter, will answer. A small fishgut suture should be passed 
through all the structures of the abdominal wall at the upper 
end of the wound, taking up the peritoneal and muscular layers 
of the bowel wall. Another should be passed in a similar 



250 THE ACUTE ABDOMEN 

manner below. Other sutures, of silk, should then be passed 
on each side to fix the peritoneum and fascia of the abdominal 
wall to the peritoneum and muscular layers of the intestine. 
It is an advantage to the patient to have the tube put in at 
once, and to facihtate this the loop should be pulled forward, 
packed off with gauze, and the bowel partly emptied with a 
trochar and canula. Two pairs of forceps placed one above 
and the other below the puncture will hold the gut in position 
whilst an assistant compresses it behind to prevent further 
escape of contents. A purse-string suture is then placed round 
the opening at a convenient distance and the tube inserted 
through the enlarged puncture and secured by the suture. 
The bowel and wound are washed with sterihsed sahne, and 
the bowel now fixed to the abdominal wall with the silk sutures, 
the parts again cleansed, a packing of thin gauze placed round 
the junction, and the free end of the tube brought through the 
dressings and put into a bottle. To the Paul's tube there is a 
wider and thinner tube already attached. The tube comes 
away in about four to five days. After this the discharge 
escapes on the skin, which rapidly becomes very excoriated 
and painful. Much may be done to mitigate the exceeding 
discomfort of this by cleanliness and the application of oint- 
ments. The use of a solution of rubber maybe useful, it should 
be painted on after the skin has been cleansed and dried. 

From the amount of misery which such an opening may 
cause, and the tendency to rapid emaciation exhibited, if there 
is reason to suspect that the fistula must become permanent 
unless something more is done, the earliest opportunity must 
be taken to explore the abdomen and do what the individual 
case may require to restore the natural channel. 

Another reason in favour of early operation for the re- 
establishment of the normal track is the tendency to the 
formation of iUac adhesions which such cases show. 

Strangulation by bands is one of the most common of the 
various forms of acute obstruction, and in its main features 
differs very little from obstruction due to a volvulus. I will 
simply give cases which speak for themselves (see Fig. 1). 

Intestinal Obstruction due to a Band. — On October 5, 1911, 
C. P., a single woman, aged 75, was admitted. -X* She was an old woman 
with sunken cheeks, and was lying propped up in bed complaining of 



i 



INTESTINAL OBSTRUCTION 251 

much paiu in the abdomen which had commenced at 6 p.m. the previous 
day. This pain had been very severe, general throughout the abdomen, 
but extending under the ribs on both sides and shooting through to the 
shoulder blades. She had been vomiting all night and the morning 
of admission hiccough came on and continued at frequent intervals. 
The bowels, after having been constipated for four to five days, acted 
the morning before admission. The abdomen was well covered, lax, 
moving fairly well ; no distension, no abnormal dulness ; no tumour. 
There was tenderness chiefly above the umbilicus. Examination per 
vaginam showed nothing abnormal. Temperature, 98° ; pulse, 92. 

There was no history of any previous illness. 

Operation, 6 p.m. — There was a large amount of blood-stained fluid in 
the peritoneum, but no spots of fat necrosis were visible anywhere, 
although the fluid suggested the possibility of acute pancreatitis. 
When the pelvis was examined a swelHng like a top could be felt on the 
right side, which on fuller examination resembled a volvulus. A very 
firm band crossed this, running from the fundus of a sterile uterus to 
the posterior part of the pelvis. This was divided with scissors. The 
small gut affected was 2 feet in length, beginning 18 inches from the 
ileo-csecal valve. It was of very dark colour, but resilient, and glossy. 
A drainage tube was inserted and much fluid drained away for four days, 
after which it was removed. There was nothing to show how the 
band originated. 

The age of this patient did not prevent her recovery. The 
question of recovery depends more upon the stage of the 
illness than upon the age of the patient. 

Intestinal Obstruction by Adhesions (the result of old pelvic 
disease which had been treated by operation, a more common type). — ■ 
M. M., a married woman, aged 25, was admitted October 31, 191 1,")^ 
with an illness of two days' duration. 

She underwent an operation for double pyo -salpinx in January, and 
remained well afterwards until the 29th, when a sudden pain was felt 
in the epigastrium. This came on soon after 10 and was very severe. 
She vomited an hour later and had done so often since. The pain had 
remained constant in the same place. The bowels acted on the 30th. 

The patient was pale and evidently suffering severe pain. Pulse 136 ; 
respirations, 32 ; temperature, 98-6°. The abdomen, which was well 
covered, moved poorly on respiration ; rather distended ; no visible 
peristalsis ; tympanitic all over. Abdominal wall soft and flaccid 
excepting in the epigastric region, where there was shght rigidity, and 
here she was very tender on palpation. The scar of former operation 
was visible in the mid-hne below the umbihcus. The vomited material 
was bile-stained. 

At the operation a coil of small intestine beneath the incision was 
adherent to the abdominal wall and to another coil. A large section of 
it was empty and collapsed. The distended coils were emptied by 
puncture and the obstructing adhesions divided. The surface of the 



252 THE ACUTE ABDOMEN 

gut was inflamed. There was some free fluid in the pelvis, which was 
removed with gauze swabs. The wound was closed. Suppuration in 
the wound ensued, but there was no other complication. 

All the hernial apertures must be examined before operation, 
especially the femoral, in stout women. I have myself operated 
for obstruction in two instances of this form of hernia. The 
patients did perfectly well ; still I could but blame myself 
for imperfect examination. It is not very unusual to find 
that digital examination of the rectum has not been carried 
out : this should always be done quite early, for very valuable 
help may be afforded by it — a rectal growth which was unsus- 
pected as it gave no symptoms ; a ballooned rectum ; an 
intussusception or gall-stone in the small intestine ; an 
impacted hydatid, or some other growth in the pelvis ; an 
inflammatory swelling about an appendix, or a suppurating 
tube. The surgeon should re-examine to confirm any statement. 
I have known the uterus when felt by rectum described as a 
tumour, and a distended ureter on the left side as an intussus- 
ception which could be easily felt. 

In the case of married women a vaginal examination is 
also usually indicated. 

There are certain varieties of acute obstruction which 
require special mention, because of their exceptional characters 
or special treatment required. These are simple strictures ; 
various growths of the bowel, or affecting it secondarily ; gall- 
stones ; internal hernia ; and, in the large intestine, volvulus. 

Simple stricture is not a very common cause of acute obstruc- 
tion, and is usually the result of injury from gut having been 
nipped in a hernial sac, sloughing of the part or the whole of 
an intussusception, tuberculous or dysenteric ulceration (not 
typhoid), atraumatic partial rupture of the intestine, or it may 
follow an acute appendicitis. 

The congenital form is not only rare, but almost invariably 
fatal, the age of the infant rendering attempts to relieve the 
stricture almost hopeless. In addition the presence of obstruc- 
tion cannot be promptly diagnosed in the majority. 

In the acquired form the method of treatment will depend 
on the stage of the obstruction. Should the stricture be a 
narrow one it may be possible to do an enteroplasty when the 
operation is undertaken early, but later nothing will be possible 



INTESTINAL OBSTRUCTION 253 

excepting (1) entero-anastomosis ; (2) excision of a sufficient 
length of intestine and an end-to-end, end-to-side or lateral 
anastomosis ; (3) enterostomy. 

The history in acquired simple strictures is very much that 
of a growth invading or commencing in the small bowel, but 
has a longer course before the onset of complete obstruction. 
There is a complaint of attacks of colicky pain in the abdomen, 
often accompanied by sickness and a " rising in the stomach." 
Visible peristalsis is found if the abdomen is examined during 
one of these attacks. The attacks last for a variable time, 
but recur and increase in severity. In the case of growths^ 
commencing in the wall of the small intestine the disease is 
usually far advanced when found, because the contents of the 
small intestine being fluid are able to pass through a small 
opening, and it is a long time before the growth contracts 
sufficiently to produce symptoms. 

On Sunday, December 14, 1913, F. K. came to the ward in which she 
had previously been a patient to request permission to come for the 
ward festivities on Christmas Day. Whilst at the hospital she had an 
attack of abdominal pain and vomiting. The resident assistant -surgeon 
examined her and found some distension of the abdomen with peristalsis. 
A history of similar attacks for a period of three weeks was obtained. 
She was admitted and operation performed the same afternoon as it was 
evident some obstruction was present. The Una of the previous incisions 
(see p. 267) was selected as the muscle fibres had not united well 
and there was a weak wall there. We could also feel a thickening about 
the size of a cherry under the upper extremity of the scar. This was 
adherent and placed at the angle of the loop which had been short- 
circuited before. There were one or two adhesions between the omentum 
and other parts, and when the pelvis was explored a tumour could be 
felt which was adherent to the summit of the bladder. It was some 
distance from the point of lateral anastomosis, encircled the small bowel, 
but did not quite occlude its lumen. The wall of the bowel above and 
below could be pressed into it, its shape, internally, resembling a dice- 
box. There was a tag of omentum adherent to it. The mesenteric 
glands were enlarged over a large area. After extension of the ab- 
dominal incision it was possible to cut away the growth from the summit 
of the bladder, the wall of which was sutured. The portion of small gut 
affected by the growth was excised (situated about 3 feet from the valve) 
with a few glands and an end-to-end anastomosis carried out. The glands 
were much too numerous for a complete operation. The small intestine 
above the growth was dilated and congested, that below somewhat 

1 An interesting paper by Dr. Speese on sarcoma of small intestme, will be found 
in the " Annals of Surgery," 1914, p. 727. 



254 



THE ACUTE ABDOMEN 



Bmaller than normal, but there had evidently been no complete obstruc- 
tion. There was a good deal of shock after the operation and the pulse 
rose to 142 next day; the bowels acted on the 17th, when the pulse 
had fallen to 80. 

Mr. Shattock reported that the growth was a round-celled sarcoma. 
At one point the growth had become necrosed and here the omentum 
was adherent externally so preventing perforation. There had been no 
bladder symptoms. 

On January 20, 1914, exploration was again performed to see if the 

glands would permit of removal 
now that the patient was in 
better health, but, although some 
of them were smaller, they were 
very extensively affected and one 
or two nodules of growth could 
be felt. Ten days later the use 
of Coley's fluid in increasing 
doses was commenced. She left 
on February 12, 1914, for a con- 
valescent home, from which Dr. 
J. G. Duncanson reported a gain 
of weight of about f lb. a week 
to the beginning of April, without 
any signs of abdominal disease, 
and she continued well when seen 
in August. 

When a sarcomatous growth 
Fig. 34.-Sarcoma of Small Intestine develops in the mesentery of 
producing obstruction in a child, the small intestine it may 
1. Eaised edge of growth, not hard . lii • . j- i n i 

or everted. 2. Base going through mvade the intestmal wall and 
to the peritoneum. 3. Area which fungate into its lumen, so 

atthfrand7;venti„g'*'"g:t"S P-d"-ng obstruction, 
peritonitis. 5. Situation of attach- 
ment to bladder. Mr. P., aged 50, was seen m 

consultation with Dr. A. E. 
Godfrey on May 12, 1911, for a swelling in the lower abdomen. Two 
years before he had had a swelling in the upper abdomen which dis- 
appeared. There had been complaint of indigestion, but no vomiting. 
The swelling of which he now complained was noticed at Christmas, 
1910, and had increased slowly without pain. The general appearance 
of the patient was that of a healthy man. In the lower abdomen was a 
tumour the size and shape of a cocoa-nut ; it occupied the niid-line and 
came forward above the pubes like an enlarged bladder. It was quite 
firm, feeling like a fibroid growth, and was fixed posteriorly to the 
tissues at the back of the abdomen, but could be moved to some extent. 
He complained of some loss of appetite, although this was never good, 
and he had to take medicine to ensure an action of the bowels. 




INTESTINAL OBSTRUCTION 



255 



This tumour was removed on May 18 with the help of Dr. A. E. 
Godfrey, the anaesthetic being given by Dr. T. Godfrey. Incision was 
made to the right of the middle line and the rectus displaced 
outwards. The tumour was growing in the mesentery of the ileum, 




and was difficult to lift out until an adhesion to the peritoneum on the 
right side of the pelvis had been divided. It was crossed by a loop of 
small intestine (ileum), which was closely adherent. 

The growth was very hard. Clamps were applied to the small 
intestine involved and 18 to 20 inches of it were removed with the 



266 THE ACUTE ABDOMEN 

tumour and a large V-shaped portion of the mesentery, the vessels being 
secured as they presented themselves. End-to-end anastomosis with a 
double row of continuous sutures was performed and the mesentery 
sutured above and underneath, no raw surface being left. No glandular 
enlargement could be found. The wound was closed in layers. 
The recovery from this operation was uneventful. Mr. Shattock 
reported the nature of the growth as spindle-celled sarcoma, and the 
specimen has been added to the collection of the Royal College of 
Surgeons. 

The specimen shows fungation of growth into the lumen of the 
intestine, not completely blocking the canal. Some peritoneum has 
been removed to show the rough section of the main growth. 

This patient was seen again on March 4, 1912. During January and 
February he had two illnesses with night sweats, with some fever 
(102° — 103°) lasting a week on each occasion. There had been no pain 
or bladder trouble, but he had constipation, and for ten to fourteen days 
had noticed renewed swelling in the lower abdomen. This was rounded 
in outline, tympanitic on percussion, and appeared fluctuating. 

Exploration on the 9th showed an extensive growth with a broad 
base and infiltration of the mesentery. The peritoneum was very 
vascular with a quantity of large veins. The fluctuation was due to 
haemorrhage into the growth. It was not considered operable and the 
incision was closed. The patient died in the following July. Coley's 
fluid produced no effect. 

A hydatid cyst may press upon the intestine when it grows 
within the mesentery, or compress the large bowel when it 
develops within the pelvis. Uterine fibroids are very unlikely 
to cause acute obstruction, bat it may arise as a secondary 
consequence owing to the formation of bands or adhesions 
when there has been inflammation of a fibroid possibly due to 
a t^vist. 

Obstruction of Small Intestine, due to Adhesions secondary 
TO A Pedunculated Fibroid which had undergone Rotation. 
— A. M., a married woman, aged 48, was sent to me by Dr. Southey, of 
Colnbrook, on May 24 and left June 10, 1912. The catamenia had been 
more frequent and irregular for twelve months, and she had noticed 
increasing stoutness for six months, during which time she had suffered 
from occasional pain in the abdomen and backache. On May 12 she 
had been taken with very severe pain in the abdomen, which had 
continued since, with constipation. On the 22nd she had vomited, and 
this had occurred often since. She was a thin, wrinkled woman looking 
quite old, rather restless, and complaining of attacks of abdominal pain 
of varying severity. On examination of the abdomen, there was a 
hard centrally-placed tumour the size of a cocoa-nut, reaching above 
the umbilicus and going down into the pelvis, which it filled. It was 
sUghtly movable. On opening the abdomen we found the omentum 



I 



INTESTINAL OBSTRUCTION 257 

adherent to a greyish -brown mass, and the transverse colon and small 
gut were also adherent round it. It was a pedunculated fibroid which 
had undergone one complete rotation on its pedicle, which was attached 
to the fundus uteri. Several bands were divided and a multilocular 
cyst of the right ovary removed. A groove was found in the wall of 
the ileum made by one of the larger bands. Above this the intestine 
was distended, below contracted. This groove was invaginated with a 
continuous Lembert suture. 

Carcinoma is very rare as a primary growth in the small 
intestine. 

I have only been called upon to operate for it once ; it was in 
the jejunum high up. There was much glandular enlargement, and 
some secondary deposits in the peritoneum. A lateral anastomosis 
gave relief. 

In obstruction from gall-stones there is a different clinical 
picture. A sudden attack of pain in the upper abdomen, 
with vomiting and shock, in a woman of advancing years. 
The vomiting is troublesome, and with the pain, which is 
paroxysmal, varies much according to the progress or arrest 
of the stone. The majority of stones are arrested in the 
ileum, because this part of the intestine is the narrowest, 
especially near the ileo-caecal valve, but arrest is common in 
other parts as a result of muscular spasm. Absolute obstruction 
is temporary high up. During this time there is no action of 
the bowels. The pain moves to the neighbourhood of the 
umbilicus, and if the woman is thin the stone may be felt 
until a spasm of the bowels occurs, when peristalsis will be 
seen and tenderness complained of. 

The stone which is shown in the illustration (Fig. 36) was removed 
at operation from a stout elderly woman, and before operation could be 
felt per rectum as a hard, very tender lump in Douglas's pouch. The 
mucous membrane was ulcerated over it and of a dark colour, making 
it probable that the stone had lodged there for some time It could not 
be moved in either direction. The patient, who was very ill, did not 
recover. 

These cases may go on for a long period if no operation is 
done. 

I once saw an aged lady in consultation who had had symptoms for 
eighteen days, and as she was in bad health and unlikely to survive any 
operation the effect of local application of glycerine and belladonna was 
tried. On the twentieth day she passed a large non-facetted stone. 

A.A. S 



258 



THE ACUTE ABDOMEN 



In another case the lady had been suffering with varying 
symptoms of obstruction, and was extremely ill. Her state 
was thought to be due to a gall-stone. 

On March 26, 1913, a lady of 65 was seen with Dr. SpauU in consulta- 
tion for intestmal obstruction. There was a history of an attack of 
gall-stones five years before, and the present illness began with rather 
severe epigastric pain on March 13. She had vomiting and was very 
ill for a day or two ; improvement ensued, but she kept her bed and her 
condition varied from day to day. The pain left the epigastric region 
and has varied in position since, being mostly in the umbilical region. 
On the 24th she had a severe attack of pain with vomiting and was very 
ill, with a rapid pulse. When seen on the 26th she was feeling much 
better, having passed wind, and at no time 
during the illness had she failed to have an 
action of the bowels, after enemata, for more 
than a day or two, excepting during the 
attacks of greater pain. The patient was 
rather stout, feeling ill, and not able to talk 
clearly about her condition. The abdomen 
was somewhat distended, without rigidity or 
particular tenderness anywhere, and without 
tumour. The tongue was furred and the 
bowels had acted after an enema. Pulse, 90 ; 
temperature, 99°. Suffers from haemorrhoids. 
She had an acute obstruction on the 28th 
and 29th and almost died, but this was relieved 
towards the evening of the 29th. On April 1 
she probably passed the stone through the ileo- 
csecal valve, as improvement began, and the 
stone was passed towards the end of the week, 
about twenty-three days from the commence- 
ment of symptoms : for a time it was fixed at 
the anal orifice. She regained her usual health. 
The stone was not completely cylindrical, being compressed laterally, 
measuring about 1^ inches by 1^ inches : one end was facetted, the other 
rounded. 

In spite of such cases, early operation gives the best chance 
of success. 

If you find a patient who is too iU, or who refuses operation, 
in whom you diagnose gall-stone obstruction, you are not 
justified in withholding all hope of recovery. You cannot 
estimate the exact size of the stone, and there is always a 
chance that it may be forced into the large gut at any moment 
should relaxation of local muscular spasm take place. 

When you find a gall-stone in a coil of small intestine, the 




Fig. 36.— Gall Stone, 
natural size, removed 
from the Small Intes- 
tine during Life. It 
caused Acute Obstruc- 
tion: St. Thomas's 
Hospital Museum. 



a 



INTESTINAL OBSTRUCTION 259 

best treatment is to draw the loop outside, push the stone 
higher up the bowel (for you cannot estimate the amount of 
morbid change in the encircling mucous membrane), and cut 
down upon it from the ante-mesenteric border, suturing the 
incision through which it has been extracted with a double 
row of continuous sutures, the inner being passed through all the 
coats, the outer through peritoneum and muscular layers only. 

Acute obstruction the result of passage of the small intestine 
through an aperture is not often seen, although several cases 
are on record. There is a specimen in the St. Thomas's 
Hospital Museum (Fig. 8), which shows an aperture of the 
kind, likely to snare intestine, in the mesentery. Apertures 
may be congenital or the result of injury to the abdomen. The 
symptoms are those produced by a band in a similar position. 
These obstructions are included under the heading Internal 
Hernia, which also comprises the cases where intestine becomes 
entangled in a retro -peritoneal pouch, the foramen of Winslow, 
or in an opening in the diaphragm. Pouches which have been 
found to ensnare intestine are found in both the upper and 
lower abdomen : of the former there are the duodenal (right 
and left) ; of the latter, the intersigmoid, the retroc^ecal 
and the pouch of Douglas. As these pouches can mostly be 
demonstrated in the anatomical department and they rarely 
cause obstruction, it is probable that some abnormality exists 
when the intestine gets ensnared. As a rule the aperture can 
be dilated ; if incision is required, the possibility of the presence 
of vessels in the constricting fold must be remembered. After 
the intestine has been reduced, the opening of the pouch should 
be closed with a stitch. This statement does not apply to the 
foramen of Winslow, where the surgeon should not attempt to 
close the opening because of the very important vessels which 
surround it. In hernia into the lesser sac, in addition to acute 
symptoms there is a definite swelling in the epigastric region, 
with possibly retraction of the lower abdomen. It is possible 
that if the distended intestine which occupies the lesser sac 
and forms the tumour can be emptied, traction from outside 
the foramen will reduce it. 

In duodenal herniae it is possible to find a swelling in the 
region of the umbilicus, but in the series met with in the lower 
abdomen there is no special guide* > 

s 2 



260 THE ACUTE ABDOMEN 

Diaphragmatic hernia is well illustrated by the dramatic case 
which has been related (p. 236). 

The abdominal contents may pass into the chest and become 
strangulated through one of the natural openings of the dia- 
phragm through a congenital deficiency in it, through a wound, 
or through the scar which follows a wound. This hernia is 
rarely recognised during life, but a consideration of the liistory 
with an examination of the chest may assist the surgeon in 
arriving at a correct solution of the case. The signs in the 
chest are often similar to those produced by a pneumo-thorax, 
with dyspnoea and palpitations. Before strangulation of the 
protrusion has taken place it may assist diagnosis if the patient 
is examined with the X-rays, but as the stomach is often 
implicated and vomiting frequent, when severe symptoms are 
developing, it is often too late (see " Strangulation of Stomach," 
p. 236 ; " Rupture of the Diaphragm," p. 15). 

INTUSSUSCEPTION OR INVAGINATION OF THE 
BOWEL. 

Under this heading is comprised a large group of the obstruc- 
tions met with in practice ; in fact, it is so large and important 
that it requires a section to itself. There is hardly a week 
passes in which there is not some case admitted to the hospital, 
and as a rule they are brought at a comparatively early stage 
of the obstruction, because of the passage of blood from the 
bowel. This symptom is one which profoundly impresses the 
mother of the child, and she cannot pass it over, as it occurs in 
addition to pain of which the child gives evidence. She knows 
there is something wrong inside. 

In this form of obstruction as met with in the living subject 
a varying amount of the bowel becomes invaginated into a 
section below. Thus a tumour of -varying size is produced 
which consists of three layers — the entering, the returning, and 
the ensheathing. These layers, with possibly some omentum, 
form what is usually called the " sausage-shaped " tumour, 
which is so characteristic of the disease when it can be felt. 

It is sometimes, especially in the chronic form, met with in 
adults, but is by far most commonly seen in children (male 
children) under one year old. A remarkable fact, which has 



INTUSSUSCEPTION OF THE BOWEL 261 

been mentioned by many writers, is that the patient at the 
time of onset of the illness is often a very healthy and well- 
nourished child. 

It is generally acknowledged that the cause of intussuscep- 
tion is an irregular peristalsis of the bowel, possibly due to 
intestinal irritation from within. The actual cause of this is, 
however, difficult to trace. There may be some swelling of a 
Peyer's patch, a haemorrhage into the mucous membrane, or a 
polypus to start it. There is no clinical advantage to be derived 
from a minute division of the varieties of intussusception, and 
students only become confused if terms are multiplied. The 
divisions into enteric, colic, and entero-colic, as suggested by 
Mr. C. S. Wallace, are quite satisfactory ; more are superfluous. 
Practically, reducible and irreducible are recognised. 

The symptoms are those of " peritonism," sudden abdominal 
pain, vomiting, and shock, followed by the passage of blood 
from the rectum and the formation of a tumour in the abdomen 
which can be felt. 

There is a history given of a sudden screaming on the part 
of the child, which looks frightened, and becomes white-faced 
evidently from shock. Vomiting soon appears and the child 
rallies from the shock, but the attacks of pain and screaming 
continue at intervals. There is an action of the bowels, which 
contains little if any faecal matter, but consists mostly of 
mucus and blood. 

If the abdomen is examined between the attacks of pain it 
will be found flaccid and without distension. Sometimes the 
child is found kneeling in bed with his head buried in the 
pillow. Examination is not resisted as a rule until the swelling 
caused by the intussusception is touched, when there is a 
complaint of pain, the lump hardens, and the muscles over it 
become rigid. Sometimes rigidity is present when the child is 
examined and the tumour cannot be felt, examination being 
resisted by the frightened child, who instinctively hardens the 
abdominal wall until an anaesthetic has been given to relax the 
muscles ; but this anaesthetic should only be given when 
arrangements to operate have already been completed. The 
tumour varies in size and position, and is like a large sausage ; 
in the early stages it will be most frequently found on the right 
side below the liver. A rectal examination will often prevent 



262 THE ACUTE ABDOMEN 

the useless administration of an anaesthetic, for in cases where 
no blood has been passed some may be found on the finger 
when it is withdrawn after this examination. In addition, the 
apex of the intussusception may be felt as a ring of mucous 
membrane within the rectum, into which the finger can be 
passed. The tumour may also be felt bimanually, but not as 
a hard tumour, in the pelvis outside the bowel wall. In cases 
where there is prolapse of the intussuscepted part this has been 
mistaken for a prolapse of the rectum, but examination shows 
in the latter that it is not possible to pass the finger up the 
bowel by the side of the protrusion owing to the attachment of 
the skin. 

There may be no action of the bowels, but complete obstruc- 
tion is very rare ; usually the intussusception permits the 
passage of intestinal contents through it, therefore distension 
may be regarded as a bad sign. When it is present the case is 
a late one, and there is peritonitis as a complication. 

One of the signs of intussusception which is not of great 
value is that known as the Signe de Dance. It was first 
described by M. Dance, " Medicin de I'Hopital Cochin," Paris, 
in 1824.^ It is applied to the condition of the right iliac fossa 
when the caecum has been drawn away in an intussusception. 
This withdrawal of the usual contents is supposed to leave a 
comparative hollowness of the fossa when compared with the 
other side. 

Adams and Cassidy (p. 182) say that they have known 
" abdominal section performed when the tumours were respec- 
tively the lower edge of the liver, Reidel's tongue-shaped 
projection from the right lobe of the liver, and the right 
kidney." 

It is, however, obvious that a child with the passage of 
mucus and blood from the bowel and a tumour in the abdomen 
should be thoroughly examined, but the history given in these 
cases should prevent unnecessary opening of the abdomen. 
Henoch's purpura is sometimes associated with an intus- 
susception and may require mechanical assistance to reduce 
the bowel to a condition more nearly approaching the 
normal. 

Tuberculous affections of the glands, omentum, and peri- 
1 Repert. d' Anatomic, etc., 1824. 



INTUSSUSCEPTION OF THE BOWEL 263 

fconeum are much more likely to cause difficulty in diagnosis 
in chronic rather than in acute intussusception. The position 
of these lesions, their shape and number, will help in the 
diagnosis. 

When the intussusception has once commenced, the apex of 
the entering part remains constant and increases in size as a 
result of congestion from interference with the venous return. 
By peristaltic action of the sheath it is forced further along- 
until it may protrude from the anus. Meanwhile the conges- 
tion of the entering layers has extended in amount and the 
difficulty in reduction increased. The mesentery enters with 
its section of bowel, and by its pull on the elongated swelling 
causes it to assume a curve with its convexity downwards. 
The compression of the mesentery increases, the venous return is 
more impeded, the bowel forming the intussusceptum becomes 
more engorged. There is an increased flow of mucus from the 
surface, the smaller veins yield to pressure, and as time passes 
there is an escape of blood-stained mucus from the anus, and 
haemorrhage into the tissues from which it is escaping. Adhe- 
sions between the opposed peritoneal surfaces form early, and 
if relief is not afforded within a few hours gangrene of the 
intussusceptum ensues from complete stoppage of circulation, 
aided by bacterial invasion of the damaged tissues. Peritonitis 
is a frequent cause of a fatal ending, but the patient rarely dies 
from complete obstruction. If, however, the strangulation of 
invaginated bowel is complete from the first, blood and mucus 
will not be passed. 

If no attempt is made to relieve the obstruction, death 
usually occurs before many days have passed, and although 
spontaneous reduction is spoken of, it is one of those rare 
occurrences which cannot be seriously considered. Some years 
ago Brinton made a collection of 500 fatal cases of obstruction 
and of these 215 were intussusceptions. Another way in which 
a patient may recover is by sloughing of the intussusceptum : 
of this there are many known instances. 

A child under my care at the Koyal Free Hospital was suffering from 
intussusception with prolapse for which the parents refused operation. 
The child was taken home to die, and was indeed very ill. About a 
fortnight afterwards the dresser of the case was walking through the 
street where the family resided and to her surprise saw the former 



264 THE ACUTE ABDOMEN 

patient playing with other children and sucking an orange. She made 
inquiries, and was told that a few days after leavmg the hospital the 
portion of bowel which was prolapsed when she went home had come 
away and the child rapidly recovered health. It is not possible to say 
if stricture developed later. 

It is interesting to see the various methods of treatment 
which have been tried in the past, many founded on a complete 
failure to understand the pathology of the disease. Fagge 
states that cases have been cured by the passage of bougies 
up the rectum.^ Maydieu, of Argent,^ used a mixture of 
No. 5 shot and olive oil, 7 oz. of the former to 4 oz. of the 
latter, and quoted twelve cases of supposed examples of the 
disease thus treated.^ He has not found many imitators. 
Taliaferro relates the case of a prisoner who was cured by the 
use of effervescing powders in the rectum, but died of parotid 
bubo some weeks later ; his gaoler acted as medical adviser. Iced 
injections have also been tried. The method of inflation which 
was in vogue some twenty years ago was introduced by Gorham ^ 
in 1838. This when combined with external manipulation and 
the use of chloroform in children not infrequently succeeded, 
but was uncertain and not without risk. Cheadle "^ wrote of 
this method : " The success of inflation in the cure of intussus- 
ception depends largely, no doubt, upon its early employment. 
Higginson's syringe proved of most use." Fagge ^ wrote of 
the same treatment : "It has now been frequently employed, 
and sometimes with the result of curing the disease. More 
often perhaps its success has been partial. The tumour has 
been reduced in size, or it has changed its position, returning 
towards the seat which it had occupied at an earlier period." 
Bryant wrote warningly : " Bowels have been ruptured by its 
use." The substitution of water pressure, by means of a 
funnel and tube introduced into the rectum, care being taken 
to prevent too much force being employed, has been similarly 
tried, and with varying success. The funnel should be elevated 
about 2 feet above the level of the rectum and warm saline 
solution allowed to flow quietly into the bowel whilst the child 
is under a general anaesthetic. Manipulation of the tumour 

1 Fagge, " System of Medicine," Vol. II., p. 413. 

2 Lancet, Vol. I., 1870, p. 737. 

8 Guy's Hospital Reports, Vol. III., p. 345. 
< Lancet, Vol. I., 1888, p. 321, 



\ 



INTUSSUSCEPTION OF THE BOWEL 



26fi 



through the abdominal wall should be carefully carried on as 
the injection enters. It is a method which I have used success- 
fully in the past ; it has been abandoned because of its un- 
certain effect, yet there may be occasions when it will appear 
to the attendant well worth a trial. To succeed the case 
should be an early one. The combination of this method with 
that of laparotomy has been found useful by some, but it is 
better in my opinion to trust entirely to opening the abdomen 
with manipulation of the intussusception. Incision on the 







Fig. 37. — Reduction of an Intussusception by Manipulation outside the 
Abdomen. 1. Intussuscipiens, Intussusceptum. 2. The peritoneal 
cavity has been packed off with gauze. 

right side over the rectus muscle, with opening of the sheath 
and displacement of the uninjured muscle outwards, is the 
best. You will not have a weak wound afterwards, as is often 
the case if the fibres of the muscle are separated. The upper 
limit should extend above the umbilicus. When the peri- 
toneum is opened, the prolapse of small intestine is prevented 
by a gauze pad or plug and the position of the tumour defined. 
If two fingers are passed to the lower end of this and pressure 
is made over the end of the intussusception, it will quickly 
recede before the pressure until a variable amount is left, perhaps 
a firm sausage-like lump of 2 inches in length which is more 



266 THE ACUTE ABDOMEN 

resistant. This should be deHvered out of the wound and 
complete reduction effected by linn but gentle pressure. As a 
rule some patience is required to reduce the part which has 
formed the apex of the intussusception, and sometimes when 
it has been reduced the operator has a doubt as to whether a 
thickening which is frequently felt inside the gut is a growth or 
only congested and oedematous mucous membrane. It is not 
wise to open the bowel in order to make certain ; growths 
are very rare in the acute variety and give some distinctive 
feature when present. Incision into a bowel such as this is 
inadvisable because the wall is probably softened and contains 
many organisms. Manipulation of the parts involved must be 
gentle but firm, violent or hasty pulHng will do harm, and often 
cause a splitting of the peritoneum of the outer layer and 
damage which cannot be repaired. 

If in spite of careful manipulation the intussusception cannot 
be reduced completely, there are practically two courses open 
to the operator in the case of children : — 

(1) To perform a lateral anastomosis above and below the 
irreducible part when the bowel is healthy. 

(2) To excise the intussusception by the method which goes 
in this country under different names : Maunsell, Jesset, Barker, 
etc. 

It is especially indicated where the intussusception is 
gangrenous but the ensheathing layer good. Apply a con- 
tinuous Lembert suture of silk to the bowel at the neck, uniting 
the adjacent surfaces in the whole circumference. With the 
usual precautions against the escape of bowel contents into the 
wound, make an incision in the ensheathing layer which shall 
fully expose the upper part of the intussusceptum. An 
incision is next made through this close to its upper end, by 
which the anterior two-thirds is divided into the central canal. 
Sutures are passed, four in number, through the entire thickness 
of this, one in front and one on each side. The fourth is passed 
in the following manner so that it may also act as a haemostatic. 
The needle is made to penetrate the two parts of the intussus- 
ceptum from within outwards, is passed round the uncut part 
of this, which contains the mesentery with its vessels, and back 
again into the centre of the bowel. This is now tied, the 
complete division of the inner tubes (and mesentery) completed, 



INTUSSUSCEPTION OF THE BOWEL 267 

and the opening in the sheath closed with a continuous Lembert 
suture, after the parts have been cleansed inside and out with 
warm saline. 

If for some reason too much damage has been inflicted on 
the bowel during the manipulation for reduction to permit of 
its recovery, then it must be excised ; but the prognosis of this 
operation in the case of intussusception is very bad. If it has 
to be done, the peritoneum must be packed off with gauze 
moistened with warm saline and the operation done swiftly. 

If the patient has stood the operation well, the wound in the 
abdominal wall may be sutured as usual ; if there is much 
shock, the best plan is to insert a number of interrupted 
sutures of thick salmon gut, which pass through all the layers. 

It is unnecessary to give statistics : suffice it to say that 
prognosis depends very much on the ability of the surgeon to 
reduce the intussusception without resection of the intestine ; 
therefore every effort short of causing serious injury to the 
bowel must be made in order to effect that object. This is 
more likely to be successful if immediate operation is performed. 

A Case in which Intussusception recurred, Lateral Anasto- 
mosis AT Second Operation. — F. K., a girl aged 8, was admitted •)(- 
on May 17, 1913. She was subject to constipation. For twenty-four 
hours she had suffered great pain in the abdomen with frequent vomit- 
ing. Nothing had passed by the bowel. She looked pinched and very 
ill, pulse 100 ; temperature, 100° ; respirations, 24. Examination 
showed a movable irregular mass in the right side ; the iliac fossa 
below felt empty and was tender on pressure, but the abdominal wall 
was everywhere soft. Examination per rectum normal. Operation was 
done through the right rectus (separation of fibres), and a large ileo- 
colic intussusception reduced with some difficulty after it had been 
brought outside. A hard button-shaped patch was left at the apex. 
She left on May 30, recovery having been uneventful. 

On June 28 she returned from a convalescent home. Next day she 
had abdominal pain and vomiting ; the bowels acted twice, but there 
was no slime and no blood in the motions. She came in suffering from 
intermittent attacks of pain which caused her to roll about in bed and 
cry out. The abdomen was rather distended ; no visible peristalsis. 
On the 30th the bowels had not acted, although an enema of glycerine 
had been given. In the afternoon the old scar was reopened. The 
small gut was considerably distended, and there was some clear serous 
fluid in the peritoneum. The mesenteric glands were large. The 
intussusception was 2 to 3 feet above the ileo-csecal valve and about 
4 inches long. It was easily reduced in part ; the terminal piece, 
however, was much thickened and complete reduction impossible, firm 



268 THE ACUTE ABDOMEN 

adhesions extending between the peritoneal surfaces. The intestinal 
contents passed this section with difficulty. Lateral anastomosis above 
and below was performed. The mucous membrane of the lump looked 
rather sloughy examined through one of the incisions. There was no 
evidence of tubercle on examination and application of von Pirquet's 
test. She left the hospital well July 26. 

Some months later this patient returned for symptoms of obstruction 
due to sarcoma of a different part of the small intestine (see p. 252). 

A recurrence of the intussusception after complete reduction 
has been met with in more than one case, and to prevent this 
it has been recommended that the mesentery of the ileum near 
to the valve should be shortened by the insertion of a con- 
tinuous stitch. It so seldom occurs that it is not advisable to 
adopt it as part of the routine treatment. 

The separation of a slough of the mucous membrane may be 
seen some days later in consequence of strangulation from 
tight nipping. In the following case it came away about three 
Aveeks after operation, and, although there were some uneasy 
symptoms complained of about three years later, there has not 
been any proof of the formation of a stricture ot the bowel, 
though such might be expected. The abdominal wall remained 
perfect. 

The patient was a boy 3 years old, an only child, seen with Dr. Cope- 
land on April 20, 1908. Vomiting had been present since the early 
morning and there had been complaint of abdominal pain. The bowels 
had acted, but no special attention had been paid to the character of 
the motion. There had been no blood or mucus passed. When seen 
earlier in the day by Dr. Copeland there had been nothing abnormal 
to be felt, and the temperature was about 100°, not over. In the 
evening when seen again there was a swelling in the iliac region. At 
7 p.m. there was a flattened, sausage-shaped and somewhat tender 
swelling above the iliac fossa. The abdomen was generally flaccid 
elsewhere. Pulse, 80. 

The abdomen was opened at 8.45 p.m. after displacement of the 
rectus ; and an ileo-csecal intussusception reduced by manipulation. 
The terminal inch of ileum and early part of the caecum were oedematous 
and thickened. He made a good recovery, but three weeks later passed 
a broad band-like circular slough of the mucous membrane from the 
lower ileum. The detachment of the slough was accompanied by some 
abdominal pain and a rise of temperature in the morning of the day 
on which it was passed. 

With regard to the prognosis in cases where there is 
some sloughing of the intussusceptum a case recorded in 



OBSTRUCTION OF THE LARGE INTESTINE 269 

*' Holmes' System of Surgery," Vol. II,, p. 722, is very 
encoaraging : — 

A boy of 5 under the care of Dr. Buckley, of Sutton-on-Trent, passed 
S inches of the ileum, the caecum with its appendix, and about 4 inches 
of the colon, after an illness of four months' duration, and recovered 
in six weeks' time. Sixteen years later he was reported as having had 
perfect health during the whole of the intervening time. 

Chronic intussusception is mostly met with in adults, and 
is not infrequently due to a growth. These intussusceptions 
being mostly irreducible, are usually treated by excision of the 
affected portion of the bowel, the amount removed depending 
on the position and nature of any growth that may be present, 
A removal of a wedge-shaped piece of the mesentery will be 
necessary if the tumour is malignant. Under no circumstances 
should an attempt at a complete operation be made if acute 
has been superadded to chronic obstruction. 

In those cases where a carcinomatous growth of the large 
bowel has been intussuscepted and prolapsed through the anus, 
I have on three occasions excised the growth with success 
so far as the immediate result of the operation was concerned, 
but one of them returned with general dissemination in the 
abdomen a few months later. The sphincter ani should be 
dilated and the growth drawn well into view. The bowel well 
above the growth, which is usually annular in shape, should be 
gradually divided with scissors completely round, forceps being 
put on the edges as they are cut. Silk sutures should then be 
passed through both layers and tied from before backwards. 
When the bowel is released it readily passes up into the upper 
part of the rectum. The objection to this operation is the fact 
that very few glands can be removed. The prolapse of itself 
indicates that there cannot be very much infiltration in the 
mesentery or great enlargement of the glands. There is usually 
some, but much of it may be secondary to a sloughy state of 
the growth, which is not uncommon, and often associated with 
haemorrhage. The distress which it causes occasionally renders 
operative interference an urgent matter. 

OBSTRUCTION OF THE LARGE INTESTINE. 

In this section it is necessary to include a consideration of 
the forms of obstruction which are of a chronic nature, because 



270 THE ACUTE ABDOMEN 

the prevention of an acute and often fatal attack should be 
possible if the condition is recognised in time. It is far too 
common to find that for a long time the patient has had 
discomfort and troublesome constipation for which various 
forms of purgation have been tried, and succeeded, more or 
less imperfectly, in giving rehef, then a complete obstruction 
has supervened which the most persevering and injudicious 
attempts at forcing a passage have failed to overcome. During 
the years 1903 — 12 inclusive, there were 121 cases under 
treatment in St. Thomas's Hospital in which a carcinomatous 
growth of the large bowel was present in acute obstruction, 
and of these 70 died and 51 recovered. Acute obstruction 
was produced in 14 others by the pressure of maUgnant growths, 
and of these nine died. A case of carcinoma of the jejunum 
also proved fatal. 

The causes of death in the cases of malignant obstruction 
treated by colostomy are summed up as follows by Mr. 
Rouquette : — 

Death due to operation, 21 per cent. : peritonitis, 9 per cent. ; 
pneumonia, 12 per cent. 

Death due to prolonged obstruction, 79 per cent. : toxsemia, 
67 per cent. ; perforation of growth or stercoral ulcer, 12 per 
cent. 

This is a large percentage of fatal cases to be found in any 
series of diseases of the bowel at the present day which if 
recognised early are quite amenable to surgical treatment. It 
must be conceded that the subjects of malignant growth of the 
large bowel are often advanced in years, and may be suffering 
from bronchitis or some other complication ; but with the 
inevitable ending which awaits delay, it would often be the 
wisest course to take the smaller risk and submit to a palhative 
operation such as that of lateral anastomosis, if on exploration 
more curative procedures are not possible. It is very sad to 
find a patient suffering from an obstruction of some two to 
three weeks' duration, caused by a ring carcinoma of the colon 
which is quite operable, and have death follow a colostomy, 
because the patient is already poisoned by absorption from the 
distended bowel above the obstruction or exhausted by 
vomiting, pain and want of food. Even the causes of death 
which are put down to surgical interference are in most the 



OBSTRUCTION OF THE LARGE INTESTINE 271 

result of changes in the bowel due to prolonged obstruction, 
and the pneumonia, a complication of the anaesthetic in an 
exhausted patient already suffering from hypostatic congestion 
of the lungs. 

The majority of the cases of cancer of the intestine occur 
between 40 and 65 years of age, but it has been met with quite 
early in life. Nothnagel collected 61 cases the ages of which 
were between 20 and 30 years, and mentions others in which 
it was found at 3, 3 J, 11, 12, and 13 years of age. The youngest 
patient in my own series was a boy of 14, in whom it was 
necessary to perform colostomy for a fixed and extensive 
carcinoma of the pelvic colon. Maydl says that one-seventh 
of the cases are met with before 30 years of age. 

Of the cases in our general series from the hospital the 
majority were males ; of a series of 151 in the London Hospital 
65 were men and 86 women (Barnard). 

The situation of the carcinoma is important and in a larg« 
series of cases was as follows, when it arose below the stomach: 





i 

c 

s 
Q 


S 


1 

.2 




a 

1 

< 


i 

1 


1 

il 


Us 

WE 


S3 


o 9 

Is 

is 


^5 


II 




Barnard : 




























London Hospital, 




























1900-1905 . 


5 


3 


'-' 


5 




41 


6 


3 


ir 


12 


6 


103 


278 


Nothnagel ; 




























Vienna . 


7 




10 




2 


23 


6 




so 






53 


Ifi-^ 


St. Thomas's Hospital, 




























1903— 1912 (incl.) . 






1 






4 




- 


13 


17 


5 


58 


22* 


Total.. 946. 


12 


3 


13 




2 


68 


12 


5 


110 


29 


11 


214 


462 



Producing acute obstruction only. 



With reference to the mahgnancy of carcinoma of the large 
intestine, it is recognised that secondary deposits occur less 
frequently than in cancer elsewhere. The outlook in early 
excision is therefore more hopeful. When it does occur it is 
commonly in either glands or liver, but varies somewhat 
according to the exact nature of the growth. 

A cancer of the large bowel may remain apparently without 
change for many months. A surgeon to one of our large 
hospitals told me of a case of carcinoma of the rectum for which 
he was consulted owing to an attack of obstruction which was 



272 THE ACUTE ABDOMEN 

relieved by castor oil. Eight years later the patient was still 
alive and did not appear to suffer excepting from an occasional 
difficulty with the bowels which " his medicine " always 
relieved. I can recollect the case of a woman of 40 who was 
treated for obstruction due to a ring carcinoma of the sigmoid. 
Lumbar colostomy was performed and gave relief for several 
years. I saw her myself six years later, when the growth was 
assuming large dimensions. This was in the days of lumbar 
colostomy, before excision was practised. 

The early symptoms of the presence of a malignant growth 
of the large intestine are not very decided ; they may consist 
of a loss of strength, anorexia, lassitude, abdominal uneasiness, 
loss of flesh, and increasing pallor. 

In the early stages pain varies very much, but it is not often 
a cause of much distress until obstruction has begun or peri- 
tonitis complicates the case. In the small intestine, transverse 
colon, and sigmoid it is referred to the umbilicus ; when in the 
more fixed parts of the bowel it is at the point of fixation. If 
there is an increase of pain when food is taken the growth may 
be in the lower ileum or caecum. Many parts are not accessible 
to palpation, and in fat people even a large growth may be 
difficult to find, whilst a contracted rectus may conceal it. 
There may be more than one tumour felt in the line of the colon, 
making the diagnosis difficult ; under these circumstances a 
purge will get rid of the scybala, and the growth can then be 
demonstrated. In shape and size these cancerous growths 
vary very much ; if there is a large growth without any 
obstruction there may be a colloid change, a solid cylinder 
being formed without much, if any, contraction. 

Blood, mucus, and pus may be found in the faeces if ulcera- 
tion is present. 

Occasionally a growth can be felt above the finger on examina- 
tion fer rectum, which from its mobility gives the impression 
that it is operable, but it is necessary to give a cautious opinion 
before examination from above has been done. Quite recently 
two patients have been under my care ; in the male it was 
found at operation that the growth which had been felt was a 
carcinomatous deposit secondary to a stricture of the same 
nature higher up, and there were many secondary deposits in 
peritoneum and bowel wall without obstruction. In the 



OBSTRUCTION OF THE LARGE INTESTINE 273 

female, who had suffered from abdominal pain and irregularity 
of the bowels with some loss of flesh, the tumour was a small 
ovarian cyst which was adherent to the front of the rectum in 
Douglas's pouch. 

Sometimes the X-rays give great assistance in the diagnosis 
of these conditions when the lumen of the bowel is narrowed 
but obstruction is not complete. A carcinomatous growth 
continues to contract and the symptoms associated with 
chronic obstruction appear sooner or later. 

There is a complaint of increasing constipation which 
ordinary purgatives do not appear to relieve ; indeed, they 
cause pain. Enemata are then tried and fail after a time. 
There are attacks of diarrhcea which alternate with the constipa- 
tion. Growths in the lower colon may cause almost continuous 
looseness of the bowels ; sometimes an alteration in the shape 
of the motions. Examination of the abdomen will often show 
a spasmodic contraction of the bowel above an obstruction, or 
abnormal thickening of its walls. This is found at or above 
the region to which the pain is referred. Later this becomes 
more extensive, and friction of the surface will excite painful 
peristalsis. Attacks of colic may come on with vomiting, 
rumbling of wind, and distension. In lead-colic and enteritis 
intestinal coils are not visible. 

Continued distension of the abdomen follows when the 
obstruction is complete or almost so, and is greater the lower 
down the obstruction is placed ; it may increase until the whole 
abdomen is rounded and balloon-like, the distended intestine, 
both small and large, filling the peritoneal cavity and even 
pushing forward the ribs and ensiform cartilage. There will 
then be a general tympanitic note with perhaps a dulness in the 
flanks from the fluid faeces in the colon, whilst the superficial 
veins show up clearly in the stretched skin. I have seen some 
cases which had taken four to six weeks to get into this state 
and were still not much troubled by either vomiting or pain. 
Many of our hospital cases have been '' worse " about three 
weeks : The first week, paroxysmal pain with wind and 
constipation ; second week, constipation, vomiting, distension, 
pain ; third week, increased pain, greater distension, with 
offensive vomiting, dry tongue, hiccough, thirst, and rapid 
emaciation. 

A.A. T 



274 THE ACUTE ABDOMEN 

Occasionally a patient who was " doing nicely " gets acute 
blocking of the carcinomatous stricture from a foreign body, a 
faecal lump, or some other complication, and there is a rapid 
development of urgent symptoms. The pain is more severe 
and continuous with exacerbations, the vomiting is distressing 
and the vomit changes its character, becoming feculent. 
Nothing is passed by the bowel, and all enemata fail to bring 
away any faecal matter or wind ; the distension increases 
rapidly, and at last the separate coils are indistinguishable. 
Should perforation now occur, or peritonitis arise from some 
other cause, tenderness and rigidity will be manifested, and 
there may be a temporary rise of temperature with a rapid failure 
in the strength of the pulse. The patient becomes collapsed, 
covered with cold sweat, the hands and feet are cold, pain 
ceases, the pulse dies away, and for some hours before death may 
cease altogether. The breath even gives a cold sensation to 
the hand, a quantity of foul fluid is perhaps poured from the 
mouth, arid the end comes so suddenly that the friends, who 
are perhaps talking with the patient, are quite unprepared for it. 

In the diagnosis of the cause of obstruction of the large 
intestine, besides cancerous growth there are various other 
conditions which must be considered, the chief of which are : — 

(1) Faecal impaction, distinguished from growth by the 
result of rectal examination and enemata. 

(2) lleo-caecal tuberculosis ; can often only be told by a 
microscopical examination after removal. 

(3) Foreign bodies, such as concretions and gall-stones, have 
been mistaken for growths until operation. 

(4) Sigmoiditis, with thickening about the bowel secondary 
to the development of a pouch in the wall of the bowel, is more 
common than is generally believed. 

(5) Tumours of neighbouring organs, such as — 
A. The stomach. 

On February 3, 1914, I operated for Dr. Mackenzie on a case of 
tumour of the abdomen which was regarded as one of growth of the 
descending colon. It was the size of a closed fist, on the left side below 
the level of the umbilicus, tender and adherent to the abdominal wall. 
There were no stomach symptoms, and free hydrochloric and free lactic 
acids were present in the gastric contents. 

Coeliotomy and separation of the swelling from the parietal peritoneum 
enabled us to examine it thoroughly. It was lying to the outer side of 



OBSTRUCTION OF THE LARGE INTESTINE 275 

the descending colon, but was in the stomach, having arisen in the 
greater curvature, and there were many enlarged and obviously 
malignant glands near. 

B. Gall-bladder. A hard painful swelling in the right iliac 
fossa, the outline of which was not easily defined in an aged 
lady with constipation, proved to be a distended gall-bladder 
containing many stones. 

C. Uterus and ovaries. Mahgnant growths having their 
origin in these organs may invade the bowel, and without 
operation it may not be possible to distinguish them . Palliative 
measures only would be possible. 

In cases of obstruction due to a growth in the large intestine 
it is advisable to operate as soon as you can. Do not wait for 
the onset of vomiting and distension ; an early operation may 
give the patient a chance of cure. Unfortunately it is not 
possible to say, until the growth has been seen, if it will be 
possible to remove it. You will, however, have no reason for 
seK-reproach if this is so, and may be able to save the patient 
much pain and suffering by performing a short-circuit operation. 
It cannot be too frequently repeated that anything like an 
attempt at immediate removal of the growth and the formation 
of an anastomosis when obstruction is present is certain to 
prove fatal. The patient's friends should be warned of the 
necessity of doing the operation in two stages. Many lives are 
still being lost in consequence of neglect of this rule. 

When a patient comes for relief with a greatly distended 
abdomen, and the position of the obstructing cause is unknown, 
the best plan is to make an incision to one side of the middle 
line, open the rectus sheath, and displace the muscle outwards. 
A distended coil will present itself and should be drawn to the 
surface, precautions taken to prevent soiling of the wound 
or peritoneum, and the coil emptied through a puncture or 
small incision. After this coil is emptied of gas and fluid 
contents another should be taken and treated in a similar 
manner, and a third or fourth if necessary. Each puncture is 
closed with a purse-string suture, the coil cleansed and returned. 
By this means the distension is much diminished and the 
pressure on the diaphragm greatly relieved. It is now possible 
to pass the hand into the abdominal cavity and learn the 
position of the growth and its connections, also the presence or 

T 2 



276 THE ACUTE ABDOMEN 

absence of secondary growths in the liver, glands or peritoneum. 
This is important. On more than one occasion I have found an 
operable growth in the intestine with a short history of obstruc- 
tion and a large secondary growth in the liver. If there is a 
fixed growth in the sigmoid or pelvic colon, and it is not possible 
to do a short circuiting operation, colostomy should be done 
on the left side in the usual position and a Paul's tube put in 
the bowel where it comes easily to the surface. A similar 
operation is required if there is a fixed growth in the rectum, 
but as a rule the rectal growths are found before operation and 
the exploratory incision is not needed. In the performance of 
colostomy for the relief of obstruction I am strongly in favour 
of the completion of the operation at the time. In this way 
relief is afforded at once, and experience convinces me that it 
is quite safe. 

Many years ago I commenced a colostomy at the Royal Free Hospital 
for obstruction due to carcinoma in the pelvis. The patient was a 
woman in good condition and the obstruction did not appear very 
urgent. The colon was sutured to the wound ready for opening later. 
Two days afterwards the patient died suddenly and we found that the 
thickened but softened wall of the bowel had been ruptured above the 
sutured part by excessive muscular action. The obstruction was 
complete but the amount of distension not excessive. 

Since that accident occurred I have always placed a tube in an opening 
in the bowel at once when operating under similar circumstances. 

The operation is performed as follows : — An incision of 
3 to 4 inches, according to the thickness of the abdominal wall, 
is made in the direction of the fibres of the external obhque — 
that is to say, at right angles to a line drawn from the left 
anterior superior spine to the umbilicus. The external oblique 
is divided in the same direction for the full length of the wound 
and the fibres retracted (Fig. 38). The internal oblique and 
transversalis are divided in the interval, which is in the centre of 
the wound and is shown by the line of fat deposit between the 
muscular fibres, which now extend at right angles to the incision. 
This part of the wound is also opened up with retractors and 
the subperitoneal tissue shown. Incision through this, the 
transversalis fascia, and the peritoneum should be of limited 
extent, according to the distension of the bowel to be brought 
outside. The bowel is recognised by its longitudinal muscular 
bands and appendices epiploicae. To secure this in position, a 



OBSTRUCTION OF THE LARGE INTESTINE 277 




loop of it is drawn up until 

the finger and thumb can be 

made to hold the mesentery 

beyond. A thick fishgut 

suture is then passed across 

from side to side of the 

wound so that the loop of the 

bowel is fixed well outside 

without tension. This suture 

should go through the meso- 
colon or meso -sigmoid about 

an inch from the posterior 

margin of the loop, and its 

passage is facilitated if forceps 

are placed on the peritoneum 

at the points near which it is 

to penetrate. These should 

be put below the middle of 

the opening, thus leaving the 

longer space for the proximal 

part of the loop (Fig. 39) . Two 

silk sutures are passed above 

and below the loop of bowel, which include muscle, peritoneum 

and the wall of the bowel itself. By these sutures the size 

of the opening through 
which the bowel passes 
is limited if necessary 
and no further pro- 
trusion is possible. 
They are also a safe- 
guard against falling in 
of the gut should the 
stitch through the meso- 
colon give as a result 
of violent vomiting. I 
have never seen it do so. 

Fig. 39.— Colostomy. Diagram of cross- ^^^^^ fishgut SUtures 
section of abdominal layers with are placed in the wound 

toneum and skin. 2. Meso-colon. required. There is now 



Fig. 38.— Left Iliac Colostomy. The 
line of incision, with, retraction 
of divided external oblique. The 
arrangement of internal oblique 
fibres is shown. 




278 



THE ACUTE ABDOMEN 



a good-sized loop of bowel protruding ; in order to open this at 
once and safely it is encircled with a strip of gauze, only the apex 
being left exposed. An adequate incision is made in this for 
the insertion of the tube, the knife going into the lumen of the 
gut, any contents being wiped away. Forceps are now 
placed at four equidistant points on the wall of this incision 
and a continuous stitch of No. 2 silk passed with a straight 
round-bodied needle. A small-sized Paul's tube is inserted, 




Fig. 40.— Colostomy. 1. The bowel 
has been brought outside and the 
wound closed. 2. Deep suture 
passing through abdominal wall 
and mesocolon. 3. Line of in- 
cision for tube. 4, Muscular band. 



Fig. 41. — Colostomy. Opening held 
by forceps to facilitate passing of 
running thread and introduction 
of tube. The wound is protected 
by gauze, which is changed after- 
wards. 



the suture tied, drawing the edges of the bowel incision round 
the tube beyond the flange. The ends are passed round the 
peritoneal aspect outside and beyond the forceps, again tied, 
and cut off. The bowel and surrounding parts are cleansed, 
and another strip of gauze drawn round and round the loop of 
bowel so that a thick layer protects the wound and at the same 
time supports not only the tube but also the loop into which it 
is inserted . A dressing of sterilised gauze, reinforced with a thick 
layer of wool secured in position by a many -tailed bandage, 
supports the parts. When the patient is in bed the thin rubber 



OBSTRUCTION OF THE LARGE INTESTINE 279 



tube attached to the Paul's tube is placed in a convenient recep- 
tacle by his side. One effect of the circular stitch is to cause a 
slough to form, and the tube comes away in four to six days 
after the operation. 

In all these cases it is advisable to empty the stomach with 
a tube before the operation and give saline afterwards by the 
rectum. These patients are often 
not only starved by their long 
abstinence from food, but dehy- 
drated by the amount of fluid 
which they have vomited and 
been unable to replace. The 
results of this operation are very 
satisfactory . 

I recently saw (January, 1914) a 
woman for whom this operation was 
done for inoperable carcinoma of the 
rectum, and she spoke most enthusi- 
astically of the benefit which she 
had derived from it, and the small 
discomfort which it caused. She had 
learned to manage her artificial anus 
excellently during the four years 
which had elapsed since it was made, 
and preferred the application of a 
pad and circular bandage to the more 
elaborate apparatus with which she 
had been supplied. She went about 
as usual both on foot and in public 
conveyances. 




Fig. 42. — Colostomy. Completion 
of operation. The strip of 
gauze covers junction of tube 
and bowel; it also covers 
the wound in abdominal wall 
and the gut at its emergence. 



Many surgeons are in favour 
of Paul's method of treatment 
of a malignant stricture of the 
bowel when it can be brought to 

the surface, whether there are secondary growths or not, and 
there is much to be said for it. By this operation the growth 
is brought outside, and either 

(1) Fixed with the loop in which it is growing in the wound, 
a Paul's tube being put into the upper limb. Here the growth 
is removed later, or 

(2) The growth is brought outside and cut away. A Paul's 
tube is then fixed in each end. These ends are sutured together 



280 



THE ACUTE ABDOMEN 



and fixed in the wound. Even if there are secondary growths, 
removal of the primary one will probably prolong hf e and make 

the future less liable to 
painful complications. No 
attempt is here made to 
restore the integrity of the 
canal, and there can be but 
inadequate removal of the 
glands in the second method. 
It is regarded as an opera- 
tion rather more perfect than 
a simple colostomy. 

The two-stage operation is 
often advisable when it is 
possible to perform a lateral 
anastomosis in cases where 
it is not good surgery to 
excise a growth. The wall 
of the bowel above, and 
often for some distance 
above, is so ill-fitted to hold 
sutures that they not infre- 
quently give, and the patient 
dies from peritonitis. 

In the same way ileo- 
colostomy maj- appear indi- 
cated in a case, but the 
condition of the distended 
small bowel with its softened 
wall will show how dangerous 
such a procedure would be 
until things have settled 
down. 

Should, however, the ob- 




FiG. 43. — Lateral Anastomosis. 1 . Large 
bowel. 2. Small bowel. These have 
been clamped and the clamps 
approxhnated. '3. The posterior con- 
tinuous sero-muscular suture has 
been completed. 4. Incisions in back 
portions of bowel. 5. The ends of 
the sutures are held by artery- 
forceps. 6. Gauze has been placed 
behind the parts engaged in the 
anastomosis, and structures around. 



struction be subacute after 
a more acute attack, the former operation may be done 
as follows : — 

The portions of bowel to be united are brought outside and 
isolated by means of gauze strips. They are then placed side 
by side and clamps put upon them in such a way that there is 



OBSTRUCTION OF THE LARGE INTESTINE 281 



a sufficiency of bowel isolated on each side to permit of a com- 
munication of about 3 inches being established. A continuous 
silk suture is then inserted commencing above and including 
the serous, muscular, and part of the submucous coats. The 
end of this suture is placed 
in artery forceps, and when 
it has been completed the 
needle is placed in gauze, 
or into one of the sterilised 
cloths, until again wanted. 
This line of suture should 
be about J inch from the 
part of the bowel most 
distant from the mesentery. 
The intestine on each side 
in turn is now incised in a 
straight line in front of this 
suture (Fig. 43). The two 
incisions, being parallel, are 
carried down to the mucous 
membrane from which the 
outer coats have receded ; 
scissors are now used to 
open the bowel and cut 
away the ellipse of mucous 
membrane which is ex- 
posed. The parts of the 
bowel beyond the clamps 
are cleansed carefully with 
saline and gauze swabs 
held at the end of 
forceps. These forceps are 
again placed in the steri- 
liser. A whipping suture in- 




FiG. 44. — Ijaterai Anastomosis. The 
posterior part of outer suture com- 
pleted, the bowel openings made, and 
the inner suture commenced. The 
needle passes through all the coats, 
which are held together with forceps. 
1. Large bowel. 2. Small bowel. 
3. Clamps. 4. Outer continuous 
suture. 5. Inner continuous suture. 
6. Forceps holding the coats of both 
portions of bowel in position. 7. 
Gauze. 



eluding all the coats is then 
inserted, and it is a great help in doing this if the peritoneal 
surfaces are kept in apposition by forceps (Fig. 44). Much 
help is also afforded in the suturing if the needle, passed across 
the two opposed walls of the bowel, is grasped with forceps by 
the assistant, who holds it until you can take it, and keeps with 



282 



THE ACUTE ABDOMEN 



his other hand the thread at the right degree of tension. This 
inner thread is passed tlu'ough all the coats, at its commence- 
ment about I inch from the end of the incisions and tied out- 
side, the end being placed in forceps. It is continued circularly 

round the opening until the 
edges have been brought 
together, when it is tied to 
the end held by the pair of 
forceps. As the thread comes 
round to the front it is not 
difficult to continue it with 
the left hand. The clamps 
are now removed and the 
parts washed with steriUsed 
saline. If the gloves are 
soiled they should be changed 
and fresh gauze packed round. 
Any bleeding point in the 
edge can be ligatured. The 
needle of the first thread is 
now taken and the outer 
suture continued in a manner 
similar to that which was 
done behind and at the same 
distance from the imier 
suture (Fig. 45). The ends are 
tied, cut short, and the junc- 
tion is effected. If there is 
any doubt about the security 
of the suturing, extra sutures 
should be inserted at the 
ends to bring more of the 
peritoneum together in the 
long axis. 




Fig. 45. — Lateral Anastomosis. The 
outer continuous suture almost 
completed. If there is any tension 
the clamps may be removed before 
this jmrt of the suture is con- 
tinued. 1. Larp:e bowel. 2. Small 
bowel. 3. Clamp. 4. Inner 
suture. 5. Outer suture, to be 
tied to 6, which is left long foi 
this purpose. 7. Gauze. 



This anastomosis must not 
be too close to the growth, there must be no dragging on the 
line of sutures, and the two portions brought together should 
be isoperistaltic. Should it be considered best to make a 
short circuit between the ileum and large bowel, the same 
method by lateral anastomosis may be used or the end of the 



OBSTRUCTION OF THE LARGE INTESTINE 283 



divided small intestine may be inserted into the large bowel, 
the distal end being closed with a double layer of sutures and 
dropped. The portion of large bowel selected is isolated with 
a clamp as it is in lateral anastomosis, and the free end of the 
ileum which projects beyond another intestinal clamp treated 
as follows : — 

After thorough cleansing, the first outer suture is put in, 
taking up all the coats to the submucous layer ; this begins 
above about J inch from 
the open mouth of the 
small bowel. An in- 
cision of length corre- 
sponding to the open 
mouth is made in the 
side of the large bowel 
and a running thread 
carried round to unite 
all the coats and act 
as a haemostatic suture 
(Fig. 46) . After removal 
of the clamp and cleans- 
ing of the parts the first 
suture is then continued 
round the line of anasto- 
mosis at the same dis- 
tance from the com- 
pleted inner suture. 
This union should also 
be without tension. 

In order to give an 
aged patient relief for a distant journey when much distended 
I have punctured the transverse colon and given exit to 
enough gas to enable him to travel to his home in comparative 
comfort. He was a man who refused any other operative 
help. 

Volvulus is the most common cause of acute obstruction of 
the large bowel, and is found in the sigmoid flexure, and at the 
ileo-csecal junction. Of these the former is the more common 
and the patients mostly men. 

The attack begins suddenly ; pain is severe and often 




Fig. 46. — Ileo-colostomy. A. Implanta- 
tion of the small intestine, end to 
side. The posterior part of the outer 
continuous suture, uniting the peri- 
toneal and muscular layers, has been 
inserted and the incision made into 
the large bowel. The clamps are 
not shown. 1. Ileum. 2. Colon. 



284 



THE ACUTE ABDOMEN 



paroxysmal ; tenderness appears quite early. Vomiting is not 
usually a symptom which causes distress, and may even be 
absent. Distension of the abdomen comes on with, considerable 
rapidity, and the respiration quickly becomes embarrassed 
in consequence of pressure on the diaphragm. The involved 
portion of the bowel tends to become gangrenous in a few 
hours, and peritonitis (as indicated by the marked tenderness) 

is an early complication. As a 
rule no separate coil of gut can 
be distinguished. When the 
ileo-csecal region is affected the 
symptoms are of less urgency ; 
here there may be a resonant 
tumour of considerable size. 
Vomiting is present, but not 
usually of urgent character. 

Without early operation the 
prognosis is very grave. Very 
often the coil affected is gan- 
grenous and resection is indi- 
cated. If the patient is very 
bad, the gangrenous bowel is 
drawn out of the abdomen and 
a Paul's tube put in. Later 
the gangrenous part is resected 
and the bowel restored by an 
end-to-end or lateral anasto- 




FlG. 47. — Ileo-colostomy. B. The 
posterior part of the inner suture 
encircling all the coats of the 
bowel has been inserted. The 
ends of both inner and outer 
sutures are left lon^^, so that 
they may be continued and 
ultimately tied at A. 1. Ileum. 
2. Colon. 

mosis. 

Recurrent Volvulus of the Sigmoid (Enterostomy : Re- 
covery). — Mr. R., aged 76, was seen with Dr. A. E. Godfrey on 
March 22, 1914, for intestinal obstruction. 

The present attack commenced with colicky abdominal pain and 
constipation ten days before. But having had some five or six similar 
attacks during the previous five years which had yielded to treatment, 
he had rather put off calling in medical aid. At first there had been a 
certain amount of relief from the use of remedies to act on the bowels, 
and enemata had been partly successful, but gradually the distension 
had become extreme and the pain paroxysmal, whilst little but coloured 
water could be washed from the bowel. 

The abdomen was much distended, and the distension was most 
marked on the left side, where there was a large coil of the large intestine 
which contracted spasmodically during the examination. The abdomen 
was resonant all over (very tympanitic in front), but not tender. Rectal 



OBSTRUCTION OF THE LARGE INTESTINE 285 

examination was negative. He was not sick, and was able to take 
fluid food. Pulse, 100 ; arteries rather hard ; tongue furred ; not 
emaciated. 

Operation permitted on the 24th. An incision was made to the left 
of the middle line, the rectus displaced outwards, and the peritoneum 
opened. A very large coil of large intestine presented itself, so large 
that when outside the abdomen it measured 8 inches to 9 inches in 
diameter. This was emptied of a very large amount of gas by a stab 
wound with the point of a scalpel, there being only a few drops of fluid 
in the bowel. After closure of this opening with a stitch it was possible 
to examine the interior of the abdomen more fully and bring more of 
the sigmoid outside. It was then quite evident that the obstruction 
followed a volvulus of the sigmoid, there being a complete turn of a loop 
from left to right, the point of rotation being at the level of the promon- 
tory of the sacrum. The mesosigmoid was very long and the bowel 
wall thickened and hypertrophied. When this part of the gut had been 
emptied the upper abdomen looked quite concave, and although the 
small intestine was somewhat distended, it was quite remarkable how 
very little faecal matter was seen and how little difference to the general 
distension had been contributed by the small bowel. A tube was 
placed in the sigmoid below the middle of the loop, and this was secured 
in the upper end of the wound. There was no evidence of growth which 
the recent history of the case had suggested before operation. The 
want of certainty made it advisable to explore before opening the large 
gut, as is usually done in the obstructed sigmoid when there is not 
a malignant stricture to be felt. He did well after the operation, and it 
was not long before the bowels acted naturally. The faecal fistula was 
very useful for some days, and the attachment of the large bowel at 
that point will prevent a return of the volvulus. 



PAKT VII 

CONGENITAL DIVERTICULUM OF THE Ci^STIC DUCT 

In considering fluctuating swellings in the subhepatic region, 
whether abscesses or suppurating hydatids, there is a condition 
to be referred to which, although very rare, closely resembles 
them. It is that of congenital diverticulum of the cystic 
duct. The remarkable characters which this disease may 
assume is shown by the case described. 

F. G., a girl aged 14, was admitted "^ on July 16 and died 
November 14, 1907. 

She had been healthy until a month before, when she began to 
complain of pains in the right side with vomiting. For five days the 
pain had been continuous and more severe. 

A fluctuating, prominent, rounded, very tender swelling was present 
on the right side below the liver, not moving well with respiration, and 
its outline towards the middle line was obscured by rigidity of the rectus 
muscle. The swelling passed backwards towards the lumbar region. 
Her pulse was 116; respiration 36; temperature, 103-2°. The tongue 
was furred and bowels confined. There was no jaundice. 

An incision was first made in the loin and the peritoneum opened ; 
the swelling was found to be covered with peritoneum and attached 
to the under surface of the liver. A second incision was made 
in front through the right rectus. Through this the cyst was tapped 
and 36 oz. of thick green bile drawn off. The wall of the cyst was very 
thick, especially the lining, which was white in colour. The gall- 
bladder was lying between the cyst and under surface of the liver, 
being flattened and empty, looking like a dog's tongue. The gall- 
bladder and cyst were removed and the cystic duct, which was a good 
deal elongated, secured in the wound. The cyst wall was composed of 
fibrous tissue and completely retroperitoneal. There were no calculi 
present, and there was no pus. 

A tube was passed to the bottom of the wound and a gauze plug 
placed below it. 

The patient improved quickly and bile came through the wound, all 
attempts later to make it flow in the normal direction being useless. 
At the end of October three attempts caused pain, and jaundice followed. 
On November 13 the cystic duct was inserted into the second part of 
the duodenum and sutured there with a double row of silk sutures. It 



CONGENITAL DIVERTICULUM OF CYSTIC DUCT 287 

was easily turned to the duodenum without tension, and no artery- 
required ligature during the operation. It was thought best to place a 
tube and gauze plug down to the line of union. She became restless 
during the following night and died a few hours later. 

Necropsy: — There had been extensive haemorrhage into the right 
side of the abdomen, but Dr. Box could not find the source of the 
bleeding. The dilated bileduct had been anastomosed successfully to 
the duodenum immediately beyond the pylorus. The common duct 
terminated about an inch below the liver ; beyond this it could not be 
traced downwards. Explored from the bile papilla in the duodenum, 
it ran up for an inch and then ended, but blindly. The intervening 
portion was missing. There was no peritonitis, but a certain amount 
of adhesions about the area of operation. 

A case of diverticulum of the cystic duct is also found in 
the St. Thomas's Hospital Reports for 1907. 

The case was that of a girl of 18 under the care of the late Mr. 
Glutton. She had complained of pain and swelling on the right side of 
the abdomen for a fortnight, and had vomited a day or two before 
admission. There was then a painless swelling in the right kidney 
region, extending sHghtly below the level of the umbilicus and almost 
to the middle Une. The urine was normal ; temperature, 98-2°. Eleven 
days after admission lumbar incision, paracentesis of an intraperitoneal 
cyst, withdrawal of two and a half pints of olive-green ghstening fluid 
which did not contain bile, although fluid which flowed from the 
woimd later did so. Cyst wall taken away ; the colon was adherent 
to it, there was free venous haemorrhage : arrested by plugs. There 
were numerous facetted calculi in it : a communication with cystic 
duct at a point where there was a small nipple-shaped projection. 
There was a discharge of bile after removal of the plugs, and she 
appeared to be progressing satisfactorily until twenty days after opera- 
tion, when she died from haemorrhage. 

The internal opening was close to the neck of the gall-bladder in the 
cystic duct. The gall-bladder contained a few calcuh ; the common 
duct was normal. The haemorrhage had probably come from a branch 
of the portal vein in the portal fissure. 

Search has been made with the view of adding something 
to the somewhat bare records of these cases, but nothing has 
been found in surgical literature to give any help. It is very 
remarkable that both patients should have reached the ages 
attained before symptoms developed, and that there should 
have been no jaundice present in either of them at the time 
when they came to operation. It is also a curious fact that 
in each of them the fatal ending ensued after a haemorrhage 
the origin of which was quite obscure. 



APPENDIX 



THE OPERATION OF GASTROSTOMY 

As gastrostomy may be required as an emergency operation 
in a neglected case of oesophageal obstruction, I have thought 
it advisable to add a few lines which may encourage its per- 
formance in a patient who appears almost at his last gasp. A 
man who has been taking even fluid nourishment with difficulty 
by the mouth, and is much emaciated, with a dry, harsh skin 
and sunken eyes, will improve marvellously as a result of the 
introduction of fluid through an opening into the stomach. 
There still appears to be a kind of prejudice against gastrostomy, 
firstly, because of the shock which it is supposed to cause ; 
secondly, because of the inconvenience which leakage from the 
opening may produce. 

If a local anaesthetic is used there is no shock, and the method 
of Senn prevents leakage of the stomach contents. The 
illustration (Fig. 48) shows the normal state of the skin in a 
patient who had gastrostomy performed two years ago for 
impermeable stricture of the oesophagus, the result of taking 
acid. There is not the slightest abrasion, whilst the girl is well 
nourished and looks healthy, although she is quite dependent 
for her food supply on the opening. The incision is made 
through the left rectus at its outer border, and should be from 
2 to 3 inches in length, commencing just below the costal 
cartilage. The stomach is easily found, although usually 
retracted and small. Traction on the omentum will bring it 
down, and a point for the operation is selected. This should 
be about midway between the greater, and the lesser, curva- 
tures, as far as possible from the pylorus. A rubber tube, or 
better, a Jacques catheter. No. 12 — 14, is introduced through 
an incision large enough to admit it, and fastened in position 
by means of a suture which includes all the coats of the stomach. 
A cone which projects into the stomach is made in the following 



APPENDIX 



289 



manner : A purse string suture is passed half an inch away from 
the tube, completely encircling it, the tube is depressed by an 




Fig. 48. — 1. The opening two years after gastrostomy by Senn's 
method, in a girl aged 16. 2. The scar of an operation for 
acute appendicitis one year after the gastrostomy. 

assistant whilst the suture is tied. Two similar sutures are 
passed and tied, the tube being pushed in on each occasion. 
The stomach is then fixed to the posterior rectal sheath and 

A. A U 



290 APPENDIX 

peritoneum of the wound, above and below, by sutures which 
take good hold of it. Sutures are inserted on both sides, 
shutting off the peritoneal cavity. The sheath of the rectus 
above and below the opening is sutured and then the skin 
incision. 

The tube is brought through the dressing and secured outside 
to the bandage with a safety-pin. A wooden plug is inserted 
and prevents escape of fluid from the stomach. The stitch 
through the tube rarely holds for more than ten days, but 
unless the dressing is carelessly changed or the patient interferes 
the tube will retain its position. No difficulty will be found in 
changing the tube, but one of the original size should be retained 
until the patient is used to feeding himself and has lost all 
apprehension of hurting himself by passing it. It can then be 
replaced by a gastrostomy plug, which is more easily managed 
by a patient who wishes to get about. 

Feeding should be commenced at once, a half a pint of milk 
with an ounce of brandy being given on the table. Subsequent 
feeds should be given through the tube, a small glass funnel 
being used, and there should be no disturbance of the dressing. 



INDEX. 



Abdomen, acute, 99 

injuries of, 13 
wounds of, 18 
Abdominal catastrophles, 217 

incisions, planning 

of, 1 
influenza, 113 
injuries, 1 

after-effects, 74 
table of, 35, 36 
muscle, rupture of, 14 
muscular groups, 4 
suppurations, 139 
waU, oedema of, 88 
Abscess, appendicular, 130 
hepatic, 139 
perigastric, 141 
subphrenic, 141, 143 
Abscesses, 132 

concealed, 147 
Acquired strictures, 253 
Actinomycosis, 134 
Acute abdomen, 99 

dulness, 221 
appendicitis, 169 
dilatation of the stomach, 
causation of, 224 
symptoms, 220 
distension of gall-bladder, 

218 
haemorrhagic pancreatitis, 

214, 218 
intestinal obstruction, 167 
pancreatitis, 167, 216 
pneumonia, 111 
Acute dilatation of stomach, 214, 

220, 223 
Adhesions, 251 

Anaesthesia, administration of, 1 1 
Anastomosis, end-to-end, 241 

lateral, 280, 281, 282 
Anterior gastro - enterostomy 
operation, 166 



Appendicectomy, incision for, 120 
Appendicitis, acute, 169 

and kidney, 115 
diagnosis of, 110 
incision for, 5 
operation for, 119 
treatment of, 119 
Appendicular abscess, 130 
Appendix, 288 

empyema of, 106, 157 
vermiformis, influence of 
disease, 96 



Bile-duct, perforations of, 227 
Biliary passages, rupture of, 59 
Bowel, intussusception of, 260 — - 
269 
invagination of, 260 
Bullet wounds, 22, 23, 25 



Cancer of large bowel, 271 
Carcinoma, malignancy of, 271 

of small intestine, 257 
Colloid growth of colon, 134 
Colon, colloid growth of, 134 

rupture of, 50 
Colostomy operation, 276 
Concealed abscesses, 147 
Congenital diverticulum of cystic 
duct, 286, 287 
stricture, 252 
Contusions, 12 
Cyst, hydatid, 256 
Cysts of pancreas, 80 

suppuration of, 208 



Diagnosis of appendicitis, 110 
Diaphragm, rupture of, 15 
Diaphragmatic hernia, 260 



292 



INDEX 



Diverticula, perforation of, 188 
sigmoidal, 189 

Diverticulum, congenital, of cystic 
duct, 286, 287 

Doyen's clamps, 246 

Dulness in acute abdomen, 221 

Duodenal hernia, 259 

u'cer, haemorrhage from, 
230 

Duodenum, perforation of, 167 
rupture of, 48 



KcTOPic gestation, 201 

Klaterin, 128 

Embolism of mesenteric vessels, 

224 
Emphysema, 46 

Empyema of appendix, 106, 157 
Entero-anastomosis, 166 
Enterospasm, 228 

symptoms of, 228 
Enterostomy operation, 249 
Extra-uterine gestation, 196 

ruptured, 168 



Fallopian tube, infection, 186 
Fibroids, uterine, 256 
Fibro-myomata necrobiosis, 212 
Fistula, renal, 83 

urinary, 82 
" Fowler " position, 47, 124 



Gall-bladder, 

acute distension of, 218 
perforation of, 171, 227 
rupture of, 58 
Gall-stones, obstruction from, 257, 

258 
Gangrene, localised, 246 

of intestine, 245 
treatment of, 246 
Gastric crises, 171 

ulcer, causation of, 231 
operation for, 157 
perforation, 154,155 
ulcers, 152 

haemorrhage from, 230 
G astro -enterostomy, 165, 232 
anterior, operation, 166 



Gastro -jejunal ulcer, 172 

ulcers, perforation 
of, 172 

Gastro-jejunostomy, 178 

Gastrostomy operation, 288 

Gestation, ectopic, 201 

extra -uterine, 196 
intramural, 202, 205 

Gimbernat's ligament, 20 

Glands, tuberculous, 262 

Gunshot wounds, 20, 23 



HEMORRHAGE from duodenal 

ulcer, 230 
Haemorrhage from gastric ulcers, 

230 
Henoch's purpura, 262 
Hepatic abscess, 139 
Hernia, diaphragmatic, 260 
duodenal, 259 
internal, 259 
Hernial apertures, examination of. 
252 
protrusions, 238 

symptoms and signs, 
238 
Hydatid cyst, 256 
Hydro -salpinx, 203 
Hyperplastic, tuberculosis, 134 
Hysteria, 113, 170 



Incision for appendicectomy, 
120 
appendicitis, 5 
Influenza, abdominal, 113 
Injuries, abdominal, 1 

after effects, 74 
of the abdomen, 12 
Internal hernia, 259 
Intestinal obstruction, 118, 239 
acute, 167 
adhesions, 251 
cause unknown, 248 
symptoms, 218 
resection, 247 
tuberculosis, 186 
Intestine, gangrene of, 245 
injuries to, 22 
rupture of, 38 
sarcoma of, 253, 254 
Intramural gestation, 202, 205 
Intussusception of bowel, 260 — 
269 
symptoms of, 261 



INDEX 



293 



Intussusception, treatment of, 

264—266 
Invagination of bowel, 260 



Jejunal ulcer, 172, 173 



Kidney and appendicitis, 115 
rupture of, 66, 67, 69 



Large bowel, cancer of, 271 
Large intestine, 

obstruction of, 269 
symptoms of malignant 
growth, 272 
Lead colic, 114, 171 
Liver dulness, 46 

rupture of, 54 
Localised suppuration, 130 



MacBurney operation, 135 
Malaria, 114 

Malignant growth of large bowel, 
symptoms of, 272 
obstruction, 270 
Meckel's diverticulum, 229, 244 
Mesenteric vessels, 

embolism of, 224 

thrombosis of, 224 
Mesentery, the, 78 

rupture of, 51 

sarcoma of, 255 
Meteorism, 17 
Muscles, rigidity of, 43 
Muscular fibres, 10 

rigidity, 167 



Necrosis, fat, 217 

" No loop " operation, 178 



Obstruction from gall-stones 
257, 258 
intestinal, 118 
malignant, 271 
of large intestine, 
269 
Obstructions, 236 
(Edema of abdominal wall, 88 
Omentum, 7 

torsion of, 229, 230 
tuberculous, 262 
Ovarian cyst, suppuration, 132 



Ovarian cyst, symptoms of rup- 
ture, 209, 210 
cysts, rupture of, 209 

suppurating, 209 
tumours, 206 



Pains, reflex, 117 
Pancreas, cysts of, 80 

rupture of, 52 
Pancreatitis, acute, 167, 216 
hsemorrhagic, 214, 218 
operation for, 219, 220 
Paul's method, 279 
Pedicle, torsion of, 206 
Pelvis, examination of, 164 
Percussion, value of, 156 
Perforation and temperature in 

typhoid, 182 
Perforation in typhoid, 179 
Perforation of diverticula, 188 
duodenum, 167 
gall-bladder, 171 
gastric ulcers, 154, 

155 
gastro-jejunal 

ulcers, 172 
small intestine, 179 
stercoral ulcers, 189 
stomach, 167 
sub acute, 163 
ulcers, 152 
Perforations, 86 

of bile-duct, 227 
gall-bladder, 227 
Pericolitis sinistra, 190 
Perigastric abscess, 141 
Perisigmoiditis, 147 
Peritoneum and typhoid, 185 
treatment of, 161 
tuberculous, 262 
Peritonism, 38, 48, 98, 101, 179, 

207, 239, 244, 261 
Peritonitis, 86 

pneumococcal, 90 
puerperal, 197 
streptococcal, 92 
symptoms, of, 86 
toxic, 240 
tuberculous, 95 
Pneumococcal peritonitis, 90 
Pneumonia, 171 

acute. 111 
Pouches, 259 
Protrusions, 20 
Puerperal peritonitis, 197 
Pulse-rate, 102 



294 



INDEX 



Pyosalpinx, 133, 196 
rupture of, 198 
tuberculous, 150 



Rectus abdominis muscle, 6, 8 

Reflex pains, 117 

Renal fistula, 83 

Resection of intestine, 247 

Rupture of biliary passages, 59 
duodenum, 48 
gall-bladder, 58 
intestine, 38 
kidney, 66, 67, 69 
large bowel, 50 
liver, 54 
mesentery, 51 
ovarian cyst, symptoms 
of, 209,.210 
cysts, 209 
pancreas, 52 
pyosalpinx, 198 
spleen, 60, 63 
urinary bladder, 70, 71 

Rupture, symptoms of, 39 

Ruptured extra-uterine gestation, 
168 

Ruptures, causes of, 37 



Salpingitis, 196 

Sarcoma of intestine, 253, 254 

mesentery, 255 
Sigmoid, tuberculous, 187 
volvulus of, 284 
Sigmoidal diverticula, 189 
Simple stricture, 252 
Small bowel, tuberculous ulcer of, 
186 
intestine, carcinoma of, 257 
perforation, 179 
Spleen, rupture of, 60, 63 
Sterocral ulcers, 190, 193 

perforation of, 189 
Stomach, acute dilatation of, 214, 
220, 223 
causation of acute dila- 
tation, 224 
perforation of, 167 
strangulation of, 236 
symptoms of acute dila- 
tation, 220 
wounds, 24 
Strangulation by bands, 250 
of stomach, 236 



Streptococcal peritonitis, 92 
Stricture, congenital, 252 

simple, 252 
Strictures, acquired, 253 
Subphrenic abscess, 141, 143 

operation, 146 
Suppurating ovarian cysts, 209 
Suppuration, localised, 130 
of cysts, 208 
ovarian cyst, 132 
Suppurations, abdominal, 139 
Symptoms, 18, 21 



Tabes Dorsalis, 114 
Temperature, rise of, 44 
Thrombosis of mesenteric vessels, 

224 
Torsion of omentum, 229, 230 

pedicle, 206 
Toxaemia, 98, 122, 129 
Toxic peritonitis, 240 
Tubal abortion, 205 
Tuberculosis, hyperplastic, 134 

intestinal, 186 
Tuberculous glands, 262 

omentum, 262 
peritoneum, 262 
peritonitis, 95 
pyosalpinx, 150 
sigmoid, 187 
ulcer, small bowel, 
186 
Tumours of ovaries, 206 
uterus, 206 
Typhoid and peritoneum, 185 
fever, 112, 179 
perforation in, 179 

and tempera- 
ture, 182 



Ulcers, gastric, 152 

perforation of, 152 
stercoral, 190, 193 
Urinary bladder, operation, 73 

ruptureof, 70, 71 
fistula, 82 
Uterine fibroid, sub -peritoneal, 
211 
fibroids, 256 
tumours, 206 
Uterus, rupture of, 31, 32 



Viscera, rupture of, 34 
Volvulus, 245, 283 



INDEX 



295 



Volvulus of sigmoid, 284 
Vomiting, 207 



Wounds of the abdomen, 18 
bladder, 29, 30 
diaphragm, 25 



Wounds of gall-bladder, 26 
kidney, 27 
liver, 25 
pleura, 25 
portal vessels, 25 
renal pelvis, 28 
ureter, 28 



BRADBURT, AGNEW, & CO. LD., PKINTKRS, LONDON AND TONBRIDGE. 



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