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LECTURES ON THE
ACUTE ABDOMEN
Pig. 1. — Diagram to illustrate by shading the relative
proportions of various perforations of the hollow
viscera. Appendix, A. Gastric, B. Duodenal, C.
BiHary, D. Jejunal, E. Typhoid, F. Tubal, O.
Stercoral, H.
CLINICAL LECTURES
ON THE
ACUTE ABDOMEN
BY
WILLIAM HENRY BATTLE, F.R.C.S.
SURGEON TO ST. THOMAS's HOSPITAL, AND JOINT LECTURER ON
SYSTEMATIC SURGERY IN THE MEDICAL SCHOOL; FORMERLY
SURGEON TO THE ROYAL FREE HOSPITAL; ASSISTANT SURGEON
TO THE EAST LONDON HOSPITAL FOR CHILDREN ; HUNTERIAN
PROFESSOR OF SURGERY AT THE ROYAL COLLEGE OF SURGEONS
OF ENGLAND ; "oRATOR" OF THE MEDICAL SOCIETY OF LONDON,
1910; AUTHOR (with MR. E. M. CORNER) OF " THE SURGERY OF
THE DISEASES OF THE APPENDIX VERMIFORMIS AND THEIR
COMPLICATIONS," ETC.
TORONTO
THE MACMILLAN COMPANY OF CANADA LTD.
1912
PREFACE
It has been suggested that I should place the following
Lectures, which were given in the Clinical Theatre at St.
Thomas's Hospital, in book form, so that they may reach larger
audiences than those to which they were delivered, and also
complete the subject, to some extent, for those who were not
present on the occasions when all of them were given. For
some time I have refrained from doing so, but the increasing
importance of the subject, with the improved results that are
met with when the sufferers from most of the surgical catas-
trophes included in their scope are submitted to early operation,
has induced me to do it, in the hope that some good may ensue.
So far as possible the cases related have been treated aseptic-
ally, and without unnecessary multiplication of instruments, for
if the practitioner gets the idea that he cannot operate without
someone's special bobbin, clamp, or suture needle, he may
postpone operation, and the patient in all probability lose his
life. Prompt operation must follow on diagnosis, and there is
usually no time for the removal of the patient to a surgical
home if more than an hour or two will be lost by doing so.
In all the operations silk was used for sutures and ligatures ;
No. 1 is the size which is most frequently employed and gener-
ally useful, with fishgut sutures for the skin. I am strongly of
opinion that catgut should not be used in acute abdominal
viii PEEFACE
cases ; it is apt to soften and yield too quickly should any strain
be placed on it. In all abdominal cases it is best to use silk ;
some may recollect the statement of Kocher that in the clinique
of Madelung over 100 abdominal cases had burst their wounds
open because of the unreliability of catgut. Silk is safe, and
can be quickly and readily sterilised.
June, 1910.
SYNOPSIS
I.— THE INFLUENCE OF THE APPENDIX VERMIFORMIS AND
ITS DISEASES
Importance of the subject — Peritonitis — Value of individual symptoms —
Local and general — Character of the pulse most important — Illustrative
cases— Necessity for careful observation — Danger of a suppurative
attack during pregnancy — Empyema of the appendix — Eupture of
abscess into general peritoneal cavity.
II.— THE TREATMENT OF ACUTE APPENDICITIS WITH
PERITONITIS
The choice of anfBsthetic — Position of incision — " Acute abdominal conflux
and incision of incidence " — Drainage generally the safest — Collapse —
Toxaemia — Value of saline infusion — Position — Vomiting after opera-
tion— Use of purgatives and enemata — Distension — Fascal fistula — Black
vomit — Heart failure.
III.— PATHOLOGICAL PERFORATIONS OF THE DIGESTIVE
TRACT
Perforation of Ulcers of the Stomach : Simple — Most common
position — Symptoms— Importance of early symptoms — Illustrative case
— The value of percussion in determining the amount of free fluid —
Pelvic drainage — Chance of double perforation.
Perforation of Ulcers of the Duodenum : Difficulty in diagnosis from
acute appendix mischief — Reason for this — Importance of examining
the pelvis.
Perforations of Gastro-Jejunal and Jejunal Ulcers : Always
following gastro-enterostomy — Nearly always the anterior method —
Improvement of this operation by the Mayos — "Posterior no loop"
the best — Illustrative cases — Occasionally no drainage required.
Perforations during the Course of Typhoid Fever : Symptoms —
Patients under observation — Peritonitis without perforation — Illustrative
cases— Character of the ulcers — Excessive effusion into the peritoneum
during the course of typhoid.
Perforations of Stercoral Ulcers : Ulcers secondary to other disease
of the large bowel — Their rarity — Illustrative cases — Treatment — Diffi-
culty of cleansing peritoneum and of treating original disease.
X SYNOPSIS
rV.— ACUTE INTESTINAL OBSTEUCTION
Effects of bands — Eesemblance to acute inflammatory conditions — Peritonism
— Examination of abdomen — Selected cases — ^Volvulus of small intestine
— Meckel's diverticulum — Treatment of gangrene — Excision of intestine
— Effect on patient of removal of large quantities of small intestine
— Importance of resection of sufficiently large amount.
v.— DISEASES OF THE FEMALE GENEEATIVE ORGANS
Eupture of pyosalpinx — Diffusion of pus —Associated obstruction —
Illustrative cases — Gonorrboeal peritonitis by direct extension — Eupture
of extra-uterine gestation — Effects of loss of blood — Importance of
early operation — Illustrative cases — Eesemblance to intraperitoneal
rupture of a localised abscess.
VI.— SOME OF THE MOEE EAEE CAUSES OF THE ACUTE
ABDOMEN
Acute HiEMORRHAGic Pancreatitis : Symptoms— Importance of super-
ficial tenderness — Percussion — Illustrative case^Treatment — Type of
patient — Effect of escaping fluid on tissues— Odour of fluid— ^Fat
necrosis.
Acute Dilatation of the Stomach: Extremely fatal— Toxic variety-
Treatment — Illustrative case — Post-operative— Illustrative case — Dis-
tension affecting bowel also — Later history of case.
Embolism and Thrombosis of Mesenteric Vessels : Association with
cardiac disease — Intestinal haemorrhage — Embolism elsewhere — Treat-
ment.
Perforations and Acute Inflammation of the Gall-Bladder :
Symptoms — History of colicy attacks— Symptoms arising in the liver
region — Illustrative cases — Difficulty in diagnosis.
VII.— SOME NEUEOSES WHICH MAY CAUSE SYMPTOMS OF
UEGENCY
Hysterical manifestations— Haemorrhage from the stomach — Hysterical
perforation — Illustrative case — Enterospasm.
x\
LIST OF ILLUSTRATIONS
FIG.
1.
Diagram to Illustrate by Shading the Eelative Pro-
portions OF Various Perforations of the Hollow
Viscera Frontispiece
Acute Appendix— (24 hours)— (Pelvic) ....
Ord's Apparatus for keeping Patient up in Bed
Apparatus used for the Continuous Administration of
Pluids per Rectum
Acute Perforation of a Gastric Ulcer
Stomach Perforations— Most Common Position .
Perforation of Typhoid Ulcer
Continuous Suture introduced after Lembert's Method
Lembert's Sutures, introduced separately — Peritoneum
AND Muscular Coats taken up
10. Obstruction produced by Meckel's Diverticulum
PAGE
1
23
24
28
29
46
58
59
61
CLINICAL LECTURES ON
THE ACUTE ABDOMEN
THE INFLUENCE OF THE APPENDIX VERMIFORMIS
AND ITS DISEASES ON THE PRODUCTION OF THE
ACUTE ABDOMEN
There is no department of surgery which demands greater
consideration than that which I propose to discuss, for it com-
prises a group of cases some of which will certainly cause you much
Fig. 2. — Acute appendix — (24 hours) — (pelvic). Contains concretion
at A, which blocks the passage like a ball-valve. The distal
portion is gangrenous in patches. The highly-septic contents
partly escaped at B, where a patch has given way. Female,
aged 15.
trouble and anxiety in future life. It is of the greatest import-
ance, therefore, that you should have a good working knowledge
of this subject from the clinical standpoint.
At one time all we could do was to follow acute abdominal
cases to the post-mortem room, for they almost invariably went
there ; but with increased knowledge of the various conditions on
which " the acute abdomen " depends, a better estimation of the
A.A. B
2 LECTUEES ON THE ACUTE ABDOMEN
value of local signs and symptoms, and a satisfactory operative
technique, we now save many who in comparatively recent years
would have been condemned to death from the manifestation of
the first symptom. Upon your early recognition of the import-
ance of symptoms many a life may depend ; for whilst our medical
papers show wonderful instances of recovery from advanced and
apparently hopeless states of disease, which give encouragement
to us, they do not record the numerous others which have not
responded to treatment equally skilful, but applied too late.
On thinking over the subject for a clinical lecture it seemed to
me that it would be an advantage to recall some of the more
important cases of acute abdominal disease which have been in
the hospital under my charge, and, many of them, under your
observation, especially choosing those in which operation
revealed a definite lesion which could be regarded as the cause
of a condition, the treatment of which led to the saving of the
life of the individual.
In the early stage of acute invasion of the peritoneum, or a
serious lesion of it, there will be the signs of " peritonism " — that
is, the patient will suffer from shock, local pain, and vomiting.
There is then an interval of varying duration, when the powers
of the individual are being fully employed in rallying from the
shock, combating the invasion, and limiting its spread. Probably
a peritonitis will immediately commence, and other symptoms
be superadded as the inflammation extends and the toxins
j)roduced by the invading hordes of bacteria become to a certain
extent absorbed.
An abstract from **' Diseases of the Vermiform Appendix
and their Surgical Complications "^ may be made to give you
an idea — a general idea — of what the " acute abdomen " is like
when the earlier symptoms have been misunderstood: "The
general symptoms are those of a person who is really ill, unless
the signs are obscured by the injudicious administration of
morphia. The face is almost always anxious-looking. The pulse
is increased in rapidity, the respirations are slightly more
frequent than normal, and shallower, the respiratory move-
ments being chiefly costal. The abdomen, to which the attention
is mainly called, is distended, more or less motionless, tender on
^ Battle and Corner.
I
THE INFLUENCE OF THE APPENDIX VERMIFORAnS 3
palpation, sometimes also on percussion, and often presents the
signs of free fluid, such as dulness in the flanks, which shifts on
movement. Vomiting is almost invariably present, and, after
that of the onset, may pass off a little, only to become distressing
later. The tongae is usually furred, and the breath often foul.
The bowels are almost invariably without action, neither faeces
nor flatus being passed. In some cases the onset of the attack is
accompanied by a diarrhoea, often offensive ; or a looseness of the
bowels may be a late symptom, and is then called 'septic
diarrhoea.' But there is always some difficulty in the passage of
the contents of the alimentary canal. A rectal examination
should always be made, although in the majority of cases it
yields a negative result. The urine is usually scanty ; at first
normal, later it may contain albumin, but rarely blood." This
description may appear inadequate, and it is necessarily so.
There are hardly any two cases that are alike in the exact cause
of the sudden illness and in the 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 treat-
ment, whilst in another the local signs indicate the dangerous
nature of the illness.
You will naturally ask, what are the signs and symptoms to
be s})ecially noted in any case coming under care with this
history of sudden abdominal pain, shock, and vomiting ? I take
it that what is really required is to give such indications as may
be useful in showing you when the state of the patient is one
which requires operation, and to point out the symptoms which
cannot be neglected with am^ consideration for the patient's
welfare. These I will give briefly.
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 an 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 disease present.
The pulse-rate is a very important indication as to whether
b2
4 LECTUEES ON THE ACUTE ABDOMEN
the case may be safely left, it is advisable to operate, or the
patient is too far gone for relief. 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 ; every hour lost renders a successful operation less
probable. Any abdominal case with a pulse-rate of over 100
should be carefully watched ; if it continues to rise beyond
this the patient will probably require surgical aid, although
other symptoms may be improving. The temperament must
be considered in estimating the value of the pulse-rate, for
occasionally a patient may be unusually excited by the medical
man's visit or be suffering from a neurosis.
The temperature is often misleading ; there may be the most
widely-diffused septic suppuration, with a normal or subnormal
temperature. Usually there is a rise at first, but it should begin
to fall on the second day. A low or subnormal temperature
with a rapid pulse is a very bad combination.
Vomiting should cease after the onset ; its continuance is a
bad sign. The effortless pumping up of large quantities of
greenish fluid should cause much concern.
Eestlessness is an unfavourable symptom ; so, indeed, is a
condition of manifest indifference and apathy. Usually you will
find your patient lying on the back, with the arms thrown above
the head, and the lower limbs flexed on the abdomen. This
attitude is not, however, universal.
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 and oedema, and when the
abdomen is fully exposed note the amount of movement on
respiration as naturally performed, and then ascertain how much
the patient can voluntarily increase this. Find out the exact
seat and character of the pain by asking the usual questions ;
also the history of previous attacks of a similar kind. 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. Percuss the abdomen throughout, but with
a light hand, paying great 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
I
THE INFLUENCE OF TIIE APPENDIX YEEMIFOEMIS 5
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 increasing
in amount.
It is hardly necessary to remind you of the necessity of learning,
from the friends, the state of the bowels, if there has been inaction
or diarrhoea. But you should in nearly all cases make a rectal
examination at once, and in most this has to be repeated. You
thus ascertain from the beginning if the contents of the pelvis
are normal or not. 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, of course, vary much with
the nature of the case and the duration of the illness.
The number of cases of acute abdominal disease, which are
secondary to disease of the appendix, naturally makes us, in the
first instance, consider the subject from the point of view of that
part of the digestive tract. 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, 1901, and 1902. In all, there were
456 cases, of which 168, or 37 per cent., caused by inflammation
of the appendix, formed by far the largest class.
Acute Abdominal Cases
Appendicitis and its complications .... 37 per cent.
Intestinal obstruction (other than intussusception) . 24
Intussusceptions ....... 16
Perforations of the alimentary tract . . . .11
Pelvic or gynaecological cases ..... 6
Abdominal abscesses (other than appendicitis) . . 3
The remainder ........ 3
The great importance of the role which the appendix plays is
clearly shown by this table. The first four of the groups in the
list are the most important, 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
6 LECTURES ON THE ACUTE ABDOMEN
obstruction from the age of 30 upwards, with increasing frequency
to a maximum between 50 and 60.
The simple and uncomplicated cases of inflammation of the
appendix, and the attacks which end in localised abscess (a far
more common occurrence than is generally taught), I shall not
consider here. My remarks are chiefly concerned with cases in
which the inflammation of the surrounding peritoneum is not
only a septic one, but tends to diffusion, and ends fatally if
unrecognised or wrongly treated. I desire to illustrate by the
description of cases the course of events in this type. When the
illness is ushered in with a rigor, severe vomiting, very acute
pain, or other startling symptoms, the friends, as well as the
medical attendant, are alarmed and on the alert ; but when the
onset is rather indefinite, and the patient does not appear very
much worse from one hour to tlie other, there is a danger that
surgical assistance may be asked for when it is too late to do any
good. I have unfortunately seen this often in cases of gangrene
and perforation of the appendix, in which the extent and nature
of the mischief had been quite unsuspected by the relatives.
The case of a boy, aged six and a half years, is a very good
example of the type of which I am speaking. He was admitted
to the Leopold Ward (house surgeon, Mr. J. C. D. Vaughan ;
dresser, Mr. S. Churchill) March 30th, 1905, and left on May 20th.
He first began to be unwell on March 27th, 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 I agreed with him, when we
saw the boy together about twelve o'clock, that he had diffuse
peritonitis secondary to disease of the appendix. The state of
the boy at that time 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 in his bed fully he did so easily and with a smile. The
THE INFLUENCE OF THE APPENDIX VERIVOFORMIS 7
abdomen was somewhat distended, not rigid, but with greater
resistance in the right iUac 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 without morphine. The
temperature was 99° F., but his pulse was 140. At the 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 gangrene running round it about three-quarters of an inch
from its distal end, and in the 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 2nd 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.
This case has been given because the symptoms were not those
typical of the acute abdomen ; the onset was insidious, but I
think it is a very important and excessively dangerous type.
Operation was only just in time, and I feel confident that if it
had not been for the skill and devoted attention of the sister of
the ward he would have slipped through our hands, for his state
was very serious for some days afterwards. In these cases a
slow absorption of toxin takes place by the lymphatics of the
peritoneum, and it may be only when renewed vomiting is added
to the rapid pulse that the gravity of the case is appreciated.
How often do we hear it said, " But I never suspected it ; he had
so little pain, and seemed so well."
8 LECTUEES ON THE ACUTE ABDOMEN
A typical example of acute abdominal disease secondary to
appendix mischief is the following : A schoolboy, aged 11 years^
was admitted to St. Thomas's Hospital, under the care of Dr.
Hector Mackenzie (house physician, Mr. A. Bennett ; house
surgeon, Mr. A. C. Birt ; dresser, Mr. G. M. Custance). His
illness began four days before (January 21st) during the night,
with acute pain in the right side of the abdomen ; on the
following day he was much w^orse. 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 epigas-
trium 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 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° F, This patient was restless, and protested vigorously
against operation. When the abdomen was opened pus in con-
siderable 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
haemorrhagic 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 ; some of the lymph was gently
removed with gauze sponges j 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 8th, fourteen days after operation. At first he was
THE INFLUENCE OF THE APPENDIX VERMIFORMIS 9'
peevish and difficult to please, but left the hospital quite well on
March 17th.
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 considera-
tions. We may take as an example the case of a stout strong man,
aged 35, who had suddenly improved about 12 hours after the
commencement of symptoms. Dr. Yeld asked me to see him
because he was not satisfied with the general condition. We found
him (21 hours) without pain, but with a pulse of 120. He pro-
tested 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 commenc-
ing suppurative peritonitis (spreading). The following also
affords an instructive example of this type : On October 2nd,
1905, the patient, previously a healthy girl, aged 19 years, was
slightly troubled with diarrhoea, the cause of which was not
known. On the morning of the Brd she was awakened the first
thing by severe pain in the lower abdomen. She vomited
throughout the day, being unable to retain any nourishment.
The bowels did not act ; she was kept in bed. On the 4th there
was a severe attack of vomiting and diarrhoea at 3 a.m., and
the pain persisted. When she was first seen the abdominal move-
ments were very slight. There was general tenderness, especially
in the epigastric and right iliac regions, but the abdomen was
not very rigid. The tongue was coated and rather dry. The
pulse was 136 and the temperature 100° F. At 9 a.m. on the
5th the tenderness was rather more marked in the right iliac
region than elsewhere. The abdomen was more distended and
harder to the touch. Per rectum, the chief tenderness was to
the right; there was no tumour. Vomiting had ceased at 3 a.m.
The pulse was 120 and the temperature was 99*6°. About
12.30 p.m. when seen with Mr. Roalfe-Cox, she was rather
flushed and looked rather tired, but was quite cheerful and
clear headed. The tongue was furred ; it had been dry. No
morphine had been given. The abdomen was slightl}' distended,.
10 LECTURES ON THE ACUTE ABDOMEN
generally tender, not moving well, and the patient was unable
to draw a deep breath. There was tenderness, especially in
the right iliac fossa ; the right rectus muscle in its lower part
was somewhat fixed. On percussion there was dulness in the
right flank, and more resistance than elsewhere, but no definite
swelling. Otherwise the abdomen was normal. The pulse
was 140.
An operation was performed as soon as possible. Free purulent
fluid was found on opening the peritoneal cavity and thick pus
filled the pelvis ; this was very offensive. The appendix was
lying upwards and to the left, and was adherent to the peri-
toneum of the umbilical region. It measured about 3| inches
in length, was fleshy and contained a large concretion ; below
this was a patch of gangrene, and in the mesenteric border of
tbis patch was a perforation. The pelvis was carefully cleaned
with dry aseptic gauze. Some pus was removed from both
flanks. The coils of intestine in the pelvis were covered with
thick lymph which adhered closely, and it was only sponged
away where it was lightly adherent. A gauze plug was inserted
and the pelvis was drained. On the 8th the patient was doing
extremely well. The pulse was 60. There was no pain. The
temperature was normal. The bowels acted after calomel.
The abdomen moved satisfactorily, and was no longer tender.
The plug was removed and the glass tube replaced by a rubber
one. She made a good recovery.
The reason that the medical attendant was not consulted at
the commencement of the illness was that the patient always
suffered much at the commencement of the period, and as this
was due on October 3rd her pain was put down to that. The
period came on at the proper time, but without relief of the pain.
It was then recognised that the period was not responsible, and
tliat the patient had some serious illness.
Here it was the rising pulse on the fourth day of illness more
than anything else that induced us to urge operation on the
relatives. Had there been a definite swelling in the iliac fossa
or pelvis, perhaps one would have felt less certain of the need
for immediate operation, for it would have been probable that
some attempt at localisation was taking place. All the other
symptoms were quite satisfactory.
■
I
THE INFLUENCE OF THE APPENDIX VERMTFORMIS 11
In yet another case, also seen in consultation away from the
hospital, after a definite attack of severe pain, the patient was
apparently quite recovered from the peritonism and felt perfectly
well. Here the verdict in favour of operation was given because
of the excessive rigidity of the lower part of the right rectus
which a dose of morphine had not in any way diminished. The
patient, a man, aged 32 years, was seen with Dr. G. D. Davidson
about ten o'clock in the morning of March 15th, 1905. He had
complained of some stomach-ache on the previous evening and
vomited after a dose of castor oil. He then sent for Dr.
Davidson who, knowing that he had had a mild attack of
appendicitis two years previously, examined him very carefully.
The man had a normal temperature and natural pulse- beat, and
the only thing unusual was tenderness above Poupart's ligament
on the right side. The pain was not very severe, so no medicine
was given to make him sleep, hut he went to bed earlier than
usual and slept until 4 a.m. on the 15th, when he was awakened
by a severe pain in the abdomen. He again sent for Dr. Davidson
who found him suffering severely and gave morphine to relieve
the pain. The pulse was then 70 and the temperature was
normal. At ten o'clock, when we met, the patient had been
sleeping and the pain was completely gone. His expression was
good. The pulse was 80, the respirations were 20, and the
temperature was 98*6° F. The tongue was thickly coated but
moist ; the bowels were confined. The abdomen was rather
rigid generally but not distended. Tenderness was complained
ot on pressure in the right iliac region, but the lower part of th9
right rectus was so very hard and rigid that nothing could be
felt in the iliac fossa. The percussion note in this region was
impaired, but it was difficult to define any dull area.
Immediate operation was advised and performed. There were
some ounces of pus diffused in the iliac fossa and pelvis, with
peritonitis affecting the coils of small intestine in the area exposed,
some of which were covered with lymph. The appendix was large,
measuring 5 J inches in length and about 1^ inches in its greatest
transverse diameter. It was much distended and discoloured,
being gangrenous in places. There was a stricture of the proximal
end and beyond that was the distended portion ; the gangrenous
wall had given way in places — one of these openings was partially
12 LECTUEES ON THE ACUTE ABDOMEN
blocked by a stercorolith. Three other stercoroliths were present
and the whole of the mucous lining was gangrenous. The
appendix was difficult to bring to the surface and could not be
lifted until its attachments had been divided. The peritoneum
was very sensitive ; during the operation pulling on a coil of
small intestine or sponging the peritoneum caused at once a
change in respiration, and it may be that this unusual degree
of sensitiveness was accountable for the paralysis of a part of
the small intestine near, which subsequently developed, causing
subacute obstruction. All inflammatory symptoms ceased after
the operation ; the temperature remained normal, whilst the
abdomen was without distension or pain, and the bowels acted,
but nothing appeared to relieve the patient of his sickness.
A second abdominal incision a week later showed the complete
absence of peritonitis, but disclosed a portion of small intestine
about 12 inches in length near the right iliac fossa, which was
flaccid, and above which the gut was distended. This was
emptied through a puncture which was then closed, but the
patient did not survive may hours.
In this instance, then, the patient suffered from the local effects
of the acute mischief and not from the general results of the
absorption of toxins. Dr. Davidson deserved success, for no one
could have been more prompt in the recognition of the severity
of the case or have treated it with more skill than he showed.
We are told by some surgeons that the removal of the appendix
should be carried out immediately in all cases when signs of an
attack of appendicitis are recognised. This may be called the
counsel of perfection. The public, which has become somewhat
familiar with the disease in its milder aspects during the past
few years, can tell you of so many friends who have recovered
without operation that the suggestion is often scouted as soon as
made. You cannot with a good conscience say that the attack
will not in all probability pass over without risk of life in the
majority of those treated without operation. What I do think
is that your duty as a medical adviser renders it imperative that
you should be so skilled in the recognition of the various aspects
of the disease that you should be able to say definitely when
immediate operation is ''imperative," not only when it is
** advisable." There are quite sufficient proofs in the hands of
THE INTLUENCE OF THE APPENDIX YERMIFORMIS 13
the profession that such excellence can be obtained. My advice
to you is to endeavour to attain it.
There is another thing that should be remembered, and that
is not only the need for operation in these serious cases, but for
early operation. A few hours may make all the difference
between a life saved and a life lost. Do not behave with over-
anxious fussiness that shows your alarm to the friends, if you
conceal it from the patient himself, but see that sufficiently
frequent visits enable you to observe the earliest signs of any
unfavourable change. There are undoubted recoveries on
record from a general acute septic peritonitis, but they are not
so numerous as published 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 these cases.
The occurrence of an acute suppurative peritonitis in a pregnant
woman is a very serious complication and frequently proves
fatal. This subject cannot be adequately discussed here. (I
would refer you to a larger publication on diseases of the
appendix.^) As a rule the only chance for the patient is immediate
operation, or operation within 24 to 36 hours of the onset. I
have not mentioned cases of peritonitis which presented no
prospect of recovery from the time of admission (the too late
type) ; they would not do more than emphasise what I have
endeavoured to impress upon you — the importance of the early
recognition of symptoms, and promptitude in acting upon them
in the conditions on which the " acute abdomen " when due to a
diseased appendix depends. There are other cases in which the
immediate symptoms are extremely urgent, and these are the
examples of sudden rupture of an empyema of the appendix
into the general peritoneal cavity. The following case under
the care of Dr. T. D. Acland is an interesting one in this
regard.
The patient, F. B., a boy, aged 11, was admitted to St. Thomas's
Hospital under the care of Dr. Acland (house physician, Dr.
Perry), on September 29th, 1909. It was stated that the patient
awoke at one o'clock on the day of admission, complaining of
severe general abdominal pain, worse in the right iliac fossa. There
1 Battle & Corner.
14 LECTURES ON THE ACUTE ABDOMEN
was no vomiting ; the bowels had been constipated for 36 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 he had had no
previous illnesses, with the exception of an attack of abdominal
pain four weeks prior to admission, which was unattended by
sickness and localised itself in the right lower abdomen. On
admission he was a thin anaemic boy, with a six hours' history of
abdominal pain. His pulse was 120, regular, of good volume
and tension. His respiration 20 per minute, not laboured ;
temperature 101°. The abdomen was poorly covered, and did
not move very much on respiration. On percussion the liver
dulness was normal; dulness was present in the right flank,
which disappeared with change of position. Tenderness on
palpation was general, but most marked in the right iliac fossa.
At 10.30 a.m. when I saw him the pulse rate was 132, volume
and tension not so good ; temperature 102°, abdominal pain
more acute. There was also more dulness in the right side of
the abdomen with some over the pubes, the amount of free fluid
having increased in quantity. At this time the boy was pale,
looked anxious and pinched. Operation was performed 10 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 sub-
cutaneously 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 by
THE INFLUENCE OF THE APPENDIX VERMIFORMIS 15
1 inch. A good deal of thick, rather offensive pus welled up.
On the night before the temperature was 100*2°, next morn-
ing 99'2°; bowels well opened through the use of sulphate of
magnesia, one teaspoonful having been given hourly until they
acted. The child was very well and enjoyed looking at some
illustrated papers. He had lost all pain. On the 8th there was
still a fair amount of discharge, and a small tube was still kept
in, but the temperature was normal, pulse 86, and he had no
pain. He continued to progress satisfactorily, and left the
hospital October 31st.
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-thirds 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 perfora-
tion communicated, and from which pus was exuding when the
appendix was found. The patient had had an empyema of the
appendix which had ruptured suddenly into the general peri-
toneal cavity and so caused the symptoms of unusual urgency
which have been described. 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.
In the consideration of the acute abdomen and its relationship
to disease of the aj^pendix there is another way in which a most
serious condition may arise, and that is through the bursting of
an appendix ab3ess into the peritoneal cavity. This is a most
formidable complication to control and until a few months ago
it was in the experience of most, invariably a fatal one. As you
are aware, in cases of 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 sj^read
of the pus and involvment of more of the peritoneum. This
appears to take place slowly and is not accompanied by the
definite signs which we have spoken of as peritonism. A
very different clinical picture is presented by the patient in whom
16 LECTURES OX THE ACUTE ABDOMEN
an abscess containing a large amount of pus has suddenly burst,
distributing its septic contents throughout the abdomen.
Examples of this complication of appendix abscess have been
under treatment during the past few months ; they are very
instructive, and the result gives hope for the future. Several
such cases have been under my care since July, 1904.
A patient, aged 19, a ward maid at a fever hospital, was
admitted into St. Thomas's Hospital under the care of Dr. Hector
Mackenzie on November 3rd, 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
15 hours before she came into hospital, when a sudden acute pain
attacked her and she was again obliged to go to bed. There had
been diarrhoea for two or three days. "When I saw her with
Dr. 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. Respira-
tion was 32, pulse 100, and temperature 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, especially
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. The respiration was thoracic and shallow, the
tongue furred and dirty. 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 was admitted under the
care of Dr. Mackenzie on the day following the admission of the
I
THE INFLUENCE OF THE APPENDIX VERMIFORMIS 17
patient whose case I have just recorded. The patient had had
an attack of pain in the abdomen on October 31st, chiefly on the
right side, but did not give up his work. During the night of
November 3rd 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° F. There
was no vomiting, the bowels were 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 dulness was obscured. The
abdominal muscles were rigid, this rigidity being most marked
on tlie 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 closed by December 17th, 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.
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
A. A. c
18 LECTUBES ON THE ACUTE ABDOMEN
following account is accurate of a type of which I have seen more
than one fatal example. On September lOfch, 1909, 1 saw a man,
aged 73, with Mr. Eoalfe-Cox. During the night of Tuesday, 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 Mr. Eoalfe-Cox, who found him with a
temperature of 100° and symptoms of a mild attack of appendi-
citis. 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 the fact that they
kept him in bed. The only symptoms of anything wrong were
a very dry tongue and some sharp, indefinite, superficial tender-
ness 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 formed 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.
I
I
II
THE TEEATMENT OF ACUTE APPENDICITIS
WITH PERITONITIS
The treatment of appendicitis, with infection of the surrounding
peritoneum, whether this be still localised or more generally
diffused, must be carried out on definite principles, so that no
time is lost before the source of the evil is removed.
Most surgeons still prefer the use of a general anaesthetic ;
my own practice is to give gas, followed by ether in early cases,
where there is no evidence of respiratory complications, leaving
it to the anaesthetist to substitute chloroform if he thinks fit
during the progress of the operation. The open method of
administering ether has proved very satisfactory, even in quite
young children.
In America the practice of giving gas and oxygen is in much
favour, whilst in the Children's Hospital, Great Ormond Street
intraspinal injection has been tried and approved.
The incision to be employed for opening the abdomen will vary
somewhat with the nature of the case ; occasionally, when the
diagnosis is uncertain and where pelvic disease cannot be excluded,
a median section may be necessary.
In most instances, in thin adults and children, an incision,
through the sheath of the right rectus, and a separation of the
muscular fibres of the latter, is the best ; in stout patients, with
thick fat abdominal walls, especially if rapid operation is called
for (and it usually is), or if the surgeon is short-handed, the
incision is better made through the linea semilunaris. I think
that this incision is more likely to lead to a subsequent hernial
protrusion, 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,
who knows exactly what to do and what not to do, will obtain a
c2
20 LECTUEES ON THE ACUTE ABDOMEN
higher percentage of successes than a man who begins by making
an inadequate incision through which he cannot manipulate and
examine the parts without pulling and pushing with some degree
of force, and considerably bruising the wound. All handling of
abdominal organs should be quiet but firm, and inflamed gut in
the region of the appendix should be dealt with very gently.
Let the incision be made from the first sufficiently large to
admit the operator's hand ; an opening smaller than this has
so often to be enlarged, on account of the difficult position of
the appendix, or its firm adhesion to parts around.
Mr. C. P. Childe has written a most 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 recom-
mends in cases where the abdominal condition is obscure is one
which is placed midway between these lines. This would, how-
ever, 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 abdominal cases, and I have
no doubt of its advantages in many cases ; but there must be a
clear understanding of the line which will lead to its margin, if
the operator wishes to take that. The conditions which most fre-
quently produce the acute abdomen vary somewhat at different ages;
but taking an average of a large number of patients, a diagram
may be shown which expresses fairly well these positions and the
frequency of their occurrence by means of shading (see Fig. 1).
In Fitz's table of acute intestinal obstructions no less than
67 per cent, had their origin in the right iliac fossa.
When the peritoneum is opened, pus, usually of an offensive
1 The Area of "Acute Abdominal Conflux" and the ' Incision of Incidence,"
Laneet,^ld07, Vol. I., pp. 936.
lATMENT OF ACUTE APPENDICITIS WITH PERITONITIS 21
odour, will at once escape in varying amount, but it is not
necessary to wait until this flow has ceased before proceeding
with the operation. Let the end of a strip of sterilised gauze,
4 inches wide, be put down into the pelvis and the bowel pushed
aside with other strips of similar material, arranged so that
they shall protect the edges of the wound. One of these plugs
should be passed into the right loin to the outer side of the
c?ecum. Search should then be made for the appendix, which
must be removed. When found it is wrapped in gauze, to pre-
vent the diffusion of more septic material. As a rule, if more
than 36 hours have elapsed since the beginning of the attack,
it is necessary to remove the appendix by the "coat sleeve"
method, and it is well to bury the stump securely in the caecum
with more than one row of sutures.
After removal of the appendix, the plugs, which are now
saturated, should be taken away, and the infected parts cleansed
with gauze. This should not be done with any roughness, for
the injury to the peritoneum, resulting from too vigorous
handling, may cause the subsequent formation of adhesions.
No harm results from gentle lavage of the region involved
with warm saline solution, but the fluid should not be used
too freely, as there is undoubtedly a danger of disturbing
defensive exudation and of disseminating septic material into
areas as yet uninfected. In the case of females the pelvic
organs should be examined at this stage.
Having seen, in the earlier days of the operative treatment of
these cases, the evils which may follow from the lack of provision
for drainage, I have no hesitation in recommending it, in all
instances where any free pus has been found in the peritoneal
cavity. It is true that in exceptional cases satisfactory results
may be obtained after the wound has been closed without
drainage, but the average of success will be higher if it is pro-
vided for. It has been my custom to place two rubber tubes in
the wound, one extending into the pelvis and the other into the
right loin, and to bring them out at the lower end of the incision.
The practice of introducing multiple tubes through separate
openings is unnecessary. There is much to be said, however,
for the insertion of the loin tube through a separate opening
above the right iliac crest in cases where extensive infection on
22 LECTUEES ON THE ACUTE ABDOMEN
the outer side of the ascending colon has been found. An open-
ing of the size required will not be followed by a hernia, and the
duration of the after treatment is possibly shortened. In the
earlier stage of peritonitis, due to disease of the appendix, it is
advisable to close the abdominal wound in layers, leaving room
merely for the passage of the drainage tubes, but in the late
stages, when the condition is serious, it may be advisable to only
put in a few strong interrupted fishgut sutures, penetrating all
the layers of the abdominal wall. In still more rare instances,
"when the state of the patient is very bad, the best course may
be to leave the wound unsutured, packed with sterilised gauze,
and secured with a firm bandage. The accurate closure of the
wound can be undertaken after the patient has rallied from his
collapse.
The tubes should be removed in two or three days, but if
the discharge at this period is still profuse, or the temperature
high, they must remain in place for a longer period.
I have described the routine treatment which is required in
an average straightforward instance. If this plan is carried out
with reasonable despatch, recovery may confidently be expected
in the majority of cases which are subjected to operation. It
must not, however, be thought that all cases of spreading
peritonitis are cast in one mould, and that the surgeon's
task is an easy one in every example of 12 to 72 hours'
duration. They differ one from the other very considerably, and
each requires to be studied most carefully by itself. In one
instance the amount of systemic disturbance is so slight that
the patient lies comfortably in bed, without premonition of his
danger ; in another of similar or even shorter duration the vital
depression is so severe that operation is only possible after intra-
venous infusion of sterilised saline has been given. This it may
sometimes be necessary to continue during the performance of
the operation, for rectal or subcutaneous infusions in such cases
are too slow in their action to be of value. Liquor strychninae
and caffein may be useful, though their action is but transient.
When the depression is part of the primary peritonism, some
recovery from it may be expected after a w^ait of a few hours ;
but if the collapse is secondary to a general toxaemia, marking
the onset of the final stage, it is wrong to wait. Every moment
TREATMENT OF ACUTE APPENDICITIS WITH PERITONITIS 23
increases the amount of poison absorbed, and diminishes the
chances of recovery. Occasionally it may be possible only to
make an incision into the peritoneum, to give exit to the pus,
and so endeavour to localise the spread of the purulent effusion,
a drainage tube being inserted to drain off the remainder of the
fluid gradually. Combined with the free rectal exhibition of
saline, this may be successful without immediate removal of the
appendix; but without proctoclysis, the incision and drainage
Fig. 3. — Ord's apparatus for keeping patient up in bed.
t
^B alone is not likely to succeed at the present time any more than
^B it did twenty-five years ago in similar cases.
^H So much for the operative considerations in this condition.
^B It must not, however, be forgotten that the ultimate course of
^H the case is greatly influenced by the details of the after
^H treatment.
^B It is now customary to place the patient in bed in a sitting
^B attitude — "the Fowler position." 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 maintenance of the position may be
facilitated by the fixation of a padded block or stretcher across
the bed, just below the level of the buttocks. It is kept in place
by straps passing to the head of the bed on each side. In any
case in which the patient's condition is not good at the comple-
tion of the operation, a pint of warm saline, containing an ounce
24
LECTURES ON THE ACUTE ABDOMEN
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 is introduced into the rectum, the end
of this is attached by means of rubber tubing to a reservoir
containing the fluid, kept at a temperature of 105° F. The flow
ElG. 4. — Apparatus used for the continuous administration of fluids
per rectum.
is controlled by a screw-clamp on the tube. The vessel should
be about 1 foot above the level of the rectum.
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 estab-
lished. If this method proves impracticable, subcutaneous
infusion must be employed, and may 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."
TEEATMENT OF ACUTE APPENDICITIS WITH PERITONITIS 25
It is not usually advisable to give anything by the mouth in
the first six hours after operation ; the absorption of saline into
the circulation relieves the sensation of thirst and increases the
dilution and rapidity of excretion of toxic products. On 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 appears to very 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 24 hours for two or three days.
Joint pains and fleeting rashes not infrequently follow this
administration. It is probably given too late in most cases.
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
paralysing action on the bowel the dose should not be repeated.
After every operation some vomiting is to be expected, and for
the first 24 to 36 hours no definite treatment 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 aV'g^'- doses of
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 carbonate 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 or secondary intestinal obstruction
is present.
An attempt to obtain an action of the bowels should be made
on the second day following the operation. I usually give a 8 to 5-gr.
■26 LECTUEES ON THE ACUTE ABDOMEN
dose of calomel, followed after four hours by 5! doses of
magnesium sulphate or other saline purgative at hour intervals till
an effect is obtained ; in obstinate cases I have found a -^^ gr. of
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 many cases. Indi-
cating as it does a paralysis of the muscular coats of the intestine,
its persistence will always give cause for anxiety ; a turpentine
■enema (^i — ^ij turpentine in 5X of acacia emulsion) or the
action of one of the above-mentioned purgatives may relieve
the condition. If these fail, and the passage of a long rubber
xectal tube proves equally ineffective, three or four subcutaneous
injections of eserine salicylate (j-Jo 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 intestinal stasis, when the
necessity of a second operation must be considered. If the
•obstruction is caused by an intense local peritonitis little can be
done by such interference ; in cases where it is due to mechanical
kinking or strangulation of the bowel operation may 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 1 in 80 carbolic is to be preferred.
Any local tension must at once be relieved by the removal of
skin sutures. Cellulitis or sloughing of the abdominal wall may
require more radical measures such as incisions and the frequent
application 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 faecal fistula may develop in the wound, from
the second or third day to the eighth ; they may be due to a giving
of the sutures in the caecum at the point of removal of the
appendix or to the sloughing of part of the bowel wall in a part
of the intestine involved in the inflammation. They tend to
spontaneous healing in practically all cases ; the diet in these
I
TEEATMENT OF ACUTE APPENDICITIS WITH PERITONITIS 27
circumstances should be readily digestible or such as to leave
little debris ; violent purging should be avoided, the dressings
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 very 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 distension
of the abdomen. Washing out of the stomach with the adminis-
tration of turpentine enemata may prove very useful. Should
turpentine fail, the administration per rectum of a pint of
molasses or common treacle will not infrequently cause an
action of the bowels and a rapid general improvement.
A serious amount of cardiac weakness leading to rapid pulse,
breathlessness, and dropsy of the legs, may develop during
convalescence ; it requires energetic treatment with cardiac
stimulants, diet, etc., over a period which may be prolonged and
demands much patience, even when the wound (usually in an
adult) has done well.
Ill
PATHOLOGICAL PEEFORATIONS OF THE DIGESTIVE
TRACT
Perforation of Ulcer of the Stomach
In considering the perforations of ulcers of the digestive tract
that give rise to the " acute abdomen," it is not proposed 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 ulcerations of the stomach or bowel into the general
peritoneal cavity. It is not my
intention to enter closely into the
cause of these ulcerations ; this is
fully discussed elsewhere, and is
beside the present question.
Gastric Ulcers. — In the autumn
of 1894 Mr. A. Pearce Gould
opened a discussion at the annual
meeting of the British Medical
Association at Bristol, on the sur-
gical treatment of simple ulcer
of the stomach, duodenum, and
typhoid ulceration of the ileum and
colon.^ The influence of this debate in Great Britain did a great
deal to encourage this branch of surgery and clearly defined the
steps of the operation which are essential when any of these
ulcers have perforated. There is no doubt the profession has
been much indebted to Mr. Gould for the able manner in which
he brought forward this subject, for it did much to encourage
operative treatment as a matter of routine. At that time the
introducer of the discussion only knew of seven cases of successful
operation for the perforation of a gastric ulcer. At the present time
1 British Medical Journal 1894, Vol. II., p. 862.
Fig. 5. — Acute perforation of a
gastric ulcer, a. (St. Thomas's
Hospital Museum.)
PATHOLOGICAL PEEFOEATIONS OF THE DIGESTIVE TEACT 29
the diagnosis and main principles of treatment are so well under-
stood that no surprise is expressed when recovery follows
operation. Success is usual, and depends more on the individual
patient and the time which has elapsed since the perforation took
place than on anything else.
In the volume of the St. Thomas's Hospital Keports for 1904
will be found a paper by Mr. Percy Sargent on pathological
perforation of the stomach and duodenum, founded on 124 cases
which had been treated in St. Thomas's Hospital. The series
Fig. 6. — Stomacli perforations. Most common position,
includes seven cases in which perforation complicated carcino-
matous ulcer, 20 in which the peritonitis was localised to the
neighbourhood of a chronic gastric ulcer, and two in which this
limited inflammation complicated chronic duodenal ulcer. This
leaves us with 74 perforations of gastric ulcer (four of them
acute), and 21 perforations of duodenal ulcer (three of which
were acute) in which there was more or less diffuse peritonitis.
He reminds us that 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. Altogether 49 cases had been submitted to operation,
the ulcer being treated by suture, and the peritoneum washed
out. 581 per cent, of them recovered. The average time in the
30 LECTURES ON THE ACUTE ABDOMEN
successful cases that had elapsed between perforation and
operation was 23 hours ; in the fatal cases 32'6 hours.
I am permitted by Mr. Sargent to reproduce an illustration
which shows very clearly the position of the ulcer in 77 examples
of perforation, and you will notice how much more frequent the
perforations are on the anterior than on the posterior surface.
His series thus confirms the recognised fact as to the greater
frequency of perforations on the anterior surface, these being
anterior 66, represented by black dots; posterior 11, represented
by circles.
The results of operation in the second half of the period which
he has selected are better than in the first. Cases are recognised
and sent into hospital earlier, and operation is more quickly and
surely performed.
For the first five months of this year, 1910, the numbers of
perforated gastric ulcers at St. Thomas's Hospital were 9, — B
male, 6 female, with 8 recoveries. In all the anterior surface
was affected. The average interval in the cases which recovered
between the perforation and time of operation was 12-47 hours.
In these cases the symptoms, which are grouped under the
word *' peritonism," are usually very marked, the pain causing signs
of distress which are unmistakable. There is considerable varia-
tion 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 dies in a few hours without response to medical
treatment. In the autumn of 1905 a girl was admitted to the
care of Dr. H. Mackenzie with a history of sudden seizure of pain
in the region of the stomach so severe that she screamed out and
had to be carried home from the tram out of which she had just
alighted. When seen at the hospital about an hour later the
diagnosis of gastric perforation was confirmed, but the state of
shock was so profound that all means to combat this, including
saline infusion into the veins, were without success, 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 perforation, about the size of a penny,
in the anterior wall of the stomach, near the pylorus. A curious
fact noted by Dr. Harwood-Yarred was the presence of extensive
gaseous emphysema of the body a few hours after death.
PATHOLOGICAL PEEFORATIONS OF THE DIGESTIVE TEACT 3t
As a rule the patient rallies from the shock and other symptoms
develop which resemble those met with in perforations of other
parts of the digestive tract. In gastric and duodenal cases
perhaps more than in others the previous history is of import-
ance, especially if morphia has been given to relieve the pain.
There is no drug which has a power like that of morphia to mask
symptoms, and many a case has been lost owing to the injudicious
administration of the drug in an attempt to relieve the pain at
all costs. It is not wrong to give this drug 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 after the perforation,
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 amount of fluid to be found free in the peritoneum.
At the operation onl}^ a few hours after a perforation has taken
place one has been surprised to find the flanks and pelvis quite full
of a thin greenish fluid, acid and sour-smelling. This statement
applies to cases in which the stomach was comparatively empty
at the time as well as to those in which the perforation followed
a large meal. Much of it is doubtless of a protective character
thrown out from the surface of the bowels and omentum in
response to the irritation of the acid contents of the stomach..
In this respect it resembles very closely the condition which
obtains soon after a sudden rupture of the w^all of an appendix
abscess, or an empyema of the appendix, and the escape of the
pus into 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 in which 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 accident,
should give a strong leaning towards the stomach as the site of
the mischief causing the symi^toms. A tympanitic note over the
liver region in an abdomen which is not distended is a very
32 LECTURES ON THE ACUTE ABDOMEN
important proof of intestinal perforation, and is commonly
observed in gastric perforations soon after the sudden onset of
pain. Its absence must not, however, be regarded as a reason
for postponing operation in a case otherwise calling for it. It was
not present in the following instance of severe perforation, in
which the accident occurred although the patient was under
exceptionally advantageous conditions, the stomach having had
rest for two days.
J. M., a groom, aged 48, was admitted under the care of Dr.
Hector Mackenzie on September 30th, 1904, with symptoms of
gastric ulcer. (From notes by Mr. Birks, house surgeon, and
Mr. A. J. Cooke, dresser.)
The history of the case was that he had been often sick in
1902 and 1903. Vomiting occurred about half a 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
epigastric 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.
In the next few days he complained at times of severe local
pain, and hot fomentations were required for his relief. Vomiting
also occurred at intervals. On October 22nd, 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. Hector Mackenzie 12 hours later he was
evidently suffering acutely. Lying on his back with head and
shoulders raised, he looked pale, agitated, and intensely anxious,
whilst his face and forehead were covered with sweat. His respira-
tions were hurried, painful, shallow and irregular, the pulse rapid
and he complained much of jpain in the abdomen ; he was unable
to take a deep breath on account of the pain, and on examina-
tion 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,
I
PATHOLOGICAL PERFOEATIONS OF THE DIGESTIVE TRACT 33
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 diagnosis of perforation of ulcer in
that situation made by Dr. Hector 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 opening
of this ulcer was closed with interrupted sutures. The peri-
toneal cavity ai)peared 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 whole abdomen thoroughly irrigated 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. Eecovery was slow, but satisfactory, and he left on
December 7th, 1904, for his home in Devonshire. From recent
accounts it is probable that he is now suffering from pyloric
obstruction and dilated stomach; indeed it would be very strange
if he escaped this complication, for the induration surrounding
the ulcer compelled the infolding of an unusual amount of stomach
wall.
In the diagnosis of gastric perforations, I do not think that
sufficient attention has been paid to the valuable information to
be obtained by percussion. In nearly every case the amount of
free fluid present is considerable, 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 diagnosis made. The
presence of this excess of fluid helps us to place out of court such
conditions as pneumonia, diaphragmatic pleurisy, thrombosis of
A. A. D
34 LECTUEES ON THE ACUTE ABDOMEN
the superior mesenteric vein, various kinds of poisoning, and
acute dilatation of the stomach. There are mainly four states
of the acute abdomen in which we get an excess of fluid : per-
forated gastric ulcer (or duodenal ulcer), rupture of an appendix
abscess, rupture of extra-uterine foetation, and ruptured pyosal-
pinx. As a rare occurrence it is seen in a ruptured empyema of
the appendix. A case in which there is reason to suspect gastric
perforation should be carefully examined for the signs of free
fluid, not only at the time when first seen, but every hour after-
wards, for there are few emergencies that better repay prompt
surgical attention. And the fluid collects quite early.
In all, the ideal operation is one which includes closure of the
perforation by means of suture ; but occasionally it is not possible
to apply sutures, for you may not be able to reach the opening,
or the thickening may be so great that you cannot infold the
stomach wall. Under these circumstances a piece of omentum
may be sutured over the hole, a drainage-tube may be passed
into the opening and secured by a stitch, gauze being used to
pack it off ; or a cigarette drain may be passed to the position of the
ulcer and removed in from 36 to 48 hours. A gastro-enterostomy
may be performed under these circumstances by either the
anterior or posterior methods, if the condition of the patient
admits of it. As a rule the additional operation of gastro-enter-
ostomy should not be performed if the ulcer can be sutured. I
have known the extra strain on the resources of the patient
prove more than could be borne. Before closing the incisions
after flushing carefully, examine for a possible second perforation.
In some instances the patient may be too bad, and he must take
the risk ; you would remove his last chance by searching the
posterior surface of the stomach after an operation in the late
stage. In one case under my care I expressed a desire to examine
the posterior surface of the stomach, but could not do so, although
I thought it possible he had a second ulcer there, for the collapse
w^as so intense it seemed hardly possible to get the man off the
table alive, and, indeed, he died soon afterwards. A large perfora-
tion existed in the posterior surface, in addition to the one which
had been sutured in front of the stomach.
If no ulcer is found on the anterior surface of the stomach
(and any accumulation of lymph may hide a small perforation),.
I
I
I
PATHOLOGICAL PERFORATIONS OF THE DIGESTIVE TRACT 35
the duodenum should be examined. In 10 per cent, of the cases
collected by Paterson, the ulcer was on the posterior wall.
Access to this should be gained by tearing through the lesser
omentum and inverting the anterior wall, after which sutures
can be applied.
The epigastric wound should be closed by suture in the usual
manner, and a drain placed in the pelvis through the lower
incision, as part of the usual routine.
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. Osier ^ says they may be
distinguished by the following definite characters : " (a) Sudden
intestinal haemorrhage in an api3arently healthy person, w^hich
tends to recur and produce a profound anaemia. Haemorrhage
from the stomach may precede or accompany the melaena.
(h) 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." Unfortu-
nately, in many cases, there is no history of local pain preceding
the acute attack.
From the surgeon's point of view they are especially interesting,
because it is frequently very difficult to distinguish perforations
of these ulcers from acute disease of the appendix with peritonitis,
especially if the appendix is situated io the outer side of the
caecum, or has never attained its proper position in the iliac
region. It must be remembered that occasionally the perforation
may be accompanied by an appendicitis.
When the perforation is that of an ulcer of the stomach, the
symptoms are those of a general peritoneal invasion ; when the
perforation is in the duodenum, the escaping fluid flows down
the right side, by the side of the colon, into the pelvis. In these
cases, therefore, the resemblance of the attack to one of acute
perforative appendicitis is very close, and a mistake has been
^ " Principles and Practice of Medicine," p. 400.
d2
36 LECTURES ON THE ACUTE ABDOMEN
made by the most experienced. 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, to examine
the duodenum in its first part, when the apparent 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
siu'face) or other parts of the digestive tract.
In the following case diagnosis was easy, for not only was there
a clear history of pain, but the amount of fluid was large : —
A cabman, aged 39, was admitted to the care of Dr. Mackenzie,
in St. Thomas's Hospital, on June 13th, 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 12th he had taken a glass of beer, the
drinking of which w^as followed immediately by violent pain in
the abdomen. This was worse over the pubes. He vomited
1^ hours afterwards and was in great pain all night, and he 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 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. Or
June 29th, a subdiaphragmatic abscess was opened, after resection
of part of a rib. He left hospital on July 31st.
1 Lajicet, 1901, Vol. II., p. 1658.
I
PATHOLOGICAL PERFORATIONS OF THE DIGESTIVE TRACT 37
Perforations of Gastro-Jejunal and Jejunal Ulcers
The knowledge that an ulceration of the jejunum is one of the
forms of disease of the small intestine, 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 jDerforated 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
post-mortem examination. 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-enterostomy had been performed for the relief of some
form of gastric ulceration, or the result of it. From a clinical
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 perfora-
tion into the peritoneum, if it does perforate ; in the latter no
warning is given, but if the patient has previously had a perfora-
tion 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 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 ulcers (to be mentioned
later) in two cases of perforation of the ileum during the course
of typhoid fever, in which operation was (successfully) performed
at the request of Dr. Hector Mackenzie ; '^ the naked eye appear-
ances were quite similar. Some of them 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 54
cases 12 followed posterior gastro-jejunostomy, 1 the supracolic
. 1 Lancet, 19U3, Vol. II., p. 8G8.
38 LECTURES ON THE ACUTE ABDOMEN
operation, 2 the " en-y " operation of Koux, 11 the anterior
operation, combined with entero-anastomosis, and no less than
28 followed anterior gastro-jejunostomy alone.
The most startling complication of jejunal ulcer is acute
perforation when the patient is apparently quite well in health,
and in this, as in its other complications, it resembles the
common simple ulcers 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^ ; May lard, 2^ ; Battle, 4). This improved record of
results for perforation 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 a faecal fistula, but it may be
necessary to operate for the local ulceration, 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 careful synopsis of cases given by Mr. Paterson^ in
his paper on jejunal and gastro-jejunal ulcer, is most useful and
full of interest to all engaged in the practice of abdominal surgery.
By a perusal of the short histories of these cases it is possible to
get some idea of the extensive treatment occasionally required,
but this is outside our present consideration, as are many
questions, which are considered in that paper.
The cases which have been under my treatment are as
follows : —
Case I. — J. F. L., a clerk, aged 30, was admitted to City Ward,
St. Thomas's Hospital, July 15th, 1904, for acute abdominal
distress. (Mr. T. Guthrie was house surgeon and Mr. Eobson
dresser of the case.) He stated that about four hours before
admission he had been seized with violent pain in the abdomen,
vomiting and hiccough.
^ "Kongress bericht," 1902, p. 10.
2 Revue de Chlrurgle, 1906, p. 30.
3 Lancet, 1910, Vol. 1.
* 'Transactions R. Soc. Med., June, 1909.
I
I
PATHOLOGICAL PERFOEATIONS OF THE DIGESTIVE TRACT 39
On admission the abdomen was moderately distended and did
not move on respiration. A rounded prominence was visible in
the epigastrium, and immediately below this another and smaller
prominence, the latter being situated immediately above the
umbilicus. Distension was most marked in the epigastric and
umbilical 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 entirely obliterated,
the note over the region of the liver being decidedly tympanitic.
The general condition of the patient was good. Temperature 98°.
Pulse 100. Kespirations 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 ago he underwent an
operation in Queen's Hospital, Birmingham, for pyloric obstruc-
tion after gastric ulcer. Anterior gastro-enterostomy was per-
formed, a ^lurphy's button being used to approximate the parts.
His progress after this operation was uninterruptedly good until
March 4th, 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 symptoms, an incision was made to the
left of the middle line above the umbilicus through the rectus
sheath, the muscle being temporarily displaced outwards. There
was a rush of gas when the peritoneum was opened and a greatly
distended coil of bowel presented below the wound; this was
punctured 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
40 LECTURES ON THE ACUTE ABDOMEN
defined, and a small, round, perforating ulcer, about a sixth of
an 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's sutures. The
coils of jejunum in the immediate neighbourhood of the perfora-
tion were greatly distended, thickened, 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 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 operation 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 magnesia (two teaspoonfuls) was given every
four hours. The abdomen was very slightly distended and not
very tender, it moved to some extent with respiration, though
not freely. Pulse 104. Eespirations 20.
The bowels acted again 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 little discharge.
Two days later this was removed altogether. He left the hospital
on August 8th, having completely recovered.
The second case was a very interesting one, being almost
unique from the course of the various conditions for which opera-
tion was required.
K. F. C, aged 37, an unmarried woman, was sent to the
hospital by Dr. J. Scott Battams, and admitted under the care
of Dr. Hector Mackenzie, on March 25th, 1903, with symptoms
of perforated gastric ulcer, which had commenced 4J hours
before. (Mr. Vaughan was house surgeon and Mr. Thompson
dresser.) Operation was performed by me at 11.15 p.m., and an
PATHOLOGICAL PERFOEATIONS OF THE DIGESTIVE TRACT 41
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 narrowing of the pylorus. She left hospital on May 12th 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 strictured. The operation was on the 8th, and she left
hospital on the 28th April.
She appears to have done very well afterwards and regarded
herself as cured, until May 5th, 1905, when she was again sent to
the hospital by Dr. 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 slight 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 left
of the umbilicus. There 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
described, but the distension of the small intestine in the
umbilical region was greater, and there was visible peristalsis.
Operation was performed 23 hours after the first onset of pain,
the abdomen being opened through the left rectus sheath about
an inch from the middle line. 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,
oedematous and distended, there being lymph on the surfaces
near the perforation. A knife was introduced through the ulcer
42 LECTUEES ON THE ACUTE ABDOMEN
and a cut made upwards, so that the line 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 openings.
The continuous silk suture, which had been employed to unite
all the coats of the stomach and intestine, was felt lying partly
detached, and removed. It was apparently unaffected by the
action of the gastric juice. After the distended coils had been
emptied, the incision was closed with Lembert silk sutures, and
the intestine washed with sterilised saline. A second incision
was now made in the middle line 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 w-as well cleansed with
sterilised saline, and both wounds were then sutured — without
drainage. Shock was counteracted by the administration of
half a pint of saline per rectum every two hours.
She soon rallied and complained of no pain. Progress was
satisfactory until the 11th, when she vomited once. She vomited
several times on the 16th, and again on the 17th, and on this date
the pulse was quick and feeble. Her temperature was, however,
normal and the abdomen moved well, and was not distended.
Eectal feeding and washing out of the stomach sufficed, and no
vomiting occurred after May 20th, when she was allow^ed to take
milk in small amounts. On June 1st she was taking ordinary
•diet. She left on June 2nd.
She came again for operation^ in 1906 on account of symptoms
which she herself diagnosed as due to "perforation." She had
not been feeling very well for a fortnight, but there had been
nothing very definite. There was, however, some pain in the
abdomen on March 12th which she could not localise. 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 slightly
sunken, but not at all anxious-looking. Her pulse was 85 and
temperature 100*6° F. The abdomen was moving fairly on respira-
tion. 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
1 Clin. Soc. Trans , Vol. XL., p. 250.
PATHOLOGICAL PERFORATIONS OF THE DIGESTIVE TRACT 43
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
liver 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 especially evident on the line of
junction of the stomach and small intestine ; one of them, of
rounded shape, covered the ulcer, vvhich had perforated, and the
probe passed directly through it into the gut. It was about
J 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 sutures of silk. 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 12th. 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 hernia.
The fourth was under my observation last autumn in private.
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 26th, 1910.
That morning about half-past eight, 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
something like those which he had experienced at the time of per-
foration 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
etrongly did Dr. Currie feel that some perforation had taken
44 LECTUEES ON THE ACUTE ABDOMEN
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, 3 hours after the commencement of symptoms,
a dull area was evidently spreading from this spot, and from the
great tenderness which existed down the left side of the abdomen
and the rigidity of the left rectus, it was considered that fluid
was gradually escaping and 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 the patient had undergone
the two operations mentioned. Operation in this case was per-
formed at one 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 cleansed, some fluid mopped from the pelvis and the
wound closed without drainage. The patient made a good
recovery. Tlie 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
I
PATHOLOGICAL PERFOBATIONS OF THE DIGESTIVE TRACT 45
and, in one instance, peristalsis of the bowel near the per-
foration.
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 advisability of closing
the incisions depends entirely on the state of the peritoneum.
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 w^ould appear, because it is very
probable that the anterior operation has been performed far
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 ones before the
profession. Since the account of it was published, I have
invariably performed it in cases requiring gastro-jejunostomy,
if the state of parts involved permitted.
Perfoeations of the Small Intestine met with during the
COURSE of an attack OF Typhoid Fever
This group differs from the others which we have been con-
sidering 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 of all cases of typhoid fever
die from this complication ; and further that 69*6 per cent, of
them occur during the second, third, or fourth weeks of the
1 Laiicef, 1903, Vol. II., p. 863.
46
LECTUEES ON THE ACUTE ABDOMEN
illness. His lecture is so very interesting and instructive that
you cannot do better than read it for yourselves.
Dr. E. W. GoodalP 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.
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 Dr. Osler'^
in cases of typhoid be
enforced, the 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 prepara-
tion should be made for
there is any sudden change
Pig. 7. — Perforation of typhoid ulcer, A.
Other ulcers are shown, b. (St. Thomas's
Hospital Museum.)
operation at the earliest moment if
in the abdominal symptoms.
Then again the contents of the ileum in this disease are
frequently scanty, and the perforation may not admit of the
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.
I give the notes of two cases of this type in which operation
led to recovery.
In November, 1904, a man, aged 30, was under treatment for
suppurative periostitis of the femur, and when the pus was
evacuated a bacteriological investigation showed the presence of
many typhoid bacilli in it. When he left the hospital the wound
had closed. (This account is from the notes by the house
physician. Dr. Crompton, and the dresser, Mr. Pinches.) The
1 Lancet, 1904, Vol. IT., p. 9.
2 Philadelphia Medical Journal, 1901, Jan. 19. See also Mackenzie, loc. cit.
PATHOLOGICAL PEEFOEATIONS OF THE DIGESTIVE TEACT 47
history of this patient was briefly as follows : At the request of
Dr. Mackenzie operation was performed on July 11th, 1902,
5J hours after the commencement of symptoms indicating per-
foration. There had been sudden pain in the umbilical and
right iliac regions, soon followed by vomiting. There were
before operation the following local signs : resistance and tender-
ness in the umbilical and right iliac regions, with deficiency in
movement of the lower abdomen. The liver dulness was normal
and there was no evidence of free fluid. The pulse was 104 and
the temperature 101°. The amount of shock was slight. An
incision below the umbilicus showed a round clean-edged per-
foration, about J inch in diameter, some yellowish feculent
fluid around the perforation, and a small amount of lymph.
He made a satisfactory recovery from the effects of the per-
foration, but returned later for pain in the thigh which subsided
under appropriate treatment. He was able to return to his work
as a coal-heaver in the following year, and continued to do it
until the attack of periostitis to which I have alluded.
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, 1906, the pus contained typhoid bacilli
on bacteriological examination. It is sad to relate that his wife,,
who dressed his wound for him, caught typhoid about August and
died soon after admission to the hospital as a result of the
severity of the attack.
The other patient was also under the care of Dr. H. Mackenzie,
and symptoms of perforation had been noted 12 hours before
operation on December 4th, 1901. (From notes by Dr. Lack,
house physician, and the dresser, Mr. Chauncey.) He was a
man, aged 22, and the complication developed during a relaj)se.
At the time of operation there were pain, distension, shifting
dulness, indicating fluid in the flanks, extreme tenderness in
the right iliac fossa, and a complete absence of dulness in the
liver region. The pulse was 94, respirations 26, and tempera-
ture 102*4°. This temperature fell rapidly to 97° after operation,,
but soon rose again.
Incision below the umbilicus showed a similar condition to-
that in the previous case, yellowish fluid, a coil of ileum, to which
a tag of omentum was adherent, and when this was lifted up a.
48 LECTUEES ON THE ACUTE ABDOMEN
sharply -cut circular ulcer, measuring about one-eighth inch
across, was seen below it.
Suture of the ulcer and cleansing of the peritoneum sufficed
to prevent further local mischief, and the patient recovered.
In both instances the ulcers were of a punched out character,
and did not suggest that they resulted from the s^Dread of the
necrotic process in the site of an ordinary typhoid ulcer.
The amount of shock was not severe in either patient. 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 10 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 straightforward. Patients suffering from
this disease frequently complain of abdominal pain. This has
occasionally been so severe that an exploratory operation has
been performed, but without any lesion being found to account
for the symptom.
The signs upon which chief rehance should be i^laced in
making a diagnosis are pain and tenderness with rigidity, and
fixation of the abdominal muscles, and disappearance of the liver
dulness. In one of these cases the latter sign was not evident
5 1 hours after the perforation had occurred.
A sudden drop in the temperature, in the absence of hemorr-
hage, is suspicious, but there may be no change in this respect
for some time.
Earely peritonitis has been found without evidence of perfora-
tion, whilst in some instances this condition has evidently
preceded the symptoms, for which operation has been under-
taken.
I do not think that 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. There
should not be any amongst physicians. The fact that exj^loration
has not revealed a perforation in every instance in which the
i
I
'PATHOLOGICAL PEEFOKATIONS OF THE DIGESTIVE TEACT 49
abdomen has been explored is not against it ; a fatal ending is
assured in practically every case if the perforation is not treated
by operation.
As a rule, the incision should be made through the right rectus
muscle, or in urgent cases through the linea semilunaris. Suture
of the perforation should always be carried out, if possible, the
formation of an artificial anus, or the re-section of the part of the
intestine affected, giving very unsatisfactory results.
Operation, to be successful, must be early. You must not
wait for recovery from collapse. Armstrong says that in ten
operations performed during the first 12 hours there were four
recoveries ; but that in ten done during the second 12 hours
success was only once obtained. All those died which were
operated on 24 hours or more after the onset.
Ashurst states that two out of 31 cases recovered in the
third 12 hours, and 18 out of 55 when more than 36 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 opera-
tion 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
Avliole 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 occurrence of
fluid in the peritoneum of a typhoid patient is very unusual, but
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 26th 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 See Trans, of the Med. Soc. of London, p. 3G8, 1908, Vol. XXXI.
A.A. E
50 LECTURES ON THE ACUTE ABDO^^IEN
It is evident that this fluid had been present before the signs of
perforation were manifested.
Perforation of Stercoral Ulcers
As recently as 1896 the late Mr. Greig Smith wrote about
stercoral ulcer : " Although no special description of this disease
has, so far as the writer knows, been written, and although it is
not of frequent occurrence nor of great importance, 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. Some of the abscesses that I have met with on
the right side of the abdomen may have been of this mode of
origin, but they were mostly secondary to perforations of the
appendix.
Mr. J. Bland-Sutton has given examples of faecal abscess,
associated with small but sharp foreign bodies, in the large
intestine; and Dr. H. D. Eolleston, in a paper on "Pericolitis
Sinistra," gives instances in which ulceration developed in a
diverticulum of the colon, and produced suppuration beyond.
These ulcerations were rightly called stercoral, but were not, like
the common variety found, secondary to an obstruction of the
bowel below.
But outside these groups of cases, stercoral ulcers behave very
much 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 remembered that these ulcerations are usually
secondary to a condition which of itself is seriously threatening
the patient's life, it can 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
i
>ATHOLOGI(:^AL PERFOEATIONS OF THE DIGESTIVE TRACT 51
ith the very septic contents of the bowel above the obstruction,
n a patient, already weakened and distressed by the obstruction,
his additional attack is usually more than can be successfully
ombated, and proves fatal.
When anyone the subject of chronic intestinal obstruction
f a mechanical kind complains of sudden increase in abdominal
ain and has a rise of temperature, not necessarily a very high
ne, the possibility of the giving way of a stercoral ulcer must
be remembered. This possibility 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 : Some years ago I was
asked by Mr. C. Mortimer Lewis, then of Steyning, to see a lady
with him, who had carcinoma of the rectum. She was over
0 years of age, and had only sent for him that morning
ecause her bowels had not acted for a week. He examined
he abdomen, found it much distended and tympanitic, whilst
he 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° F., the pulse was good, but the tongue was brown and dry.
Incision was made to perform colotomy in the left iliac region,
but when the peritoneum was opened it was found to have been
flooded with black liquid faecal niatter, 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 line of the abdomen.
Pints of this offensive 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 any relief,
whilst the immense accumulation of faecal matter above the
constriction had caused excessive stretching and local injury to
an area of the bowel, which had ended in acute bacterial
necrosis. The necessary removal from the bed to the operating
e2
o2 LECTUEES ON THE ACUTE ABDOMEN
table may have caused a further escape and diffusion in the
peritoneum.
Treatment of this most unfortunate complication should be
directed, as in this case, to the cleansing of the peritoneum, the
insertion of a Paul's tube in the opening from which the faecal
matter is escaping, and the securing 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 colotomy
opening and the obstruction relieved. The difficulty in cleansing
satisfactorily the fouled peritoneum will render the pros-
pect of recovery doubtful. Yet success may occasionally be
obtained.
On March 27th, 1901, I saw a patient in consultation with
Dr. S. Faulconer Wright, of Lee. He was 71 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 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 line below the umbilicus, 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 outline 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 iliac 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 (probably
PATHOLOGICAL PERFORATIONS OF THE DIGESTIVE TRACT 55
jhronic). Under the skilful management of Dr. Wright the
)atient recovered, and was still able to go daily to the City to
msiness when I last heard of him. The artificial anus never
jlosed completely, and gradually, as time has gone on, this
>pening has become more important, until hardly any faecal
latter finds its exit by the natural anus. The patient wears a
[flat, circular indiarubber bag, containing a large flat sponge,
itting accurately to the abdomen over the artificial anus. The
[dieting has to be very carefully arranged, on account of occa-
sional stoppages, which, when they occur, cause considerable
pain, which is only relieved by the escape of faecal matter by the
artificial opening. His general health has remained excellent.
What the nature of the obstruction was in this case it is impossible
Ito say ; the fouling of the peritoneum and the condition of the
patient made it inadvisable to explore. The complication of
perforation was such a serious one that the clear indication was
^to deal with that, more especially as its treatment was calculated
to give relief to the obstruction which was responsible for it.
The cleansing of the peritoneum was no doubt aided by the
limitation of tlie fouled area in consequence of the old intestinal
adhesions. The after-history of the case is instructive, inasmuch
as the obstruction has often recurred, and a "safety-valve"
action has permitted of relief on each occasion. It was thought
at the time of operation that the obstruction was caused by a
carcinoma of the sigmoid flexure, the growth of which is some-
times very slow ; anyway, the case is a most instructive and
encouraging one.
The surgeon of the present day considers that chronic intestinal
obstruction should be rare in actual practice ; there must be some
neglected case, but it should not be met with so often in good
hands as it is. Our knowledge of the early symptoms, and of the
greajt possibilities of successful treatment, is so much better than
it was only a few years ago. However, I am not dealing with
that condition in considering the acute abdomen ; for although
a chronic obstruction may become acute, the diagnosis is
easily made, whilst the indications for treatment are usually
straightforward.
Stercoral ulcer is one of the most serious complications of
chronic intestinal obstruction, even when the peritonitis produced
54 LECTUEES ON THE ACUTE ABDOMEN
is purely local in its character. In any adult with a history of
chronic constipation who gives an account of a more recent
attack of pain, usually in the right side of the abdomen, which
has been followed by a rise of temperature, examination should
be made for the signs of localised extravasation of f?ecal matter
into the peritoneum. If there is an ill-defined area of dulness
in the c?ecal 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 accompanied 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 extravasation and abscess, is specially met with in
elderly females who give a history of chronic constipation,
recently more obstinate, and associated with " wind in the
stomach." The rise of temperature is not great, and the area
of tenderness is not so easily localised as in appendicitis.
The collection of fluid faeces which forms in the peritoneum
has a tendency to spread laterally, 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 into the caecum
be found, a tube should be passed into this, so that the contents
of the bowel, which will escape freely, may be conducted beyond
the abscess cavity. The contents of the abscess cavity, pus
mixed with fluid faecal matter, are extremely offensive, more so
PATHOLOGICAL PERFORATIONS OF THE DIGESTIVE TRACT 55
than most abdominal collections of a purulent character, and
that is saying a good 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
exhaustion. 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 a colotomy 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
satisfactory course of events, the opening acting as a safety valve
when required by the temporary stoppage beyond, and causing
but little 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 subhepatic or subphrenic
regions ; a second incision would be required for the better
drainage of this extension, but exhaustion from the discharge
would not unlikely be the ultimate ending of such a case. It
will be evident that recovery from these collections will take
some time, during which the original cause of the trouble —
probably a malignant growth — is increasing in size and becoming
more difficult to treat satisfactorily.
lY
ACUTE INTESTINAL OBSTEUCTION
In the calculation of the percentage of causation of '' the acute
abdomen," it is found that acute obstruction is responsible for
no less than 24 per cent., without including the cases of intus-
susception, which of themselves constitute 16 per cent. The
forms of acute obstruction which are most common, and there-
fore most likely to be confused with some of the varieties of
peritonitis due to perforation of the hollow viscera, are those
caused by the action of various forms of bands. Here the
resemblance may be very marked, whether the obstruction is
incomplete or whether it is complete and the strangulation of
bowel absolute. The cases of incompletely strangulated bowel
may closely resemble some of the more insidious forms of peri-
tonitis due to perforation or gangrene of the appendix. There
may be a history of previous attacks of abdominal pain, and
jDerhaps signs of an exudation of free fluid into the peritoneum
are found on examination, with localised tenderness. The
temperature record is important, as is also the mode of onset of
the attack, a rise of temperature, and maybe an initial rigor,
being much in favour of the purely inflammatory nature of the
illness.
"Peritonism" (Giibler) — abdominal pain, shock, vomiting,
etc. — is such as described in the cases of perforation of ulcers of
the digestive tract, and the same careful examination of the
abdomen and consideration of symptoms will be required. The
character of the pain is of little value, but it is usually much
increased by percussion (even when quite gently performed) in
peritonitis, more so than ^by palliation. In obstruction per-
cussion is always painless, while palpation is more often painful.
The abdomen in peritonitis is immobile and rigid, whilst in
obstruction it is mobile and soft. Vermicular movements are
more commonly seen in obstruction, but may be found in
ACUTE INTESTINAL OBSTRUCTION 57
localised diffuse peritonitis as in the cases of perforated simple
ulcer of the jejunum already described.
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 griping pain. 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 increases and any localised swelling will be gradually
merged in the general enlargement. Septic absorption and
inflammation are superadded 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 inflam-
mation 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.
It would be obviously impossible to enter fully into all the
varieties of acute obstruction which come under the heading of
" the acute abdomen." I have selected two which I think are
most instructive. They represent the typically acute type of
obstruction in which there must be no attempt at medical com-
promise ; operation is imperative and must be performed as soon
as possible, otherwise the condition passes rapidly beyond the
power of relief.
A patient was under treatment for volvulus of the small
intestine, for which it was necessary to do an extensive resection.
The portion of bowel involved was the lower part of the ileum
which is the usual part affected, and the twist was from right to
left on the mesenteric axis.
A man, G. D., aged 28 (house surgeon, Mr. Birks ; dresser,.
Mr. A. I. Cooke) was admitted to St. Thomas's Hospital on
November 7th, 1904, with acute intestinal 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 con-
58
LECTURES ON THE ACUTE ABDOMEN
tinuous 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. The
abdomen does not move at all in its lower part during inspira-
tion, and movement is poor in the upper part. There is a
marked prominence in the hypogastric region in the middle
line, looking like a much distended bladder. The percussion
note over this area is resonant and the part very tender. The
liver dulness is not diminished and the abdomen appears to be
normal in other parts." The pulse was 120 and the temperature
was 100*6° F. Catheterism did not diminish the size of the
Fig.
-Continuous suture introduced after Lembert's method.
swelling. When seen with Dr. C. E. Box, under whose care the
man was, the local signs had become less acute and there was
less complaint of pain. Acute intestinal obstruction was
diagnosed, due to volvulus of small intestine, or strangulation
by a band. The patient was a strong, healthy-looking man,
without any history of previous abdominal pain.
At 5.45 the abdomen was opened below the umbilicus to the
right of the middle line, the rectus being displaced outwards.
When the peritoneum was incised a very black coil of small
intestine presented ; this was very tense and hard and could not
be drawn up through the wound. It was therefore punctured,
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
ACUTE INTESTINAL OBSTRUCTION
59
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 lift the whole of the affected gut
out of the abdomen. The portion affected was quite black, and
when emptied of its contents was without resiliency, although
the peritoneal covering was not without polish. The twist which
had occurred was one on the mesenteric axis from right to left,
Fig. 9. — Lembert's sutures, introduced separately — peritoneum
and muscular coats taken up.
but when this had been reduced no improvement occurred in the
circulation of the affected portion 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 application 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 involving all the coats, and a continuous *' Lembert "
outside that. The upper 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 peri-
60 LECTURES ON THE ACUTE ABDOMEN
toneum that came under observation. After washing out the
pelvis and cleansing the parts involved in the operation with
sterilised saline solution the wound was closed with deep and
superficial sutures. Chloroform was administered and during
the operation two injections of 5 minims of liquor strychninae
were given hypodermically and, later, 15 ounces of saline 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. Eectal feeding was
employed for three days. There is now a good abdominal wall
without hernial protrusion. We had in this case a formidable
complication, 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.
Dr. C. L. Gibson, of New York, collected 1,000 cases of intes-
tinal 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 form 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,,
and manifestations of shock are more marked, possibly its
mobility allows of a tighter twist. Knowing the tendency there
is to publish only successful cases, it is very probable that
Dr. Gibson's statistics are more 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 condition is presented by a case of
obstruction by a Meckel's diverticulum, the symptoms of which
are praptically those produced by any kind of band. There is
ACUTE INTESTINAL OBSTEUCTION
61
less frequently a history to guide you as to the actual cause of
the obstruction in these cases ; no account being given of a pre-
vious inflammatory attack or of injury, although you may 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 ; obstruc-
tion due to a Meckel's diverticulum is not a common variety.
The symptoms produced by the compression of small intestine
by a band are practically the same as those described when the
EiG. 10.
-Obstruction produced by Meckel's diverticulum, A.
(St. Thomas's Hospital Museum.)
cause is a twist — viz., peritonism — with the formation of a localised
swelling in the lower abdomen, which swelling is resonant on
percussion. Any swelling of this kind should be regarded as of
the utmost importance and as an indication that nothing but
operative treatment is possible. This must be at once declared
by the surgeon in charge. The friends will very probably
protest and the patient demand morphia for the relief of his
pain, but you must be firm.
At the time of the operation the diagnosis in this case was
becoming more difficult, the localised swelling having merged in
the general swelhng caused by the distended intestines. You
62 LECTUEES ON THE ACUTE ABDOMEN
should always have abdominal operations performed before
general distension sets in ; in all cases the operation is much
more difficult in the face of distension, and the result is likely to
be so much less satisfactory.
A man, W. S., aged 46 years (house surgeon, Mr. Birt ; dresser,
Mr. A. I. Cooke), was admitted under the care of Dr. Hector
Mackenzie, on February 26th, 1905, with acute intestinal symp-
toms of 12 hours' duration. Twelve hours before admission
he awoke feeling out of sorts and had a headache. Acute pain
soon came on in the region of the umbilicus and he vomited three
times in the course of half an hour. The bowels had not acted
for two days. On admission he was found to be a heavily-built
man with a tendency to obesity, and was evidently enduring
severe pain, which was not relieved by any change of position.
The abdomen was not universally distended, but there was an
obvious rounded swelling in the right iliac fossa. The respiratory
movement was poor in the right lower segment of the abdomen.
The greatest tenderness was immediately around the umbilicus,
and the right rectus was the more rigid of the two, whilst a
distinct sw^elling could be defined just below, and to the right of,
the umbilicus. The resonance was everywhere normal, there
being no sign of free fluid. The pulse was 62, and the tempera-
ture was 98° F. During the ni^ht the pulse quickened consider-
ably and the temperature commenced to rise. At 10 p.m. two
enemata w'ere given without any result. Hot fomentations and
morphine did not fully relieve the abdominal pain. In the
morning the temperature was 100*6° and the pulse was 110, and
the abdomen was much distended. Dr. Mackenzie was asked to
see the patient at 2 p.m. and advised immediate operation, con-
sidering the case one of strangulation by band.
At the operation it was found that the cause of the obstruction
was the pressure of a Meckel's diverticulum across a large
amount of small intestine. The extremity of the diverticulum
was firmly adherent to the mesentery and the coils of gut involved
were of a chocolate colour, and without any resiliency. The
mesentery was partly filled with extravasated blood and the
vessels were without pulsation ; the strangulation had been com-
plete. The diverticulum was divided and most of it removed,
the stump being sutured into the side of the gut. About
ACUTE INTESTINAL OBSTRUCTION 63
inches above this a section was made of the gut where it appeared
to be healthy, and another above the gangrenous part. Altogether
46 inches were removed, an end-to-end anastomosis being effected
ith two continuous sutures. The peritoneum was cleansed from
small amount of blood-stained, foul-smelling fluid and the
wound closed. Remedies were applied to diminish shock. Both
lines of intestinal suture gave way, the sutures having apparently
been placed in damaged bowel ; an attempt to close these was
unsuccessful, and the patient died on March 9th, from exhaustion
and localised peritonitis. The diverticulum had had its origin
8 inches from the ileo-caecal valve.
In both these cases the progress of events was rapid, the
strangulated gut having become gangrenous in a few hours from
the onset of symptoms. In dealing with the cause of the obstruc-
Ition, in the first case it was only necessary to empty the involved
intestine, and after drawing it from the abdomen twist it round
in the required direction. In the second, after the band had been
found (not always an easy thing, if one may judge by recorded"
cases), it required to be divided and the ends afterwards dealt
with. I may here 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 care-
less division of a Meckel's diverticulum allow of extravasation of
faeces into the peritoneal cavity, v*'hich unhappy occurrence
resulted in a rapidly fatal peritonitis. In appendix cases we are
able to excise the diseased part without interfering with the
lumen of the bowel ; in perforations of the digestive tract we do
not seriously alter the size of the lumen by our sutures. In this
group of cases we are met by a very formidable complication
which requires special consideration. More or less extensive
gangrene of the intestine may suddenly confront you in any
acute abdominal case in which operation is performed, and you
must be able to deal with it on the spot. 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 deal with things as they are, at once, if
you wish to save the life of the patient. The faith which was
formerly placed in the special instrument should now be placed
'64 LECTUEES ON THE ACUTE ABDOJ^IEN
in an accurate method of suturing, the judicious selection of the
point 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 which it is
found that a portion 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 Caird. I have done this with
satisfactory results in cases of strangulated hernia.
The treatment of gangrene of the small intestine when the
entire circumference is affected will depend on the general condi-
tion of the patient, and the circumstances of the case, rather than
on the extent of the gangrene, for the procedure will be much
the same whether you resect 1 inch or 1 yard. In favour-
able circumstances this will be that adopted in the case of
volvulus : Delivery of the gangrenous part from the abdominal
cavity, examination to define the extent of bowel, not only
gangrenous but affected 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. Mr. Barker's method is a very good one.
In the resection of the gut in both cases which I have recorded
Doyen's clamps were used and answered their purpose well. I
used them because they were handy. In other cases of resection
I have used pieces of drainage tube with equal success, passed
through the mesentery and secured by tying or by forceps.
Strips of gauze would answer in case you had no drainage tube
available. The proximal and distal clamps should be placed
^ inches above or below the line 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 is quite evident that
the suturing failed because the stitches could not hold in tissue,
which had been stretched and which underwent afterw^ards an
inflammatory reaction and softening. The bowel appeared to be
quite healthy at the time, and one was very naturally not anxious
to excise more than was absolutely necessary. It is sometimes
ACUTE INTESTINAL OBSTEUCTION 65
advisable to 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
ffected by gangrene was only about 1 inch in length. The
wel close to this was not in a healthy state. As each end of
he bowel is separated it should be cleaned and wrapped in gauze
ntil wanted. One or two vessels may require ligature. You
eed not excise a wedge-shaped portion of the mesentery, but if
t is full of thrombosed vessels there is no object in cutting close
0 the part to be resected.
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 interrupted,
^Hknd are equally efficient. According to the thickness of the
^Bntestinal wall should be the size of the suture. As a rule,
^B^o. 1 is right for the adult. The first should include all the
I^Hpoats of the bowel ; the second will take only the two outer, as
I^Bb rule. In applying this, you must see that the suture has a
I^Kood hold. If you are satisfied on this point, it is not advisable
to dip the needle too deeply, for if you pass your outer thread
into the lumen of the bowel, in the endeavour to get a supposedly
stronger hold, your patient will probably do badly. When apj^ly-
ing the deeper stitch hold the two portions of bowel with forceps,
one pair applied at the mesenteric point of attachment of each
half, the other at a corresponding point opposite. If a pair of
forceps is also placed halfway between these, also closely apply-
ing the cut edges, the suture can be introduced still more rapidly.
The omentum should then be sutured, so as to present no raw
surface, to which adhesions can form, the parts involved in the
operation 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
even 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 J 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
A.A. r
66 LECTUEES ON THE ACUTE ABDOMEN
are brought out. He also shows that the amount of shock is
much less than you might think from such an extensive opera-
tion. I have mentioned these extensive excisions 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 pre-
cautions in following the various steps of the operation, you may
hope for 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 has
passed off, and he is now in 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>j
without contraction, but the bowel on the proximal side was
somewhat larger than that on the distal side, and showed
smaller power of muscular contraction.
DISEASES OF THE FEMALE GENERATIVE ORGANS
Acute Conditions arising FRo:\r within the Pelvis
Several conditions of the female genital organs may be
rightly considered under the heading of the "acute abdomen."
The rupture of a pyosalpinx, the bursting of the sac of an ectopic
gestation, the acute necrosis of a fibroid of the uterus, the twisting
of the pedicle of an ovarian cyst, or the rupture of a cyst into the
general peritoneal cavity are examples. Here I will bring to
. »■ your notice the account of a patient who was admitted for acute
r abdominal symptoms, due to a ruptured pyosalpinx, and after-
wards remind you of some other cases formerly under treatment
in the wards, which show when it is necessary to explore the
abdomen after the onset of symptoms due to pelvic mischief
which has become acute. There is a certain amount of similarity
in the symptoms caused by a ruptured pyosalpinx and those
due to a ruptured ectopic gestation ; and it is to a consideration
of the more acute abdominal complications of these affections
that I shall limit my observations.
The account of the case to which I have already referred is.
that of a patient who was under treatment in the Beatrice Ward.
She is a woman, L. S., aged 21 years, who was admitted (house
surgeon, Mr. Bletsoe ; dresser, Mr. Fetch) under the care of Dr.
H. Mackenzie on February 20th, 1906, early in the afternoon.
The history of the case was that she had been suddenly seized
with abdominal pain during the night of the 19th. This pain
had been very severe, had been in the 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 the morning a
medical man was sent for, who gave her some medicine, which
she vomited. In her previous history there was an account of
indigestion of indefinite character some years ago. There had
f2
68 LECTUEES ON THE ACUTE ABDOMEN
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 in consultation with Dr. 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° F. 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 it was quite soft all over, but 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 being quite without rigidity, and offered no
resistance to palpation. On percussion the note over the whole
abdomen was normal. The liver dulness was normal. At 5.30
abdominal exploration was carried out, an incision was first
made in the epigastric region, and the stomach and duodenum
closely 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 pyosalpinx, and it was thought that a rupture of this would
account for the condition. A second incision was made in the
middle line above the pubes, and when the peritoneum was
opened, thin, somewhat viscid, odourless pus was found, extend-
ing from the pelvis into the flanks. The intestines were packed
off with strips of sterilised gauze, and the pyosalpinx was
removed after the application of three (No. 4) silk ligatures.
There was no inflammation of the peritoneal 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 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 pyosalpinx
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
DISEASES OF THE FEMALE GENERATIVE ORGANS 69
rupture of the tube 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 or subnormal. Pain was quite relieved. This
patient continued to progress satisfactorily, and left hospital on
March 13th.
Pyosalpinx 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 spreading 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 be diffused into the general cavity of the
peritoneum. There can be little doubt that the gonococcus is
extensively dift'used by the rupture of a tube, and although Mr.
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 sets in. The prognosis
is thereby immensely improved, and the duration and severity
of the illness are 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
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 localising 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
1 " The Bacteriology of Peritonitis," p. 53.
70 LECTUEES ON THE ACUTE ABDOMEN
of so doing, in a case formerly under my care, in which a
pyosalpinx 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 the woman returned with septic peritonitis, the result
of a rupture of the remaining tube, in the following year.
The following is an account of this case :
A woman, aged 26 years, was admitted under the care of Dr.
H. Mackenzie on January 31st, 1903 (house surgeon Mr. Hudson,
dresser Mr. W. Wilkinson). 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 25th, 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 nothing unusual. The tem-
perature was 100*6° F., and the pulse was 104. On February 3rd
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 until February 6th,
when another more severe attack of pain and vomiting induced
her to think more seriously of her illness and give her consent.
Incision was made through the right rectus sheath and the
muscle was 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 walled, but
further examination showed the swelling 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 packed off with sponges and a
large pyosalpinx, 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
DISEASES OF THE FE]VL\LE GENERATIVE ORGANS 71
was found adherent to part of the boundary wall of the pyosalpinx
which had been left behind — it was kinked from before back-
wards; another loop also adhered to this part, but was not
obstructed. These were freed and some omental adhesions were
also separated or divided between ligatures. The pelvis and
lower abdomen were carefully 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 very 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 14th, 1903.
On October 20th, 1904, the patient was readmitted to the same
ward with symptoms of diffuse peritonitis. She had enjoyed
^ood 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 previous to her coming
up it increased considerably, and was again accompanied on the
first and third days by haemorrhage. She had vomited four times
on the day of admission, but not before. The abdomen was
slightly 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° F.
A tender swelling 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 it was distended with pus.
The ovary contained 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.
72 LECTURES ON THE ACUTE ABDOMEN
The case was essentially one of peritonitis with much purulent
effusion without any haemorrhage. The occasional production of
peritonitis by the extension of gonococcal infection directly to the
peritoneum through the uterus and tubes is sometimes seen.
Here the attack may be very acute and require prompt opera-
tion. In a recent successful case, seen with Dr. Fitzgerald, pus
was escaping from highly inflamed tubes at the operation, a
fortnight after the infection, and three days after the commence-
ment of abdominal symptoms.
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 accumula-
tion of blood in the peritoneum 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 as a surgical emergency, so that you
may be able to recognise and successfully treat it. Of the more
severe cases of haemorrhage I have selected one of rupture of a sac
situated in the wall of the uterus in which symptoms w^ere (as
they usually are) very urgent, and the general state of the
patient a somewhat desperate one. It is a rare position for
the sac to occupy, but there is no means of ascertaining this in
any case before the abdomen is opened, but the indications for
operation are the same as in examples of the much commoner
accidental rupture of a tubal gestation.
A married woman, aged 35 years, was admitted (house surgeon
Mr. Bradford, dresser Mr. Wilkinson), under the care of Dr. H.
Mackenzie on April 23rd, 1903, on account of acute abdominal
symptoms. Her history was as follows: She was treated in
a London hospital nine years before for "peritonitis" after a
confinement. 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
DISEASES OF THE FEMALE GENERATIVE ORGANS 73
pain in the abdomen. A fortnight previously she attended the
^out-patient department and was treated for gastritis. The
tbdominal pain got worse, and at four o'clock on the day of
idmission she had a very severe attack which doubled her up
md later completely prostrated her. She vomited several times
md became very cold, pale, and collapsed. During the afternoon
}he fainted. She was brought to the hospital 13 hours after the
)nset of the severe pain. She had had five children, four of
rhom were still living — one died at the age of 6 years. The
roungest was 18 months old. The last menstrual period was
jix 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. On admission
ihe was blanched, emaciated, and in a state of collapse. The
ibdomen 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 were 26 and
sighing, and the temperature was 97*2° F. 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 felt to be enlarged, and so was brought to the surface. The
enlargement was found, however, to be due to a hydrosalpinx,
so the uterus and tube were drawn up for inspection. The
uterus was ruptured at a point on the fundus to the inner side
of the place where the right tube joined it. The uterus was
longer than normal ; the opening was about IJ inches in length
and placed transversely. From it there protruded a fluffy mass
of delicate moss-like tissue which filled the opening and bulged
over the edges. From this j)lace there was a constant oozing of
blood. This was evidently placental tissue. It was removed
with a curette, and the cavity from which it came was scraped
out. The opening was then closed with a continuous Lembert
suture. This apparently arrested all bleeding. The left tube
was then removed, and the pedicle was ligatured with silk. The
74 LECTURES ON THE ACUTE ABDOMEN
intestines appeared pale, almost bloodless, and contracted. The
peritoneal cavity was carefully cleansed of clots and free blood
by saline irrigation and 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 from the shock of the operation
and the large loss of blood. On the third 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 con-
tinued for about three days, but the temperature continued
normal, and the pulse about 100. Convalescence was slow, and
she did not leave the hospital until June 29th.
In another patient the diagnosis was rendered difficult because
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 (house surgeon, Mr.
N. C. Carver ; dresser, Mr. H. T. Grey) to St. Thomas's Hospital
on April 14th, 1904. There was history of irregular periods, and
a white discharge on and off between the periods, but general
good health until April 8th. She was then seized with a severe
internal pain, which was so bad that on the following day she
was obliged to go to bed ; it improved, but returned again 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
was slightly distended and tender, and it was difficult to examine
satisfactorily, as she 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 found to be normal and
freely movable, and a little 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° F. On the 18th she was again
seized with pain in the right iliac region. The vaginal discharge
recommenced, being of a red colour. She felt very faint. The
DISEASES OF THE FEMALE GENERATIVE ORGANS 75
pain passed off 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
extra-uterine gestation which was leaking into the peritoneum
as a result of some rupture of the sac. On the 29th the operation
by temporary displacement of the rectus was performed, and a
diseased appendix was 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 line
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 ligament. This
was excised, and proved to be an intraligamentous cyst with
papillomatous growth inside it. The appendix was catarrhal,
and was strictured near its base. The right Fallopian 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 ligament. The
incisions in the abdominal wall were closed without drainage,
after the pelvis had been sponged and flushed with warm saline
solution. A week later she complained of pain in the left side of
the pelvis, and a hermatocele gradually formed and suppurated,
being opened per vagina about three weeks after the operation.
She left hospital quite recovered on June 4th, 1904.
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
L
76 LECTUEES ON THE ACUTE ABDOMEN
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 these cases of operation for haemorrhage
the uterine appendages should at once be examined, and if any-
thing abnormal is found brought out of the wound. No attempt
to clear away blood clot must be permitted until the source of
haemorrhage is found and its flow arrested. Examine both sides,
for 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 extra-uterine gestation, if menstrual
irregularity and no marked rise of temperature are present. A
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 rallied. This had been
regarded by her medical attendant as probably due to the rupture
of an extra-uterine 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 extremities 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 first seen
her it was possible to open a large collection of pus which 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
DISEASES OF THE FEMALE GENERATIVE ORGANS 77
expressed from this part when everywhere 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. The patient has enjoyed good health since.
VI
SOME OF THE MOEE EAEE 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, and search must be made for other
possible causes of the symptoms. Acute pancreatitis or acute
cholecystitis are perhaj)s the most likely of these. Very occa-
sionally an acute dilatation of the stomach may be the cause of
the acute abdomen.
Acute Hemorrhagic Pancreatitis
In this disease the onset is sudden, and associated with severe
abdominal pain, located usually in the upper abdominal and
umbilical regions. The signs often suggest acute intestinal
obstruction ; at other times perforation of the stomach may be
suspected. A history suggesting previous inflammation of the
gall bladder or ducts is occasionally obtained. The following
case is an example which recovered after operation. For the
notes of this case I am indebted to Mr. E. W. Witney, house
surgeon, and Mr. T. G. Cobb, dresser of the case : —
A widow, aged 57, was sent to my care at St. Thomas's by
Dr. G. Brebner Scott, of Brixton, for an acute abdominal illness,
on February 23rd, 1909. At six o'clock on February 22nd, 1909,
she complained of great pain in the abdomen. She said that it
began in 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
bow-els had acted naturally the previous morning.
There was no history of biliary colic or of injury, and she
SOME OF THE EARE CAUSES OF THE ACUTE ABDOMEN 79'
had been quite well until this illness. She was a well-nourished
woman, who still complained (at 6 p.m. on February 23rd) of
abdominal pain. This was now general all over the abdomen..
She looked ill, had a pulse of 110, and a temperature of 101°.
The abdomen was distended, generally hard to the touch, and
very tender, but not specially so in the iliac fossa. On percus-
sion there was patchy dulness, both in front and on the lateral
aspects of the abdomen, but not in the flanks. No abnormal
swelling could be felt, but the wall of the abdomen was fat ; it
was distended and resistant. Her tongue was dry, and bowels
not acting. Operation was decided upon, and an incision made
on the right side through the rectus muscle. When the peri-
toneum 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 saline solution, and the incision
closed. She was relieved by the operation, but on the following
evening her temperature rose again to 100° and pulse to 136, so
at my request the incision was reopened by Mr. J. E. Adams,
who confirmed the condition of fat necrosis, evacuated more
fluid, and put in a drainage tube. The following day Cammidge's
test (c) was reported as positive. The patient was very ill for
some days, and at one time appeared very flushed, weak, and
despondent. Drainage was continued until March 10th, after
which she gradually improved. It is not necessary here to give
any further details of the case. She left hospital on April 20th,
and has since had good health, having quite recovered.
This is the only successful case of operation for acute
haemorrhagic pancreatitis that I can record, but it is fairly typical
of the disease as found in actual practice. I have now seen
several cases which practically group themselves so that one
can give an average description of fair accuracy when they are
met with within forty-eight hours of the commencement of the
attack.
The patient is commonly an adult of more than 40 years.
80 LECTURES ON THE ACUTE ABDOMEN
of age, well nourished and even fat, apparently in good health
until seized with a sudden attack of severe abdominal pain. On
examination the abdomen has been more resistant generally than
it should have been, but not rigid. There has been a diffused
superficial tenderness, especially on unexpected light palpation,
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, there has been anxiety,
and not infrequently a flushed face.
If the abdomen is opened within 24 hours, the amount
of blood-stained fluid will be small, 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 areas,
which are yellowish white in colour and of small size. If nothing
is found 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, having a peculiar
mawkish smell which, so far as I know, resembles nothing else.
There may be no evident swelling of the pancreas. These
patients are not good subjects for abdominal section, and I believe
you will get better results in most cases from simple drainage,
than from a more elaborate operation, such as incision of the
pancreas, etc., possibly with drainage of the gall bladder. Most
of them will not stand the additional manipulations required,
with the prolongation of the period of anaesthesia ; 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 pancreas, with
due regard to the duct and main vessels, and establish a direct
route for drainage ; unfortunately the action of the secretion
from the gland, if much escapes, is very destructive on the
tissues with which it comes into contact, and if the flow is profuse
you will find it difficult to prevent actual digestion of parts.
Acute Dilatation of the Stomach
This is a rare condition, whose origin is sometimes doubtful, at
other times it follows an operation involving the peritoneum.
SO^IE OF THE RARE CAUSES OF THE ACUTE ABDOMEN 81
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.
I will give two contrasting examples, one occurring in the
course of an acute pulmonary attack, the other secondary to an
abdominal operation and associated with general intestinal
distensions.
Case 1. — On January 21st, 1903, I was asked to see R. T.,
aged 15, with Dr. Michael Bulger. The history of the
case was as follows : Dr. Bulger was called to see her on the
19th, when she complained of pain under the left breast on
breathing, which was increased by taking a deep breath ; there
was slight expectoration tinged with blood. Over the painful
area there was some dulness, increased vocal resonance, and
crepitation on respiration. On the 20th the patient was much
easier. Temperature 102°; pulse 96 ; could take food easily, bowels
acting. She was the subject of angular curvature of the dorsal
^^pine, the result of old tuberculous disease.
^B On the 21st she began to vomit about 7 a.m., the vomited
material being of a bilious character, and yellow in colour. The
bowels acted at 8 a.m. The pain in the side was much better,
but the constant vomiting masked all other symptoms. Tempera-
ture, 99°; pulse, 80. Nothing relieved 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 complained of no pain since the vomiting came on, but
the abdomen was becoming distended. About 11.30 p.m., when
I saw her with Dr. Bulger, the abdomen was somewhat distended
a
82 LECTUEES ON THE ACUTE ABDOMEN
but not markedly so, dull on percussion all over the front and down
the left flank to Poupart's ligament. 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 line showed a greatly distended
stomach, the lower margin of which passed down to the pubes ;
it was bluish in appearance and flattened. 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
fluid was drained off from the stomach by this tube, and vomiting
ceased ; but very little relief was afforded, and the patient died on
the following day from exhaustion.
Case 2.^ — A woman, aged 27, came under my care at St.
Thomas's Hospital, sent to me by the late Dr. Heath, of St.
Leonards-on-Sea, on November 7th, 1901, for a swelling in the
abdomen, which had been noticed to be increasing for the last
nine years. On November 12th a coeliotomy was performed,
the diagnosis of ovarian cyst confirmed, and the 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° F.
The abdomen became increasingly distended ; there was no vomit-
ing beyond that directly following the anaesthetic. A week after
the operation there was evidence of slight suppuration in the
abdominal wound, and pus was evacuated with a director. There
continued to be great distension of the abdomen and much
discomfort.
I am indebted to Messrs. G. A. C. Shipman, S. Hunt, F. J.
Child and T. W. H. Downes, house surgeons, and to Mr. G. T.
Birks, dresser, for much assistance in this case.
On November 21st, Dr. C. R. Box saw the case 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 elicited on shaking the
1 See Lancfit, 1903, Vol. I., p. 1031.
SOME OF THE EAEE CAUSES OF THE ACUTE ABDOMEN 83
patient ; there was no vomiting. Lavage of the stomach was
commenced and carried out twice daily from this time. Twenty-
six days from the operation parotitis developed, associated with
a septicemic 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 tempera-
ture, and the diarrhoea, it continued for about three months ;
uch oedema of both legs and the lower part of the abdominal
all supervened. Some peristalsis in the region of the umbilicus
as occasionally seen, and the stomach still showed the physical
signs of dilatation.
On August 12th, 1902, the gastro-intestinal functions had
come practically normal, the oedema in the lower part of the
ody, 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
thrombosis 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
as readmitted to St. Thomas's Hospital under my care on
ovember 19th, 1907, for another abdominal swelling. Mr. G. M.
Huggins was house surgeon, and Mr. F. K. Thornton dresser to
the case. 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 swelling but no vomiting. The abdomen
was a good deal distended and tense on admission, the superficial
eins dilated, chiefly in the lower part, and there were numerous
lineae albicantes in the same region. A dull rounded area was pre-
sent reaching almost to the umbilicus from the pelvis. This was
fluctuating and tender, whilst around it the intestines were dis-
tended and tympanitic. Her temperature was slightly raised.
She was kept in bed for some time in order to give the inflam-
matory state a chance of quieting down, but the distension did
not appreciably diminish. On December 4th an incision to the
left of the mid line was made, and an inflamed ovarian cyst
removed. Tlie pedicle was long and had been twisted three times
from left to right. The cyst was very adherent to the omentum,
wa
sig
Hbo(
wa
Ja
th:
_dil
84 LECTURES ON THE ACUTE ABDOMEN
but not suppurating. It was an ordinary niultilocular 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 the 25th of that month. There
was no suppuration or rise of temperature 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 application 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
temperature 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 left lung
found by Dr. Bulger, when he first saw the patient. Spinal
SOME OF THE EAEE CAUSES OF THE ACUTE ABDOMEN 85
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 this second case were published by
Dr. Box and myself on account of its rarity, and as an encourage-
ment in the treatment of such desperate conditions. We are
inclined 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 recovery
^to the fact that her' distension was general and not absolutely
jonfined to the stomach and duodenum. Dr. Laffer, from an
malysis of his series of cases, writes : " The pathology and
lodus operandi of acute dilatation of the stomach and gastro-
lesenteric-ileus is not definitely known, but the experimental,
jlinical and pathological evidence points to a primary innervation
iisturbance affecting the gastric nerves or their centres in the
)rain or cord. It has not been proved that the compression of
khe duodenum by the root of the mesentery is the primary cause
it the so-called arterio-mesenteric ileus."
Embolisim 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
quality. 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
1 "Annals of Surgery," Vol. II., 1908.
86 LECTUEES ON THE ACUTE ABDOMEN
examination. Gerbardt gives the following as necessary for a
diagnosis : (1) The presence of a source for the embolus ;
(2) Copious intestinal haemorrhages, not to be explained by
disease of the wall of the bowel, 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 pre-
vious occurrence of embolism in other parts ; (6) the occasional
presence of tumour in the abdomen, due to the infiltration of the
mesentery with blood. All of these signs are not, however,
present in every case. Valvular disease is found on examination.
The operative treatment consists in a resection of the part of
the bowel that appears involved in the process of gangrene, and
the formation of an artificial anus. This is done (1) because in
resection of a portion of gut the line of suture, if enterorraphy is
to follow, must be in sound bowel, and it is always doubtful in
these cases if the gangrene will not spread ; (2) The full opera-
tion would in most instances take too long when consideration is
paid to the grave state of the patient.^
Peritonitis arising from Disease of the Gall Bladder
Symptoms of peritoneal involvment 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 17th, 1903, I was requested to
see a patient, aged 58, with Drs. Harper and Godfrey, of
Finchley. 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
*". 1 See Moynihan, "Abdominal Operations."
SOME OF THE EARE CAUSES OF THE ACUTE ABDOMEN 87
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 biliary colic. 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 earlier than usual, and sent for Dr. Godfrey, who found
him again complaining of pain in the abdomen, with a tempera-
ture of 101°. On the following morning he was worse, and
during the day he had occasional vomiting, the abdominal pain
continued to be severe and gradual distension came on, whilst
his expression became changed to that associated with serious
abdominal disease.
When I saw him about 11 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, especi-
ally on the right side below the ribs, the area of most marked
tenderness being midway between the ribs and the iliac 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 I could not decide what
the origin of the trouble was. Dr. Godfrey inclined to the gall
bladder as the cause, having seen the earlier attacks of pain ; my
opinion was given in favour of the appendix as the origin of his
trouble. Incision over the iliac 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 localised. 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 anaesthetic 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 was well in 1909, not
having had any return of symptoms in the interval.
88 LECTUEES ON THE ACUTE ABDOMEN
The cases may be very acute in their course, and early opera-
tion affords the only chance of success. The peritoneum fills
very rapidly sometimes from this source, and as a rule there is
very 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.
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 admis-
sion, during which time he had also had a little vomiting and
constipation. On admission the abdomen was distended, it con-
tained a large quantity of fluid, and the man was emaciated and
rather yellow in appearance. He appeared aj^athetic, had no
pain, and at this time was not vomiting, but from the history it
was supposed that he might have incomplete malignant obstruc-
tion of the large bowel with secondary growths about the
peritoneum and in the liver. Nothing abnormal could be felt per
rectum. His pulse was not more than 70 ; his temperature was
normal. An exploratory operation was done and the peri-
toneum found to be full 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 seen
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. It is j)ossible, there-
fore, to get very 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 fatal
peritonitis is the usual consequence when the contents of the
gall bladder have escaped through ulceration in gangrene of the
wall of that viscus, a process in which micro-organisms are very
active.
VII
SOME NEUEOSES AVHICH MAY CAUSE SYMPTOMS OF
UEGENCY
HAEMORRHAGE FROM THE StOMACH
^No surgeon has any doubt that operative treatment is
ometimes absohitely necessary in haemorrhage from gastric or
duodenal ulcers. It may be the only means of saving life, but
jjbhe indications for its performance should be clear and definite,
some cases it may be possible to find and deal with the exact
'cause of the haemorrhage ; in others it will only be possible to
treat the distension of the stomach (by gastro-enterostomy) on
which the occurrence of the bleeding so frequently depends. It
may be the wiser plan, when possible, to perform the operation
of gastro-enterostomy although the local trouble has also been
lirectly treated.
In dealing with these cases it may be advisable to remember
the possibiUty of the haematemesis being of hysterical origin, for
such a condition is always amenable to medical treatment, and
in my opinion should not be submitted to operation under any
circumstances. The history of the case given below not only
proves this, but shows in a marked degree the ills that may
follow such ill-advised interference.
A woman, aged 29, was sent to me by Dr. Frank Boxall of
Eudgwick, 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 (Mr. T. Guthrie was house surgeon),
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 beea
90 LECTURES ON THE ACUTE ABDOMEN
due to perforation of the ulcer, and an exploratory incision was
made in the epigastric region by a surgeon, who found nothing
hut 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 earlier days after her admission, when she was look-
ing 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 appear-
ance, the pulse-rate, or temperature, and other symptoms were
not in agreement with perforation ; we had also the history to go
upon.
This patient left St. Thomas's about a fortnight after the
operation for the 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 with-
out 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 haematemesis of similar character, from
which she recovered in from 3 to 4 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 haematemesis 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 19th, 1905
(Mr. Yaughan was the house surgeon and Mr. G. M. Custance the
dresser) when she was found to have a faecal fistula, which commu-
nicated 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 haemorrhage was found at the examination, it
t.
NEUEOSES WHICH MAY CAUSE SYMPTOMS OF URGENCY 91
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 faecal fluid came through if she had an enema administered.
The abdomen was opened in the middle line 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 a
wooden match. She left at her own request.
Eeadmission 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
s 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
uld not feel sure that it was not kept open in some way by
echanical means at the command of the patient. A smaller
ressing was then applied, and this was covered and held in
osition by means of collodion. After this was applied she com-
lained of excruciating pain and said that she could not possibly
ar the agony of it. It was not, however, removed for a week,
hen the fistula had completely closed. I may perhaps mention
hat the fistula was found to have become distinctly larger after
he had had a bath without the presence of a nurse ; this was
efore the collodion was applied.
We were for a time under the impression that the case was
ow completed, but in March, 1909, she again came into the
ospital during the cleaning of a charitable institution to which
he had gained admission. A faecal fistula had formed at the
site of the former one, and she refused to have anything done
with a view to closing it. When questioned as to the formation
of this fistula she said that an abscess had come and burst, leav-
ing the fistula behind it, but there is a strong possibility that it
92 LECTUEES ON THE ACUTE ABDOMEN
did not form in this manner. If it had been closed, and this
would soon have occurred under simple treatment, for there waa
a free normal passage for the fseces, 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
{Clinica Moderna, May, 1905 ; British Medical Journal,
Epitome, August, 1905) has given the account of a case of similar
origin. 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 operation. 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 (/oc. cit.).
Enteeospasm
By this term is now recognised a condition in which there is
a spastic 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 varying 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 quote from 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 frequency in the
two sexes. The individuals affected are usually of a neurotic type
and often of sedentary habits.
^ British Medical Journal^ January 13th, 1906.
NEUEOSES WHICH MAY CAUSE SYiMPTOMS OP URGENCY 93
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 localised in the right iliac region and
so appendicitis may be simulated.
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 peri-
tonitis may be so close that the mind of the observer is left in
doubt as to the right diagnosis, and exploration of the abdomen
ill 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 recent case operated on for me by the resident assistant
surgeon, 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
is a typical neurotic in appearance. I have met with the condi-
tion 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.
INDEX
Abdomen, see alto Acute Abdomen,
Dilatation of, and Disten-
tion of
I Area of, affected by Acute diseases,
Childe on, 20
Condition of, in Acute Abdomen, 2-3
in Acute Obstruction, 56
in Peritonitis proper, 56, 57
Examination of, in diagnosis for opera-
tion, 4, 5
Incisions in, positions for,
in Appendicitis, 17, 19, 20
in Cellulitis, 26
in Perforation during Typhoid, 49
bdominal Abscesses, percentage of,
in Acute Abdominal Cases,
St. Thomas's Hospital, 5
Muscles, condition of, in Perforation
during Typhoid, 48
Operation, Acute Dilatation usually
secondary to, 85
Swelling, abnormal, search for im-
portant, in Acute Obstruc-
tion, 57, 61
Tension, local, after Operation, to
relieve, 26
Wound, how to close, 22, 34
I Post-operative treatment of, 26
Abortion, Tubal, 75
^bscess, Abdominal, percentage of,
L in Acute Abdominal Cases,
[ St. Thomas's Hospital, 5
f Origin of, 50
of Appendix ; —
Rupture of, condition simulated by,
76 ; excess of Fluid in, 31, 34
into Peritoneal Cavity, 15, danger
of, cases of, 16-17
Faecal, in Large Intestine, with small
sharp foreign bodies, 50
Intra-abdominal, 50, 54
Intraperitoneal, caused by extension
of Stercoral Ulcer, 50, 54
Localised, after Operation for
Perforation of Gastric Ulcer, 38
Volvulus of Ileum, 60
Subdiaphragmatic, 36
Acland, Dr. T. D., 13
Acute Abdomen ; —
Causes of ; —
Acute Intestinal Obstruction,
cases illustrating, 56, 67
et sqq.
Age in relation to, 5, 6, 20
Appendix aflfections, 1-18
Diseases of Female Generative
Organs, 67-77
Intussusception, 5, 56
Rarer Causes, 78-88
Acute Dilatation of Stomach,
78, 80-5
Acute Hasmorrhagic Pancreatitis
and case illustrating, 78-80
Embolism and Thrombosis of the
Mesenteric Vessels, 85-6
Peritonitis from Disease of Gall
Bladder, and case illustrat-
ing, 86-8
Diagnostic points to heed in, 3-5
Secondary cases of, due to disease of
Appendix, and to other
causes, relative proportion
of, 6
Symptoms of. General, Individual and
Local, value and nature of, 2, 3
Acute forms of Abdominal Disease, see
under Acute Abdomen, Ap-
pendix, Dilatation, Intestinal
Obstruction, ^'c.
Adams, J. E., 79
Adhesions, AlDdominal, 91
between Coils of Small Intestine,
Obstruction due to, 77
Omental, 71
Adults, site for Abdominal Incision in,
Stout, 19
Thin, 19
Age in relation to
Cause of Acute Abdomen, 5, 6, 20
Importance of Subacute Symptoms of
Appendix disease, 17-18
Albumin in Urine in Acute Abdomen, 3
Alimentary tract, Perforations of, see
Perforations
America, Gas and Oxygen as Anaesthetic,
much used in, 19
'96
INDEX
Anesthetics used in treatment of
Acute Appendicitis with Peritonitis, 19
Acute Intestinal Obstruction, 60
Anastomosis of Large Bowel, lateral, 91
Anti-bacillus-coli Serum, use of, 14, 25
Antl-streptococcic Serum, and its re-
sults, 83
Anus, Artificial, after Perforating Ster-
coral Ulcer, position of, 55
Formation of, in Resection for
Embolism and Thrombosis of
Mesenteric Vessels, 86
in after history of Active patient, 53
Apathy, in Acute Abdomen, 4
Appendicitis, 77
Acute, resembling Perforation of
Duodenal Ulcer, 35
Appendix Vermiformis ; —
Abscess of, Rupture of, 76 ; danger
from, and cases of, 15-17 ;
excess of Fluid in, 31, 34
Acute disease of, Age in relation to, 5,
<!' see Fig. 2., 1
Catarrhal, 75
Concretions in, 7, 8, 10, 18
Condition of, in operation for Duo-
denal Ulcer, precautions
advisable, 36
Diseases of, 2, 5, 6
Induration in, 54
Others secondary to, 5
Percentage of, in Acute Abdominal
Cases at St. Tliomas's Hos-
pital, 5
Serious complication of, 15-17
Empyema of, Rupture of into Peri-
toneal cavity, case illustrat-
ing, 13-15 ; excess of Fluid
in, 31, 34
Oangrene of, 10, 11
<jrangrene and Perforation of, late
realised, cases illustrating,
6-7, 8-9 ; results liable to be
mistaken for those of Incom-
pletely Strangulated Bowel,
56
Influence of, in causation of Acute
Abdomen, 1-18
Perforation of {see also Gangrene
supraJ), Suppuration after,
15, 17
Removal of, 75, 77 ; cases referred
to, 6-7, 8, 9, 10, 11, 14,
16, 17
" Imperative," or " advisable,"
12-13
Operative procedure, 19-23, and
after treatment, 23-7
Stercoroliths in. 12
Stfij3ture of, 10, 11, 15, 17, 75
Appendix Vermiformis, continued.
Stump of, after removal, how dealt
with, 21
Suppuration of, sudden onset of,
simulating Rupture of Extra-
uterine Gestation, 76
Armstrong, Dr., on early operation in
Perforation in Typhoid
cases, 49
Ashurst, Dr., on Recovery in cases of Per-
foration during Typhoid, 49
Atony of Stomach, 81
Attitude commonest in Acute Abdo-
men, 4
Bacillus Coli communis, Infection of,
Appendicitis generally due
to, 25
Pus of suppurative periostitis of
Femur, 46, persistence of,
and fatal Infection from, 47
Typhosus in fluid in Peritoneum
during Typhoid, 49
Bacterial Necrosis, Acute, causing
Stercoral Ulcer, 51
Bands, Intestinal Obstruction by, symp-
toms of, 44-5, 56, 61
Care needed in examining those found
during Operation, 63
Barker, A. E. J., method of, for treat-
ment of Gangrene of Small
Intestine, 64
Papers by, on Enterectomy, cited,
65, 66
Battams, Dr. J. Scott, 40, 41
Bed, Position in, for patient after ab-
dominal operation, 23
Biliary Colic, history of, associated with
Peritonitis from Gall Bladder
disease, 86, 87
Birks, G. T., 32, 57, 82
Birt, A. C, 62
Black vomit, an indication of toxaemia,
27, 81, 82
Bland- Sutton, J., on fascal abscess with
small sharp foreign bodies in
Large Intestine, 50
Bletsoe, J. H., 67, 68
Blood, see Clots
Bowels, see also Gut, Intestines, and
Resection
Action of, after Operation, to secure,
25-6, 27
in Acute Abdomen, points to note, 3, 5
in Embolism and Thrombosis of
Mesenteric Vessels, 85
Incompletely Strangulated, possible
mistakes concerning, 56
Ulcerated, Resection of, when neces-
sary, 38
rNTDEX
97
Box, Dr. C. R., 58, 82, 85
Boxall, F., 89
Bradford, Dr. A. B., 72
Brauns, Prof., discovery by, of Jejunal
ulceration, 37
Breathing in Acute Abdomen, 3
British Medical Association Bristol
Meeting, 1894, Gould's paper
at, on Ulcer of Stomach
&c., 28
Bulger, Dr. M., 81, 84
CiECUM, Stercoral Ulcer on, perforating,
52, after-history of case, 53
Iaffein, to meet Collapse before
Operation, 22
aird, Prof. F. M., on use of Lembert's
Sutures in Operation for
Intestinal Obstruction, 64
alomel, dose of, after Operation, 26
ammidge's test (c), 79
(Jarbolic-soaked gauze, when used, 26
Carcinoma of
Large Intestine, low down, with
Perforating Stercoral Ulcer,
effect on sufferer, 50-1
t Rectum, with perforation of Stercoral
Ulcer, undiscovered till
Operation for obstruction,
51-2
Sigmoid flexure, slow growth of, 53
arcinomatous Ulcers of the Stomach,
Perforation of, 29
ardiac disease, in Embolism and
Thrombosis of the Mesenteric
Vessels, 86
Weakness after Operation, results,
and treatment of, 27
Carver, N. C, 74
Catarrh of Appendix, 75
Cellulitis, diffuse, sub-peritoneal, Greig
Smith on, 50
Cellulitis, after Operation, treatment
for, 26
Chauncey, J. H., 47
Child, F. J., 82
Childe, C. P., on Position of Incision in
Operations for Acute Abdo-
^■^ men, 20
^^fchildren, site for Abdominal Incision
^m 19
^KChildren's Hospital (Hospital for Sick
^^ Children) Great Ormond St.,
Intraspinal injection of
Anaesthetic approved at, 19
Chloroform in Appendix Operations, 19
in Acute Intestinal Obstruction
Operations, 60
Cholecystitis, Acute, 78
A.A.
Churchill, S., 6
Cigarette di-ain, 34
Clamps, use of, 75, 76
Doyen's, 59, 64
Clinical Society, the, 43
Clots of Blood in Peritoneal Cavity, 73,
74
"Coat sleeve" method of Removing
Appendix, 21
Cobb, T. G., 78
Cocaine, in Vomiting after Operation, 25
Coeliotomy, 82
Colic, see Biliary Colic
Collapse, i)asHim.
before Operation, cause and treatment
of, 22
in Acute Dilatation of Stomach, 81
in Rupture of Appendix Abscess, 76
Colon, Diverticulum of, Ulceration in,
RoUeston on, 50
Typhoid Ulceration of, 28
Colotomy ; —
Opening of, 51
on Right side, drawbacks of, 55
Perforation by Stercoral Ulcer dis-
covered during, 51
Concretions in the Appendix, 7, 8, 10, 18
Constipation in Acute Abdomen, 3, 5
Chronic, recent Pain and rise of Tem-
peratui-e, deduction from, 51,
54
Convalescence after Abdominal Opera-
tion, Cardiac weakness
during, 27
Cooke, A. I., 32, 57, 62
Crompton, K. E., 46
Currie, Dr. A. S„ 43, 44
Custance, G. M., 90
Cyst, Rupture of, into general Peri-
toneal Cavity, 67
Intra-ligamentous, with papilloma-
tous growth inside, 75
Ovarian. 71, 82
with Twisted Pedicle, 67
Inflamed, removal of, 83-4
Pedunculated intra-ligamentous, 75
Davidson, Dr. G. D., 11, 12
Depression, see Collapse
Diagnostic certainty as to removal of
Appendix, need for skill in,
12, 13
Observations indicating Operation, in
Acute Abdomen, 3-5
Diarrhoea, in Acute Abdomen, 3, 5, 85
Diet, after Operation, 26, 27
for Recovered Patient after Stercoral
Perforating Ulcer with ob-
struction, 53
98
INDEX
Digestive Tract, Pathological Perfora-
tions of, 28-55
Dilatation of Stomach after Operation,
33,71
Acute, of Stomach, 78, 80
Cases illustrating, 81-5
Causation, 84, 85
Pathology of, Laffer on, 85
Discharge, in Acute Haemorrhagic Pan-
creatitis, 80
Diseases of Female Generative Organs,
causing Acute Abdomen,
67-77
Distension of Abdomen and Intestines
Qice aim Swelling), cases in
which present, 2, 5, 7, 16, 17,
36,39, 40,41, 43, 45, 47, 51,
52, 57, 58, 61, 62, 71, 73, 74,
79,81,82,83,84,85,87,88,90
Downes, T. W. H., 82
Doyen's Clamps, use of, 59, 64
Drainage (passim), importance of, where
free Pus exists in Peritoneal
Cavity, methods of, 21-2
Pelvic, in Perforation of Stomach
Ulcer, 35
Simple, in Acute H^emorrhagic Pan-
creatitis, 80 ; in Appendicitis
with Peritonitis, 23
Drainage tubes
Cigarette, 34
Glass, 33
Keith's, 40
Paul's, 52
Dressings, hot, in Cellulitis, 26
Dudgeon, Dr. L. S., and Sargent,
P. W. G., on Pathogenicity of
Gonococcus, when introduced
into Peritoneal Cavity, 69
Duodenal Ulcer, 28
Chronic, Peritonitis due to, 29
Perforation of, 29, 35-6
Case illustrating, 36
Diagnostic difficulties in, 35-6
Operation for, St. Thomas's Hos-
pital, 29
Symptoms, Osier on, 35
Kesemblance of, to those of Acute
Perforative Appendicitis, 35
Ectopic Gestation, Rupture of
Cases illustrating, 72 et sqq.
Excess of Fluid in, 34
Haemorrhage, into Peritoneum in, 72-6
Elaterin, dose of, after Operation, 26
Embolism and Thrombosis of Mesenteric
Vessels, consequences of, 85
Diagnostic essentials in, Gerhardt cited
on, 86
Operative treatment for, 87
Empyema of Appendix, Rupture of, into
Peritoneal Cavity, case illus-
trating, 13-15 ; excess of
Fluid in, 34
Gaseous, after Death from Gastric
Ulcer Perforation, 30
Enema, simple, when needed, 24
Turpentine, when used, 7, 26, 27, 40
Enterectomy for Gangrenous Hernia,
Barker's paper on, cited, 65-6
Enteric fever, see Typhoid fever
Entero-anastomosis, with Anterior Gas-
tro-enterostomy, case de-
scribed, followed by Gastro-
jejunal perforated Ulcer, 43-4
Enterorrhaphy, Suture-line in, 86
Enterospasm, Neuroses in connection
with, 92-3
En-y Gastro-jejunostomy of Roux, 38
Epigastric region, tenderness in, in
Perforated Gastric Ulcer, 31
Wound in, how to close, 35
Eserine Salicylate, Subcutaneous Injec-
tion in relief of Meteorism, 26
Ether, following on Gas, Anaesthetic
used by Author, 19
Facial Expression and Colour in
Acute Abdomen, 2, 3
Appendix Perforation, 8, 9, 14
H hemorrhagic Pancreatitis, 80
Intestinal Obstruction, 58
Peritonitis from Gall Bladder dis-
ease, 87
Rupture of Ectopic Gestation, 73
Volvulus of Ileum, 58
Fffical Abscesses, in Large Intestine,
with sharp small foreign
bodies, Bland-Sutton on, 50
Fistula, see Fistula
Faeces, Fluid, in Perforation of Stercoral
Ulcer, 50-5
Fallopian tube. Rupture of. Gonococcal
infection spread by, 69
Fat Necrosis, 79, 80
Female Generative Organs, Diseases of,
67-77
Femoral Strangulated Hernia, Resection
for, 65
Femur, Suppurative Periostitis of, with
Typhoid bacilli in the Pus,
46-7
Fibroid of Uterus, Acute Necrosis of, 67
Fishgut sutures, when, and how used, 22
Fistula, Fascal, in Abdominal Wound,
after Operation, causes, 26,
38, prognosis and treat-
ment, 26-7
in Hysterical Patient, 90-2
INDEX
99
Fitz, — , on Position of Acute Intestinal
Obstructions, 20
Fitzgerald, Dr. J. G., 72
Fluid, see also Pus
Black, see Black Vomit
Free, when found in
Abdomen, 3, 4, 5, 14, 15, 43, 71
Pelvis, 3, 5, 36, 44, 50, 59
Peritoneum, 10, 15, 31, 33-4, 49-50,
58, 63, 85, 88
Stomach, 82
Greenish, vomited in Acute Abdo-
men, 4
Fluids, see also Injections, &c., and
Saline
Continuous Rectal administration of,
Apparatus for. Fig. 4., 24
Introduction of, after Operation for
Peritonitis, why so valu-
able, 25
" Fowler Position " for patients after
Abdominal Operation, 23
Gall Bladder, Inflammation of, causing
Peritonitis, 86-8
Perforation of. Peritonitis from, 86,
87,88
Rupture of, effects of, 88
Gall Stones, behaviour of, in Gall
Bladder, 88
Removal of, remotely followed by
Enterospasm, 93
Gangrene of
Appendix, with Perforation, cases
illustrating, 6-12
Gut, as complication in Acute Ob-
struction, 60, 63 et sqq. ; in
Obliteration of Mesenteric
Vessels, 85 ; in Volvulus of
Small Intestine, 60
Small Intestine, general, treatment
for, 64-6
Gangrenous Hernia, Barker's paper on,
cited, 65-6
IGardini, — , on a case of Hsematemesis
of hysterical origin, 92
[Gas followed by Ether, Anaesthetic used
by the Author, 19
[Gas and Oxygen, as Anaesthetic favoured
in America, 19
[Gaseous Emphysema, after Death
from Perforating Gastric
Ulcer, 30
I Gastric nerves, part played by in Acute
Dilatation of Stomach &c.,
Laffer cited on, 85
Ulcer, Chronic, local Peritonitis due
to, 29
Perforation of, Acute, Fig. 5,, 28
Gastric Ulcer, eontimied.
Perforation of. Acute, continued.
Diagnosis of, points differentiating
from results of Gangrenous
Appendix, &c., 31-2, 33-4
Treatment and Prognosis, 28-9
Hysterical simulation of symp-
toms of, 89, 90
Operation for, 32-3, 40-3, after-
consequences, 33-5
Peritonic and other symptoms in
cases of, 30, cases illustrating,
30, 32
Position of, most frequent, 30,
4' see Fig. 6., 29
Gastro-enterostomy, see also Gastro-
jejunostomy
Anterior method of, 34, 43
Author's views on best form of, 45
Cases illustrating, 38
Posterior method of, 34
No-loop form of, 45
Gastro-jejunal and Jejunal Ulcers,
Perforations of, 37-45,
two classes of, when met
with, 37
Gastro-jejunostomy, Gastro-jejunal per-
forating Ulcers, subsequent
to, 37 ; form of operation
most conducive to, 37-8
Gastro-mesenteric Ileus, Acute Dilata-
tion of. Pathology of, Laffer
on, 85
Gastrotomy for Haematemesis of Hys-
terical origin, 92
Gauze, Sterilised, as Used in Treatment
of Abdominal wound during
Operation and after, 22, 26
et passim
Generative Organs, Female, Diseases of,
67-77
Gerhardt, — , on essentials in Diagnosis
of Embolism of the Mesen-
teric Vessels, 86
Gestation, Ectopic, Rupture of, 34,
72 et sqq.
Gibson, Dr. C. L., on Intestinal Ob-
struction due to Meckel's
diverticulum, 61, to Stran-
gulated Hernia, 60, to
Volvulus, 60
Godfrey, Dr. A. E., 86, 87
Goepel, — , Successes of, in Operation
for Jejunal Ulcer, 38
Gonococcal infection, sources and route
of, in producing Peritonitis,
69, 72
Goodall, Dr. E. W., on percentage of
Perforation in fatal Typhoid
cases, 46
100
INDEX
Gnodall, Dr. E. W., cont'invrd.
on Shivering in Perforation in Typlioid
cases, 48
Gould, Sir A. Pearce, on Surgical treat-
ment of Gastric and other
Ulcers, 28
Grey, H. T., 74
Gtibler, 56
Gut, see also Bowels, Intestines, Sfc.
Gangrene of, 60, 63 et sqq., 85
Guthrie, T. 89
H^MATEMESiS, cases of, due to
Perforated Duodenal Ulcer, 35
Perforated Gastric Ulcer, 32
Possible Hysterical origin, medical
treatment indicated for, and
case illustrating, 89-92
Haematocele, formation of, after opera-
tion, 75
Haemorrhage from
Ostium abdominale, 75
Kuptured Ectopic Gestation, 72
et sqq.
Operations for, 76
Stomach, see Hgematemesis
Intraperitoneal, 72-4
Intestinal in perforation of Duodenal
Ulcer, 35
Hgemorrhagic Pancreatitis, Acute, case
of, with successful operation,
78-9 ; general features of,
79-80
Hallam, S. E., 16
Harold, Dr. J., and Elaterin, 26
Harper, Dr. C. J., 86
Harwood-Yarred, Dr., on Gaseous
Emphysema of body after
death from Perforated Gas-
tric Ulcer, 30
Hayes, — , Enterectomy by, 65
Hawkins, Dr. H. P., on Enterospasm,
92, 93
Heath, Dr. (the late), 82
Hernia ; —
Gangrenous, Barker's paper on, cited,
65-6
Strangulated, 60
Femoral, Kesection for, 65
Herjiial protrusion, subsequent to Inci-
sion through Linea Semilu-
naris, 19
Sac, Abdominal Distention caused by
Ligaturing, 84
Homerton Fever Hospital, percentage of
Perforation in fatal Typhoid
cases at, 46
Hudsop, A. C, 70
Hugging, G. M., 83
Hunt, S., 82
Hybrinette, — , Successes of, in opera-
tion for Jejunal Ulcer, 38
Hydrosalpinx, in left Fallopian tube, 73
Hypodermic Injections for Collapse
during Operation, 22, 60
Hysterical simulation of Serious con-
ditions. Medical treatment
indicated, 89, instances of,
89, 90-2
Ileum ; —
Typhoid Ulceration of, 28
Perforation in, nature of Ulcers,
37 ; risk of overlooking, 46
Volvulus of. Acute Intestinal Obstruc-
tion due to, operation for,
and cases illustrating, 57-60
Iliac fossa, right, pain in from Per-
forating Stercoral Ulcer, 54
Site of Acute Obstruction, in 67
per cent, of cases, Fitz on, 20
Incisions in Operation, Site of. in
Appendicitis, 17, 19, 20, 23
Cellulitis, 26
Perforation during Typhoid, 49
Induration, in disease secondary to
Appendix disease, 54
Inflammation of
Gall Bladder, causing Peritonitis,
86-8
Lung, po-sible toxic effects of, 81, 84
Injections, Infusions, &c., see Hypoder-
mic, Intramuscular, Intra-
venal, Rectal, Saline, &c., see
also Infusion, awr7 Instillation
Instillation, continuous of Fluids per
Rectum after Operation,
14,24
Intestinal Distension, see Distension of
Abdomen and Intestines, see
also Swellings
Obstruction, Age in relation to, 5-6
Diagnosed (in error) in Acute
Dilatation of Stomach, 81
due to Bands, 44-5
Carcinoma of Large Intestine,
consequences of Perforation
of Stercoral Ulcer in cases
of, 50-1
Pyosalpinx, case illustrating,
70-2
Percentage of, in Acute Abdomi-
nal Cases at St. Thomas's
Hospital, 5, and in causation
of the condition, 56
Position of Patient in, 57
Recurring after, or resulting from,
Operation. 26, 53
INDEX
101
Intestinal Obstrnction — conthivod.
Simulated in Euterospasra, 92-3
Stercoral Ulcer most serious com-
plication of, 53-4
Acute, ofi-GG
Cases illustrating, 57 et sqq.
Commonest forms of, 56
Due to Adhesions between Coils
of Small Intestine, 77
Meckel's diverticulum, case
illustrating, 60-4
Volvulus, 57-60
Gangrene as Complication in, 60,
()3, treatment for, 63 et aqq.
Position frequent of, Fitz on, 20
Chronic, diagnosis of easy, 53
Intestines, nee Large Intestine, and Small
Intestine, and others, under
their iiames
Distension of, diagnostic observation
of, 5
Enterospasm as aflEecting, 92, 93
Intra-abdominal Abscess, 50, 54
Intramural Gestation, case of, 72-4, 76
Intra-muscular injection of Anti-b-coli
Serum, 25
Intraperitoneal, localised. Abscess,
caused by extension of Ster-
coral Ulcer, 50, 54
Intraspinal Injection of Aniesthetic in
Appendicitis, used at the
Hospital for Sick Children,
19
Intravenal Injections of Saline, 22, 30,
33, 74
Intussusception, Age in relation to, 5
Percentage of, as cause of Acute
Abdomen, 5, 56
Iodine, Tincture of, in Vomiting after
Operation, 25
Jejunal Ulcers, Perforation of, 37,
complication of, 38
Keith's Drainage-tube, use of, 40
Laffer, Dr. J, L., on Acute Dilatation
of the Stomach, 85
on Percentage of cases of Acute Dila-
tation of the Stomach, sub-
sequent to operations, 85
Large Intestine ; —
Carcinoma of (low down) effect on
sufferer from, of Perforation
of Stercoral Ulcer, 50-1
Frecal Abscess in, with sharp, small
foreign bodies, 50
Volvulus of, mortality from, 60
Lavage of Stomach in
Appendix operations, 17, 25, care
needed in, 21
Black Vomit, 27
Vomiting after Operation, 25
Lembert sutures, use of, 39, 40, 42, 43,
58, 59, 64, 73, ^- see Figs.
8 & 9., 58, 59
Lewis, C. M., 51
Ligatures, silk, 68, 73
Linea semilunaris, site for Abdominal
Incision, 19, 20 ; in urgent
operation for Typhoid Per-
foration, 49
Liquor StrychniniB Hypodermic injec-
tion of, against Shock, 22, 60
Liver, Diagnostic observations on
{pass'un^ in
Acute Abdomen, 5
Perforated Gastric Ulcer, 31
Localised Abscesses, after Operation for
Perforation of Jejunal Ulcer, 38
Volvulus of Ileum, 38
caused by Extension of Stercoral
Ulcer, 50, 54
Lock, Dr. J. L., 47
Loin (drainage) tube, location for, 21
Lumen of Bowel in Removal of Appen-
dix, and other cases, 63
Lung, Inflammation of, possible Toxic
Effect of, 81, 84
Mackenzie, Dr. Hector, 16, 31, 32, 33,
36, 37, 40, 45, 47, 62, 67,
68, 72
Magnesium sulphate, dose of, after
Operation, 26
Manipulation of exposed Organs during
Abdominal Operations, 20, 21
May lard, E., Successes of, in operation
for Jejunal Ulcer, 38
Mayos, the, posterior " no loop " opera-
tion introduced by, 45
Meckel's diverticulum. Acute Obstruct ion
due to, case illustrating, 60-4,
Fig. 10., 61
Risks of careless division of 63
Medical Treatment, indicated in Hysteri-
cally simulated Acute Abdo-
men, 89, 92
Melaena and Haemorrhage from Stomach
with, 35
Menstrual Irregularity, in cases of
Acute Abdomen, 68 et sqq.,
passim
Pain, Pain of Peritonitis mistaken
for, 10
Menstruation, Vicarious, Hfematemesis
an occasional form of, 92
102
INDEX
Mesenteric Vessels, Embolism and
Thrombosis of, 85-6
Diagnostic Essentials in, Gerhardt
on, 86
Meteorism, after Operation, 71, treat-
ment for, 26
Molasses or Treacle, use of, as Enema, 27
Morphia, Diagnosis complicated by
previous use of, 31
Morphine, after Operation, use, and
drawback of, 25
Mortality from
Perforation of Gastric Ulcers and in
that in Typhoid fever in
relation to earliness of
Operation, 29-30, 49
Perforation of Small Intestine in
Typhoid fever, 45, 46, 49
Volvulus of Small Intestine, 60 ; of
Large Intestine, 60
Mouth-feeding, after Operation, earliest
time for, 25
Moynihan, B. G. A,, on difficulty of diag-
nosis in Duodenal Ulcers, 36
Murphy's button, 39
Muscles into which Anti-b-coli Serum
should be injected, 25
Necrosis, Acute, of Fibroid of Uterus, 67
Bacterial, Acute, in perforated
Stercoral Ulcer, 51
Fat, 79, 80
Nervous Element in Causation of Con-
ditions of Diseases, 84, 85,
89 et sqq.
Nervous Mechanism, as affecting Intes-
tines in Enterospasm, 92-3
Neuroses causing Symptoms of Urgency,
84, 89-93
Norbury, L., 93
Nostrils in. Acute Abdomen, 3
Nurses, Rules for in Typhoid, by
Osier, 46
Skill of, value, after Operation, 7
Obstruction, see Intestinal Obstruc-
tion
Pyloric, double Operation for, 43
(Edema, after Operation for Acute Dila-
tation of Stomach, 83
Omentum, in Operations for perforated
Gastric Ulcer, 34, 35
Suture of, in Resection for Gan-
grene, 65
Operation in Acute Abdomen
Early, extreme importance of, 2. 6,
13, 22-3, 29-30, 31, 37, 38,
46, 49, 63-4
Operation in Acute Abdomen, eontimiefl.
Incision for. positions for, in various
cases, 17, 19, 20, 23, 26, 49
Infusions or injections before, dur-
ing, and after, see Caffein,
Liq. Strychninae and Saline
Manipulation of Organs exposed
during, 20, 21
Quickness in, 19, 20
Sequelaj, see Abscesses, Dilatation,
Hernia, S^'c.
Operations for
Abdominal Distension, 81-5
Acute Hgemorrhagic Pancreatitis
(ideal), 80
Obstruction, 57, 61, 6.3-4
Suppurative Peritonitis in Pregnant
Woman, 13
Embolism and Thrombosis of Mes-
enteric Vessels, 86
Excision of Uterine Tumours, 75
Gangrene of Small Intestine, 59, 64-6
Gastric and Duodenal Ulcers, Sargent
on Early Cases of, 29-30
Haemorrhage into Peritoneum due to
Rupture of Sac in Wall of
Uterus, 72-4
Perforation of
Gastric Ulcers, 29, 30, 32-5, 43,
during Enteric, 49
Ileum, in Typhoid, 37, 46, 47, 48, 49
Jejunal Ulcer, 38-40
Stercoral Ulcer, with Rectal Car-
cinoma, 51
Removal of
Appendix, 22-3, 75, 77
Obstructions due to Adhesions in
Coil of Small Intestine, 77
due to Pyosalpinx, 70-1
Ovarian Cyst, 82, 83-4
Rupture of
p]ctopic Gestation, 72
Empyema of Appendix into Peri-
toneal Cavity, 13
Pyosalpinx, 68
Septic Peritonitis, 13
Trendelenberg's, for Varicose Veins, 89
Volvulus of Small Intestine, 57 et sqq.
Ord's Apparatus for keeping Patient
up in Bed, Fig. 3., 23
Osier, Dr., on Characteristics of Duo-
denal Ulcers, 35
Rules of, for Nurses of Typhoid
cases, 46
Ostium Abdominale, Haemorrhage from,
75
Ovarian Cyst, 71
Removal of, 82
with Twisted Pedicle, 67
Inflamed, removal of, 83-4
INDEX
103
Ovary, Cystic, 75
Oxygen, see Gas and Oxygen
Pads, Deodorizing, use of, 27
Pain, in Diagnosis of, and cases of,
Acute Abdomen, 4
Acute Intestinal Obstruction, non-
Appendix-caused, 56
Enteric Perforations, 48
Local, in, Peritonism, 2, 3
Perforation of Duodenal Ulcer, loca-
tion of, 35
Peritonitis from. Disease of Gall
Bladder, 86-8
Stercoral Perforating Ulcer, loca-
tion of, 5-i
Tubal Abortion, 74-5
History of, previous to attack under
consideration, importance of,
4, 11,14, 15,35
Menstrual, Appendix-pain mistaken
for, 10
Palpation of Abdomen, 3, 4, 56, 80
Pancreas, Incision of, 80
Pancreatic Secretion, destructiveness
of, 80
Pancreatitis, Acute Hemorrhagic, and
case illustrating, 78-80
Paralysis of Distended Abdomen, sug-
gested cause for, 84
Parotitis, and complications, post-opera-
tive, 83
Paterson, H. J., on location of Perforated
Stomach Ulcers, 35
Paper by, on Jejunal and Gastro-
jejunal Ulcer referred to,
38
Pathological Perforations of the Diges-
tive Tract, 28-55
Paul's tube, when used, 52
Pedicle of Ovarian Cyst, twisting of, 67,
83
Pelvic, or Gynaecological cases, percen-
tage of, in Acute Abdominal
Cases, St. Thomas's Hos-
pital, 5
Organs, moment for examining, in
Appendix Operation, 21
Pelvis, Acute conditions arising from
within, 67-77
Contents of, condition of, diagnostic
observation of, 5, 31, 35, 36
Drainage of, in Perforation of Stomach
Ulcer, 35
Pus in, 10, 17, 68, 71, et alibi
Sterilization of, during and after re-
moval of Appendix, 10, 21
et passim
" Peptic" Ulcers, 37
Percussion of Abdomen, 3, 4, 11, 33-4,
68, 79
in Diagnosis of Gastric Ulcer Perfora-
tion, 31, value of, 33-4
Pain increased by, in Peritonitis, 56
Perforation in
Alimentary Tract,
Age in relation to, 5
Percentage of, in Acute Abdominal
Cases, St. Thomas's Hos-
pital, 5
Appendix, with Gangrenous condi-
tion, late realised, cases
illustrating, 6-12
Peritonitis from, possible mistake
in diagnosis of, 56
Suppuration after, 15, 17
Digestive Tract, Pathological, 28-55
Duodenal Ulcer, 28, 29, 35-6
GallB ladder. Peritonitis from, 86,87,88
Gastric Ulcer, 32-5, 43
Hysterical Simulation of, 89, 90
Gastro-jejunal and Jejunal Ulcers, 37
Hollow Viscera, Peritonitis from,
forms of Acute Intestinal
Obstruction producing simi-
lar effects, 56
Ileum, during Typhoid, 37, 45-6, 48,
49, 50
Diagnostic difficulties concerning,48
Operation for, consensus of opinion
favouring, 48, mode of, 49
Stercoral Ulcers, 50-5
" Pericolitis Sinistra," paper on, by
Rolleston cited, 50
Periostitis, Suppurative, of the Femur,
with Typhoid bacilli in Pus,
46-7
Peristalsis, 5, 42, 43
Peritoneum, Acute invasion of, or serious
lesion of, indications of, 2
Blood in, accumulating from rupture
of Ectopic Gestation, 72,
sometimes clotted, 73, 74
Fouling of, by Perforating Stercoral
Ulcer, 50-5
Free fluid in, 10, 20, 31, 33, 34, 63 et
alibi., rare case of, 49, 50
Gentleness essential in dealing with,
during Operation, 20, 21
Incision into, object of, aspis aller, 23
Mode of affection of, by Gangrene and
Perforation of Appendix, 7
Pus in, 10, 17, 68, 71, et alibi
Rupture into, of
Cyst, 67
Ectopic Gestation, 34, 73, 74
Septic inflammation of, tending to
diffusion, fatality of, if un-
recognised, 6
104
INDEX
Peritonism from Perforation of Ileum
(luring Typlioid, risk of over-
looking, 46
in Acute Intestinal Obstruction (non-
Appendix-caused), diagnostic
methods in, 5(5-7
of Embolism and Thrombosis of
Mesenteric Vessels, 85
Indications of, 2
Peritonitis ; —
Acute
Secondary to disease of Appendix,
cases illustrating, G-12
Septic, rarity of recovery from, 13
Suppurative in a Pregnant
Woman, early operation
essential in, 13
" DifEused," 6, and " General "
difference between, empha-
sized, 13
or "Spreading," varying charac-
teristics of, 22
Position (usual) of Patient in, 57
Diagnosed in Acute Dilatation of
Stomach, 81
Due to Chronic Gastric and Chronic
Duodenal Ulcers, 29
Gall Bladder disease
Diagnostic errors possible in, 86
Nature of, 87-8
When usually fatal, 88
Gonococcal Infection, source and
route of the infection, 60, 72
Pelvic causes, Pyosalpinx the most
important cause of, 69
Perforation of Hollow Viscera, forms
of Obstruction likely to be
confused with, 56
of Stercoral Ulcer, 50
Fluid introduced into system after
Operation for, value of, 25
Septic, due to Ruptiure of Fallopian
tube, 70, 71
Perry, L. B., 13
Petch, C. H., 67
Pinches, H. J., 46
Position of Gastric Ulcers, most frequent,
30, Sf see Fig. 6., p. 29
Position for Incision in Operation for
Appendicitis, 17, 19, 20
of Patient in Intestinal Obstruction,
57
usual in Perforations leading to Peri-
tonitis, 57
Post-operative Treatment in Acute Ab-
domen, 23-7, ^' .we each case
Posterior Gastro-jejunostomy, and Ulcer
Perforation subsequent to, 37
"No loop" Gastro-enterostomy intro-
duced by the Mayos, 45
Poynton, F. J., on Fluid in Peritoneum of
Typhoid patient, 49
Pregnancy, Acute Suppurative Perito-
nitis in. Early Operation
essential in, 13
Proctoclysis, practically essential to cure
in some Abdominal Cases, 23
Promptitude in face of Gangrene as
Complication in Operation
for Acute Obstruction, 63-4
Pulse in Acute Abdomen, 2, 3, 4, 7,
et jujssiiii
Purgatives used after Operation, 25-6, 27
Pus, in Abdomen (lower), 76
in Abdominal wound, 82
in Peritoneum, 10, 17, 21, 68, 69, 71 et
alibi
Pyloric Obstruction, double Operation
for, 43
subsequent to Operation for Per-
forated Gastric Ulcer, 33
Operation for, 39
Stenosis, followed, after Operation,
by I'erforating Ulcer of
Jejunum, 37
Pylorus, Stricture of, 41
Ulcer near, operation for, 41
Pyosalpinx, Intestinal Obstruction due
to, case illustrating, 70-2
Rupture of, cases illustrating, 67-72
Excess of Fluid in, 34
Rash, following use of Anti-toxic
Serum, 25, 83
Rectal Examination in Acute Abdomen,
necessity for, 3, 5
Injection of Warm Saline, when,
why, and how given, 14, 23-4,
33, 36, 42, 60, 74 ; when un-
suitable, 22
Tube, long rubber, when used, 26
Recti muscles. Rigidity of, in Perforated
Gastric Ulcer, 31
Rectum, Carcinoma of, with Perforation
of Stercoral Ulcer, undis-
covered till Operation for
obstruction, 51-2
Rectus, the right, as site for Abdominal
Incision, 14, 17, 19, 20, 49
Reflex effect of injury to Abdomen, 84
Removal of Appendix, see under
Appendix
Resection of Intestine in
Embolism and Thrombosis of Mesen-
teric Vessels, 85
Gangrene of Small Intestine, 59,63 et
seq. ; length of gut removed,
65, shock in relation to, 66
Jejunal Ulcer, 38
INDEX
105
Resection of Intestine Qconthiued)^ in
Perforation in Typhoid, 49
Volvulus of Ileum, 57-66
Respiration in Acute Abdomen, 2, 3, 4,
&% et passim
Restlessness, in Acute Abdomen, 4
~ ght Iliac Fossa, Pain in, from
Stercoral Ulcer Perfora-
tion, 54
Site of much Acute Intestinal Obstruc-
tion, Fitz on, 20
Roalfe-Cox, W., 9, 18
Rolleston, H. D., on Stercoral Ulcers, 50
Roux, Prof., " en-y " operation of, and
so-called "Peptic" Ulcers, 38
Rupture of
^ Appendix Abscess, 15, cases, 16-17 ;
excess of Fluid in, 34
Condition simulated by, 76
Cyst, into general Peritoneal
Cavity, 67
Ectopic Gestation, excess of Fluid
in, 34
Other conditions simulating, 76
Empyema of Appendix into Perito-
neal Cavity, case illustrat-
ing, 13-15 ; excess of Fluid
in, 34
Fallopian tube. Gonococcal Infection
spread by, 69, 72
Gall Bladder, effects of, 88
Pyosalpinx, cases illustrating, 67-72 ;
excess of Fluid in, 34
Sac of Ectopic Gestation, 67, cases
illustrating, 72-7
Tubal Gestation, 72, 75
Uterus, 73 H xqq.
St. Thomas's Hospital,
Cases at, illustrating
Acute Abdominal disease, 1900-2,
porportion due to Inflamma-
tion of the Appendix and
other causes, 5
Disease Secondary to Appendix
mischief, 8
Intestinal Obstruction, 57 et
sqq.
Haimatemesis of Hysterical origin,
with subsequent Faecal fis-
tula, 89, 90 et sqq.
Intestinal Obstruction due to
Meckel's diverticulum, 62-3
Ovarian Cyst, 82-4
Perforation of
Gastric Ulcer, 29, 30, 32-3
Jejunal Ulcer, 38 et sqq.
Small Intestine, in Typhoid, 46-8
A.A. .
St. Thomas's Hospital, continued.
Cases at {continued), illustrating
Peritonitis due to Gangrene and
Perforation of Appendix, 6-12
Rupture of
Appendix Abscess, 16, 17
Empyema of Appendix, 13
Pyosalpinx, 67-72
Sac in Uterine Wall, 72-6
Subdiaphragmatic Abscess, 36
Suppurative Periostitis of the
Femur, with Typhoid bacilli
in Pus, 46-7
St. Thomas's Hospital Reports for 1904,
cited on Pathological Per-
foration of Stomach and
Duodenum, 29
Solutions, variously administered,
see Lavations, Injections,
&c.
after Operation, 24-5
in relief of Shock, 22, 23, 30, 33,
42, 60, 74
Sargent, P. W. G. (see alto
Dudgeon), 71
on Pathological Perforation of Stomach
and Duodenum, 29-30
Scott, G. Brebner, 78
Septic Inflammation, see binder Peri-
toneum
Suppm'ation, Temperature in relation
to, 4
Serum treatment, 14, 25, 83
Sex in relation to
Acute Hasmorrhagic Pancreatitis,
79-80
Duodenal Ulcer, 35
Stercoral Ulcer with Extravasation
and Abscess (localised), 54
Shipman, G. A. C, 82
Shivering, in Ulcer Perforation during
Typhoid, 48
Shock, in
Perforation of Gastric Ulcer, 30, 31
Peritonism, 2, 3
Volvulus of Small Intestine, 60
Resection, in relation to length of
Gut removed, 66
Saline Injection to combat, 12, 22,
23, 30, 33, 36, 42, 60, 74
Sigmoid flexure ; —
Carcinoma of, slow growth of, 53
Distension of, 51, 84
Perforation of, by Stercoral Ulcer,
51-2
Silk Ligatures, 68, 73
Sutures (see also Lembert's), in Resec-
tion, 65
Skin, examination of, in Acute Abdo-
men, 4
106
INDEX
Small Intestine ; —
Gangrene of, Resection for, 51»,
68-6 ; length of gut re-
moved. 65, shock in relation
to, 66 '
Obstruction due to adhesion between
coils of, Operation for, 77
Perforation of, during Typhoid,
4r)-6, cases illustrating, 4G-8,
49-50
Volvulus of, case illustrating, 57-60
Mortality from, 60
Smith, Greig, on Stercoral Ulcer and
Intra- abdominal Abscess, 50
Sodium carbonate, dilute solution of, as
Stomach lavement in A'^omit-
ing after Operation, 25
Spinal Deformity in association with
Acute Stomach Dilatation,
81, 84-5
Splenic flexure, Enterospasm as localised
affection of, 93
Stenosis, Pyloric, operation for, 37
Stercoral Ulcer ; —
Behaviour of, generally, 50
Chronic Intestinal Obstruction,
complicated by, 50, instances
of, 51-3, serious nature of
complication, 53-4
Perforation of, 50-5, cases illustrat-
ing, 51-2, 52-3
Prognosis, 55
Symptoms suggestive of, 51, 54
Treatment. 52
Stercoroliths in the Appendix, 12
Sterilising the Pelvis during Operation,
10, 21 et jms.niu.
Stomach ; —
Acute Dilatation of. and cases illus-
trating, 78, 80, 81-5
Pathology of, Laffer on, 85
Atony of, 81
Dilatation of, after Operation for Per-
forated Gastric Ulcer, 33
Haemorrhage from, see Hfematemesis
Lavage of, in
Appendix operations, 17, 25, care
needed in, 21
Black Vomit, 27
Vomiting after Operation. 25
Ulcers of. Perforation of, 28-35
Position in which most frequent, 30,
4- see Fig. 6., p. 29
Stout Adults, site for Abdominal In-
cision in, 19
Strangulated Hernia, 60
Femoral, Resection for, 65
Strangulation of Bowel {see (d.so Ileum,
Volvulus of). Incomplete,
possible errors concerning, 56
Stricture of
Appendix, 11, 15, 17, 75
Pylorus, 41
Sub-acute Symptoms of Appendix
Disease, Age in relation to,.
17-18
Subcutaneous Infusion of Warm SaUne^
after Operation, 24-6
When unsuitable, 22
Subcutaneous Injection of
Anti-b-Coli Serum, after Operation
for Appendix removal, 14, 25
Anti-b-Typhosus Serum, case illus-
trating, 83
Eserine Salicylate, in relief of
Meteorism, 26
Subdiaphragmatic Abscess, 36
Succussion, in. Acute Dilatation of
Abdomen, 81, 82
Suppuration after Perforation of Ap-
pendix beyond a Stricture,
15, 17
Septic, Temperature in relation to, 4
Suppurative Periostitis of the Femur,,
with Typhoid bacilli in
Pus, 46-7
Supracolic Gastro-jejunostomy, 37-8
Sutures, see also Fishgut, Lembert's, and
Silk Sutures
Applications of, 14, 21, 33, 34, 35, 48,
49, 52
Failure of, instance of, 63, 64
When to remove, 26
Swelling, see also Dilatation, and Dis-
tension
Abdominal, search for, important in
Acute Obstruction, 57, 61
Inflammatory on right side of Pelvis,
in Acute Abdomen, 5
Symptoms of Acute Abdomen, General
and Local, importance of, 3
Subacute, of Appendix Disease, Age
in relation to, 17-18
Tate, Dr. W. W. H., 75
Temperament, in relation to Pulse-rate, 4
Temperature in relation to Acute Abdo-
men (^see passim, all cases,
referred to) 4, 48, 56, 85
Tenderness in Acute Abdomen, 5, 31,
48, 56 et passim
Thin adults, site for Abdominal Incision
in, 19
Thompson, R. J. C., 40
Thornton, F. R., 83
Thrombosis after Operation for Acute
Stomach Dilatation, 83
and Embolism ot Mesenteric Vessels,
85-6
INDEX
107
Tongue, in, Acute Abdomen, 3
Toxaemia, after Operation indications
of, 22, and treatment for, 27
Treatment, see Medical, Serum, Opera-
tion(s), and Post Operative
Tubal Abortion, 75
Gestation, Rupture of, 72, 75
Tubes, drainage (see Drainage, and
Keith's), positions for, 21, 23,
that chosen in Appendix
operation, 23
Tumour, Uterine, see Cyst Intra-liga-
mentous, aiid Pyosalpinx
Turpentine enemas, 7, 26, 27, 40
Twist (see also Volvulus), in
Pedicle of Ovarian Cyst, 67, 83
Small Intestine, 61
Typhoid fever. Bacillus of, see
B. Typhosus
Fluid found in. Peritoneum in, in
rare cases, 49-50
Perforation during, of
Ileum, 37, 46 et sqq.
Small Intestine, 45-8
Ulceration of Ileum and Colon
during, Gould's paper on, 28
Ulceration During Typhoid, of Ileum
and Colon, 28
Ulcers ; —
Carcinomatous, of the Stomach, Per-
foration of, 29
Duodenal. Perforation of, 28, 29,
35, 36
Gastric, Chronic, Peritonitis due to, 29
Perforation of, diagnosis, treatment,
and prognosis, 28-9
Jejunal, and Gastro-jejunal, Perfora-
tions of, 37-45
Stercoral, Perforation of, 50-5, cases
illustrating, 51-2, 52-3
Stomach, Perforation of, 28-35,
Second Perforation to be
looked for, 34
Urine, in Acute Abdomen, 3
Uterine Fibroid, Acute Necrosis
of, 67
Uterus, Sac in Wall of, Bupture
of and consequences, 72
et sqq.
A^ALVULAR Disease of the Heart, in
Embolism and Thrombosis
of the Mesenteric Vessels, 86
Varicose Veins, operation for, 89
Vaughan, J. C. D., 6, 40, 90
Vermicular movements, when observed,
56-7
Vital Depression, see Collapse
Volvulus of Large Intestine, Mortality
from, 60
of Small Intestine, case illustrating,
57-60 ; mortality from, 60
Vomiting ; —
after Operation, 25, 27, 81, 82 ;
persistence of, prognosis, 25 ;
treatment for, 25
in Acute Abdomen, 2, 3, 5, 6, 7
in Acute Dilatation of Stomach, 81, 82
in Perforation of Appendix, 9
in Perforation of Gastric Ulcer, 31, 32
in Peritonism, 2, 3
Watson, Gordon, Fluid found by, in
Peritoneum of Typhoid
patient, 49
Whitehead, E. T., 6
Wilkinson, W., 70, 72
Witney, E. W., 78
Women, elderly, with chronic Constipa-
tion effects on, of Perforating
Stercoral Ulcer, 54
Wound, Abdominal, how to close, 22,
34, 35
Wright, Dr. S. Faulconer, 52, 53, 55
Yeld, Dr. W. H., 9
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