7. Ureteral calculus may exist without tient complains of sudden excruciating, terri. pain (post-mortems are rich in this testi. ble pain which at first is generally diffuse, mony).

but rapidly localizes in the pelvio region. 8. Calculus may exist with the manifesta The sudden pain is persistent, muscular rition of pain in some adjacent visceral tract gidity is intense, the abdomen is tender and only, for example, pain in testicle, or ovary the patient's face is anxious, with the im(genitals).

pending crisis vomiting is not conspicuous. 9. Other diseases of the urinary tract than If the hemorrbagic peritoneal extravasation ureteral caloulus may simulate or duplicate is ample the pain is excruciating and faint. a pain (ureteritis, malignancy, hematuria tu. ness, syncope, shock with extreme anemia ocberculosis, vesical calculus, growth, cystitis). curs. Death frequently occurs from hemor

10. Reno-ovarian reflex, reno-testicular re. rhage. flex,or reno-uterine reflex pains are not signs

Lawson Tait used to advocate that the ovi. of ureteral calculus, but are simply intensi. duct would rupture not later than the fourfied looalizations of pain along the ureter, teenth week. However, it may rupture or which may exist from numerous conditions. abort at any time previous to that. To the 11. Unilateral pain, stabbing pain, mus.

experienced gynecologist a bimanual vaginal cular trauma pain (Jordan Lloyd), stamping and rectal examination reveals in most cases muscular pain (Clement Lucas), pain from ample evidence for an operation. In sudden corporeal trauma (muscular), pain from the

abdominal pain, rapid rise of pulse with lowsensitive ureteral proximal isthmus or pelvis, ering of temperature indicates (hemorrhage) may arise from various conditions other than

gravity and demands surgical intervention. ureteral calculus.

It may be stated that during a decade of at. 12. The characteristic of pain in ureteral

tendance in the Mary Thompson Hospital for calculus is inconstanoy, variation or radiation Women and Children Dr. Lucy Waite and and reflexion. It has a tendency to produce myself bave operated on considerable numsympathetic aching in other abdominal vis- bers of run

bers of ruptured gestating oviducts in which cera.

the patient could not furnish a clinical his13. The pain in ureteral calculus depends tory of very much pain or exact date of rupchiefly on its position (ureteral pelvis and proximal istbmus, sensitiveness) and also on

PYOSALPINX. the mobility of the calculus. 14. Pain (colic) can arise in the ureter from

In pycsalpinx the pain may be sudden and increased ureteral pressure (calculus, strio. excruciating (involving the peritoneum). ture, flexion-obstructing the urinal stream) The patient enforces upon herself extreme or from inflamed ureteral wall-ureteritis. physical quietness, breathing with the prox

15. Ureteral-lithiasis, cholelithiasis, appen- imal end of the abdomen only. The thighs dicitis, ureteritis cystitis, nepbritis, may pro. are flexed, the face flushed, the abdomen duce practically identical symptoms.

tender, sensitive and rigid, the expression Intoxications.-Uremia may be accom. that of impending crisis. Bimanual vaginal panied by abdominal pain, lead colio, blue examination reveals a large uneven niass, gum line and occupation. Food of concen- which is excruciatingly painful. trated nature as meats may produce such The mass should be palpated gently for concentrated urine that ination is accom. fear of rupture. One of my patients with a panied by pain.

very large pyosalpinx strained at stool, caus

ing rupture and death from peritonitis. At TRACTUS GENITALIS.

the autopsy I found perhaps a qnart of pus, The sudden acute abdominal pain arising free in the peritoneal cavity. She died from from the genitals is more easily interpreted excruciating pain and shook in some ten and managed. The pain can be more defin. hours. itely located by the patient; and sudden dis. In regard to the character of sudden aborganization of viscera, being accessible in dominal pain arising from the genitalis is the pelvis, is much more within control of more easily interpreted and managed. The the gynecologist. The sudden acute abdom- pain can be more definitely located by the inal pain from the genitals is generally due patient; and sudden acute abdominal pain, it to a ruptured ectopic pregnancy, or the very varies as to its mode of attack, and as to vis. rare matter of the rupture of a pyosalpinx cera attacked. into the peritoneal cavity. Most of the pains are of slower origin and almost diagnosable.

AXIAL TORSION OF PEDICLES OR VISCERA. Sex and the reproductive age aid in the inter. Torsion of style or rotation of pedicle of a pretation of the case.

visous is characterized by sudden severe abWith a ruptured pregnant oviduct the pa- dominal pain. The intensity of the pain depends on the completeness of the constriction Axial torsion of abdominal viscera (tuin the pedicle.

mors) are no doubt rotated by the peristalsis The tumor rotated on its axis gradually en- of the viscus itself or tbat of adjacent vis. larges because the venous blood can not re- cera, especially the colon (sigmoid), wbioh by turn, while the arterial blood continues to its rhythmic movements cotates the ovarian pass into the tumor. Ovarian tumors rotate tumor the omentum and the ilium about the on their axis or pedicles perbaps the most cecum. Tumors with axial torsions should frequently subsequent to parturition. The be at once removed, while vital viscera with initial pain is generally severe but not excru- axial torsion should be reduced, untwisted, oiating like extravasation in the peritoneal detorsioned, and sutured in situ for axial tor. cavity. As usual the pain is first diffuse, sion tends to recur. It may be due to the and later becomes localized in the region of constriction, to the blood vessels, to the perthe increasing tumor from accumulating istalsis cr adjacent peritonitis. verous blood and nerve trauma.

Hyper-rigidity of abdominal muscles and CHIEF FACTORS INVOLVED IN SUDDEN ABDOM. hyperesthesia of abdominal skin accompanies,

INAL PAIN. exists (on account of reflex irritation in the spinal cord).

The accompanying table presents a bird'sOne of the most important aids to diagno- eye view of some of the practical factors insis is that the women possess a tumor, and volved in sudden abdominal pain. Indelible that with accompanying abdominal pain the opinions must be entertained in the diagnotumor gradually enlarges because the rotat- sis as to the signification of the abdominal ing pedicle easily constricts the thin walled pain whether it be from peritonitia (sentia veins, while the rigid walled artery persists lesion from adjacent viscera) or pain from in injecting its continuous stream into the violent peristalsis (colio) or tubular viscera tumor.

(due to mechanical irritation, calculus, stricI have witnessed torsion of pedicles in ture, flexion or from inflamed parietes). For ovarian tumors, oviduct sigmoid, ileocecal practical purposes I will present a skeletal apparatus, myoma, enteron, omentum and table of sudden pain of the six visceral tracts, kidney. Torsion of pedioles may apply to intestinal, urinary, vascular, lymphatic, nertubular viscera (ureter, intestine, oviduct) vous, and genital. It is evident that abdomas well as vessels.

inal pain rests on some common factors, as I bave operated on subjects with mycmata (a) flexion (b) stricture; (c) calculus (violent rotated to such an extent that the entire orig. peristalsis, colic) of tubular viscera, in which inal blood supply was completely obliterated, the danger and pain are limited. Perforation the tumor being nourished by newly formed (extravasation into the peritoneum) of tu. blood vessels from adjacent viscera, especially bular viscera in which danger and pain are from the omentum majus. Rokitansky of unbounded. A decade ago it was thought Vienna, first called attention to the axial ro- sufficient to remember the three dangerous tation of tumors some forty years ago.

peritonitis regions, viz, pelvic, appendicular, The facility of pedicular torsion depends and gall-bladder. With the present accumuon the elongation and limited dimension of Tated knowledge of the abdominal viscera the the pedicles. Volvulus is but axial torsion field presents problems of increasing complex. fucilitated in the sigmoid by a narrow foot or ity as presented in the following bird'seye base (due mainly to mesosigmoiditis).

view of numerous causes of abdominal pain Axial torsion of the digestive tract consti. in the several visceral tracts: tutes about one-fortieth of intestinal obstruction. Perhaps 6% of ovarian and parovarian

1. Gastrium, en tumors experience axial torsion. Mr. Lawson

teron, appendix.

calculus Tait saw some 70 cases, and as his pupil I

2. Biliary ducts. witnessd with admiration his amazing acumen

3. Pancreatic in diagnosing and successfully operating on axial rotated tumors. My assistant, Dr. A.

(sigmoid 60 per cent Zetlitz, operated on a paiient with almost

4. Volvulus complete torsion of the uterus, and in exam

(enteron 10 per cent ining the specimen evidence demonstrated it.

5. Strangulation.

apertures self that it was a slow chronic process and closely associated with peristalsis.

( ileocecal apparatus Axial torsion of viscera may be acute or

6. Invagination chronic, complete (pathologic) or incomplete (physiologio), hence the manifestations of

7. Ulceration (gastrium, enteron, colon) pain will vary.

i 8. Splanchnoptosia.

flexion stricture


1 colic


Jileocecal apparatus 130 per cent

1. Tractus



70 per cent enteron 15 per cent (colic 15 per cent

(c) ducts - calculus,
inflammation, neo-

plasm, pancreatitis.
I (d) parenchyma-ne-

perforation, colic.

II. Tractus


2. Bladder

1. Oviduct

torsion, neoplasm.

III. Tractus


perforation, abortion

inflammation, colic,
torsion, neoplasm.

IV. Tractus


V. Tractus


VI. Tractus


pain-on pressure.

(a) ducts - calculus,

caloulus, stricture, obstruction, volvulus, flexinflammation, neo(a) Liver plasm.

ion, uviduotal gestation, parturition, constipaTib) parenchyma, heplatitis, neoplasm.

tion, aneurism, invagination, hernia, strangu

lation by bard (inflammatory) (pain limited, (Appendages)

periodic, life not in jeopardy); (c) that from | (b) Pancreas

painful peristalsis (colio inflammatory) from 1 crosis, neoplasm. inflamed parietes of tubular viscera, as | (c) Spleen--splenitis neoplasm

ureteritis, oboledochitis, salpingitis, cholecys. flexure, stricture, cal

titis, cystitis, myometritis, myocorditis, en( 1. Ureter culus, inflammation, teritis, colitis, appendicitis (pain periodic. in.

flammatory, life not in jeopardy). First and ( calculus, inflamma tion, perforation,

foremost for practical purposes it will be incolic.

structive to consider sudden abdominal pain ( 3. Prostatitis-vesiculitis, seminalitis. from perforation of the three excretory mu

cous visceral tracts, viz: intestinal, genital ( perforation, abortion, and urinary (as they not only perforate but colic, inflammation,

develop immediate sepsis and jeopardizes (perforation, inflam.

life). Second, sudden abdominal pain should 2. Ovary

mation, torsion, be considered from perforation of the two neoplasm.

non-excretory, non-mucous visceral tracts, 3. Uterus

viz., vascular and lymphatio (as they perfor

ate, but do not develop immediate sepsis nor Veins-phlebitis, thrombosis.

place life in immediate danger). Vascularis

II. In making a diagnosis of sudden ab(Artery-aneurism.

dominal (constant) pain probability is the ( peritoneum- peritonitis.

rule of life, e.g., (a) sudden abdominal pain Lymphaticus (ducts-lymphangitis.

(constant) pain accompanied with vomiting, (pain-constant, periodic.

abdominal rigidity, rise of pulse and temperature, tym panitis, is peritonitis (perforative), as appendioular, genital, biliary, gastro-intestinal, hemorrbagio pancreatitis. (b) Sud.

den (inconstant) abdominal pain with prac. CONCLUSIONS AS REGARDS SUDDEN ABDOMINAL

tically negative pulse temperature, abdominal PAIN.

rigidity, tympanitis and perhaps vorniting, is I. There are three kinds of sudden abdom. violent peristalsis (colio), as flexion, stricinal pain, viz: (a) that of peritonitis, perfor. ture, calculus, inflammation, strangulation, ation (inflammatory, septic lesions from ad. invagination, volvulus, axial torsion. jacent visceral peritoneal extravasation, con. III. Extravasation in the peritoneal cavity tinuous excruciating pain (pain, continuous, is accompanied by agonizing, excruciating unlimited, and life in jeopardy), as 1, perfora. pain. tion of the tractus intestinalis (gastriun, IV. The leading symptoms should not be enteron, colon, appendix-its appendages, obscured by opiates until its complete clinibiliary or pancreatic channels).

cal history as possible is obtained. 2. Perforation of the tractus genitalis (ovi. V. The clinical history is frequently a ductal gestation, pyosalpinx, bydrosalpins, pencil of light in the diagnosis of sudden abuterus, orary).

dominal pain. 4. Perforation of the tractus urinarius VI. Examine the patient completely from (kidney, ureter, bladder).

bead to foot (especially per rectum and per 4. Perforation of the tractus lymphaticus vaginum). (chyle duct, chyle cysts, chyle channels). VII. Exploratory peritonotomy is chefly

5. Perforation of the tractus vascularis justified only in ascertaining the exten of (aneurism, hemorrhage, embolus, oviductal visceral diseases and rarely justified to de. gestation, is hemorrhage). (The tractus in termine a diagnosis. testinalis, urinarius, genitalis, vascularis, VIII. Delay in deciding the diagnosi of lymphaticus may perforate, intraperitoneal sudden serere abdominal pain should be or extra peritoneal. In extra peritoneal per avoided. Prompt diagnosis is the neet foration, the pain is similar to intraperi. anchor for immediate successful mediod or toneal perforation except in degree, how surgical treatment. ever, the danger of the extraperitoneal vis. IX. It must be remembered that suden ceral perforation is limited); (b) that of vio- severe abdominal pain is a matter of raptent peristalsis (colio, non-inflammatory) of ity, and prompt investigation with propt lubular viscera, as in mechanical irritation. decisions should occur so that the patiat's

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life may not be placed in jeopardy by de. ever in 1888 by one of the greatest surgical lay or disastrous treatment be instituted geniuses of his age-Lawson Tait (1845-1900).

X. (a) Determine, if possible, the location of the initial pain; (b) enquire if the

Heat (hot, moist cornmeal poultice, hot paid was at first diffuse in the central abdo.

water bag, hot bath) aids to relieve pain. men for a while; (c) later and final observe

No cathartics—cathartios stimulate peris. whether the pain localizes itself in the region

talsis, increases pain and distribution of sep. of the affected organ (peritonitis).

sis. They induce vomiting. A rectal enema XI. The location of the pain may be su.

(or two) may be etoployed—the composition perficial (hyperesthesia of the skin) or deep

may be equal parts of molasses and milk, soap in the muscularis (rigidity). McBurney's suds, glycerine, magnesium sulphate. Recpoint is a skin hyperesthesia (from the cutane

tal injections of air. ous branches of the twelfth dorsal and first lumbar nerve-the ileo-hypogastric). XII. The location of the sudden abdom.

THE REASON FOR “PATENTS.”—And here inal pain is indicated by the segment (80

it may be remarked that there is a reason matic) of the spinal nerves in adjacent ab.

for the “patent-medicine fake.” Many dominal muscles (rigidity), skin (byperes.

patent and proprietary” compounds are disthesia). The diseased abdominal viscus is protected, fixed by muscular and nerve mech

tinotly useful. · Sometimes they fill a void anism similar to the muscular protection

in wbat we are wont to term "legitimate"

therapeutics. Most of those that are fixation of an inflamed joint.

worthy of confidence have been manufactured XIII. The topographic anatomy of the

in the first instance, from the prescriptions abdominal viscera should be mastered, for, it

of physicians. Many patent compounds is the solid ground of nature on which rests rational diagnosis. This can be accom

have become distinct evils, whatever they

may have been originally.-M. F. Cupp, plished by study in the cadaver and at au.

American Jour. of Clinical Medicine. XIV. Remember the major regions of peri. CONCERNING THE DIAGNOSIS.—Joseph N. tonitis-appendicular, pelvic and that of the Study declares that upon the correot diaggall-bladder.

nosis depends the intelligent administration XV. Remember the major regions of vio- of therapeutio agents, the proper use of sur. lent peristalsis, colic (calculus), biliary, gical appliances, and the all-important quesgreteral, oriductal and pancreatic.

tion of the necessity of operative surgical pro. XVI. Call the most available and compe- cedure. After reviewing the history of tent abdominal surgeon early in consultation. some of the modern aids to diagnosis, he

XVII. Remember that operations do not concludes that we are justified in saying kill-it is disease that tolls the funeral bell. that it is unwise to declare that an indi. XVIII. Operations on the dying are unsat vidual is suffering from some disease sin

ply because the specifio bacillus is found in GENERAL TREATMENT OF SUDDEN ABDOMINAL

the body, that the Widal or diazo methods in.

dicate typhoid fever, or that the tuberculin PAIN.

test indicates tuberculosis. These helpful First and foremost, should be introduced: methods of diagnosis the writer believes to be -(a), anatomic rest which is maximum somewbat limited in value, and too mucb dequietude of skeletal or voluntary muscles. pendence should not be placed in them as a Retire to bed not to rise for defecation or class unless they are accompanied by the urination; (b), physiologic rest which is clinical phenomena which are characteristio minimum function of viscera. Food and Auid of the disease. The microscopical examinaare probibited per mouth.

tion of diseased structures, secretions and exNo anodynes or in minimuin repeated doses

ceptions has often cleared up a doubtful diag. until clinical history and the diagnosis is

nosis. The writer concludes by saying it

would perhaps be fair to say at the present completed (maximum doses of anodynes ob. scures the diagnosis).

time that there are many cases both of a med.

ical and surgical nature, in which the diag. (NOTE.—The method of treatment for ab. nosis must be somewhat limited. The phy. dominal pain by anatomic and physiologic sician who would serve his patient best must rest was especially advocated by the distin. use all methods for correctly interpreting dis. guished English physician, Wilkes, in 1865 ease and other abnormal conditions of the fliving at present), continued hy the cele. body, not relying upon any one procedure to brated American Alonzo Clark (1807-1887) the exclusion of others which have been by the 'opium splint" and established for proven to be meritorious.--Medical Record.


The Medical Society of City Hospital Alumni

President, LOUIS H. BEHRENS, 3742 Olive Street
Vice-Pres., WALTER C. G. KIRCHNER, City Hospital

Secretary, FRED. J. TAUSSIG, 2318 Lafayette Ave.
Treasurer, JULES M. BRADY, 1467 Union Avenue


Scientific Communication, Wm. S. Deutsch, 3135 Washington Ave. Executive, A. Ravold, Century Building

Publication, W. E. Sauer, Humboldt Building Entertainment, Frank Hinchey, 4041 Delmar Ave.

Public Health, R. B. H. Gradwohl, 522 Washington Ave


Thibout half this is the that he me

A CASE DIAGNOSED CARCINOMA VEN- says about a teaspoonful-of blood and mu.

TRICULI WITH RARE AND UNEX- cus. This relieved his pain considerably, PECTED FINDINGS.

and deglutition became much easier. I saw

the patient for the first time the next mornJEROME E. COOK, M. D.

ing. He then told me that he had just

"choked up”—this is the expression be used ST. LOUIS, MO.

-about half an ounce of light red blood. I wish very briefly to present the history This I saw, it was partially clotted with a and course of a case wbich to me at least was small amount of mucus not intimately both interesting and instructive. The case mixed, which on microscopical examination was seen by several more experienced than I was seen to consist mainly of red blood cells without suspecting the correct diagnosis; in good condition with a number of nonthe history, with the exception of the one fact degenerated leucocytes and a few bacteria. which would have made the diangosis, was On the same day patient had a very large, fairly complete and accurate as substantiated tar-like passage from the bowels. With the by the patient's daughter. Following is an exception of this local trouble patient has abbreviation of the history and clinical nota no pain or discomfort, but he feels very weak. tions:

He says that during the past three months White, male, age about 70, and a brick. he has lost considerable weight, even as layer by occupation; entered the City Hospi. much as 25 or 30 pounds. (His sister also tal November 15th, 1905, with the diagnosis says that in the past half year he has lost of debility. Habits were good; takes beer greatly in weight and strength.) occasionally, no whiskey. Family history Physical examination shows a fairly well shows no bereditary taint, no tuberculosis, built man of large frame, somewhat emaciated, canoer or neurotic tendencies.

skin loose, cheeks sunken, clavicles promi. Previous History.-Had measles, scarlet nent, sallow complexion, mucous membranes fever and varioloid in childhood. Has had very pale, only one or two teeth remain in the several attacks of rheumatic fever, the last mouth, tongue dry and swollen, pupils equal one occurring a year ago. Has been subject and reaot. The breath has a peculiar foul, to attacks of sore throat.

fishy odor. The swelling which the patient Present Trouble.- Patient says he has had says is at the base of his neck is not evident. an attack “just like this" before. This is Chest is quite well formed, etc., no rales, no corroborated by his sister, who says that abnormal dullness, area of cardiao and hepaabout ten years ago he was taken with the tic dullness not increased. Second aortio same kind of sickness, and the doctors did sound is slightly accentuated. Abdomen flat, not think he would live. His present illness epigastrio pulsation, muscles flabby, no tenbegan a week before the patient entered the derness, no palpable masses, no ascites, no vishospital when he noticed that his throat was ible bernia. No general glandular enlargegetting sore, swallowing was very painful, ment, no edema, arteries very markedly and he became very hoarse. He did not take sclerosed. Pulse 96, respiration 24, temper. solid food, because it gave him too much ature 98.4. The temperature remained about pain, but liquids he was able to take without this point, or was a little subnormal during so much discomfort, and they passed readily bis illness. The urine shows a low specifio enough to the stomach. Two or three days gravity, a trace of albumin, and some casts. after the beginning of the trouble patient The trouble is evidently about the upper says a diffuse swelling appeared at the base part of the digestive traot. The tongue is of bis neck, he indicates the suprasternal re- dry, swollen and glazed, the under surface is gion.

congested and shows dark blue dilated veins; On the day he was admitted to the hospi. the mouth and pharynx are dry. The laryntal he expectorated a small amount-patient goscope shows the lower pharynx and the

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