MEETINGS ^Bristol
OF
SOCIETIES.
/iDefcico^Cbmircjical April 10th,
Society*
1912.
Mr. C. A. Morton, President, in the Chair.
diagB0^ ca^at
Dr. J. Odery Symes opened a discussion on The of the causes of chronic recurrent abdominal pain. The of chronic and recurrent abdominal pain are so numerous time will only permit to mention many of them, then to the consideration of those presenting the greater culties. The headings of his address are as follows:?
^
Passinjj0i-
MEETINGS OF SOCIETIES.
(1) Stomach, duodenum, Functional.
and intestinal appendix. Obstructive.
Inflammatory.
Malposition.
Ulcerative.
(2)
283
Pancreas and liver and
gall-bladder.
Inflammatory.
Calculi.
Tumour.
(3)
Renal.
Aneurysm
of aorta or mesenteric arteries, diseases of spinal cord and membranes (tabes, caries, psoas abscess),
^n,
j
and diseases of the
Co^c. hysteria, neurasthenia,
or?
pelvic
t)r. Walter Swayne dealt with
the incidence and symptovalue of abdominal pain in diseases of the female nerative organs. He called attention to the localisation of ^.1 e different pathological conditions by the pain to which they rise, and to the way in which inflammation of the appendix s^e was aPt t? he associated with inflammatory aft ?f the right appendages, while on the left diseases of th ec^0ris left Sl^rrL?i(i might lead to mistaken diagnosis of disease of the ?vary and tube. He alluded to the fact that uterine disacements, especially retroversion of the uterus, might give *? Pain in the hypogastrium. He also pointed out how in tumours and fibroid tumours of the uterus abdominal Was an imPorfant indication of such accidents as twisted aicles in the one and degeneration in the other. The occurCe ?f abdominal pain in pelvic inflammation was also alluded and its special characteristics described. The characteristics ,0j* abdominal pain due to ectopic gestation were also noticed, and atten1ion drawn to its sudden onset and engravement cha racterThe characters of the pain produced in pregnancy bv *s Prohably rheumatic myositis were also dealt with, Was shown that acute abdominal pain during pregnancy, Co *n ^Pe anexcept as the concomitant of some gross pathological such as tumour of the gravid uterus of or the pedicle of tumour existing with pregnancy, or of concealed The pain due to carcinoma of the bod ental hemorrhage. uterus was als? alluded to, as well as to the acute taw by a stone in the ureter, which might be mis-
atlc
0riVe .
0ve Da^rian De!r
^
'
acci?|Var^an
Ipaijf
Pj?duced
11
oophoritis.
Waterhouse referred app^/upERT dyspepsia, which x
There Was
of
he had
to the condition known as two cases in young girls.
seen
pain and vomiting after food, but laparotomy revealed
284
MEETINGS OF SOCIETIES.
appendical adhesions and concretions to be the probable causeHe thought surgeons were apt to overlook the gastric crises o1 He had, tabes and lead poisoning as causes of abdominal pain. lea seen cases in which ulcer followed had however, gastric colic, and in one case of the kind, with perforated gastric ulcer> an operation was not performed, because the patient was know11 to have suffered from lead colic. The speaker had no belief the moral effect of operation in hysteria, and consider? operation should be avoided in abdominal hysteria. thought the signs and symptoms of that form of abdomina trouble were not sufficiently taught. The patients were fre and vivacious women, quently alert, complained of stomac no rigidity and no hyperalgesiaThere was and pain vomiting. Deep pressure into subjacent structures elicited pain, w^lC seemed to lie along the aorta and iliac vessels.?Mr. Carwahd1^ referred to the surgical causes of abdominal pain, and gave tn following classification : (1) Colics of internal origin, 1 mesenteric and omental twists, (3) inflammation of organ when the inflammation spread to the peritoneum, (4) impapti? "
"
.
'
'
pointe tn3^
of viscera, (5) thrombosis and embolism of vessels. He out that the organs themselves are generally painless, but the mesenteric attachments and parietal and visceral pe*"1 toneum are susceptible to pain. Referred pains cannot ^ associated with any particular organ unless at some time for other that organ is tender. accurate Conversely, the local tenderness should correspond with definite pains. The application of the foregoing to specific instanc was then detailed. Gastric ulcer may be present without pa " " The so-called hunger pain is associated with lesions inW ^ right hypochondrium involving the peritoneum, not alone a duodenal ulcer. The pain of gall-stones, renal mobility
diagn?s1^
re^erree5.
calculus, appendicitis, intestinal colic, twisted ovarian
pedic
'
etc., was discussed on the same lines.?Dr. Michell Cla said that if severe abdominal pain and tenderness were In obsC the cause was something more than dyspepsia. cases of pain a lead line should be looked for and the k jerks tested. A patient with chronic recurrent abdominal p 01 gradually becomes neurotic. Mucous colitis as a cause c had to be remembered, also abdominal pain due to chest unresolved Swain ditions, e.g. pneumonia.?Dr. James the subject too large to admit of a full discussion of the causes of chronic and recurrent abdominal pain, which had ^ so well classified by Dr. Symes. He agreed that the ^ common causes of such pain were usually found in with the appendix, kidney and gall-bladder. These, ^ rarely presented any difficulty. The tenderness at McBnr the reflection of the * in the case of the
Prese.re
"
"
th?u&^
assoCiaver, hmveey's
point, along
the last dorsal,
appendix, ilio-inguinal and
ilio-hypogastric
ne
285
OBITUARY. 111
affections
of the kidney, and the sub-costal tenderness in the gall-bladder, were very helpful in diagnosis in these Several conditions. Many cases of chronic and recurrent pain
Case of the
jvere
due to
lstory
some
form of intestinal adhesions, and here
a
simple?of hernia, peritonitis?tuberculous or appendicitis would aid us in coming to a conclusion ?Peration, as regards the probable origin of the trouble. Mucous colitis ?Ust also be thought of, and he (the speaker) had occasionally consulted in such cases with a view to operation for supposed lSease of the appendix. An examination of the stools would PreVent error. There was one class of case to which reference no^ been made, namely simple colic, which is often very 'tficult to differentiate from intestinal adhesions or malignant f ?wth. He had seen many cases where the recurrent pain, C?nstipation, abdominal distension, and even wasting and ?Ccasional vomiting, which may occur in cases of colic, caused ?reat difficulty in arriving at an accurate diagnosis. The occurfice of occult blood in the fasces would be suggestive of an cer either simple or malignant, but he was not inclined to give Uch weight to the fact of retardation of a bismuth meal as an to the diagnosis of obstruction from malignant growth. J. anY cases of simple colic could only be diagnosed from the patient in bed. l^hgnant disease by carefully watching spite of the relief of constipation and careful dieting, the Patient steadily lost weight the abdomen should be explored, an early" malignant neoplasm would probably be found ; if improvement took place under these conditions, the case one of simple colic, and we could justifiably a0uld probably be Brasher agreed that a interference.?Mr. surgical t^?id in obscure cases should be made by lanor?ugh exploration Parotomy, but opposed the advice to use a transverse incision. v
of former
or
OF
SOCIETIES.
/iDefcico^Cbmircjical April 10th,
Society*
1912.
Mr. C. A. Morton, President, in the Chair.
diagB0^ ca^at
Dr. J. Odery Symes opened a discussion on The of the causes of chronic recurrent abdominal pain. The of chronic and recurrent abdominal pain are so numerous time will only permit to mention many of them, then to the consideration of those presenting the greater culties. The headings of his address are as follows:?
^
Passinjj0i-
MEETINGS OF SOCIETIES.
(1) Stomach, duodenum, Functional.
and intestinal appendix. Obstructive.
Inflammatory.
Malposition.
Ulcerative.
(2)
283
Pancreas and liver and
gall-bladder.
Inflammatory.
Calculi.
Tumour.
(3)
Renal.
Aneurysm
of aorta or mesenteric arteries, diseases of spinal cord and membranes (tabes, caries, psoas abscess),
^n,
j
and diseases of the
Co^c. hysteria, neurasthenia,
or?
pelvic
t)r. Walter Swayne dealt with
the incidence and symptovalue of abdominal pain in diseases of the female nerative organs. He called attention to the localisation of ^.1 e different pathological conditions by the pain to which they rise, and to the way in which inflammation of the appendix s^e was aPt t? he associated with inflammatory aft ?f the right appendages, while on the left diseases of th ec^0ris left Sl^rrL?i(i might lead to mistaken diagnosis of disease of the ?vary and tube. He alluded to the fact that uterine disacements, especially retroversion of the uterus, might give *? Pain in the hypogastrium. He also pointed out how in tumours and fibroid tumours of the uterus abdominal Was an imPorfant indication of such accidents as twisted aicles in the one and degeneration in the other. The occurCe ?f abdominal pain in pelvic inflammation was also alluded and its special characteristics described. The characteristics ,0j* abdominal pain due to ectopic gestation were also noticed, and atten1ion drawn to its sudden onset and engravement cha racterThe characters of the pain produced in pregnancy bv *s Prohably rheumatic myositis were also dealt with, Was shown that acute abdominal pain during pregnancy, Co *n ^Pe anexcept as the concomitant of some gross pathological such as tumour of the gravid uterus of or the pedicle of tumour existing with pregnancy, or of concealed The pain due to carcinoma of the bod ental hemorrhage. uterus was als? alluded to, as well as to the acute taw by a stone in the ureter, which might be mis-
atlc
0riVe .
0ve Da^rian De!r
^
'
acci?|Var^an
Ipaijf
Pj?duced
11
oophoritis.
Waterhouse referred app^/upERT dyspepsia, which x
There Was
of
he had
to the condition known as two cases in young girls.
seen
pain and vomiting after food, but laparotomy revealed
284
MEETINGS OF SOCIETIES.
appendical adhesions and concretions to be the probable causeHe thought surgeons were apt to overlook the gastric crises o1 He had, tabes and lead poisoning as causes of abdominal pain. lea seen cases in which ulcer followed had however, gastric colic, and in one case of the kind, with perforated gastric ulcer> an operation was not performed, because the patient was know11 to have suffered from lead colic. The speaker had no belief the moral effect of operation in hysteria, and consider? operation should be avoided in abdominal hysteria. thought the signs and symptoms of that form of abdomina trouble were not sufficiently taught. The patients were fre and vivacious women, quently alert, complained of stomac no rigidity and no hyperalgesiaThere was and pain vomiting. Deep pressure into subjacent structures elicited pain, w^lC seemed to lie along the aorta and iliac vessels.?Mr. Carwahd1^ referred to the surgical causes of abdominal pain, and gave tn following classification : (1) Colics of internal origin, 1 mesenteric and omental twists, (3) inflammation of organ when the inflammation spread to the peritoneum, (4) impapti? "
"
.
'
'
pointe tn3^
of viscera, (5) thrombosis and embolism of vessels. He out that the organs themselves are generally painless, but the mesenteric attachments and parietal and visceral pe*"1 toneum are susceptible to pain. Referred pains cannot ^ associated with any particular organ unless at some time for other that organ is tender. accurate Conversely, the local tenderness should correspond with definite pains. The application of the foregoing to specific instanc was then detailed. Gastric ulcer may be present without pa " " The so-called hunger pain is associated with lesions inW ^ right hypochondrium involving the peritoneum, not alone a duodenal ulcer. The pain of gall-stones, renal mobility
diagn?s1^
re^erree5.
calculus, appendicitis, intestinal colic, twisted ovarian
pedic
'
etc., was discussed on the same lines.?Dr. Michell Cla said that if severe abdominal pain and tenderness were In obsC the cause was something more than dyspepsia. cases of pain a lead line should be looked for and the k jerks tested. A patient with chronic recurrent abdominal p 01 gradually becomes neurotic. Mucous colitis as a cause c had to be remembered, also abdominal pain due to chest unresolved Swain ditions, e.g. pneumonia.?Dr. James the subject too large to admit of a full discussion of the causes of chronic and recurrent abdominal pain, which had ^ so well classified by Dr. Symes. He agreed that the ^ common causes of such pain were usually found in with the appendix, kidney and gall-bladder. These, ^ rarely presented any difficulty. The tenderness at McBnr the reflection of the * in the case of the
Prese.re
"
"
th?u&^
assoCiaver, hmveey's
point, along
the last dorsal,
appendix, ilio-inguinal and
ilio-hypogastric
ne
285
OBITUARY. 111
affections
of the kidney, and the sub-costal tenderness in the gall-bladder, were very helpful in diagnosis in these Several conditions. Many cases of chronic and recurrent pain
Case of the
jvere
due to
lstory
some
form of intestinal adhesions, and here
a
simple?of hernia, peritonitis?tuberculous or appendicitis would aid us in coming to a conclusion ?Peration, as regards the probable origin of the trouble. Mucous colitis ?Ust also be thought of, and he (the speaker) had occasionally consulted in such cases with a view to operation for supposed lSease of the appendix. An examination of the stools would PreVent error. There was one class of case to which reference no^ been made, namely simple colic, which is often very 'tficult to differentiate from intestinal adhesions or malignant f ?wth. He had seen many cases where the recurrent pain, C?nstipation, abdominal distension, and even wasting and ?Ccasional vomiting, which may occur in cases of colic, caused ?reat difficulty in arriving at an accurate diagnosis. The occurfice of occult blood in the fasces would be suggestive of an cer either simple or malignant, but he was not inclined to give Uch weight to the fact of retardation of a bismuth meal as an to the diagnosis of obstruction from malignant growth. J. anY cases of simple colic could only be diagnosed from the patient in bed. l^hgnant disease by carefully watching spite of the relief of constipation and careful dieting, the Patient steadily lost weight the abdomen should be explored, an early" malignant neoplasm would probably be found ; if improvement took place under these conditions, the case one of simple colic, and we could justifiably a0uld probably be Brasher agreed that a interference.?Mr. surgical t^?id in obscure cases should be made by lanor?ugh exploration Parotomy, but opposed the advice to use a transverse incision. v
of former
or
