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Acute surgical conditions of the abdomen
Copyrigk,
A PRACTICAL
JOURNAL FiJty-JijtB
VOL. LXX1 I
1946 by TLe l’orke I’ublisLing Co., Inc.
Year
BUILT
of Continuous
DECEMBER,
19-16
ACUTE SURGICAL CONDITIONS
T
HE deveIopment of American surgery has been characterized by severa great epochs, such as the era up to and incIuding the time of Ephraim McDoweII; the Watson, Long and Morton period, in which genera1 anesthesia was introduced; the aseptic age of Lister and Pasteur; the period of the surgica1 giants, HaIstead, Murphy, Senn and Ochsner; the chnic era of the Mayos and CriIe; and, IinaIIy, the present epoch when improved pre- and postoperative care, chemotherapy, improved methods of anesthesia and early ambuIation have proved a most important roIe in surgery. In no field of surgery have the deveIopments of the present era pIayed a more important roIe than in that of acute abdomina1 surgery. The tremendous Iowering of mortaIity in acute perforated appendicitis, which in the past thirty years has caused soo,ooo deaths, is a triumph of chemotherapy. The sulfonamides and penicillin have IargeIy eIiminated the necessity for drainage in these patients and have consequentIy reduced to a fraction the incidence of complications such as obstruction, abscess formation, wound infection and eviseration. Chemotherapy has also in acute perforated reduced mortality, uIcer and in acute intestina1 obstruction necessitating decompression or resection. 771
ON
MERIT
Pulrlication NUhlBER
SIX
OF THE ABDOMEN
By its use better resuIts have been achieved in acute biliary tract surgery. The introduction of ethyIene, cycIopropane, pentotha1 sodium, curare, and, perhaps most important, improved methods of spina anesthesia have greatIy Iessened the probIems of the abdomina1 surgeon. Under spina anesthesia the abdomen is perfectIy reIaxed whether one is cIosing an acute perforated uIcer, expIoring the common duct or reducing a stranguIated hernia. Perhaps the most remarkabIe advancement that has come about in the past five years is earIy ambuIation. It has been difhcuIt to convince surgeons, as we11 as nurses, long accustomed to keeping their patients in bed for days and even weeks, that getting patients out of bed on the Hurst or second postoperative day resuIts in a far smoother and speedier convaIescence. My onIy regret is that many years ago I did not disregard ideas which were accepted as facts regarding the advantages of prolonged bed rest in abdomina1 surgery. EarIy ambulation not onIy heaIs the incision speediIy by improving the circuIation but aIso reduces the necessity for catheterization and enemas. Norma1 peristaIsis is induced, the patient is able to eat and enjoy focd, gas pains are infrequent, duodenal suction and intravenous therapy are
772
American
Journd
of Surgery
EditoriaI
required onIy in the more critica cases and pulmonary complications seldom occur. Although great strides have been made in treating acute surgica1 Iesions of the abdomen, the problem of diagnosis often remains a confusing and bailing one that can be solved onIy by an expIoratory operation. For exampIe, I know of no reported instance in which a correct preoperative diagnosis was made in a case of acute torsion of the omentum. Not many years ago I operated upon a boy for acute hemorrhage of a Meckel’s diverticulum; this was the first recorded case in which a preoperative diagnosis (established by his family physician) was made of this condition. In 1927, I operated upon a man for acute obstruction and found several feet of thick hose-like jejunum. The diagnosis for this condition was not determined until 1932 when Crohn and his associates at Mount Sinai HospitaI established acute regional enteritis as a distinct entity. The roentgenoIogist has so improved his technic that not infrequentry he is able to detect Kantor’s string sign in the terminal ileum, as we11 as other Iesions of the small intestine, to aid the surgeon in Iocating the source of the trouble. Yet occasionally a gallstone may perforate and cause symptoms of acute obstruction far down in the small intestine. Or a young man may be admitted to the hospital in shock after a motorcycIe accident; physical examination reveals nothing. Following the administration of bIood plasma and further shock therapy he rapidly improves. Ten days Jater he returns to work, coIlapses on the third day and is rushed back to the operating room; a laceration of the liver that nature had temporarily waJJed off is revealed upon abdominal expIoration. The probIems of the acute traumatic abdomen in this machine age are such as to bring gray hair to any surgeon, but we have made it a ruIe at our chnic to operate when in doubt.
ProbabIy the commonest and yet the most confusing diagnostic problem for the thousands of American surgeons remains that of the Iowly appendix. The fact that in the past as many as 45,000 cases of perforation have occurred in a single year seems to indicate that a great number of errors occur on the part of someone, the patient, the relatives, the physician or the surgeon. Too many fail to reahze that the patient may act and appear weJ1, may have a normal temperature, a normal blood count, but slight rigidity and onIy moderate tenderness on deep palpation, and yet have a retroceca1 gangrenous appendix. Delay in diagnosis is also largely responsible for the high mortality rate that stilJ persists in acute intestinal obstruction. Earlier surgical intervention in attacking these conditions is imperative if the end results are to be improved. The art of correct diagnosis has truIy been termed the highest achievement of the surgeon. In no other part of the body is his experience and judgment so accurateJy tested as in the field of acute abdominal surgery. He must not only keep in mind the more important and frequent conditions discussed in this editorial, but must also 62 prepared to exclude acute Iesions of the genitourinary and gynecologic systems. Nor should he forget that coronary disease may occasionally resemble gallstone colicand vice versa and, still more puzzling, that they may both occur in the same individual. He must aIso remember that pneumonia in chiIdren may simulate appendicitis and that enteritis may occur aJone or with appendicitis. He should make frequent examinations of the urine to exclude pyeJitis if the first specimen is negative. Surgery in acute conditions of the abdomen is an intriguing and fascinating subject that constantly challenges the ski11 and ingenuity of the surgeon with its many compIex problems. ARSOLD
S. JACKSON M.D.
A PRACTICAL
JOURNAL FiJty-JijtB
VOL. LXX1 I
1946 by TLe l’orke I’ublisLing Co., Inc.
Year
BUILT
of Continuous
DECEMBER,
19-16
ACUTE SURGICAL CONDITIONS
T
HE deveIopment of American surgery has been characterized by severa great epochs, such as the era up to and incIuding the time of Ephraim McDoweII; the Watson, Long and Morton period, in which genera1 anesthesia was introduced; the aseptic age of Lister and Pasteur; the period of the surgica1 giants, HaIstead, Murphy, Senn and Ochsner; the chnic era of the Mayos and CriIe; and, IinaIIy, the present epoch when improved pre- and postoperative care, chemotherapy, improved methods of anesthesia and early ambuIation have proved a most important roIe in surgery. In no field of surgery have the deveIopments of the present era pIayed a more important roIe than in that of acute abdomina1 surgery. The tremendous Iowering of mortaIity in acute perforated appendicitis, which in the past thirty years has caused soo,ooo deaths, is a triumph of chemotherapy. The sulfonamides and penicillin have IargeIy eIiminated the necessity for drainage in these patients and have consequentIy reduced to a fraction the incidence of complications such as obstruction, abscess formation, wound infection and eviseration. Chemotherapy has also in acute perforated reduced mortality, uIcer and in acute intestina1 obstruction necessitating decompression or resection. 771
ON
MERIT
Pulrlication NUhlBER
SIX
OF THE ABDOMEN
By its use better resuIts have been achieved in acute biliary tract surgery. The introduction of ethyIene, cycIopropane, pentotha1 sodium, curare, and, perhaps most important, improved methods of spina anesthesia have greatIy Iessened the probIems of the abdomina1 surgeon. Under spina anesthesia the abdomen is perfectIy reIaxed whether one is cIosing an acute perforated uIcer, expIoring the common duct or reducing a stranguIated hernia. Perhaps the most remarkabIe advancement that has come about in the past five years is earIy ambuIation. It has been difhcuIt to convince surgeons, as we11 as nurses, long accustomed to keeping their patients in bed for days and even weeks, that getting patients out of bed on the Hurst or second postoperative day resuIts in a far smoother and speedier convaIescence. My onIy regret is that many years ago I did not disregard ideas which were accepted as facts regarding the advantages of prolonged bed rest in abdomina1 surgery. EarIy ambulation not onIy heaIs the incision speediIy by improving the circuIation but aIso reduces the necessity for catheterization and enemas. Norma1 peristaIsis is induced, the patient is able to eat and enjoy focd, gas pains are infrequent, duodenal suction and intravenous therapy are
772
American
Journd
of Surgery
EditoriaI
required onIy in the more critica cases and pulmonary complications seldom occur. Although great strides have been made in treating acute surgica1 Iesions of the abdomen, the problem of diagnosis often remains a confusing and bailing one that can be solved onIy by an expIoratory operation. For exampIe, I know of no reported instance in which a correct preoperative diagnosis was made in a case of acute torsion of the omentum. Not many years ago I operated upon a boy for acute hemorrhage of a Meckel’s diverticulum; this was the first recorded case in which a preoperative diagnosis (established by his family physician) was made of this condition. In 1927, I operated upon a man for acute obstruction and found several feet of thick hose-like jejunum. The diagnosis for this condition was not determined until 1932 when Crohn and his associates at Mount Sinai HospitaI established acute regional enteritis as a distinct entity. The roentgenoIogist has so improved his technic that not infrequentry he is able to detect Kantor’s string sign in the terminal ileum, as we11 as other Iesions of the small intestine, to aid the surgeon in Iocating the source of the trouble. Yet occasionally a gallstone may perforate and cause symptoms of acute obstruction far down in the small intestine. Or a young man may be admitted to the hospital in shock after a motorcycIe accident; physical examination reveals nothing. Following the administration of bIood plasma and further shock therapy he rapidly improves. Ten days Jater he returns to work, coIlapses on the third day and is rushed back to the operating room; a laceration of the liver that nature had temporarily waJJed off is revealed upon abdominal expIoration. The probIems of the acute traumatic abdomen in this machine age are such as to bring gray hair to any surgeon, but we have made it a ruIe at our chnic to operate when in doubt.
ProbabIy the commonest and yet the most confusing diagnostic problem for the thousands of American surgeons remains that of the Iowly appendix. The fact that in the past as many as 45,000 cases of perforation have occurred in a single year seems to indicate that a great number of errors occur on the part of someone, the patient, the relatives, the physician or the surgeon. Too many fail to reahze that the patient may act and appear weJ1, may have a normal temperature, a normal blood count, but slight rigidity and onIy moderate tenderness on deep palpation, and yet have a retroceca1 gangrenous appendix. Delay in diagnosis is also largely responsible for the high mortality rate that stilJ persists in acute intestinal obstruction. Earlier surgical intervention in attacking these conditions is imperative if the end results are to be improved. The art of correct diagnosis has truIy been termed the highest achievement of the surgeon. In no other part of the body is his experience and judgment so accurateJy tested as in the field of acute abdominal surgery. He must not only keep in mind the more important and frequent conditions discussed in this editorial, but must also 62 prepared to exclude acute Iesions of the genitourinary and gynecologic systems. Nor should he forget that coronary disease may occasionally resemble gallstone colicand vice versa and, still more puzzling, that they may both occur in the same individual. He must aIso remember that pneumonia in chiIdren may simulate appendicitis and that enteritis may occur aJone or with appendicitis. He should make frequent examinations of the urine to exclude pyeJitis if the first specimen is negative. Surgery in acute conditions of the abdomen is an intriguing and fascinating subject that constantly challenges the ski11 and ingenuity of the surgeon with its many compIex problems. ARSOLD
S. JACKSON M.D.