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FOREIGN BODIES IN THE ABDOMEN
627 him after he has been pushed down "-the slippery slope that leads to the department of psychiatry "1 It is really amazing how little some patients know about their " case-" after prolonged stay in hospital: it is a commonplace to discover an abdominal scar whose owner does not know what was done at the operation. A man who leaves his car at a garage for repairs usually insists on knowing what has been done before he pays the bill. But the hospital patient has never had the feeling that he pays the bill, in any sense ; he has always received medical treatment as a sort of charity. Even now, as I observed afresh when I was recently a patient in a general surgical ward, his attitude towards the medical staff is one, of almost feudal humility-he would never dream of calling them to account for their doings. At most, his self-assertion is sulky, truculent, and perplexed, He feels defeated before he starts any protest, for it is THEIR hospital;, THEY make all the rules and he is only there on sufferance. His doubt and uncertainty is, of course, further increased by anxiety : the fear of some terrifying positive knowledge makes him readier -to accept vagueness or temporising on the part of his doctors, and he may also mentally repress or falsify information they give him if ’it is too painful to contemplate. To have one doctor primarily responsible for him throughout his stay -in hospital would tend to minimise these fears, for a good rapport would more easily be achieved. If the patient were not so often treated by " birds of passage," he would be less liable to become, himself, a bird of passage from department to department, and even from hospital to hospital. F. R. C. CASSON. London, W.T.
benefits as far-reaching as those that have resulted from the work of school medical officers in the field of .
preventive paediatrics. Although the aged sick in hospital form only a small proportion of the aged community, the opportunities in hospital for continued observation and the availability of occupational therapy allow those caring for these people to make- some suggestions. The incentive to recovery in the aged sick with their long-term illnesses is often absent, yet without an incentive all medical
efforts directed towards their rehabilitation are futile. Occupational therapy of the diversional kind helps many to forget their disabilities, but the prospect of a future " spent in making articles of the "arty-crafty type can hardly provide a sufficient inspiration for the patient’s further existence. Occupational therapy must therefore be developed along vocational rather than diversional lines, and the patient should be taught a job which he can usefully carry on after his discharge from hospital. Vocational training is successfully applied to the rehabilitation of the younger disabled person, but little has been done in this direction for those suffering from the disabilities of old age. In considering the occupation most suitable for the ’aged patient, there must be cooperation between hospital doctors and local employers. In this way the type of work available can .be ascertained and those patients suitable for this work selected. One example of employment which can be learned in hospital and carried on after discharge is the assembly from component parts of small mechanical articles ; boxes of components are collected from the factory and their assembly is paid for on a piece-work basis. We, must, however, always remember that while there are some for whom a design for employment is possible, SIR,—While entirely agreeing with Dr; Lipscomb’s -there are others for whom old age brings enforced leisure. theme that there is often a failure of medical coordination Whether this leisure becomes an intolerable burden or in handling patients who come to hospital, I do not think a source of happiness depends largely on individual all his remedies should be accepted. education and the variety of interests acquired during a that He suggests that it should be the first assistant’s duty person’s working life. to reassure the patient. Should this not be the duty of University College Hospital G. S. CROCKETT the chief under whose care she is supposed to be ?’? Is (St. Paneras Hospital), A. N. EXTON-SMITH. N.W.1. London, not his reassurance and, explanation likely to be far more than that of the anyone else, and cannot convincing FOREIGN BODIES IN THE ABDOMEN patient reasonably expect to hear direct from him ?And is it not utterly deplorable if the only contact she has SIR,—There is a widespread belief in medicine that with the chief is on one occasion when this " important unusual cases will present in a series of two or three gentleman visits her with great ceremony and a numerous within a short time of each other. Mr. Travers’s article retinue " ? If he does no more than this, should he not in your issue of Sept. 10 was noted with interest and the it was seen so give up the pretence that she is his patient’? case is reported because following Dr. Lipscomb’s statement that " if he [the clinical assissoon afterwards. tant who first saw the patient] could not make a diagnosis The patient, a woman, aged 63, was admitted to hospital on the evidence available in the outpatient department, on Sept. 15 with a history of acute colicky lower abdominal his duty was to admit the patient .to hospital for further pain for some thirty-six hours. The pain continued in " investigation should also not pass unchallenged. Why spasms, particularly if any fluid or solid food was taken. There was no nausea or vomiting. Within a few hours the should someone with symptoms of the kind being conpain spread over the lower abdomen as a constant ache and sidered enter hospital at all ?’? Even if it is not thought subsequently became generalised. that many of the investigations done on these patients, On admission the general condition was excellent. The such as gastric analyses and, as a rule, cholecystograms, breath was normal and the tongue clean. The abdomen are quite futile,’ why cannot they all be done in the showed the signs of a general peritonitis with.maximum outpatient department Does not the very fact of- the tenderness below the umbilicus. In view of these findings, a patient’s being admitted suggest to her that she must diagnosis was made of peritonitis of unknown cause and have something seriously the matter and thereby direct laparotomy was carried out through a right paramedian incision. her to " the slippery slope that leads to the department A small amount of seropurulent fluid was found on opening of psychiatry"? the abdomen. The appendix and the uterus and appendages J. W. TODD. Farnham, Surrey. were normal, but on examination of the small bowel some loops which were brought out of the pelvis were found to be THE EMPLOYMENT OF ELDERLY PERSONS covered with colon was exudate. The ,
_
.
‘
purulent
SIR,—Your leading article of Sept. 10 mentions the
importance of activity in the aged. Dr. Sturdee (Sept. 17) says that in the investigation of the most suitable forms .of activity and employment for elderly persons, general practitioners, district medical officers of - health, and factory medical officers can make the most valuable contributions. Probably studies in this field may bring
sigmoid
and a sharp object was felt projecting through the medial wall near the apex of the sigmoid loop. With retraction the area was visualised and the foreign body was seen to be a fish-bone. The paramedian wound was closed and a left oblique muscle-splitting incision made and the colon with. the foreign body delivered externally. It was impossible to withdraw the bone through the perforation and the colon was opened, the bone removed, and a Paul’s tube inserted.
palpated
628 found to measure about 2 in. long expanding 1/2 in. wide. The immediate postoperative period has been satisfactory and the temporary colostomy will shortly be closed. The bone
showed a triangular scarred area 1/2 in. across the base. This was excised. On further exploration the right side of the liver was seen to be almost filled by a firm, rounded, greyish mass lightly attached on its upper surface to the undersurface of the diaphragm. The mass was explored in a A detailed history taken from the patient after opera-’ number of places with a wide-bore aspirating needle, but no tion shows that she had eaten some plaice about five pus was located. The abdomen was then closed with misdays before the onset of the pain. Her lower dentures givings as to the wisdom of operation. The spleen was were uncomfortable and she had left them out for that enlarged and soft. After operation the patient made an it for was her meal and believes uninterrupted recovery, and the liver regressed and finally easily possible particular disappeared under the costal margin. Subsequently she was to have swallowed the bone without noticing it. In seen regularly and six months later was perfectly well. view of the size of the bone it is surprising that it could The patient remembered after operation that at the negotiate the narrow terminal ileum. The sigmoid loop was much less mobile than normal and this may have age of 10 she fell over and a pin on the carpet penetrated been the cause of perforation at this level. the abdominal wall, but it gave her no trouble and she C. F. CHAPPLE quickly forgot the incident. The histological report on Central Middlesex Hospital, excised portion of the liver stated that the specimen the B. W. MCGOWAN. N.W.10. London, was
at the base to
SIR,—The article by Mr. Travers (Sept. 10) and his
request for further reports prompts following two cases : CASE I.—On Dec.
me
to record the
31, 1943,
a woman, aged 57, was admitted that five days previously she had had sudden onset of acute upper abdominal pain, which had steadily become worse. On admission her temperature was 101.2°F; pulse-rate 104 per min., blood-pressure 85/60 mm. Hg. Examination revealed epigastric rigidity and tenderness, and on pelvic examination a severely eroded pessary was removed, accompanied by faecal discharge. The signs indicated an acute inflammatory lesion in the upper abdomen, and the primary site of infection was thought to be in the
to
consisted
of scar tissue - with chronic inflammatory around a central focus consistent with the presence of a foreign body. R. F. HENDTLASS. London, N.11.
changes
hospital complaining
pelvis. At laparotomy, after careful preoperative treatment, a high right paramedian incision was made, and on opening the abdominal cavity a grossly œdematous falciform ligament presented. The right side of the liver and the gall-bladder appeared normal, but to the left of the falciform ligament the liver was plum-coloured. On dividing the falciform ligament an abscess cavity about li/2 in. in diameter was opened and typical Bact. coli pus escaped. The exploring finger palpated a sharp object on the right wall of the abscess, which on removal was seen to be a portion of a rabbit rib. This measured 11/2 in. in length ; the sharp end was bevelled, giving it the appearance of a bent aspirating needle. The abdomen was closed with drainage without exploring the pelvis. Postoperatively there was much discharge, but recovery was uneventful and the faecal nstula healed spontaneously.
Of particular interest is the fact that the patient volunteered that two months previously she had had a similar attack of acute abdominal pain which was intensified on any thoraco-abdominal movement, particularly flexion. Presumably this was the time when the bone perforated the pylorus. In the few days before her admission the patient experienced the same postural intensification of pain. The description she gave was
convincing. CASE 2.-Early in January, 1944, a woman, aged 35, was admitted with acute right-sided abdominal pain. The clinical picture was not clear and a provisional diagnosis of acute cholecystitis was made with subsequent expectant treatment. The patient had been admitted some months previously for an abortion, which was dealt with without incident, but one physician noted at that time that the spleen was palpable. During the days of observation the consultant surgeon was asked to see the. case, but no definite diagnosis was made. The liver became palpable and gradually increased in size, eventually reaching the right iliac fossa. The patient aroused considerable interest among the medical staff and many investigations were performed with normal results. However, on further careful questioning the patient gave the information that the pain was intensified on movement, particularly flexion. Up to this time laparotomy was considered unwise, but in view of the case already described the many radiographs were re-examined and revealed the distal half of a broken pin or needle lying on the deep surface of the anterior abdominal wall. Laparotomy followed, with a provisional diagnosis of hepatic abscess. At operation the metallic body was found on the deep surface of the rectus abdominis, and just deep to this on opening the abdominal cavity the free margin of the liver
THE FIRST MEDICAL EXAMINATION
SIR,—Dr. Johnson’s plea (Sept. 17) searching consideration of the nature of
"for a more the standard "
of the 1st M.B. _examination would have some validity if the medical schools could absorb all who pass the examination. My daughter was successful in the London external 1st M.B. examination this year but has been unable to obtain a place to continue her studies either in London or the provinces. She informs me that there are
dozens in similar plight.
Truro.
V. E. WHITMAN. WHY NOT GENERAL PRACTICE ?
SIR,—Your leading article of Aug. 27 touches on fundamental points. Very little, however, is said about immediate changes which could be made without adjustment of the curriculum or new appointments to the staff. A large number of disorders encountered in general practice in themselves rarely necessitate admission to hospital. Many of these complaints, however, arise in patients seen in hospital, and too little is done to bring the notice of students to them. Mild neuroses, bronchitis, fibrositis, headaches, and mild hallux rigidus and osteoarthritis are probably some of the commonest. They must be taken into consideration anyway if the patient is to be treated as a whole. There are, however, a large number of very important conditions commonly seen in general practice which often need hospital treatment. For various reasons some of these conditions are gradually being excluded from undergraduate teaching hospitals. Acute abdominal conditions, abortions, severe chronic bronchitis and emphysema, cerebral thrombosis and hæmorrhage, and pneumonia are examples of these complaints. Medical undergraduate education has two functions : academic and vocational. An undergraduate teaching hospital also has two functions : it has to serve the society in its neighbourhood, and it has to provide means for medical education. Cases are being selected to serve this academic function : of medical education to the detriment of the vocational. From the point of view of the function of a hospital, cases are selected too much to suit sectional and individual interests, too little regard being paid to the needs of undergraduate education and even to the prime function of a hospital, which is to serve society. The changes over the last thirty years have been so that they have not been fully appreciated. There is much truth in the statement that the best places to teach undergraduate students now are the former local-authority hospitals.
gradual
benefits as far-reaching as those that have resulted from the work of school medical officers in the field of .
preventive paediatrics. Although the aged sick in hospital form only a small proportion of the aged community, the opportunities in hospital for continued observation and the availability of occupational therapy allow those caring for these people to make- some suggestions. The incentive to recovery in the aged sick with their long-term illnesses is often absent, yet without an incentive all medical
efforts directed towards their rehabilitation are futile. Occupational therapy of the diversional kind helps many to forget their disabilities, but the prospect of a future " spent in making articles of the "arty-crafty type can hardly provide a sufficient inspiration for the patient’s further existence. Occupational therapy must therefore be developed along vocational rather than diversional lines, and the patient should be taught a job which he can usefully carry on after his discharge from hospital. Vocational training is successfully applied to the rehabilitation of the younger disabled person, but little has been done in this direction for those suffering from the disabilities of old age. In considering the occupation most suitable for the ’aged patient, there must be cooperation between hospital doctors and local employers. In this way the type of work available can .be ascertained and those patients suitable for this work selected. One example of employment which can be learned in hospital and carried on after discharge is the assembly from component parts of small mechanical articles ; boxes of components are collected from the factory and their assembly is paid for on a piece-work basis. We, must, however, always remember that while there are some for whom a design for employment is possible, SIR,—While entirely agreeing with Dr; Lipscomb’s -there are others for whom old age brings enforced leisure. theme that there is often a failure of medical coordination Whether this leisure becomes an intolerable burden or in handling patients who come to hospital, I do not think a source of happiness depends largely on individual all his remedies should be accepted. education and the variety of interests acquired during a that He suggests that it should be the first assistant’s duty person’s working life. to reassure the patient. Should this not be the duty of University College Hospital G. S. CROCKETT the chief under whose care she is supposed to be ?’? Is (St. Paneras Hospital), A. N. EXTON-SMITH. N.W.1. London, not his reassurance and, explanation likely to be far more than that of the anyone else, and cannot convincing FOREIGN BODIES IN THE ABDOMEN patient reasonably expect to hear direct from him ?And is it not utterly deplorable if the only contact she has SIR,—There is a widespread belief in medicine that with the chief is on one occasion when this " important unusual cases will present in a series of two or three gentleman visits her with great ceremony and a numerous within a short time of each other. Mr. Travers’s article retinue " ? If he does no more than this, should he not in your issue of Sept. 10 was noted with interest and the it was seen so give up the pretence that she is his patient’? case is reported because following Dr. Lipscomb’s statement that " if he [the clinical assissoon afterwards. tant who first saw the patient] could not make a diagnosis The patient, a woman, aged 63, was admitted to hospital on the evidence available in the outpatient department, on Sept. 15 with a history of acute colicky lower abdominal his duty was to admit the patient .to hospital for further pain for some thirty-six hours. The pain continued in " investigation should also not pass unchallenged. Why spasms, particularly if any fluid or solid food was taken. There was no nausea or vomiting. Within a few hours the should someone with symptoms of the kind being conpain spread over the lower abdomen as a constant ache and sidered enter hospital at all ?’? Even if it is not thought subsequently became generalised. that many of the investigations done on these patients, On admission the general condition was excellent. The such as gastric analyses and, as a rule, cholecystograms, breath was normal and the tongue clean. The abdomen are quite futile,’ why cannot they all be done in the showed the signs of a general peritonitis with.maximum outpatient department Does not the very fact of- the tenderness below the umbilicus. In view of these findings, a patient’s being admitted suggest to her that she must diagnosis was made of peritonitis of unknown cause and have something seriously the matter and thereby direct laparotomy was carried out through a right paramedian incision. her to " the slippery slope that leads to the department A small amount of seropurulent fluid was found on opening of psychiatry"? the abdomen. The appendix and the uterus and appendages J. W. TODD. Farnham, Surrey. were normal, but on examination of the small bowel some loops which were brought out of the pelvis were found to be THE EMPLOYMENT OF ELDERLY PERSONS covered with colon was exudate. The ,
_
.
‘
purulent
SIR,—Your leading article of Sept. 10 mentions the
importance of activity in the aged. Dr. Sturdee (Sept. 17) says that in the investigation of the most suitable forms .of activity and employment for elderly persons, general practitioners, district medical officers of - health, and factory medical officers can make the most valuable contributions. Probably studies in this field may bring
sigmoid
and a sharp object was felt projecting through the medial wall near the apex of the sigmoid loop. With retraction the area was visualised and the foreign body was seen to be a fish-bone. The paramedian wound was closed and a left oblique muscle-splitting incision made and the colon with. the foreign body delivered externally. It was impossible to withdraw the bone through the perforation and the colon was opened, the bone removed, and a Paul’s tube inserted.
palpated
628 found to measure about 2 in. long expanding 1/2 in. wide. The immediate postoperative period has been satisfactory and the temporary colostomy will shortly be closed. The bone
showed a triangular scarred area 1/2 in. across the base. This was excised. On further exploration the right side of the liver was seen to be almost filled by a firm, rounded, greyish mass lightly attached on its upper surface to the undersurface of the diaphragm. The mass was explored in a A detailed history taken from the patient after opera-’ number of places with a wide-bore aspirating needle, but no tion shows that she had eaten some plaice about five pus was located. The abdomen was then closed with misdays before the onset of the pain. Her lower dentures givings as to the wisdom of operation. The spleen was were uncomfortable and she had left them out for that enlarged and soft. After operation the patient made an it for was her meal and believes uninterrupted recovery, and the liver regressed and finally easily possible particular disappeared under the costal margin. Subsequently she was to have swallowed the bone without noticing it. In seen regularly and six months later was perfectly well. view of the size of the bone it is surprising that it could The patient remembered after operation that at the negotiate the narrow terminal ileum. The sigmoid loop was much less mobile than normal and this may have age of 10 she fell over and a pin on the carpet penetrated been the cause of perforation at this level. the abdominal wall, but it gave her no trouble and she C. F. CHAPPLE quickly forgot the incident. The histological report on Central Middlesex Hospital, excised portion of the liver stated that the specimen the B. W. MCGOWAN. N.W.10. London, was
at the base to
SIR,—The article by Mr. Travers (Sept. 10) and his
request for further reports prompts following two cases : CASE I.—On Dec.
me
to record the
31, 1943,
a woman, aged 57, was admitted that five days previously she had had sudden onset of acute upper abdominal pain, which had steadily become worse. On admission her temperature was 101.2°F; pulse-rate 104 per min., blood-pressure 85/60 mm. Hg. Examination revealed epigastric rigidity and tenderness, and on pelvic examination a severely eroded pessary was removed, accompanied by faecal discharge. The signs indicated an acute inflammatory lesion in the upper abdomen, and the primary site of infection was thought to be in the
to
consisted
of scar tissue - with chronic inflammatory around a central focus consistent with the presence of a foreign body. R. F. HENDTLASS. London, N.11.
changes
hospital complaining
pelvis. At laparotomy, after careful preoperative treatment, a high right paramedian incision was made, and on opening the abdominal cavity a grossly œdematous falciform ligament presented. The right side of the liver and the gall-bladder appeared normal, but to the left of the falciform ligament the liver was plum-coloured. On dividing the falciform ligament an abscess cavity about li/2 in. in diameter was opened and typical Bact. coli pus escaped. The exploring finger palpated a sharp object on the right wall of the abscess, which on removal was seen to be a portion of a rabbit rib. This measured 11/2 in. in length ; the sharp end was bevelled, giving it the appearance of a bent aspirating needle. The abdomen was closed with drainage without exploring the pelvis. Postoperatively there was much discharge, but recovery was uneventful and the faecal nstula healed spontaneously.
Of particular interest is the fact that the patient volunteered that two months previously she had had a similar attack of acute abdominal pain which was intensified on any thoraco-abdominal movement, particularly flexion. Presumably this was the time when the bone perforated the pylorus. In the few days before her admission the patient experienced the same postural intensification of pain. The description she gave was
convincing. CASE 2.-Early in January, 1944, a woman, aged 35, was admitted with acute right-sided abdominal pain. The clinical picture was not clear and a provisional diagnosis of acute cholecystitis was made with subsequent expectant treatment. The patient had been admitted some months previously for an abortion, which was dealt with without incident, but one physician noted at that time that the spleen was palpable. During the days of observation the consultant surgeon was asked to see the. case, but no definite diagnosis was made. The liver became palpable and gradually increased in size, eventually reaching the right iliac fossa. The patient aroused considerable interest among the medical staff and many investigations were performed with normal results. However, on further careful questioning the patient gave the information that the pain was intensified on movement, particularly flexion. Up to this time laparotomy was considered unwise, but in view of the case already described the many radiographs were re-examined and revealed the distal half of a broken pin or needle lying on the deep surface of the anterior abdominal wall. Laparotomy followed, with a provisional diagnosis of hepatic abscess. At operation the metallic body was found on the deep surface of the rectus abdominis, and just deep to this on opening the abdominal cavity the free margin of the liver
THE FIRST MEDICAL EXAMINATION
SIR,—Dr. Johnson’s plea (Sept. 17) searching consideration of the nature of
"for a more the standard "
of the 1st M.B. _examination would have some validity if the medical schools could absorb all who pass the examination. My daughter was successful in the London external 1st M.B. examination this year but has been unable to obtain a place to continue her studies either in London or the provinces. She informs me that there are
dozens in similar plight.
Truro.
V. E. WHITMAN. WHY NOT GENERAL PRACTICE ?
SIR,—Your leading article of Aug. 27 touches on fundamental points. Very little, however, is said about immediate changes which could be made without adjustment of the curriculum or new appointments to the staff. A large number of disorders encountered in general practice in themselves rarely necessitate admission to hospital. Many of these complaints, however, arise in patients seen in hospital, and too little is done to bring the notice of students to them. Mild neuroses, bronchitis, fibrositis, headaches, and mild hallux rigidus and osteoarthritis are probably some of the commonest. They must be taken into consideration anyway if the patient is to be treated as a whole. There are, however, a large number of very important conditions commonly seen in general practice which often need hospital treatment. For various reasons some of these conditions are gradually being excluded from undergraduate teaching hospitals. Acute abdominal conditions, abortions, severe chronic bronchitis and emphysema, cerebral thrombosis and hæmorrhage, and pneumonia are examples of these complaints. Medical undergraduate education has two functions : academic and vocational. An undergraduate teaching hospital also has two functions : it has to serve the society in its neighbourhood, and it has to provide means for medical education. Cases are being selected to serve this academic function : of medical education to the detriment of the vocational. From the point of view of the function of a hospital, cases are selected too much to suit sectional and individual interests, too little regard being paid to the needs of undergraduate education and even to the prime function of a hospital, which is to serve society. The changes over the last thirty years have been so that they have not been fully appreciated. There is much truth in the statement that the best places to teach undergraduate students now are the former local-authority hospitals.
gradual