Medical Abdominal Emergencies

Medical Clinics of North America November, 1941

, MEDICAL ABDOMINAL EMERGENCIES*

M. D. WILLCUTTS,

M.D.,

F.A.C.S.

CAPTAIN, MEDICAL CORPS, UNITED STATES NAVY; CmEl!' OF SURGERY, NAVAL HOSPITAL, SAN DIEGO, CALIFORNIA

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A NAVAL Surgeon's conception of the subject, "Medical Emergencies" may prove disquieting to his medical colleague. In extenuation for stressing the surgical background so strongly, the author prays that the status of the National Emergency and wartime limitations be kept in mind. The scope of this paper will be restricted to emergencies of the abdomen, to the major and common lesions met with under wartime conditions in the Navy. War today differs from previous conflicts in that action now approaches barbarous total warfare. Stationary war, trenches, orthodox battlegrounds, gallantry and respect for women and children are replaced by blitzkrieg on land, at sea and in the air. Terror is on the march. Mechanized forces sustained by perfection in aircraft wage merciless and ruthless cruelty. Every American should be for national defense, which means that every doctor must find his stride in his work and must support with all his strength and special ability the defenders of America. An adjustment from the orderly routine of peacetime to a dynamic new order must be made if the glorious traditions and institutions of America are to be maintained. HOW NAVAL MEDICINE DIFFERS FROM CIVILIAN PRACTICE

Naval war conditions present striking variations from the civilian medical background of peacetime. Naval medicine differs in the type of doctor, patient and lesion.

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The opinions or assertions contained herein are the private ones of the writer and are not to be construed as official or reflecting the views of the Navy Department or the Naval Service at large.

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The Doctor.-The reserve or regular officer of the Naval Medical Corps may be a member of a well-balanced medical unit with equipment and facilities equal or even superior to those he enjoyed during his civilian training. Or he may be alone on independent duty charged with medical responsibilities as extraordinary and striking as those found by the general practitioner on isolated stations in the pioneer days. Medical emergencies for the staff of the balanced Naval medical unit present no greater problems than found at the civilian medical center. A benevolent government provides amply the finest equipment and spares no expense to insure adequate medical care for her patriotic sons. Immediatelyavailable are diagnostic centers, hospital facilities, excellent nursing, and efficient medical and surgical attention. The doctor on independent duty faces moments of grave responsibility. Independent judgment, decision and action must replace dependence upon hospital or ready consultation usually available in civil practice. Despite limited diagnostic facilities aboard ship the practical well-balanced medical officer will find them ample for the establishment of a safe working diagnosis and for the institution of proper treatment. The Patient.-The most striking variation from civil life is found in the patient-the sick sailor or marine. Here indeed is medical regimentation but stripped of all evils associated with socialized medicine. The man knows that his government has provided a medical officer to care for his needs. He accepts without hesitation the fact that the doctor has been selected for his post, that his professional qualifications have been checked and approved by high Naval medical authorities. Rank and name matter little; the Navy man turns with full confidence to his doctor. The relationship between medical officer and sick sailor or marine is cordially fine. The doctor feels his sense of responsibility, is truly inspired and stimulated by the knowledge that he represents a medical trust, occupies a medical post, that he must not, dare not, fail. The very fact that the man presenting himself at sick call has no choice of doctor or surgeon inspires a fine s_ense of responsive trust that stimulates and calls forth his best professional ability. There is no consideration of fee

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or expense, the seaman simply rates every medical aid. The driving thought is to correct the man's disability, to restore him to duty, back to the guns, at the earliest moment. The Lesion.-Another important variable is the physical standard of the men in service. Carefully selected by high Naval physical standards, the seaman or marine is physically superior to the civilian sick. He is young and strong and chronic organic disease is usually absent. In the older grades visceral disease and damage develop, to be sure, but upon a basic foundation of health that speaks well for the physical culture of the service. Good food, hard exercise, work and recreation repel ravages of disease common to nonmilitary men in civilian occupational activity. So we have a traditional background of Naval regimented medicine: A carefully selected doctor serving a patient who is a brother in arms. Doctor and patient patriotically serving the same good cause. No fee, no expense to be considered, a mutual desire, urge, for correct diagnosis, efficient treatment and early care that their cause may be best served. DIAGNOSIS OF ABDOMINAL EMERGENCmS

Medical lesions, emergencies, of the abdomen, what are they? To salute our medical colleague we must consider the functional disorders, the belly aches and usually self-correcting disturbances, which are the lot of all men. But always loom the potentialities of organic disease--cholecystitis with or without stones, the commonest organic disease of the digestive tract; the perforated peptic ulcer; hematemesis from an eroded artery; mesenteric hemorrhage and occlusion; deep abscess, hepatic and subdiaphragmatic; intestinal obstruction, peritonitis, intussusception, volvulus, tumor or hernia; appendicitis; genito-urinary disease; splenic disorders; pancreatitis; malignant lesions; and concealed internal injuries. Here indeed is surgical pathology, with the need for judgment, decision and action. Homely advice-a dose of salts or a bit of soda will usually suffice for the functional disorder. General diseases and reactions that produce abdominal crises must be considered: hypertension; failing heart; pulmonary tuberculosis; hyperthyroid-

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ism and hypothyroidism; pernicious anemia; arthritis of the spine; the acute intestinal infections and dysenteries; sulfanilamide reactions; overindulgence in food, liquor, coffee and tobacco; and the rare acute abdominal allergic manifestations. Surgical judgment is exercised in the above only for exclusion and differential diagnosis. Abdominal organic disea~ may not always require operative surgery but surgical discretion and judgment should always be employed. The abdominal emergency demands an early safe working diagnosis, a careful differentiation of functional from organic disease. To accomplish this diagnosis the doctor should possess a practical knowledge of fundamentals covering the mechanism of abdominal function, the distress signals of pain, the anatomical watersheds and basins and the phenomenon of peritoneal irritation. There are three major processes of alimentation, namely, secretion, absorption and excretion. A major disturbance of one process usually upsets the other two and the body economy may become seriously affected. It has been said that we eat with our small intestine and drink with our colon. Amazing insults and dietetic abuses are patiently tolerated by stomach and digestive tract. Usually alcoholic indulgence offends less than intemperance in food, coffee and tobacco. Significance of Abdominal Pain.-Presented with medical emergency, a good doctor observes one constant factorabdominal pain. No other symptom offers better evidence upon which to base an interpretation and diagnosis than the recognized type of pain, somatic or visceral, of abdominal disease. The structures intimate to the parietal peritoneum are rich in cerebrospinal nerve distribution and resent with pain responses the irritation produced by inflammation and trauma. This is in sharp contract to the sympathetic mechanism of the almost insensitive abdominal viscera. Pain will occur during increased tension or traction on the hollow organs but no painful sensation follows the application of heat or cold, or the cutting or clamping of the gut. It is important to keep in mind the thoracic course of the abdominal nerves, especially the phrenic, vagus and splanchnic nerves, for disease of the ribs, spine, pleura, lungs, heart or mediastinum may, by irritating these nerves,

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set up reflex phenomena that will simulate disease localized beneath the diaphragm. Abdominal pain may be complained'of as sharp, dull, agonizing, cramplike, radiating, diffuse or localized. The patient's tolerance for pain must be considered; contrast the low threshold for pain of the young homesick sailor with the stoicism of the salty veteran of the older grades. The youngest resident knows the classical pain of gall and kidney stone colic, but matured is he who rationalizes the referred pain of the trapezius ridge as phrenic nerve irritation produced by inflammation of the central diaphragm secondary to pus from empyema of the gallbladder, a perforated gastric ulcer or subphrenic abscess. Who differentiates the sharply painful ulcer of the fixed colon from the tolerable pain of ulcer of the ileum. Who is alert to the possibility that marginal inflammation of the diaphragm has irritated the lower six intercostal nerves with resulting referred pain to loin and flank. Who differentiates pain from the parietal peritoneum as being direct and not referred, in contrast to the pain from inflammation of the diaphragm. A great master once said, "Clinical acumen rests with the possession of no mysterious sixth sense but upon a thorough grounding in fundamentals." PATHOGENESIS

The abdomen is a mighty cavity with less skeletal support than any portion of the body. Here is generated heat, energy and strength. Vital organs of digestion, absorption and excretion, the genito-urinary mechanism, main arterial, venous and lymph trunks, are hidden deeply away. Bounded above by the diaphragm which reaches high into the thorax, and by the fourth rib interspace, and below by the bony pelvis, the abdomen is truly a bag, a belly of dynamic force and power. Nature cares little for belly appearance-for pendulous fat and ugly curves-provided healthy functions are maintained. Disturbance of physiology will produce functional disorders which if not corrected lead to organic disease and associated visceral damage. Navy conditions afloat under war conditions become severe at times. Submarine and aviation duty, landing parties, special sea details in the tropical and frigid zones entail hardships cer-

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tainly abnormal and unnatural. The ship is darkened and stripped of all loose gear; ventilation is impaired; the weather may be hot, cold or foul. Water is ample and good but food is restricted in variety, preparation and serving. Men become hard and carry on. Intestinal fortitude literally is strongly developed although alimentation becomes severely stressed. Abdominal emergencies arise. TREATMENT OF ABDOMINAL EMERGENCIES

Fatigue.-The medical officer will be on guard for fatigue and heat exhaustion. Abdominal pain and cramps may prove very puzzling and deceptive. Rest, salt tablets and sugar will give prompt relief. Acute Abdominal Allergy.-An allergic reaction may follow the taking of certain foods or drugs, or the administration of serums and pollen extracts. Any lesion of the gastrointestinal tract may be simulated. Basically there occurs an edema of the mucous membrane with spasm of the smooth muscle. Pain may become severe and cramplike but usually few positive physical findings are present. The examiner will keep in mind the possibility of co-existing surgical pathologic change and, if definite indication of peritoneal irritation is noted, it is safer to adhere to surgical principles of diagnosis and treatment regardless of the fact that allergy may mask or dominate the picture. Migraine.-Beware of the repeater at sick call who complains of headache, nausea, vomiting, prostration and severe abdominal pain. Careful history will establish the absence of indigestion between headaches and exclude the possibility of surgical abdominal disease. Abdominal Distention.-Determine the causative factors: excessive intraperitoneal fat, flatus, fluids or feces. Intestinal Gases.-In the presence of shock and major emergency, keep in mind the rapid enormous gas distention associated with mesenteric thrombosis. Prognosis is guarded, probably unfavorable, even with early surgery. Intraperitoneal Fluids.-Consider hemorrhage, septic pus, malignant peritonitis, bile peritonitis, tuberculosis, cirrhosis, Bright's disease, cardiac disorders, water imbalance and hypoproteinemia.

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Constipation.-Fecal impaction is found low in the colon. A cleansing enema will clear many suspected emergencies. Do not upset the entire gastro-intestinal tract by whipping it with purgatives. Gastro-mesenteric Dellls.-Enormous dilatation of the stomach and proximal duodenum is a prominent feature. The etiology is often obscure, but the condition usually has a sudden onset of neurogenic origin. Treatment consists of keeping the patient in a prone position, and gastric lavage. Recovery is rapid and intubation or surgery is not necessary. Intestinal Obstrnction.-The cardinal symptoms are colicky pain, regurgitant vomiting, absolute constipation and progressive distention. Be alert for prompt recognition of strangulation, a surgical emergency that will not tolerate any delay for intubation, Miller-Abbott tubing or Wangensteen siphonage. Immediate surgery is also indicated in mesenteric occlusion, intussusception, volvulus, and internal and external hernia when the severity of peritoneal irritation rapidly progresses, temperature, pulse and respiration rise, leukocytosis increases and the patient appears gravely ill. In postoperative ileus due to peritonitis or recent adhesion, try intubation. With gastric siphonage established, there is no need for haste. Water and chemical balance may be reestablished and the patient made a good surgical risk while waiting the results of expectant treatment. Paralytic Ilellls.-The rational and only uniformly successful procedure is decompression with Miller-Abbott tube or Wangensteen siphonage. Surgery is not necessary. Hematemesis.-Bleeding from peptic ulcer is rarely immediately fatal but if clinical estimation of blood loss shows severe hemorrhage and indicates an eroded artery, the case should be considered a surgical emergency. Rational management consists of blood transfusion before and during operation -before, if long transfer is to be made-with simple excision of bleeding ulcer or a partial gastric resection. Perforated Peptic Ulcer.-Bear in mind that your ship's complement includes many men of ulcer age, that perforation often occurs suddenly without warning and that a good ulcer history is seldom given by the patient before the perforation.

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Here knowledge of the abdominal watersheds and basins is of great clinical value. The ulcer lava follows the transverse colon and mesocolon through the supracolic basin to reach the right infracolic basin where the appendix bathed in the pool of acid leakage may give rise to a condition simulating acute appendicitis and mask the major lesion above. Some degree of shock, right abdominal pain and tenderness, pain of progressing peritoneal irritation from the acid leakage that keeps the patient writhing, and rapidly progressing boardlike abdominal rigidity should clear the clinical picture. Immediate surgery is indicated, with simple closure of the perforation and incisional wound without drainage. Prognosis is favorable if the perforation is simply closed during the first day. Meckel's Diverticulum.-It is estimated that in about 2 per cent of births remains of the vitello-intestinal duct and of the artery to the yolk sac persist. The condition may simulate acute appendicitis, or produce intussusception and chronic or acute ileus. The site at the distal ileum should be checked when appendiceal gross pathology appears to be less than the clinical picture of appendicitis suggested. Cholecystitis with and without Stones.-If a good surgical team and facilities are available, cholecystectomy is indicated in acute disease of the gallbladder. However, aboard ship, if limited surgical facilities exist, expectant treatment may be carried. out. Empyema, even perforation, usually becomes walled off by protective adhesions and subsidence of the attack may be expected. Referred pain to the trapezius ridge is a warning of spreading pus to the phrenic zone of the diaphragm. Carcinoma of the Gastro-intestinal Tract.-Cancers of the stomach and large bowel are usually slow' of growth and late to metastasize, hence early diagnosis is all important. Cancer is listed among abdominal emergencies in order to stress the clinical urgency of careful check-up of early suspicious signs and symptoms of gastro-intestinal malignancy. Beware of your petty and commissioned officers who attain middle age with excellent digestion, then for the first time complain of indigestion. Be alert to changing bowel habits, constipation, vague abdominal discomfort and tenderness; note the presence of asthenia, unexplained weakness and anemia, blood or tarry

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stools. As Dr. J. B. Hartzell 1 so well states: "Make painstaking and purposeful examination. A negative examination does not rule out malignancy. A negative digital or proctoscopic examination may mean a lesion higher up in colon. A negative biopsy may mean that the section has not been taken from the proper area ... an inadequate or incomplete diagnostic study is worse than no diagnostic study at all. Remember that the easier it is to make the diagnosis of carcinoma of colon, the less the possibility of halting the fatal progress of the disease." Acute Appendicitis.-Every Naval medical officer must be able to diagnose appendicitis and to institute operative treatment. The age incidence for appendicitis is known to be practically unlimited; it is very common in the young and active age of our Navy. Many Navy recruits have had untreated attacks before entering the service. Ship life, ample food-the best most of them have ever enjoyed-plus sturdy abdominal exercise in the performance of ship's work may perhaps prove too heavy traffic for an appendix previously scarred. The seaman bearing such a background becomes an emergency within the first few months of his Naval career. It will be recalled that the appendix, like the colon, concentrates intestinal· contents, secretes mucus and evacuates residue. Scarring, fibrpsis and blocking of the residue may narrow the lumen of the appendix to the extent that evacuation is impaired, fecalith develops and complete obstruction follows. The appendix is strangulated, necrosis rapidly ensues and surgical delay will prove very serious. Should perforation and abscess develop, we believe operation to be yet immediately indicated. Removal of the often offending nidus, the fecalith, now free in the pus cavity, will permit resolution of the abscess. We have never failed to remove the appendix and believe that appendectomy, gently and properly performed preferably under local, procaine anesthesia, is always indicated once the diagnosis of appendicitis is established. Intraperitoneal Injury.-Bombardments, torpedoes and depth charges may cause rupture of the colon and major retroperitoneal hemorrhage without apparent abdominal injury. Concussion and secondary blows from loose gear hurled about

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by explosive effects of near hits produce bizarre wounds and concealed injuries. Surgeon L. R. Broster,2 of London, guest speaker at the American Surgical Association meeting, April 29, 1941, reported that in the present European conflict the mortality from abdominal wounds is high; he estimated that about 2 per cent of all wounds are abdominal. He stated: "Multiplicity characterizes the wounds and damages sustained from air-bombardments. The severity of the concomitant injuries renders the prognosis of many an abdominal case hopeless. Some of those injured in the abdomen also suffer from burns of the body or limbs. These complications may be encountered in ships, where the prognosis obviously becomes very grave. The local application of sulfanilamide powder to the abdominal wound will prevent the infection of the latter, and the introduction of sulfanilamide in saline into the peritoneal cavity and possibly the application of the powder to the sites of injury or repair may improve the prognosis." Intraperitoneal injury is indicated by pain, vomiting, persistent shock and signs of internal hemorrhage or leakage of visceral fluids, dyspnea, rapid pulse, pallor, shoulder and trapezius ridge pain, hiccough, leukocytosis and shifting liver and flank dullness. However, there is no si$n or combination of signs sufficiently constant to form a basis for a safe diagnosis or estimation of the extent of abdominal injury. Exploration is the only definite means for diagnosis. CONCLUSION

The surgical aspect of most of the major medical emergencies of the abdomen is strongly stressed. Naval war conditions demand professional ability tuned to surgical judgment, decision and action. Hidden talent in operative surgery abounds. Young doctors must be encouraged and trained in traumatic surgery, in common sense, and in practical management of battle casualties and disabilities. BmLIOGRAPHY

J. B.: Carcinoma of Colon. J. Mich. State Med. Soc., 36: 42 (Jan.) 1940. Z. Broster, L. R.; Sqrgical Problems of War. Ann. Surg., No, 6, June, 1941. 1. Hartzell,