Pulse and respiration nearly always, and temperature frequently, give information of great value in abdominal conditions. A rising pulse or a rate over 112 to 120, occurring during any serious intra-abdominal condition, will stamp it as one of considerable severity, the gravity being proportionate to the increase above the figures just given. This is particularly true in acute appendicitis, with or without prominent local symptoms. A rising pulse rate, then, should always be considered as a warning. A very rapid, feeble, thready pulse will usually indicate a condition seen too late to justify surgery, the patient being then in a condition of practical collapse. Nevertheless if it appear that this be due to hemorrhage, either from injury or by rupture of an extra-uterine pregnancy, it may be felt that so long as the pulse is perceptible the indication is present.
Respiration is markedly affected in many intra-abdominal diseases. The more thoracic it becomes—i. e., the more the abdominal muscles are disused—the more it bespeaks a serious condition below the diaphragm. A rigid abdominal wall accompanying frequent thoracic respirations bespeaks a condition of grave danger. It should never be forgotten that some of the acute diseases, especially of the lungs above the diaphragm, cause symptoms and pain referred to the viscera below. Thus in the early stages of pneumonia and of diaphragmatic pleurisy there may be thoracic respiration, abdominal spasm, and pain referred even below the waist line, with strong simulation of acute appendicitis or of localized or general peritonitis.
Temperature is an uncertain feature. Rapid elevation is usually of serious import, but one is constantly surprised at the revelations of an operation, or an autopsy, where temperature is not significantly elevated or is even subnormal. Small matters may suddenly send it up—a stitch abscess, for instance—and it is often difficult to distinguish between the pyrexia of intestinal toxemia and that of actual septic infection. When elevated temperature is intermittent and accompanied by chills the surgeon is justified in suspecting the presence of pus, although the reverse of this is not true, and pus may form within the abdomen without causing chills or even fever. Intermittent fever, with tenderness in the upper abdomen, points as often to infection of the biliary tract, usually with gallstones, as to all other conditions combined. Pyrexia with chills and enlargement of the liver may indicate hepatic abscess.
When pulse, temperature, and respiration rate seem to keep pace with each other, no matter what the rate may be, they together afford a fair indication as to what is going on. A careful blood count, especially a differential count, will often be of service, though it will occasionally mislead.
The significance and importance of pain in abdominal diseases are very great, since nearly all of them are characterized, at least at some stage, by more or less suffering. Much value attaches to the history, when it can be accurately obtained, as to the suddenness of onset, the location and character of the pain; as, for instance, whether it could be accurately localized or was diffuse. Unusual intensity of pain may afford an index to the acuteness of the trouble, but in its location or reference it may be exceedingly misleading. A large proportion of patients are unable to describe their pains with sufficient accuracy, and a neurotic patient suffering severely will evince a widespread hyperesthesia which will be deceptive. It should be ascertained whether previous and like pains have ever been experienced, and, if so, where. The pains of acute appendicitis, for instance, are widely referred, and will sometimes be complained of as intense in the left side or high up in the abdomen. I have known patients to refuse operation because they could not be convinced that, with pain on the left side, it was possible to have acute appendicitis, while even an experienced practitioner may be tempted to wait too long for similar reasons. Pain, accompanied or followed by jaundice, or a history of pain so associated in time past, will point significantly to the biliary passages. A history of previous pains constantly associated with taking of food will indicate gastric or duodenal ulcer. Still pain is probably more often associated with mechanical rather than chemical conditions. Pain arising from the gall-bladder radiates usually toward the right infrascapular region, and with adhesions between the stomach and the gall-bladder pain is frequently referred to the right shoulder, while when these adhesions are between the stomach and the colon it is more commonly referred to the left shoulder. Pains due to kidney lesions usually are referred along the corresponding genitocrural nerves, although, by association of the renal nerves with the semilunar ganglia (and thus indirectly with the phrenic and pneumogastric nerves) we may hear of shoulder pains even in these cases. In most cases of acute appendicitis the first complaint of actual pain will be in the umbilical region, since the appendix receives its blood supply from the superior mesenteric artery and its nerve supply from branches which accompany this vessel, which are given off from the spine at a higher level than those which supply the colon and sigmoid. Thus the reflected pain involves the tenth and eleventh dorsal nerves.
The pain of colicky affections is usually relieved by pressure, while that of true inflammation is made worse and is continuous. When pain is accompanied by tenesmus it is generally supposed that the disease will be found in the lower third of the intestinal tract.
In this connection we may perhaps be a little more specific, and, following Hemmeter, make out a catalogue somewhat after the following fashion:
Gastritis will cause sudden abdominal pain, with sensitiveness, made worse by ingestion of fluids, by which, in all probability, vomiting will be promptly produced.
Duodenitis will cause constant pain and increased sensitiveness, especially in the right hypochondriac region, with mucus and perhaps blood in the stools.
Enteritis causes rather a colicky pain, more widely referred, with a general unpleasant sensation of pressure, accompanied by distention, diarrhea, anorexia, and thirst.