Mesenteric embolism and thrombosis also produce intense pain, with pronounced depression and speedy collapse, the complaint usually so widespread as to be suggestive.
Pain made suddenly worse by extra exertion or straining, as perhaps in defecation, may be due to pressure or to rupture of some part previously involved. When this is complained of in the lower bowel it is usually due to some ulcerative condition in the rectum.
Aside from conditions briefly specified as above, there may be numerous other causes of acute abdominal pain, as, for instance, in connection with various tumors, either those which involve the bowel, where there is suddenly precipitated a condition of acute obstruction, or ovarian cysts and pelvic or other tumors which have undergone a sudden deprivation of blood supply, as by twisting of a pedicle. In nearly all of these instances the previous existence of such a tumor has been learned, or else may be made out by such physical examination as may be permitted with or without anesthesia. Again rupture of an extra-uterine gestation may produce intense pain, followed by speedy collapse and a condition widely referred. I have been repeatedly called to operate for acute appendicitis when the actual lesion was of this character.
In general, of abdominal pain, it may be said that, excluding hysterical cases, when severe it is usually an indication of a more acute condition, while mild, chronic and intermittent pain, accompanied by more or less tenderness, indicates a chronic condition which may not amount at any given time to an emergency, but which may precipitate one that may call for immediate intervention. The nearer, anatomically, the morbid condition to the stomach and the great ganglia the more likelihood there is of nausea and vomiting of purely reflex character. When these occur with conditions low in the abdomen or pelvis, vomiting may be an expression of obstruction rather than a neurosis, pregnancy, of course, forming a well-marked exception to this statement.
In the presence of severe pain the general practitioner and the surgeon alike feel inclined, from humane motives, to do everything in their power to relieve it. While, on one side, it is kind and rational to give sufficient anodyne, usually morphine, to relieve intense suffering, it may be felt sometimes that the practise is not to be too widely extended or commended, since by relief of pain the significant feature of the disease is masked, and there may be temptation to wait longer than would be advisable. While wavering, then, as between advice in either direction, my own view is that most of these cases, when symptoms are so severe, can be classified by themselves as those justifying or demanding surgery.
One last caution in this respect is needed, lest the inexperienced regard the sudden subsidence of pain as necessarily a good sign. When a patient who has been suffering from acute obstruction or acute peritonitis becomes suddenly relieved the fear is rather that the disease has gone beyond all possibility of help, and that such relief will soon be followed by coma and death. Such cessation of pain, then, is not necessarily a favorable indication.
Localized tenderness is the next most important sign of value in determining the location and nature of abdominal diseases. The more accurately it can be localized the better, since it permits us to select, in all probability, one organ or one location as the site of the disease. When it is accompanied by radiating and diffuse tenderness it may be suggestive rather than indicative.
Muscle rigidity or spasm is the third of the trio of symptoms which give the surgeon his most imperative indications. Excluding the hysterical and purely neurotic cases there is no occasion for pronounced muscular rigidity save some disease concealed beneath it, which produces these reflex phenomena. This, too, may be localized or generalized. In the latter case it may indicate, for instance, a general peritonitis or a local process tending to become generalized. Of the trio of signs and symptoms it is perhaps the most significant and reliable.
Pain, tenderness, and muscle spasm constitute the tripod upon which the surgeon has most to rely, and which are never absent in serious disease, while conversely it may be said that serious disease is rarely ever present without producing them. These with such other phenomena as special conditions may produce—e. g., vomiting, intestinal hemorrhage, etc.—are our principal aids to diagnosis. When present and progressive they nearly always indicate necessity for surgical intervention, the most pronounced being in those instances where abdominal distention and collapse with other grave features have already taken the case beyond the help even of the surgeon.
In more deliberate cases aid is also to be obtained from examination of the discharges from the various viscera, and by examination, for instance, of stomach contents, as well as by differential blood count. All of these, however, take time, and the experienced surgeon may see clearly his indication to operate at once rather than to wait the time which they require. The whole intent of this paragraph, as, in fact, of this section, is not to make light of the ordinary means of diagnosis, but to insist upon the necessity for early appreciation of important signs and symptoms in order that one may know when it is not safe to wait, since too many lives are even now sacrificed to this kind of delay.