.A. MED'CAL 194 JCKF. 10, 1944.] AUSCULTATION OF THE AB00:'fEX. [ JOURNAL. the deliberations been restl"ided to de,'ising a scheme which, 1. i11ecllClJl/cal obstruction of: for the time being, would provide a State l\1edical Service for (£I) The large gul.-In the early stages of chronic obstruction, the indigent-both white and black--but not encroaching on the borborygmi of the large bowel become louder, more pro- the present system of private pmctice for those who can longed and even palpable, but the ileocrecal valve sounds lemain afford it. It is difficult to conceive of one profession being normal. In the later stages, when the small intestilJe begins socialised in advance of other professions, industry 01' com- to dist-end, the ileoca'cal valve becomes silent, the small intes- merce. tine sounds become very frequent, higher pitched and longer Before I close I must make peace ,,'ith my surgical, obstreti- in duration and finally, when well distended, the normal small ca! and urological friends aud fripnds in other specialities whose intestine sounds diminish and are replaced by a high-pitched domains have been "by passed" in these reflections. The tinkle resembling the coin sound of pneumothorax. brilliance of their achievements requiles no reflector 01' words (b) ::illlall intestine obslruction.-In the early stage the ileo- to recall the wonderful advances made in these branches but crecal vahe sounds cease and the lower abdomen become more which, it will be admitted, were made p::.ssible by the evolution silent, whereas in the upper abdomen the frequency of sounds is of bacteriology, radiology, new methods of anresthesia and other scientific discoveries. increased, the ounds be~ome more gassy, and as the obstruc- tion goes on the sound become progressiyely less frequent, In the limited time at my disposal it has only been possible more tinkling, and hort in duration, and the heart sounds to recall samples of the wonderful ~trides that medicine has become more audible even as far down as the umbilicus. made since the commencement of this umtury-equaUy im- pOl·tant discoverie such as radium, endocrinology, physiotherapy 2. Focal inflammation. and a ,,'hole host of other advances c'ome to one's mind but one mu. t call a halt. There are problems which still baffle Early in acute appendieitis the mall intestine ounds con- our scientific investigators such a cancer, rheumatism in its tinue nOl'mally, but the ound of the ileoc,ecal valve gra.cIually various forms, allergies and so forth, but with the magnificent becomes less and les audible. In contradistiuction to this, record of past achievements we call with confidence look for· in localised right-sided salpyngitis no change takes place in the ward to their solntion. ileocrecal Yah'e ounds and there is only a slight diminution in the volume of the mall bowel ounds. As soon as the We ha"e lived in a truly wonderful age. X one can forecast inflammation is completely walled off, as in an appendix abscess, the future, but I think we must prepare ourselves for revolu- the abdominal sounds return to normal. tionary ehanges in post-war social conditions and to the e our profession will assuredly conta-ibute with the fine public-spirited impul es and devotion which have elJ:l:actel'ised this centul'Y. 3. Peritoneal irritation. By such fluids a extravasated blood from a ruptured . pleen or ectopic, or urine from ruptnred bladder, the sound are all muttled but not otherwi e altered in character for many hours, Auscultation of the Abdomen. that is to say rhythm and pitch remain but the volume diminishes. Vvith more evere irritant fluids, such as the flooding of the peritoneum with ga tt'ic juice. all £cund cease By A. C. CO?LEY, F.R.C-.·. (E~G.), almo t immediately and the abdomen is silent. -urgeon to K i71g Edll:ard 1-/11 llu.<pital, Durban. 4. Paralytic ileus. T is :l matter of surprise that in the textbooks of SUl'gely 'Whether this condition arises from septic peritoniti , from I so little mention is made of the abdominal sounds, both normal and abnormal, which can be heard with the stethoscope. blast injury or a a post-operative complication, the sound is alwav' the same. Students :ll'e rarely taught that auscultation of the abdomen is The ileoc:ecal "ah'e cea es to function, normal small intestine as important to the surgeon a :luscultation of the chest i to sounds cea e and are replaced b;y occasional faint tinkling wunds, the physician. unlike the sound of penstalsls and probably from alteration After many years of listening to the abdomen at every oppor- of gas :lnd fluid pre sure levels within the gut. The most tunity, I am now satisfied that oue can appreciate the difference chal'ac-tel'istic .ouod of ileus, hOWeYel-, occur when the jejunal between nOl'mal and abnormal sounds and, by checking up by coils become distended and overloaded with fluid, when the lapal'otomy, gradually gain a very imp::.rtant adjunct in makin" heart ounds are trongly transmitted from sternum to deeision III abdominal cases. '" umbilicus. .The practical applicat ions of these observatlons are numerous, In attempting to write on uch an interesting subject the but> a few -6}.--am-ples will suffice: difficulty immediately arises in portraying sounds descriptively. Without a good knowledge of musical terms such as pitch. _-\ patient present himself with vague abdominal pain, un- tone, and modulation, it is easy to li ten to an abdomen and locali ed tenderne sand ome rigidity. After the routine examination. li ten to the abdomen. If the normal sounds are say "I hear tbe ileoc:ecal valve functioning", but how diffi- pl-esent. but more frequent in timing, then an acute enteriti cult it i to describe it! -is probably present and the. ~igidity i voluntary. If the ign In the normal abdomen certain sound are audible. The ancl symptoms of appendlcll1s are p~'esent and the abdominal opening and closing of the pyloru i~. I think, inaudible, s·' ounds are normal except that the ileocrecal valve has clo ed that all ounds normally heard are those of the small intes- do,nl, then it i ~n i~f1a.med appendix impingln~ «.>n the parietal tine-those above the umbilicu mo tly from the jejunum, and peritoneum cal~sll1g Irl'lt?t:on,. but not yet ~lvlllg rise to a those below mostly the ileum. The e sounds are irregularh' ~preading eptlC perltollltr, I.e. the appendiX ha not per- spaced in time, short in duration, mall in volume, and cir forated. medium pitch. If the appendix is u_pected and all sounds are normal. then The ileoc:ecal vah-e has a characteristic ound, heard ju. t it is probable a c~li~ .and not yet a. trne inflammation. If in o"er :\lcBurney's point, more rhythmic than the small iutestin addition to the l'lgldlty all abdonllnal .ounds are 10 t. then and occurring about once ever~' 45 seconds. This ound acti"e spreadinf pe:itonitis is pre ent, i.e. the appendix ha- ,-e embles a low rumbling squelch. The large inte tine i- pel'forated. . . usually silent, except in the presence of an urgent desire for Po t-operat.ively, I al~,·a:y. lIsten to th~ abdoI?e~ b fore pr&- defrecation. which is being restrained. in which case prolonged crilJil1g aperient. It IS, III .my own vle.w, ~l'l~lllal t-o force "hythmic borborygmi are heard gene:ally in the left iliae the pace in a re ting ~ut ~ntll that gut IS wllllllg, that i to fossa resembling the release of ga through water under tell sav until natural pen talhc mo\"ement can be heard. Thi sion, 'IonISer in duration, and lower pitched than the ounds no:mal revival of the gut usnally run pari passu with the the mall intestine. first free passing of f1atns per reetnm. To one who has ma tered the normal sounds. departure In ca es of inte tinal ob truction it is u eful to get some idea from normal become inten ely intere ting, particularly when of whether the obs.t.ruction is in a large or sr;na~1 gut, and If one recognise the following changes under certain conditions. the l3tt~r, how high up. Where charactenshc low-pitched S.A.TYDSKRlF VIR] GENEESKUNDE. GALLSTONE ILEUS. [JUNIE 10 19~4. 195 borborygmi are present, the obstruction is undoubtedly in the is deposited a concretion, presumably of frecal material. It is large gut, and if the ileocrecal valve is functioning as yet the thought that this ·material is deposited on it chiefly durinl!: its case is a good risk. If no large bowel sounds are present and passage along the gut. As the stone passes along the Kut it the ileocrecal valve is silent, then the obstruction is in small increases in size. In addition, the farther it passes alonK the gut, and if the lower abdomen is silent and the upper abdomen small gut the smaller the lumen of the gut becomes. vociferous, then the obstruction is probably jejuna!. These two factors seem to explain why the terminal ileum Lastly, if the heart sounds can be clearly heard in the is the common site for the stones to be held up. Naturally, abdomen down to the umbilicus there is urgent need to decom- the longer the stone stays in the gut the larger it will become. press the small gut by duodenal or Miller Abbott tube and It is difficult to explain such delay in the absence of narrowings, suction drainage; this sign shows itself before tbe onset of kinks, etc., in the gut. Grey Turner, in discussing this problem, regurgitant vomiting! suggests that many of these stones are not passed at the time This subject is an interesting one, the study of whi(·h repays the gall-bladder· ulcerates into a neighbouring viscus, but are in good measure, and year by year one hears more al,d more I'etained in the gall-bladder and only later leave the gall.badder sounds full of meaning. through the fistulous opening. Indeed the abdomen cries out to be heard! It is reasonable to suppose that the stone impacted stays in the cystic duct; other stones lying free in the gall-bladder may be passed at once, but, probably being small relath-e to the size of the gut, cause no trouble. Later the impacted stone Gallstone Ileus. may become free and fall back into the gall-bladder, by which time the gall-bladder will have shruuk, as also the fistulous opening, so stopping the escape of the stone. By A. E. D.nEOSTI, M.B., CH.B., F.R.C.S. (ENG.), The stone remains in the gall-bladder, gradually increasing J OHANliESBURG. in size as gastro-duodenal material, etc., reaches it throuKh the fistulous opening, and late.r by ulceration may extrude itself through the opening into the duodenum. It may now have had to deal I RECENTLY am promptedwith in case of ten years obstructioll from a gallstone, the first experience, and a over intestinal of clinical to record it not only on account attained a size large enough to cause obstruction. Grey Turner describes a case where portion of such a stone caused intestinal obstruction, and at post-mortem the other of its rarity, but because of the interest the whole problem portion of the stone (as shown by the facets on the stones and arouses. by fitting them together) was protruding from the gall· bladder The gall-bladder generally rids itself of gall-stones by passing through the fistula into the bowel. • them along the cystic duct into the common bile·duct and then The lapse of time between the attack of acute ob tructive into the duodenum through the ampulla of Yater. When the cholecystitis with perforation and the appearance of intestinal stones are too large to pass along the. ducts there are other obstruction can thus readily be explained. In fact, it may be ways in which nature can deal with them-by impaction and difficult, in view of the many attacks of biliary colic which fixation in the cystic duct; by fibrosis and shrinking the gall- the patient has suffered, for the patient to recall any particular bladder may fix and immobilise the stones; by ulceration it attack which may be regarded as the one responsible for the may extrude them externally into the general peritoneal cavity, development of the fistula. or into the gastro-intestinal tract, the stomach, duodenum, or colon. The last method is of chief interest, as stones that pass The stone, having reached the duodenum, pas es along tlie along the common bile·duct are not as a rule of sufficient size small gut and may produce intermittent attacks of colic, with to cause intestinal obstruction. or without obstruction. Adhesions and a fistula must exist before the stones can pass Many of the stones are passed per Q7lum. A few, however, in this manner into the gut. Such a fistula will only develop f cause obstruction. This obstruction i intermittent, which in if there is obstruction to the escape of gall·bladder contents. itself makes diagnosis difficult. Further, as patient probably The cause of such obstruction is the impaction of a stone in the have had many previous attacks of biliary colic, the ob tructive cystic duct. attack i often regarded, both by patients and the patient's doctor, as another attack of biliary colic. The diagnosi , there· According to Rutherford Morison and C. F. M. aint, one of fore, is generally made late, by which time the patient is in 8 three things may happen when a stone impacts in the cystic serious condition. This is one of the explanations of the high duct: mortality. In addition, the patients al'l' gelll'rall~' elderly. 1. If the gall-bladder is empty at the time of both bile The average age in Grey Turner's series ,as 68. The condi- and septic material, a mucocele will probably result. tion, as with cholelithiasis, is much commoner in females. The 2. If the gall-bladder is full of bile and septic material, mortality is well over SO per cent. tension gangrene rapidly develops with ruptUl'e into the The notes herewith of my own ca es illustrate most of the general peritoneal cavity, and fatal peritonitis. feature' mentioned. 3. If a certain amount of bile and septic material still remains in the gall·bladder at the time of the impaction AIrs. A. J. V., (('t. 62. Admitted on 21/10/43 General of the stone, empyema of the gall.bladder results. Hospital, Johannesburg. Complaint: evere abdominal pain and Yomiting. DI/ration: In all but the most acute varieties of this group protective 7 days. mechanisms develop. Inflammatory adhesions and the omentum History: Was perfectly well until 15/10/43, when he felt attempt to shut off the gall.hladder. tones may then pass vague, cramp-like abdominal pain, which came and went. into the stomach, colon, or duodenum through an intermediary The pain persisted and she felt naUS60U. She took a dose abscess, or directly through adhesion of the inflamed If<lll· of ca tor oil but promptly vomited it. Over tbe next few bladder to these sll'uctures, and, as has already been men- day the pain persisted and sbe vomited frequently. At the tioned, an external fistula may develop. start she merely vomited what she took by mouth and a lot Stones that reach the colon this way seldom cause any trouble of greenish fluid. Her vomit since the morning ha boon because of the large lumen of the colon. Rutherford Morison, brown and foul· melling (seen by me at 8.20 p.m.). Her however, does record one case in which he removed a large bowels had not acted since 18/10/43, and there has been no stone peT anum which was causing some obstruction and serious pa sage of flatus. tenesmus. Grey Turner records a fUliher ca~e of large gut Previous History: For the la t five year patient has obstruction. Stones that reach the stomach may be vomited. uffered from attacks of cramp-like pain in the upper The stones that cause trouble are the ones that pass into abdomen, in midlille and under each costal margin. VomitinK the duodenum; and they must be large, for, if small, they ea ed the pain somewhat. The attack lasted one to two are passed without any trouble. The st-oues that cause obstruc· hours. Ha suffered much from flatulence. TO jaundice. tion are large, elongated, and circular on section. They con ist he had one attack about two year- ago which wa ,pry of a central core, the original stone, on the surface of which e\-e"e, and la ted a bou t three days.