1894 The Lancet  
GENTLEMEN,—There is a patient now under my care in the Fitzwilliam Ward whose case illustrates so well how very deceptive symptoms of pain about the abdomen may be that I think it is a good case for your consideration, first of all because I am not quite sure that some of the causes of .abdominal pain are so well understood as they should be, and, secondly, because I happen to have seen in the .course of the last few years several other instances which .teach exactly the same lesson as this
more » ... s case. The patient I refer to is a man twenty-three years of age, who was admitted to hospital on Feb. 28th. He was sent to me with 'symptoms which were thought to be those of "perityphlitis "; he was sent, in point of fact, with a view to the removal of his vermiform appendix for the relief of the discomfort from which he has repeatedly suffered. He had, for three or four ::years, been suffering, on and off, from recurrent abdominal pain. Whenever he took any unusual exercise, if he took a long walk, or ran, or did anything of that kind, or if he happened to eat any indigestible food, he was always :.attacked by a kind of " crampy" pain in the lower part of his abdomen, just over the csecal region. This .pain sometimes lasted as long as two or three days, was invariably accompanied by tenderness over the csecum, and was also always followed by obstinate constipation. These .symptoms, as you will see, fairly well resemble the effects which sometimes follow the condition which we call "peri-' typhlitis." Upon examining the man somewhat cursorily in the surgery I could not make out any sign of thickening or 'other indication of disease about the vermiform appendix. At that time he had no pain, as he had not been exerting himself very recently and had been carefully refraining irom indigestible food. Assuming, however, for the moment that the case was one of the nature suspected, seeing that the man had been sent with a view to operation, I took him ,into the hospital. On the following day we again examined him as he lay in bed, and again I failed to find any symptoms whatever of anything wrong about the region of his carcum ; but I noticed that the right spermatic cord was considerably larger than the left. Upon feeling it, it seemed at first as if the man was the subject of a varicocele, and when 'questioned on this matter he said that for six months he had been wearing a truss because someone had told him he had large veins on that side of the scrotum, and that .a truss was a good thing to relieve the discomfort sometimes caused by that affection. Very little examination made it -evident that the case was not one of varicocele at all. There was about the right spermatic cord a softish, flabby, nodulated mass, feeling somewhat like large veins occasionally do in a very tense varicocele, but still differing altogether from a varicocele in that they ceased abruptly just above the testis, terminating in a blunt end-an arrangement never seen in a varicocele passing so far down into the scrotum. It was certain, in fact, that this man had a small nodule of omentum ,in an old hernial sac, of which he was not aware. Following that idea a little further, I came to the conclusion in my own mind-and expressed my conviction to some of you at the .time-that the symptoms which were so very like those of ,perityphlitis were due, not to the existence of any mischief round the vermiform appendix or caecum, but to this little nodule of omentum lying in a hernial sac. Upon that .assumption a few days afterwards I cut into the groin with a view to performing a radical cure for the hernia which I supposed to exist. Presently, after exposing a thin sac, I came upon the little nodule of omentum, as I expected, with -a small stalk passin ui3 through the verv narrow neck of a hernial sac. This nodule of omentum was adherent below, and could not be reduced at all; but it was connected with the parts inside the abdomen by its long stalk. Such was the condition of things then, and in my mind it fully explained the symptoms of which the man complained, the history of his suffering being, so far as I could judge, something like this. In an ordinary way the piece of omentum, connected with the omentum inside the abdomen by a long stalk, lay in the sac with the stalk quite loose and flaccid, therefore the man was usually quite unconscious of its existence; during any great exertion, however, or if he ate any particularly indigestible food, a good deal of movement in the intestines and alteration in the intraabdominal tension would be brought about, the result being that this stalk or tag of omentum was pulled upon, and so was caused the intra-abdominal pain from which he suffered; and, as it happened that the stalk went up towards the right side, the dragging upon it afforded a fair explanation of the resemblance of the pain to that of perityphlitis. It will remain to be seen whether this man again suffers from the pain which formerly troubled him. I do not think he will. I have no doubt the explanation of the symptoms which I have given you is the real one, and that the treatment adopted will cure him not only of the hernia but also of these "crampy " pains from which he suffered.1 I My next case is a very interesting one of the same kind, but a little more obscure. It occurred in a patient about thirty-two years of age, who for eight or ten years had been constantly the victim of very acute dyspepsia-at least, that was her account. She stated that after taking food, especially indigestible kinds of food, which would naturally be expected to excite rather energetic peristaltic action, she always suffered from this acute crampy 11 indigestion " (that again was her own term). She had been to more than one medical man, and had been treated for indigestion by them a,] L She had taken, so far as I could ascertain, almost every drug having any reputation for the cure of dyspepsia. Still getting no relief, she became wearied, and, for some reason or other, in the course of her peregrinations in search of relief she came to see me. Following a rule, which I think is a good one-viz., in any case of abdominal pain to always thoroughly examine the patient and not to accept the patient's word merely that the case is one of indigestion, constipation, or what not-I examined her as carefully as I could, and, I am bound to say, could find nothing. At last, however, as I happened to be examining the middle part of the abdomen, she all at once said, "That is the spot where the pain always begins." That led me, of course, to examine the spot a little more minutely ; and there I found, exactly in the middle line, about halfway between the ensiform appendix and the umbilicus, a small, round, movable nodule, about the size, apparently, of an ordinary filbert, of which the patient knew nothing, and which, she said, nobody had discovered before. Indeed, so far as I could learn, hardly anyone whom she had consulted about her symptoms had examined her abdomen at all, excepting over the liver region. It had apparently been assumed, from the symptoms she described, that she was suffering from acute indigestion, and she had been treated accordingly. The little nodule, then, in this case explained the history of the many years of "indigestion," so called. You probably know that it is not at all uncommon to find in the middle line of the abdomen little openings the result of defective coalition of the parts in that situation during development, and that when these small defects exist there is generally a tendency to a protrusion, through the opening, of the fatty tissue lining the inside of the abdominal wallthe subperitoneal fat. But occasionally the protrusion is something more than that. It is sometimes a small omental hernia lying in a little peritoneal sac just under the skin. In this woman, then, I concluded that there existed in the middle line of the abdomen a condition very much the same, from a mechanical point of view, as was found in the man whose case I have just related. She had, I believed, a piece of omentum in a hernial sac connected with the parts inside the abdomen by means of a stalk, so that when the intestines rolled about under the impetus of exercise, great exertion, or indigestible food she felt this same crampy pain which she described as indigestion and for which she had been unsuccessfully treated for years with drugs applied simply to the treatment of that complaint. The history of 1 The patient was perfectly well three months subsequently, no recurience of the old symptoms having taken place. L
doi:10.1016/s0140-6736(01)59094-7 fatcat:4rimryefsbgoneqyi542xctxwq