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194 JCKF. 10, 1944.] AUSCULTATION OF THE AB00:'fEX.

[
.A. MED'CAL
JOURNAL.
the deliberations been restl"ided to de,'ising a scheme which,
for the time being, would provide a State l\1edical Service for
the indigent-both white and black--but not encroaching on
the present system of private pmctice for those who can
afford it. It is difficult to conceive of one profession being
socialised in advance of other professions, industry 01' com-
merce.
Before I close I must make peace ,,'ith my surgical, obstreti-
ca! and urological friends aud fripnds in other specialities whose
domains have been "by passed" in these reflections. The
brilliance of their achievements requiles no reflector 01' words
to recall the wonderful advances made in these branches but
which, it will be admitted, were made p::.ssible by the evolution
of bacteriology, radiology, new methods of anresthesia and
other scientific discoveries.
In the limited time at my disposal it has only been possible
to recall samples of the wonderful that medicine has
made since the commencement of this umtury-equaUy im-
pOltant discoverie such as radium, endocrinology, physiotherapy
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
our scientific investigators such a cancer, rheumatism in its
various forms, allergies and so forth, but with the magnificent
record of past achievements we call with confidence look for
ward to their solntion.
We ha"e lived in a truly wonderful age. X one can forecast
the future, but I think we must prepare ourselves for revolu-
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.
Auscultation of the Abdomen.
By A. C. CO?LEY, F.R.C-..
-urgeon to Ki71g Edll:ard 1-/11 llu.<pital, Durban.
I
T is :l matter of surprise that in the textbooks of SUl'gely
so little mention is made of the abdominal sounds, both
normal and abnormal, which can be heard with the stethoscope.
Students :ll'e rarely taught that auscultation of the abdomen is
as important to the surgeon a :luscultation of the chest i to
the physician.
After many years of listening to the abdomen at every oppor-
tunity, I am now satisfied that oue can appreciate the difference
between nOl'mal and abnormal sounds and, by checking up by
lapal'otomy, gradually gain a very imp::.rtant adjunct in makin"
deeision III abdominal cases. '"
In attempting to write on uch an interesting subject the
difficulty immediately arises in portraying sounds descriptively.
Without a good knowledge of musical terms such as pitch.
tone, and modulation, it is easy to li ten to an abdomen and
say "I hear tbe ileoc:ecal valve functioning", but how diffi-
cult it i to describe it!
In the normal abdomen certain sound are audible. The
opening and closing of the pyloru I think, inaudible, s'
that all ounds normally heard are those of the small intes-
tine-those above the umbilicu mo tly from the jejunum, and
those below mostly the ileum. The e sounds are irregularh'
spaced in time, short in duration, mall in volume, and cir
medium pitch.
The ileoc:ecal vah-e has a characteristic ound, heard ju. t
o"er :\lcBurney's point, more rhythmic than the small iutestin
and occurring about once 45 seconds. This ound
,-e embles a low rumbling squelch. The large inte tine i-
usually silent, except in the presence of an urgent desire for
defrecation. which is being restrained. in which case prolonged
"hythmic borborygmi are heard gene:ally in the left iliae
fossa resembling the release of ga through water under tell
sion, 'IonISer in duration, and lower pitched than the ounds
the mall intestine.
To one who has ma tered the normal sounds. departure
from normal become inten ely intere ting, particularly when
one recognise the following changes under certain conditions.
1. i11ecllClJl/cal obstruction of:
(I) The large gul.-In the early stages of chronic obstruction,
the borborygmi of the large bowel become louder, more pro-
longed and even palpable, but the ileocrecal valve sounds lemain
normal. In the later stages, when the small intestilJe begins
to dist-end, the ileoca'cal valve becomes silent, the small intes-
tine sounds become very frequent, higher pitched and longer
in duration and finally, when well distended, the normal small
intestine sounds diminish and are replaced by a high-pitched
tinkle resembling the coin sound of pneumothorax.
(b) ::illlall intestine obslruction.-In the early stage the ileo-
crecal vahe sounds cease and the lower abdomen become more
silent, whereas in the upper abdomen the frequency of sounds is
increased, the ounds more gassy, and as the obstruc-
tion goes on the sound become progressiyely less frequent,
more tinkling, and hort in duration, and the heart sounds
become more audible even as far down as the umbilicus.
2. Focal inflammation.
Early in acute appendieitis the mall intestine ounds con-
tinue nOl'mally, but the ound of the ileoc,ecal valve gra.cIually
becomes less and les audible. In contradistiuction to this,
in localised right-sided salpyngitis no change takes place in the
ileocrecal Yah'e ounds and there is only a slight diminution
in the volume of the mall bowel ounds. As soon as the
inflammation is completely walled off, as in an appendix abscess,
the abdominal sounds return to normal.
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,
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
almo t immediately and the abdomen is silent.
4. Paralytic ileus.
'Whether this condition arises from septic peritoniti , from
blast injury or a a post-operative complication, the sound is
alwav' the same.
The ileoc:ecal "ah'e cea es to function, normal small intestine
sounds cea e and are replaced b;y occasional faint tinkling wunds,
unlike the sound of penstalsls and probably from alteration
of gas :lnd fluid pre sure levels within the gut. The most
chal'ac-tel'istic .ouod of ileus, hOWeYel-, occur when the jejunal
coils become distended and overloaded with fluid, when the
heart ounds are trongly transmitted from sternum to
umbilicus.
.The practical applicat ions of these observatlons are numerous,
but> a few -6}.--am-ples will suffice:
_-\ patient present himself with vague abdominal pain, un-
locali ed tenderne sand ome rigidity. After the routine
examination. li ten to the abdomen. If the normal sounds are
pl-esent. but more frequent in timing, then an acute enteriti
-is probably present and the. i voluntary. If the ign
ancl symptoms of appendlcll1s are and the abdominal
ounds are normal except that the ileocrecal valve has clo ed
do,nl, then it i appendix .>n the parietal
peritoneum Irl'lt?t:on,. but not yet rise to a
eptlC perltollltr, I.e. the appendiX ha not per-
forated.
If the appendix is u_pected and all sounds are normal. then
it is probable a .and not yet a. trne inflammation. If in
addition to the l'lgldlty all abdonllnal .ounds are 10 t. then
acti"e spreadinf pe:itonitis is pre ent, i.e. the appendix ha-
pel'forated. . .
Po t-operat.ively, I lIsten to b fore pr&-
crilJil1g aperient. It IS, III .my own vle.w, t-o force
the pace in a re ting that gut IS wllllllg, that i to
sav until natural pen talhc mo\"ement can be heard. Thi
no:mal revival of the gut usnally run pari passu with the
first free passing of f1atns per reetnm.
In ca es of inte tinal ob truction it is u eful to get some idea
of whether the obs.t.ruction is in a large or gut, and If
the how high up. Where charactenshc low-pitched
S.A. TYDSKRlF VIR]
GENEESKUNDE.
GALLSTONE ILEUS. [JUNIE 10 195
borborygmi are present, the obstruction is undoubtedly in the
large gut, and if the ileocrecal valve is functioning as yet the
case is a good risk. If no large bowel sounds are present and
the ileocrecal valve is silent, then the obstruction is in small
gut, and if the lower abdomen is silent and the upper abdomen
vociferous, then the obstruction is probably jejuna!.
Lastly, if the heart sounds can be clearly heard in the
abdomen down to the umbilicus there is urgent need to decom-
press the small gut by duodenal or Miller Abbott tube and
suction drainage; this sign shows itself before tbe onset of
regurgitant vomiting!
This subject is an interesting one, the study of whi(h repays
in good measure, and year by year one hears more al,d more
sounds full of meaning.
Indeed the abdomen cries out to be heard!
Gallstone Ileus.
By A. E. D.nEOSTI, M.B., CH.B., F.R.C.S. (ENG.),
J OHANliESBURG.
I
RECENTLY had to deal with a case of intestinal obstructioll
from a gallstone, the first in over ten years of clinical
experience, and am prompted to record it not only on account
of its rarity, but because of the interest the whole problem
arouses.
The gall-bladder generally rids itself of gall-stones by passing
them along the cystic duct into the common bileduct and then
into the duodenum through the ampulla of Yater. When the
stones are too large to pass along the. ducts there are other
ways in which nature can deal with them-by impaction and
fixation in the cystic duct; by fibrosis and shrinking the gall-
bladder may fix and immobilise the stones; by ulceration it
may extrude them externally into the general peritoneal cavity,
or into the gastro-intestinal tract, the stomach, duodenum, or
colon. The last method is of chief interest, as stones that pass
along the common bileduct are not as a rule of sufficient size
to cause intestinal obstruction.
Adhesions and a fistula must exist before the stones can pass
in this manner into the gut. Such a fistula will only develop
if there is obstruction to the escape of gallbladder contents.
The cause of such obstruction is the impaction of a stone in the
cystic duct.
According to Rutherford Morison and C. F. M. aint, one of
three things may happen when a stone impacts in the cystic
duct:
1. If the gall-bladder is empty at the time of both bile
and septic material, a mucocele will probably result.
2. If the gall-bladder is full of bile and septic material,
tension gangrene rapidly develops with ruptUl'e into the
general peritoneal cavity, and fatal peritonitis.
3. If a certain amount of bile and septic material still
remains in the gallbladder at the time of the impaction
of the stone, empyema of the gall.bladder results.
In all but the most acute varieties of this group protective
mechanisms develop. Inflammatory adhesions and the omentum
attempt to shut off the gall.hladder. tones may then pass
into the stomach, colon, or duodenum through an intermediary
abscess, or directly through adhesion of the inflamed If<lll
bladder to these sll'uctures, and, as has already been men-
tioned, an external fistula may develop.
Stones that reach the colon this way seldom cause any trouble
because of the large lumen of the colon. Rutherford Morison,
however, does record one case in which he removed a large
stone peT anum which was causing some obstruction and serious
tenesmus. Grey Turner records a fUliher of large gut
obstruction. Stones that reach the stomach may be vomited.
The stones that cause trouble are the ones that pass into
the duodenum; and they must be large, for, if small, they
are passed without any trouble. The st-oues that cause obstruc
tion are large, elongated, and circular on section. They con ist
of a central core, the original stone, on the surface of which
is deposited a concretion, presumably of frecal material. It is
thought that this material is deposited on it chiefly durinl!: its
passage along the gut. As the stone passes along the Kut it
increases in size. In addition, the farther it passes alonK the
small gut the smaller the lumen of the gut becomes.
These two factors seem to explain why the terminal ileum
is the common site for the stones to be held up. Naturally,
the longer the stone stays in the gut the larger it will become.
It is difficult to explain such delay in the absence of narrowings,
kinks, etc., in the gut. Grey Turner, in discussing this problem,
suggests that many of these stones are not passed at the time
the gall-bladder ulcerates into a neighbouring viscus, but are
I'etained in the gall-bladder and only later leave the gall.badder
through the fistulous opening.
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
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.
The stone remains in the gall-bladder, gradually increasing
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
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
portion of the stone (as shown by the facets on the stones and
by fitting them together) was protruding from the gall bladder
through the fistula into the bowel.
The lapse of time between the attack of acute ob tructive
cholecystitis with perforation and the appearance of intestinal
obstruction can thus readily be explained. In fact, it may be
difficult, in view of the many attacks of biliary colic which
the patient has suffered, for the patient to recall any particular
attack which may be regarded as the one responsible for the
development of the fistula.
The stone, having reached the duodenum, pas es along tlie
small gut and may produce intermittent attacks of colic, with
or without obstruction.
Many of the stones are passed per Q7lum. A few, however,
f cause obstruction. This obstruction i intermittent, which in
itself makes diagnosis difficult. Further, as patient probably
have had many previous attacks of biliary colic, the ob tructive
attack i often regarded, both by patients and the patient's
doctor, as another attack of biliary colic. The diagnosi , there
fore, is generally made late, by which time the patient is in 8
serious condition. This is one of the explanations of the high
mortality. In addition, the patients al'l' elderly.
The average age in Grey Turner's series ,as 68. The condi-
tion, as with cholelithiasis, is much commoner in females. The
mortality is well over SO per cent.
The notes herewith of my own ca es illustrate most of the
feature' mentioned.
AIrs. A. J. V., (('t. 62. Admitted on 21/10/43 General
Hospital, Johannesburg.
Complaint: evere abdominal pain and Yomiting. DI/ration:
7 days.
History: Was perfectly well until 15/10/43, when he felt
vague, cramp-like abdominal pain, which came and went.
The pain persisted and she felt naUS60U. She took a dose
of ca tor oil but promptly vomited it. Over tbe next few
day the pain persisted and sbe vomited frequently. At the
start she merely vomited what she took by mouth and a lot
of greenish fluid. Her vomit since the morning ha boon
brown and foul melling (seen by me at 8.20 p.m.). Her
bowels had not acted since 18/10/43, and there has been no
pa sage of flatus.
Previous History: For the la t five year patient has
uffered from attacks of cramp-like pain in the upper
abdomen, in midlille and under each costal margin. VomitinK
ea ed the pain somewhat. The attack lasted one to two
hours. Ha suffered much from flatulence. TO jaundice.
he had one attack about two year- ago which wa ,pry
e\-e"e, and la ted about three days.