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

JOURNA

the deliberations been restl"ided to de,'ising a scheme which,for the time being, would provide a State l \1edical Service forth e indigent-both whit e and black--but no t encroach ing onthe present system of private pmctice for those who canafford it . I t is difficult to conceive of one pro fess ion beingsocialised i n advance of other professions, industry 01' commerce.

Before I close I must make peace , ,' it h my surgica l, obs tret ica! and urological friends aud fripnds in other specialities whosedomains have been "by passed" in these reflections. Thebril liance of their achievements requiles no reflector 01' words

to recall the wonderful advances made in these branches bu twhich, it will be admitted, were made p::.ssible by the evolutionof bac te rio logy , r adi ol ogy, new method s of anresthesia andother scientific discoveries.

In t he limi ted time at my disposal i t has only been possibleto re ca ll s ampl es of the wonderful ~ t r i d e s that medicine has

made since th e commencement of this umtury-equaUy impOl·tant d iscoverie such as radium, endocrinology, physiotherapy

and a ,,'hole host of other advances c'ome to one' s mind bu t

one mu. t call a halt. There are problems which still baffleou r scientific investigators such a cancer, rheumat ism in it s

various forms, allergies and so forth, but with the magnificentrecord 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

th e future, bu t I think we must prepa re ourselves for revolutionary 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-.·. ( E ~ G . ) ,-urgeon to K i71g Edll:ard 1-/11 llu.<pital, Durban.

IT is :l matter of surprise that in the tex tbooks of SUl'gelyso little mention is made of the abdominal sounds, both

normal and abnorma l, which can be hea rd with the stethoscope.Students :ll'e rarely taught that auscultation of the abdomen isas important to the surgeon a :luscultation of t he ches t i toth e physician.

After many years of listening to the abdomen at every oppor

tunity, I am now satisfied that oue can appreciate the differencebetween nOl'mal and abnormal sounds and , by checking up bylapal'otomy, gradually gain a very imp::.rtant adj unct i n mak in "deeision I I I abdominal cases. '"

In attempting to write on uch an i nt er es ti ng sub je ct t hedifficulty immediately arises in portraying sounds descriptively.Without a good knowledge of musical t erms such as pitch.ton e, an d modulation, it is easy to li ten to an abdomen andsay "I hear tbe ileoc:ecal valve functioning", but how difficult it i to describe it !

In the normal abdomen certain sound are audible. Theopening and closing of the pyloru I think, inaudible, s·'that all ounds normally heard are those of the small intest ine-those above the umbilicu mo tly from the jejunum, andthose below mostly the ileum. The e sounds a re irregularh'

spaced in time, short in duration, mall in volume, and cirmedium pitch .

The ileoc:ecal vah-e has a cha racter is tic ound, heard ju. t

o"er :\lcBurney's point , more rhythmic than the small iutestinan d occur ring about once e v e r ~ ' 45 seconds. This ound,-e embles a low rumbling squelch. The large inte tine iusuall y s il ent , ex cept in the presence o f an u rgen t des ir e f ordefrecation. which is b ei ng restrained. in which case p ro longed"hythmic borborygmi are hea rd gene:al ly in the left iliaefossa resembling the release of ga t hr ough water under tellsion, 'IonISer in durat ion, and lower pitched than the ounds

the mall intestine.

To one who has ma tered the normal sounds. departurefrom normal become inten ely intere t ing, par ticu la rly whenone recognise the following changes under cer ta in conditions.

1. i11ecllClJl/cal obstruction of:

(£I) The large gul . - In the ear ly stages of chronic obstructthe borborygmi of t he larg e bowel become louder, morelonged and even palpable, but the ileocrecal valve sounds lem

normal. In the later stages, when the small intes ti lJe begto dist-end, the i leoca'cal valve becomes s ilen t, the small intine sounds become very f requent, h ighe r pit ched and lon

in durat ion and f ina lly, when well distended, the normal smintestine sounds d imin ish and ar e replaced by a high-pitc

tinkle resembling the coin sound of pneumothorax.

(b) ::illlall intestine obslruction.-In the ear ly s tage the i

crecal vahe sounds cease and the lower abdomen become msilent, whereas in the upper abdomen the frequency of soundincreased, the ounds b e ~ o m e more gassy, and as th e obstrt ion goes on the sound become progressiyely less frequmore tinkling, and hort in duration, and the he art sou

become more audible even as fa r down as the umbilicus.

2. Focal inflammation.

Early in acute appendieitis the mall i nt es ti ne ounds ctinue nOl'mally, but th e ound of th e ileoc,ecal valve gra.cIubecomes less and les audible. In contradistiuction to t

in localised right-sided salpyngitis no change takes place inileocrecal Yah'e ounds and there is only a sl ight diminut

in the volume of the mall bowel ounds. As soon asinflammation is completely walled off, as in an appendix abscthe abdominal sounds return to normal.

3. Peritonealirritation.

By such fluids a extravasated blood from a ruptured . por ectopic, or urine from ruptnred bladder, the sound aremuttled but no t otherwi e a ltered in cha racter for many hothat is to say rhythm and pitch remain but the voludiminis he s. Vvith more evere irritant fluids, such asflooding of the peritoneum with ga tt'ic juice. all £cund cealmo t immediate ly and the abdomen is s il en t.

4. Paralytic ileus.

'Whether this condi tion ari ses f rom septic peri toniti , fblast injury or a a post-operative complication, the sound

a lwav ' th e same.The ileoc:ecal "ah'e cea es to function, normal small intes

sounds cea e and are replaced b;y occasional faint tinkling wununlike the sound of penstalsl s and probably f rom alterat iof gas :lnd fluid pre sure levels within the gut. The mchal'ac-tel'istic .ouod of ileus, hOWeYel-, occur when the jeju

coi ls become distended and overloaded with fl ui d, whenheart ounds are trongly transmitted from sternum

umbilicus..The practical applicat ions of these observatlons are numer

but> a few -6}.--am-ples will suffice:

_-\ patient p re sent h imse lf with vague abdominal pain,locali ed tenderne s a n d ome rigidity. After the rou

examination. li ten to the abdomen. I f the normal soundspl-esent. but more frequent in timing, then an acute ente-is probably present and the. ~ i g i d i t y i voluntary. I f th e

ancl symptoms of appendlcll1s are p ~ ' e s e n t and the abdomounds are normal except that th e ileocrecal valve has clodo,nl, then it i i ~ f 1 a . m e d appendix i m p i n g l n ~ «.>n the pariperitoneum c a l ~ s l l 1 g Irl'lt?t:on,. bu t not yet ~ l v l l l g rise t

~ p r e a d i n g eptlC perltollltr, I.e. the appendiX ha not

forated.I f the appendix is u_pected and all sounds are normal. t

it is probable a c ~ l i ~ .and not ye t a. trne inflammation. I f

addition to th e l'lgldlty all abdonllnal .ounds are 10 t. tacti"e spreadinf pe:itonitis is p re ent , i.e. th e appendix

pel'forated. . .Po t-operat.ively, I a l ~ , · a : y . lIsten to a b d o I ? e ~ b fore

crilJil1g aperient. I t IS, II I .my own vle.w, ~ l ' l ~ l l l a l t-o fthe pace in a re ting ~ n t l l th at g ut IS wllllllg, that isav until natural pen t alhc mo\"ement can be heard. Tno:mal revival of the gu t usnally run pari passu withf ir st f ree passing of f1atns per reetnm.

In ca es of inte tinal ob truction it is u eful to ge t someof whether the obs.t.ruction is in a large or s r ; n a ~ 1 gut, andthe l 3 t t ~ r , how high up. Where charac tenshc low-pitc

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S.A. TYDSKRlF VIR ]

GENEESKUNDE. GALLSTONE ILEUS. [JUNIE 10 1 9 ~ 4 . 195

borborygmi are p resent , the obstruction is undoubt ed ly in thelarge gut, and if the ileocrecal valve is funct ioning as yet thecase is a good risk. I f no large bowel sounds are present andt he ileocrecal v alve is silent, then the obstruction is in smallgut, and if the lower abdomen is si lent and t he upper abdomenvociferous, 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 decompress the small gu t by duodena l or Mil le r Abbott tube andsuction drainage; this si gn shows itself before tbe onset of

regurgitant vomiting!This subject is an interesting one, the study of whi(·h repaysin good measure, a nd year by year one hears more al,d moresounds full of meaning.Indeed the abdomen cries ou t to be heard!

Gallstone Ileus.

By A. E. D.nEOSTI, M.B., CH.B., F.R.C.S. (ENG.),J OHANliESBURG.

IRECENTLY had to deal with a case of intest inal obstructiol lfrom a gal ls tone , the first in over ten years of c linica l

experience, and am prompted to record it not only on account

of i ts r ar it y, bu t because of the interest the whole problemarouses.

The gall-bladder generally rids itself of gall-stones by passingthem along the cystic duc t i nt o the common bile·duct and theninto the duodenum through the ampulla of Yater. When thestones are too lar ge to pass a long the. ducts there are otherways in which nature can deal with them-by impaction andf ixat ion in the cystic duct; by fibrosis and sh ri nk ing t he gallbladder may fix and immobil ise the stones; by ulceration itmay extrude them externally into the general peritoneal cavity,or into the gastro-intestinal tract, the s tomach , duodenum, orcolon. The last method is of chief int eres t, as s tones that passalong the common bile·duct are not as a rule of sufficient sizeto cause intestinal obstruction.

Adhesions and a f is tula must exist before the s tones can passin this manner into the gut. Such a fistula will only developif there is obstruction to the escape of gall·bladder 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

t hree things may happen when a stone impacts in the cysticduct:

1. I f the gall-bladder is empty at the time of both bileand septic material, a mucocele will probably r esul t.

2. I f the gall-bladder is full of bile and septic material,tension gangrene rapidly develops with ruptUl'e into thegeneral peritoneal cav ity, and fatal peritonitis.

3. I f a certain amount of bile an d sep tic material stillr emains in the gall ·b ladder at the time of the impactionof the s tone , empyema of the gall.bladder results.

In all but the most acu te v ar ie ti es o f th is group protectivemechanisms develop. Inflammatory adhesions and the omentumattempt to shut off th e gall.hladder. tones may then passinto the stomach, colon, or duodenum through an intermediaryabscess, o r directly th ro ug h adhesion of the inflamed If<lll·

bladder to these sl l'uctures, and, as has already been mentioned, an externa l f is tula may develop.

Stones that reach the colon this way seldom cause any troublebecause of the large lumen of the colon. Rutherford Morison,however, does record one case in which he removed a largestone peT anum which was causing some obstruction and serioustenesmus. Grey Turner records a fUliher c a ~ e of large gu tobstruction. Stones that reach the s tomach may be vomi ted.

Th e stones that cause trouble are the ones that pass intothe duodenum; and th ey must be l arg e, for, if small, theyare passed without any trouble. The st-oues that cause obstruc·tion are large, elongated, and circular on section. They con istof a central core, th e o rigina l s tone , on the sur face of which

is depos ited a concret ion, presumably of frecal material. I t isthought that this ·material is depos it ed on it chiefly durinl!: itspassage along th e gut. As the s tone passes a long the Kut itincreases in size. In addition, the far ther it passes alonK thesmall gu t the smaller the l umen o f the gu t becomes.

These two fa ctors seem to explain why the terminal ileumis the common site fo r the stones to be held up. Naturally,the longer the s tone stays in the gut the larger it will become.I t is difficult to explain such del ay in the absence of narrowings,kinks, etc., in the gut. Grey Turner, in discussing this problem,

suggests that many o f th ese stones are not passed at th e timethe gall-bladder· ulcerates into a neighbouring viscus, bu t areI 'etained in the gall-bladder and only later leave th e gall.badder

through the fistulous opening.

I t is reasonable to suppose that the stone impacted stays in

the cystic duct; other stones lying free in the gall-bladder maybe pass ed at once, but , p robably be ing small re lath-e to thesize of the gut, cause no trouble. Later the impacted stonemay become f ree and fall back into the gall-bladder, by wh ichtime the gall-bladder will have shruuk, as also the fistulousopening, so stopping the escape of the stone.

The stone remains in the gall-bladder, gradually increasingin size as gas tro-duodenal material, etc., reaches it throuKh thefistulous opening, and late.r by ulceration may extrude itselfth rough th e opening into the duodenum. I t may now have

attained a size large enough to cause obstruction.

Grey Turner desc rib es a case where por tion of such a stonecaused i nt es tina l obs truc tion , and at post-mortem the otherportion of the s tone (as shown by the facets on the stones andby fitting them together) was protruding from the gall·bladderthrough the fistula into the bowel. •

The lapse of time between t he a tt ack of acute ob tructiv echolecystitis with perforation and the appearance of intes tinalobstruction can t hus readi ly be explained. In fact, it may bedifficult, in v iew of the many attack s o f biliary colic whichthe patient has suffered, fo r the patient to recall any part icularattack which may b e regard ed as the one responsible for thedevelopment of the fistula.

The stone, having reached the duodenum, pas es along tliesmall gu t and may produce intermittent attacks of colic, witho r w it hout obstruction.

Many o f the stones are passed per Q7lum. A few, however,f cause obstruction. This obstruction i intermittent, which initself makes diagnosis dif ficult . Further, as patient probablyhave had many previous a tt acks of b il ia ry colic, the ob tructive

attack i often regarded, both by patients and the pat ient 'sdoctor, as another attack of b il ia ry colic. The diagnos i , there·fore , is general ly made late, by which time the patient is in 8

serious condition. This is one of the explanations of the highmortality. In addition, t he pat ient s al'l' g e l l l ' r a l l ~ ' elderly.The average age in Grey Turner's series ,a s 68. The conditi on, a s with cho le li th iasi s, is much commoner in females. Themortality is well over SO per cent.

The notes herewith of my own ca es illustrate most of thefeature' mentioned.

AIrs. A. J. V. , (('t. 62. Admitted on 21/10/43 GeneralHospital, 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 p ai n, wh ich came and went.The pain persi st ed and she felt naUS60U. She took a dose

of ca to r oil bu t promptly vomited it. Over tbe next fewday th e pain persisted and sbe vomited frequently. At thestart she merely vomited what she took by mouth and a lo tof greenish fluid. Her vomit s ince the morning ha boonbrown and fou l· mel ling (seen by me at 8 .20 p .m.) . He rbowels had not acted since 18/10 /43, and there has been nopa sage of flatus.

Previous History: Fo r the la t five year patient hasuffered fr om attacks of cramp-like pain in the upperabdomen, in midli lle and under each costal margin. VomitinKea ed the pain somewhat. The attack lasted one to twohours. Ha suffered much from flatulence. TO jaundice.he had one attack about two year- ago which wa ,prye\-e"e, and la ted a bou t three days.