A British Medical Association Lecture ON THE DIAGNOSTIC SIGNIFICANCE OF ABDOMINAL PAIN IN CHILDHOOD
Authors: R. Hutchison
Journal: BMJ (1921)

ABDOMINAL pain in a child must always be a source of anxiety to the doctor.It may mean so little or so much.It may be due to nothing worse than an attack of acute indigestion set up by a green apple; or it may indicate an attack of acute peritonitis set up by a green and gangrenous appendix.It is a matter, therefore, which craves wary walking in diagnosis, for a mistake may be fatal, and between one's anxiety not to overlook a serious cause and one's natural reluctance to alarm the parents unduly it is often difficult to steer a proper course.Our difficulty in these cases is increased by the fact that pain may be the sole symptom of abdominal disease, and the little patient may be unable to help us, as an adult can, by describing its exacttsituatiDn, character, and so forth, which are often so significant for diagnosis.It seemed, therefore, that we might -profitably employ our time this afternoon by con- sideriDg together the chief causes of abdominal pain in childhood, with a view to enabling us, when we meet such cases, to make a diagnosis by the method of exclusion if no other is available.EXTItA-ABDO31INAL CAUSES OF PAIN.At the outset it is well to remember that pain felt in the abdomen is not necessarily being caused there.In children, who localize their sensations badly, these extra- abdominal causes of pain are specially apt to lead-to error.We may divide them according as the cause has its seat (1) in thie abdominal wall, using that term in its widest sense, or (2) in the thorax.1. Causes in the Abdominal Wall.Spinal Carie8.-Ofcauses situated in the abdominal wall this is one of tlle commonest.The Dain in such cases is due, of course, to pressure on, the posterior nerve roots, and is usually referred along the lower intercostal nerves to the epigastrium.It may come on quite early in the disease before any gross spinal deformity has slhown itself, and the child will be brought to you under the belief that lhe is suffering from some abdominal trouble.It is well, therefore, to make it a rule carefully to examine the back in all cases of chronic epigastric pain in children.Slight prominence of one or more vertebral spines in the lower dorsal region can usually be detected, with tender- ness on percussion over them and some stiffness on stooping.If in doubt, one can call in the help of the radiographer.Lateral curvatlure in its more pronounced degrees is a similar source of error, but is less likely to be overlooked.RBhetmatim, or perhaps one should call it fibrositis, affecting the abdominal muscles, may easily simulate pain of intra-abdominal origin, and, like all rheumatic mani- ,festitiomg, is relatively commion ixn childhlood.It may be * Delivered before the South Midland Branch on July 8th. 1920.met with either at the insertion of the muscles into the ribs or iliac crests or in the aponeurotic sheaths of the muscles themselves.The well-known 'stitch in the side" which is common in children may, perhaps, be of this nature, but it is also met with in a chronic-and protracted form.Fibrositis may be distinguished by the fact that the pain comes on when the affected muscle is thrown into action, as, for example, when the patient tries to sit