Rebound Pain

WHILE LEAFING THROUGH some medical papers a while ago, I discovered an old reprint of an article by Emile Holman entitled, The Art of Abdominal Percussion in the Presence of Inflammation¹. The article was published 52 years ago, but over the years Dr. Holman's thesis never seems to have been taken seriously.

In his article he states, "Long since discarded has been the sign of 'rebound tenderness.' It is gross, it is cruelly painful, and it is not sufficiently accurate to be helpful when most needed in locating the primary seat of inflammation."

Unfortunately, he was mistaken in thinking that rebound tenderness has been "long discarded." In my experience it was in wide use among the doctors I encountered throughout my medical career, and I continue to hear it being referred to as a useful diagnostic tool.

On rereading the article, I began to ponder the experiences I had practicing surgery, and the opinions that I've developed. Holman felt percussion was the "most helpful single diagnostic procedure in evaluating the acutely disturbed abdomen," and that has certainly been my experience.

He makes the point of the importance of gentleness of examination in the presence of inflammation, surely something on which most surgeons would agree. And yet, there is certainly little gentleness present when examining for "rebound tenderness." It always bothered me to see patients wince, double up, or hear them cry out with a "positive" response to this test.

I found the diagnosis and treatment of acute appendicitis to be one of the most interesting aspects of the practice of surgery. Always ubiquitous, appendicitis often presented in a myriad of ways, but never, in my opinion, as an acute "surgical emergency." Early in my career, it was my experience that the diagnosis never justified rousting half a dozen or more people out in the middle of the night; the case could as easily be done before the first case in the morning.

Nor do I believe there is any excuse for "bumping" a scheduled case in the middle of the day instead of waiting an hour or two until the end of the schedule. I'm a little sensitive about that because it has happened to me, disrupting my afternoon clinic but allowing the "bumping" surgeon to keep his golf date.

As a matter of fact, a few hours delay spent hydrating the patient could benefit most cases. I am familiar with one case, a doctor's wife who had been ill for several days with vomiting and diarrhea, who probably would have profited by pre-op preparation but instead lost her life on an operating room table in the middle of the night.

Of course, one mustn't sit around for days, repeating lab tests and abdominal examinations, trying to decide whether or not to operate. Such dillydallying resulted in the rupture of my niece's appendix, all because her "white count wasn't elevated" despite her having all the findings of acute appendicitis.

Dr. Holman used to quote Opie as saying white count was "something you look at on the way back from the operating room." I never quite subscribed to that dictum, but must admit that I rarely found the count had an effect on my decision to operate. Incidentally, I've never been able to verify that quote. A surgeon named Opie lived around the turn of the century, but I've been unable to find his writings.

Although I received satisfaction from the results of my surgical efforts, I think my greatest pleasure was in my interaction with my patients. Taking a history, doing the physical examination, explaining the proposed operation, and trying to allay my patients' fears were all things that I found interesting and rewarding.

It's my impression that nowadays surgeons have little opportunity for such interaction, there usually being only time for the performance of these functions in a brief and cursory manner, if at all. But I don't want to leave the impression that I think poorly of today's surgeons. On the contrary, I'm sure they are conscientious, skilful, dedicated, and very hardworking.

I only hope they can be allowed the time to fully interact with their patients, and that they forget about rebound pain as a diagnostic tool.

peniston@mcn.org