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J R Soc Med. 2006 January; 99(1): 42.
PMCID: PMC1325083

Cope's Early Diagnosis of the Acute Abdomen

Old men dream dreams of elegant clinical diagnoses; young men see visions of perfect cross-sectional images. Early Diagnosis of the Acute Abdomen, worshipped by three generations of surgeons, is now in its 21st edition; Zachary Cope's versions (from 1921) are now in the rare-books section of medical libraries; the last seven (from 1980) have been revised by Professor William Silen of Harvard Medical School. He has made a noble attempt to retain the original emphasis on diligent clinical assessment, whilst guiding the reader towards appropriate laboratory and radiological investigations. Sadly the reproduction of the CT (computerized tomography) images is so poor as almost to defeat this objective.

Much of the original elegant text (with simple line diagrams) has been retained, and in this age of evidence-based medicine one might question some of Cope's maxims. ‘Severe abdominal pain that lasts more than six hours is caused by some condition of surgical import’. Often but not always! The ‘sweating brow’ may not be caused by a perforated ulcer; the ‘dull gaze and ashen countenance in severe toxaemia’ will not be adequately confirmed by ‘the back of the hand placed on the patient's nose and cheek’.

But I exaggerate. Professor Silen has attempted to identify appropriate complementary tests rather than suggest every conceivable investigation; for example, there is evidence that CT is over-used in patients with an ‘acute abdomen’.

The saving grace is that this same technique has led to a greater appreciation of applied surgical anatomy, which was always emphasized by Sir Zachary. Yet his standard of clinical evaluation would exceed most of our abilities. How many would ‘personally examine the blood smear and urinary sediment’? To exclude tabes dorsalis would our junior surgeons test the knee jerks and examine the pupils?

Mr Cope, as he then was, would have been perplexed by the added sections on laparoscopy or immunocompromised patients, for example, but he would doubtless rejoice that degrees Fahrenheit had not been banished by Celsius. There is much repetition in the text as individual acute abdominal problems are discussed, each with its recurring differential diagnosis; but who could resist the inclusion of Sir Zachary's personal account of his own acute cholecystitis in 1969, at the age of 80—‘one is never too old to learn’, he concluded.

No biography is offered in this new edition, nor is it necessary; the original text remains its own definitive reference. This is a brave attempt to continue the resuscitation of a unique book. It will be of interest to those with a love of books and of the history of 20th century surgery. It will appeal less to trainee surgeons seeking a core text to prepare for 21st century examinations; they must look elsewhere. Every surgeon should heed Cope's note of caution when dealing with an acute abdomen: ‘the dextrous hand must not be allowed to reach before imperfect judgment’.


Revised by William Silen 298pp Price £19.99 ISBN 0-19-517545-X (p/b) New York: Oxford University Press

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press