'Hippocrates facies' are seen in

Ans. A. Peritonitis. (Ref. Bailey and Love 26th/pg. 973; Fig. 61.6)Diffuse (generalised) peritonitis# Diffuse (generalised) peritonitis may present in differing ways dependent on the duration of infection.# Early- Abdominal pain is severe and made worse by moving or breathing.- It is first experienced at the site of the original lesion and spreads outwards from this point. Vomiting may occur. The patient usually lies still. Tenderness and rigidity on palpation are found typically when the peritonitis affects the anterior abdominal wall. Abdominal tenderness and rigidity are diminished or absent if the anterior wall is unaffected, as in pelvic peritonitis or, rarely, peritonitis in the lesser sac. Patients with pelvic peritonitis may complain of urinary symptoms; they are tender on rectal or vaginal examination. Infrequent bowel sounds may still be heard for a few hours but they cease with the onset of paralytic ileus.- The pulse rises progressively but, if the peritoneum is deluged with irritant fluid, there is a sudden rise. The temperature changes are variable and can be subnormal.# Late- If resolution or localisation of generalised peritonitis does not occur, the abdomen remains silent and increasingly distends.- Circulatory failure ensues, with cold, clammy extremities, sunken eyes, dry tongue, thready (irregular) pulse and drawn and anxious face (Hippocratic facies). The patient finally lapses into unconsciousness. With early diagnosis and adequate treatment, this condition is rarely seen in modem surgical practice.Additional Educational points:Clinical features of an abdominal/pelvic abscess# Malaise, Sweats with or without rigors, Abdominal/pelvic (with or without shoulder tip) pain, Anorexia and weight loss, Symptoms from local irritation, e.g. hiccoughs (subphrenic), diarrhoea and mucus (pelvic), Swinging pyrexia, and Localised abdominal tenderness/mass.