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sation. Rigidity of the abdominal muscles pendix lies on the psoas muscle in man diore over the seat of pathology in appendicitis is frequently than in woman, and on its longa great aid to interpreting the pain. The est range of activity, hence when the apmuscular rigidity is protective and due to the pendix contains virulent and pathogenic transmission of the visceral irritation to the germs the long range of action of the psoas spinal cord, which is reflected to the abdom so traumatizes the appendix that it induces the inal skin (sensory) and to abdominal muscles escape or migration of the accidental virulent (motor). There is a nice balance between pathogenic microbes through the appendicthe peripheral visceral and the peripheral ular walls into the peritoneal cavity. Comcutaneous nerves in the abdominal muscles mon sense and experience would dictate that through the spinal cord. Local tenderness the pain on pressure would occur in any and local rigidity of the abdominal muscles point of the abdomen possessing inflamed is a great aid in signification of the sudden structures. Since probability is the rule of acute pain in appendicitis. It might be well life it is well to look to three great regions of to suggest that the position of the appendix dangerous peritonitis, viz., the pelvic, appenis located at any point from the liver to the dicular and gall-bladder regions. floor of the pelvis, and also many times where there was more or less of a mesenter.

BILIARY CHANNELS. ium commune, the cecum approached the The digestive tract has still another comvertebral column, and the appendix is then mon seat for sudden acute abdominal pain, liable to lie among the enteronic coils—the and that is the gall-bladder region. The dangerous ground of peritonitis. It is likely sudden acute abdominal pain in bepatic the pain in appendicitis depends on the seat colic is not generally so violent as many of the disease, i.e., the mucous membrane bas others accompanying acute diseases of the di become ulcerated, inducing painful appendi- gestive tract. Patients relate that the pain is cular colic (peristalsis), while the sudden aching, dragging, and in the active stage of exacerbation of violent diffuse abdominal cutting or tearing. Some relate a feeling of pain is due to the involving of the peritoneum tightness or fulness. But it depends on itself from the extravsation and from violent whether the calculus is attempting to enter peristalsis. I see nothing especially worthy constricted portions of the duct, or whether of attention in the so-called McBurney point. it has already entered. I have had typical Pain over the seat of disease is certainly a cases where operation proved that the calculi natural feature, and generally the appendix, only attempted to enter the constricted porlies under a point midway between the um. tion of the duot. No doubt these are the bilicus and anterior superior spine of the cases which say so often that they have severe ileum. But it is not always so by any pains at any time, but especially after taking means, for I examined with great and anx hot meals or hot stimulating drinks, or vigor. ious care, a short time ago, a young physi. ous exercise; whence arises excessive peristal. cian with severe pain over the so-called sis, inducing short, temporary hepatic colic. McBurney point, when on operation the long Now, when the gall-bladder has many calouli appendix was in the pelvis and perforated. in it, and when one or less often atMcBurney's point is partially a cutaneous tempts to engage in the neck of the gall-bladhyperesthesia. Then again, pain on pressure der, the pain is rhythmical. It begins slowly may be reflex, appearing in remote regions and rises to a maximum, at the maximum of the abdomen. The sudden, acute, diffuse the pain is intense. We have observed such abdominal pain arising in appendicitis, gen. cases and afterwards operated on them, reerally subsides in the right iliac fossa after moving many small calculi. Gall-stone perthirty-six hours, and one can nearly always haps four times as frequent in women as in elicit pain on pressure there. This pain on men; why, we do not know. In my experi. pressure is doubtless the motion transmitted ence patients can generally locate the pain in to a sensitive, inflamed peritoneum, and not hepatic calculi more accurately and definitely the dragging of an adhesion, as some as than almost any other sudden acute abdomsert, for adhesions so newly formed can have inal pain. They refer the pain to its proper no nerves formed in them. But man is sub locality; however, I must admit that this refject to appendicitis four times as frequently erence is before rupture. After rupture of as woman, due, perbaps to Gerlach's valve the cholecyst or duct the pain is indetinite, being small in man, and thus not allowing like other

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like other perforation in the peritoneum. The the foreign body to escape after entrance, sudden acute abdominal pain in biliary duct and due also to the greater activity of the disease is characterized by more slowness, psoas muscle in man inducing more peri- less acute intensely and distinct periodicity, , toneal adhesions to compromise the anatomy then invagination, appendicitis or perforation and physiology of the appendix. The ap- of the digestive tract. Jaundice is not nec

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essary. Jaundice is determined by the color

URINARY TRACT. of the eyeball, and not of the skin. A fea

In ureteral colic it must be said that the ture in gall-bladder pain is that it extends well towards the dorsum. Age aids in diag. pain resembles that of hepatic colio in many nosing calculus in the biliary passages to

ways, the rhythm being paroxysmal. It in

termits and is often agonizingly spasmodic. some ex

ot.
The patient, frequently middle-aged wo-

It requires much careful study to differentiate

the sudden acute abdominal pain in hepatio men, is suddenly seized with agonizing pain

and ureteral colic. This is important, for the in the epigastrium, vomiting and occasionally collapse. The pulse rapid and small, the plan of action is very different. The pain in epigastrium tender (cutaneous hyperesthesia) appendicitis, ureteral and hepatic colic are and the right abdominal muscles rigid (inter. in close relation and resemble each other. costal motor nerves irritated, corresponding

Sudden pain in the lumbar region, with to its sensory roots of the spinal cord). With progressive radiation toward the inguinal reprogress of the case the pain localizes in the gion, and especially testicular retractions, is right hypochondrium and peritonitis begins. suggestive of ureteral calculus. The kidney I have had cases of rupture of the gall-blad is frequently tender on pressure. Ureteral der with no known premonitory symptoms.

calculus permits time to complete the diagIt must be borne in mind that gall bladder nosis, as it is non-inflammatory, hence we perforation presents a different picture than examine.the urine for albumen, blood and merely violent peristalsis (colio) due to gall. pus and with the X-ray for shadows. stone in the biliary passages.

The perforation of the ureter will result in The pain of non-perforated biliary colio extra-peritoneal extravasation which does not arises sudden, is agonizing, and especially induce suoh excruciating pain as intra-peri. intense in the gallbladder region. It is gen toneal extravasation. earlly limited in duration, and frequently 1. Pain is a cardinal symptom of ureteral associated with jaundice. Biliary calculus calculus. may exist without pain (autopsies are rich in 2. Pain is not a sign of ureteral calculus. this testimony)

3. Pain as a single standard is liable to

lead to erroneous conclusions and to an inACUTE HEMORRHAGIC PANCREATITIS.

correct diagnosis. The pain in acute hemorrhagic peritonitis 4. In eighty operations with pain as the is characterized by being sudden, terrible, guiding symptom for ureteral caclulus 70% agonizing and remains persistent in the re failed to demonstrate calculus. gion of the pancreas. The patient is attacked 5. The vast dimensions of the plexus nerso violently that he faints, collapses. The vosus ureteris in number of ganglia and numvomitus is a greenish Auid contain in bile ber of strands permits irritation from the and blood. The patient suffers intensely in ureter to pass with facility and rapidity to the epigastric region. It presents the symp the abdominal brain, whence it becomes reor. toms of peritoneal extravasation (hence ex ganized and emitted: (1) Over the sympacruciating pain) small, rapid pulse, rigid ab thetic nerves of the abdomnial visceral plexdomen with sensitive, tender skin, skin cool uses inducing pain, aching, reflexes in the and bedecked with a clammy perspiration. adjacent viscera; (2) the reorganized irritation Temperature ranges high. Profound sepsis in the abdominal brain is emitted over the gradually deepens and death super venes in spinal nerves; (a) the intercostals (pain in three days. Acute hemorrhagic pancreatitis abdominal walls); (b) over the lumbar plexus is a rare disease; I saw no case in some 700 (pain in inguinal, hypogastric and external autopsies. It is seldom diagnosed as we still geneital regions); (o) over the sacral plexus possess no standard differentiating symp- (pain in the nates, genitals, rectum, thigh, toms. Diabetes is suggestive of hemorrhagic leg and foot). (3) The irritation of the plexpancreatitis or fat necrosis.

us of nerves passes to the abdominal brain

where it is recognized and emitted over the EMBOLUS WITH MESENTERIC VESSELS.

cranial nerves (vagus which aids in inducing Embolus of the mesenteric vessels, a rare nausea and vomiting). These reflex pains in disease, produces sudden severe abdominal ureteral valculus confuses by involving the pain. It is difficult to diagnose and is likely sympathetic, spinal and cranial nerves of disto be equally difficult to treat by any means tant regions, and also because other condi. at our command. The difficulty will be in tions of the ureters than ureteral calculus my estimating the amount of intestinal resection duplicate or simulate the reflex pain. required on account of the indefinite demar 6. Pain simulating that of ureteral caloucation of the line of gangrene due to the lus is a common symptom of many diseases embolus.

of the abdominal viscera.

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7. Ureteral calculus way exist without tient complains of sudden excruciating, terri. pain (post-mortems are rich in this testi. ble pain which at first is generally diffuse, mony).

but rapidly localizes in the pelvio region. 8. Caloulus may exist with the manifesta The sudden pain is persistent, muscular rition of pain in some adjacent visceral tract gidity is intense, the abdomen is tender and only, for example, pain in testicle, or ovary the patient's face is anxious, with the im. (genitals).

pending crisis vomiting is not conspicuous. 9. Other diseases of the urinary tract than If the hemorrhagic peritoneal extravasation ureteral calculus may simulate or duplicate is ample the pain is excruciating and faint. a pain (ureteritis, malignancy, hematuria tu. ness, syncope, shock with extreme anemia ocberculosis, vesical calculus, growth, cystitis). curs. Death frequently occurs from hemor

10. Reno-ovarian reflex, reno-testicular re. rhage. flex, or reno-uterine reflex pains are not signs

Lawson Tait used to advocate that the ovi. of ureteral calculus, but are simply intensi.

duct would rupture not later than the fourfied localizations of pain along the ureter, teenth week. However, it may rupture or which may exist from numerous conditions.

abort at any time previous to that. To the 11. Unilateral pain, stabbing pain, mus experienced gynecologist a bimanual vaginal cular trauma pain (Jordan Lloyd), stamping and rectal examination reveals in most cases muscular pain (Clement Lucas), pain from ample evidence for an operation. In sudden corporeal trauma (muscular), pain from the

abdominal pain, rapid rise of pulse with lowsensitive ureteral proximal isthmus or pelvis, ering of temperature indicates (hemorrhage) may arise from various conditions other than

gravity and demands surgical intervention. ureteral calculus.

It may be stated that during a decade of at12. The characteristic of pain in ureteral tendance in the Mary Thompson Hospital for calculus is inconstanoy, variation or radiation

Women and Children Dr. Lucy Waite and and reflexion. It has a tendency to produce myself have operated on considerable num . sympathetic aching in other abdominal vis

bers of ruptured gestating oviducts in which cera.

the patient could not furnish a clinical his13. The pain in ureteral calculus depends tory of very much pain or exact date of rupchiefly on its position (ureteral pelvis and

ture. proximal isthmus, sensitiveness) and also on

PYOSALPINX. the mobility of the calculus. 14. Pain (colic) can arise in the ureter from

In pycsalpinx the pain may be sudden and increased ureteral pressure (calculus, strio

excruciating (involving the peritoneum). ture, flexion-obstructing the urinal stream) The patient enforces upon herself extreme or from inflamed ureteral wall-ureteritis. physical quietness, breathing with the prox

15. Ureteral-lithiasis, cholelithiasis, appen imal end of the abdomen only. The thighs dicitis, ureteritis oystitis, nepbritis, may pro

are flexed, the face flushed, the abdomen duce practically identical symptoms.

tender, sensitive and rigid, the expression Intoxications.-Uremia may be accom that of impending crisis. Bimanual vaginal panied by abdominal pain, lead colio, blue examination reveals a large uneven miass, gum line and occupation. Food of concen

which is excruciatingly painful. trated nature as meats may produce such The mass should be palpated gently for concentrated urine that urination is accom fear of rupture. One of my patients with a panied by pain.

very large pyosalpinx strained at stool, caus

ing rupture and death from peritonitis. At TRACTUS GENITALIS.

the autopsy I found perhaps a quart of pus, The sudden acute abdominal pain arising free in the peritoneal cavity. She died from from the genitals is more easily interpreted excruciating pain and shook in some ten and managed. The pain can be more defin hours. itely located by the patient; and sudden dis. In regard to the character of sudden aborganization of viscera, being accessible in dominal pain arising from the genitalis is the pelvis, is much more within control of more easily interpreted and managed.

The the gynecologist. The sudden acute abdom

The sudden acute abdom- pain can be more definitely located by the inal pain from the genitals is generally due patient; and sudden acute abdominal pain, it to a ruptured ectopic pregnancy, or the very varies as to its mode of attack, and as to vis. rare matter of the rupture of a pyosalpinx cera attacked. into the peritoneal cavity. Most of the pains

AXIAL TORSION OF PEDICLES OR VISCERA. are of slower origin and almost diagnosable. Sex and the reproductive age aid in the inter Torsion of style or rotation of pedicle of a pretation of the case.

visous is characterized by sudden severe abWith a ruptured pregnant oviduct the pa. dominal pain. The intensity of the pain de

pends on the completeness of the constriction Axial torsion of abdominal viscera (tu. in the pedicle.

mors) are no doubt rotated by the peristalsis The tumor rotated on its axis gradually en. of the viscus itself or that of adjacent vis. larges because the venous blood can not re- cera, especially the colon (sigmoid), wbioh by turn, while the arterial blood continues to its rhythmic movements rotates the ovarian pass into the tumor. Ovarian tumors rotate tumor the omentum and the ilium about the on their axis or pedicles perbaps the most cecum. Tumors with axial torsions should frequently subsequent to parturition. The be at once removed, while vital viscera with initial pain is generally severe but not excru- axial torsion should be reduced, untwisted, ciating like extravasation in the peritoneal detorsioned, and sutured in situ for axial tor. cavity. As usual the pain is first diffuse, sion tends to recur. It may be due to the and later becomes localized in the region of constriction, to the blood vessels, to the perthe increasing tumor from accumulating istalsis cr adjacent peritonitis. verous blood and nerve trauma.

Hyper-rigidity of abdominal muscles and CHIEF FACTORS INVOLVED IN SUDDEN ABDOM. hyperesthesia of abdominal skin accompanies,

INAL PAIN. exists (on account of reflex irritation in the spinal cord).

The accompanying table presents a bird'sOne of the most important aids to diagno- eye view of some of the practical factors insis is that the women possess a tumor, and volved in sudden abdominal pain. Indelible that with accompanying abdominal pain the opinions must be entertained in the diagnotumor gradually enlarges because the rotat. sis as to the signification of the abdominal ing pedicle easily constricts the thin walled pain whether it be from peritonitis (septic veins, while the rigid walled artery persists lesion from adjacent viscera) or pain from in injecting its continuous stream into the violent peristalsis (colio) or tubular viscera tumor.

(due to mechanical irritation, calculus, stricI have witnessed torsion of pedicles in ture, flexion or from inflamed parietes). For ovarian tumors, oviduct sigmoid, ileocecal practical purposes I will present a skeletal apparatus, myoma, enteron, omentum and table of sudden pain of the six visceral tracts, kidney. Torsion of pedioles may apply to intestinal, urinary, vascular, lymphatic, nertubular viscera (ureter, intestine, oviduct) vous, and genital. It is evident that abdomas well as vessels.

inal pain rests on some common factors, as I bave operated on subjects with mycmata (a) flexion (b) stricture; (c) calculus (violent rotated to such an extent that the entire orig. peristalsis, colic) of tubular viscera, in which inal blood supply was completely obliterated, the danger and pain are limited. Perforation the tumor being nourished by newly formed (extravasation into the peritoneum) of tublood vessels from adjacent viscera, especially bular viscera in wbich danger and pain are from the omentum majus. Rokitansky of unbounded. A decade ago it was thought Vienna, first called attention to the axial ro sufficient to remember the three dangerous tation of tumors some forty years ago. peritonitis regions, viz, pelvic, appendicular,

The facility of pedioular torsion depends and gall-bladder. With the present accumuon the elongation and limited dimension of lated knowledge of the abdominal viscera the the pedicles. Volvulus is but axial torsion field presents problems of increasing complexfacilitated in the sigmoid by a narrow foot or ity as presented in the following bird'seye base (due mainly to mesosigmoiditis).

view of numerous causes of abdominal pain Axial torsion of the digestive tract consti- in the several visceral tracts: tutes about one-fortieth of intestinal obstruc. tion. Perhaps 6% of ovarian and parovarian

rflexion tumors experience axial torsion. Mr. Lawson

teron, appendix. Tait saw some 70 cases, and as his pupil I

2. Biliary ducts.

perforation witnessd with admiration his amazing acumen

3. Pancreatic in diagnosing and successfully operating on

i colic axial rotated tumors. My assistant, Dr. A.

(sigmoid 60 per cent

ileocecal apparatus Zetlitz, operated on a pacient with almost complete torsion of the uterus, and in exam. I. Tractus ining the specimen evidence demonstrated it.

| bands self that it was a slow chronic process and closely associated with peristalsis.

( ileocecal apparatus Axial torsion of viscera may be acute or

(colic 15 per cent chronic, complete (pathologic) or incomplete (physiologio), hence the manifestations of

7. Ulceration (gastrium, enteron, colon) pain will vary.

i 8. Splanchnoptosia.

1. Gastrium, en-stricture

calculus colon.

inflammation

neoplasm

duct.

Volvulus

30 per cent lenteron 10 per cent

Intestinalis

5. Strangulation.

apertures

6. Invagination

70 per cent enteron 15 per cent

flexure, stricture, cal

1. Ureter

Urinarius.

2. Bladder

colic.

1. Oviduct

torsion, neoplasm.

perforation, inflam.
mation, torsion,
neoplasm.

Genitalis

Artery-embolus.

glands-adenitis.

pain-constant, periodic.
pain - on pressure.

VI. Tractus

Nervosus

neuroma.
neuralgia.

{(a) ducts - calculus caloulus, stricture, obstruction, volvulus, flex

i inflammation, neo-
(a) Liver
plasm.

ion, uviductal gestation, parturition, constipa-
(b) parenchyma, hep-
i atitis, neoplasm.

tion, aneurism, invagination, hernia, strangu

lation by bard (inflammatory) (pain limited, (Appendages)

((c) ducts - calculus,

inflammation, neo periodic, life pot in jeopardy); (c) that from | (b) Pancreas { plasm, pancreatitis. 1 (d) parenchyma-ne

painful peristalsis (colio inflammatory) from crosis, neoplasm. inflamed parietes of tubular viscera, as 1(c) Spleen-splenitis neoplasm

ureteritis, oholedochitis, salpingitis, cholecys.

titis, cystitis, myometritis, myocorditis, enculus, inflammation, teritis, colitis, appendicitis (pain periodic, in. perforation, colic.

flammatory, life not in jeopardy). First and II. Tractus

( calculus, inflamma
tion, perforation,

foremost for practical purposes it will be in

structive to consider sudden abdominal pain (3. Prostatitis-vesiculitis, seminalitis. from perforation of the three excretory mu.

cous visceral tracts, viz: intestinal, genital ( perforation, abortion, and urinary (as they not only perforate but colic, infiammation,

develop immediate sepsis and jeopardizes

life). Second, sudden abdominal pain should III. Tractus 2. Ovary

be considered from perforation of the two

non-excretory, non-mucous visceral tracts, ( perforation, abortion 3. Uterus inflammation, colic,

viz., vascular and lymphatio (as they perforI torsion, neoplasm. ate, but do not develop immediate sepsis nor (Veins-phlebitis, thrombosis.

place life in immediate danger). IV. Tractus Vascularis

II. In making a diagnosis of sudden ab(Artery-aneurism.

dominal (constant) pain probability is the ( peritoneum- peritonitis. V. Tractus

rule of life, e.g., (a) sudden abdominal pain Lymphaticus ducts-lymphangitis.

(constant) pain accompanied with vomiting,

abdominal rigidity, rise of pulse and temper. neuritis.

ature, tym panitis, is peritonitis (perforative),

as appendicular, genital, biliary, gastro-in(hyperesthesia.

testinal, hemorrhagic pancreatitis. (b) Sud.

den (inconstant) abdominal pain with pracCONCLUSIONS AS REGARDS SUDDEN ABDOMINAL

tically negative pulse temperature, abdominal PAIN.

rigidity, tympanitis and perhaps vomiting, is I. There are three kinds of sudden abdom. violent peristalsis (colio), as flexion, stricinal pain, viz: (a) that of peritonitis, perfor. ture, calculus, inflammation, strangulation, ation (inflammatory, septic lesions from ad. invagination, volvulus, axial torsion. jacent visceral peritoneal extravasation, con. III. Extravasation in the peritoneal cavity tinuous excruciating pain (pain, continuous, is accompanied by agonizing, excruciating unlimited, and life in jeopardy), as 1, perfora. pain. tion of the tractus intestinalis (gastriun, IV. The leading symptoms should not be enteron, colon, appendix—its appendages, obscured by opiates until its complete clini. biliary or pancreatic channels).

cal history as possible is obtained. 2. Perforation of the tractus genitalis (ovi. V. The clinical history is frequently a ductal gestation, pyosalpinx, hydrosalpinx, pencil of light in the diagnosis of sudden abuterus, ovary).

dominal pain. 4. Perforation of the tractus urinarius VI. Examine the patient completely from (kidney, ureter, bladder).

bead to foot (especially per rectum and per 4. Perforation of the tractus lymphaticus vaginum). (chyle duct, cbyle cysts, chyle cbannels). VII. Exploratory peritonotomy is chiefly

5. Perforation of the tractus vascularis justified only in ascertaining the extent of (aneurism, hemorrhage, embolus, oviductal visceral diseases and rarely justified to degestation, is hemorrhage). (The tractus in termine a diagnosis. testinalis, urinarius, genitalis, vascularis, VIII. Delay in deciding the diagnosis of lymphaticus may perforate, intraperitoneal sudden serere abdominal pain should be or extraperitoneal. In extra peritoneal per avoided. Prompt diagnosis 18 the sheet foration, the pain is similar to intraperi. anchor for immediate successful medical or toneal perforation except in degree, how surgical treatment. ever, the danger of the extraperitoneal vis. IX. It must be remembered that sudden ceral perforation is limited); (b) that of vio severe abdominal pain is a matter of graptent peristalsis (colio, non-inflammatory) of ity, and prompt investigation with prompt lubular viscera, as in mechanical irritation, decisions should occur so that the patient's

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