sation. Rigidity of the abdominal muscles over the seat of pathology in appendicitis is a great aid to interpreting the pain. The muscular rigidity is protective and due to the transmission of the visceral irritation to the spinal cord, which is reflected to the abdominal skin (sensory) and to abdominal muscles (motor). There is a nice balance between the peripheral visceral and the peripheral cutaneous nerves in the abdominal muscles through the spinal cord. Local tenderness and local rigidity of the abdominal muscles is a great aid in signification of the sudden acute pain in appendicitis. It might be well to suggest that the position of the appendix is located at any point from the liver to the floor of the pelvis, and also many times where there was more or less of a mesenterium commune, the cecum approached the vertebral column, and the appendix is then liable to lie among the enteronic coils-the dangerous ground of peritonitis. It is likely the pain in appendicitis depends on the seat of the disease, i.e., the mucous membrane has become ulcerated, inducing painful appendicular colic (peristalsis), while the sudden exacerbation of violent diffuse abdominal pain is due to the involving of the peritoneum itself from the extravsation and from violent peristalsis. I see nothing especially worthy of attention in the so-called McBurney point. Pain over the seat of disease is certainly a natural feature, and generally the appendix, lies under a point midway between the umbilicus and anterior superior spine of the ileum. But it is not always so by any means, for I examined with great and anxious care, a short time ago, a young physician with severe pain over the so-called McBurney point, when on operation the long appendix was in the pelvis and perforated. McBurney's point is partially a cutaneous hyperesthesia. Then again, pain on pressure may be reflex, appearing in remote regions of the abdomen. The sudden, acute, diffuse abdominal pain arising in appendicitis, gen. erally subsides in the right iliac fossa after thirty-six hours, and one can nearly always elicit pain on pressure there. This pain on pressure is doubtless the motion transmitted to a sensitive, inflamed peritoneum, and not the dragging of an adhesion, as some assert, for adhesions so newly formed can have no nerves formed in them. But man is subject to appendicitis four times as frequently as woman, due, perhaps to Gerlach's valve being small in man, and thus not allowing the foreign body to escape after entrance, and due also to the greater activity of the psoas muscle in man inducing more peritoneal adhesions to compromise the anatomy and physiology of the appendix. The ap

pendix lies on the psoas muscle in man more frequently than in woman, and on its longest range of activity, hence when the appendix contains virulent and pathogenic germs the long range of action of the psoas so traumatizes the appendix that it induces the escape or migration of the accidental virulent pathogenic microbes through the appendicular walls into the peritoneal cavity. Common sense and experience would dictate that the pain on pressure would occur in any point of the abdomen possessing inflamed structures. Since probability is the rule of life it is well to look to three great regions of dangerous peritonitis, viz., the pelvic, appendicular and gall-bladder regions.

BILIARY CHANNELS.

The digestive tract has still another common seat for sudden acute abdominal pain, and that is the gall-bladder region. The sudden acute abdominal pain in hepatic colic is not generally so violent as many others accompanying acute diseases of the digestive tract. Patients relate that the pain is aching, dragging, and in the active stage of cutting or tearing. Some relate a feeling of tightness or fulness. But it depends on whether the calculus is attempting to enter constricted portions of the duct, or whether it has already entered. I have had typical cases where operation proved that the calculi only attempted to enter the constricted portion of the duct. No doubt these are the cases which say so often that they have severe pains at any time, but especially after taking hot meals or hot stimulating drinks, or vigorous exercise; whence arises excessive peristalsis, inducing short, temporary hepatic colic. Now, when the gall-bladder has many calculi in it, and when one more or less often attempts to engage in the neck of the gall-bladder, the pain is rhythmical. It begins slowly and rises to a maximum, at the maximum the pain is intense. We have observed such cases and afterwards operated on them, removing many small calculi. Gall-stone perhaps four times as frequent in women as in men; why, we do not know. In my experience patients can generally locate the pain in hepatic calculi more accurately and definitely than almost any other sudden acute abdominal pain. They refer the pain to its proper locality; however, I must admit that this reference is before rupture. After rupture of the cholecyst or duct the pain is indefinite, like other perforation in the peritoneum. The sudden acute abdominal pain in biliary duct disease is characterized by more slowness, less acute intensely and distinct periodicity, than invagination, appendicitis or perforation of the digestive tract. Jaundice is not nec

essary.

Jaundice is determined by the color of the eyeball, and not of the skin. A feature in gall-bladder pain is that it extends well towards the dorsum. Age aids in diag nosing calculus in the biliary passages to some extent.

The patient, frequently middle-aged women, is suddenly seized with agonizing pain in the epigastrium, vomiting and occasionally collapse. The pulse rapid and small, the epigastrium tender (cutaneous hyperesthesia) and the right abdominal muscles rigid (intercostal motor nerves irritated, corresponding to its sensory roots of the spinal cord). With progress of the case the pain localizes in the right hypochondrium and peritonitis begins. I have had cases of rupture of the gall-bladder with no known premonitory symptoms. It must be borne in mind that gall-bladder perforation presents a different picture than merely violent peristalsis (colic) due to gallstone in the biliary passages.

The pain of non-perforated biliary colic arises sudden, is agonizing, and especially intense in the gallbladder region. It is genearlly limited in duration, and frequently associated with jaundice. Biliary calculus may exist without pain (autopsies are rich in this testimony)

ACUTE HEMORRHAGIC PANCREATITIS.

The pain in acute hemorrhagic peritonitis is characterized by being sudden, terrible, agonizing and remains persistent in the region of the pancreas. The patient is attacked so violently that he faints, collapses. The vomitus is a greenish fluid contain in bile and blood. The patient suffers intensely in the epigastric region. It presents the symptoms of peritoneal extravasation (hence excruciating pain) small, rapid pulse, rigid abdomen with sensitive, tender skin, skin cool and bedecked with a clammy perspiration. Temperature ranges high. Profound sepsis gradually deepens and death supervenes in three days. Acute hemorrhagic pancreatitis is a rare disease; I saw no case in some 700 autopsies. It is seldom diagnosed as we still possess no standard differentiating symptoms. Diabetes is suggestive of hemorrhagic pancreatitis or fat necrosis.

EMBOLUS WITH MESENTERIC VESSELS.

Embolus of the mesenteric vessels, a rare disease, produces sudden severe abdominal pain. It is difficult to diagnose and is likely to be equally difficult to treat by any means at our command. The difficulty will be in estimating the amount of intestinal resection required on account of the indefinite demarcation of the line of gangrene due to the embolus.

URINARY TRACT.

In ureteral colic it must be said that the

pain resembles that of hepatic colic in many ways, the rhythm being paroxysmal. It intermits and is often agonizingly spasmodic. It requires much careful study to differentiate the sudden acute abdominal pain in hepatic and ureteral colic. This is important, for the plan of action is very different. The pain in appendicitis, ureteral and hepatic colic are

in close relation and resemble each other.

Ureteral

Sudden pain in the lumbar region, with progressive radiation toward the inguinal region, and especially testicular retractions, is suggestive of ureteral calculus. The kidney is frequently tender on pressure. calculus permits time to complete the diagnosis, as it is non-inflammatory, hence we examine the urine for albumen, blood and pus and with the X-ray for shadows.

The perforation of the ureter will result in extra-peritoneal extravasation which does not induce such excruciating pain as intra-peritoneal extravasation.

1. Pain is a cardinal symptom of ureteral calculus.

2. Pain is not a sign of ureteral calculus. 3. Pain as a single standard is liable to lead to erroneous conclusions and to an incorrect diagnosis.

4. In eighty operations with pain as the guiding symptom for ureteral caclulus 70% failed to demonstrate calculus.

5. The vast dimensions of the plexus nervosus ureteris in number of ganglia and number of strands permits irritation from the ureter to pass with facility and rapidity to the abdominal brain, whence it becomes reorganized and emitted: (1) Over the sympathetic nerves of the abdomnial visceral plexuses inducing pain, aching, reflexes in the adjacent viscera; (2) the reorganized irritation in the abdominal brain is emitted over the spinal nerves; (a) the intercostals (pain in abdominal walls); (b) over the lumbar plexus (pain in inguinal, hypogastric and external geneital regions); (c) over the sacral plexus (pain in the nates, genitals, rectum, thigh, leg and foot). (3) The irritation of the plexus of nerves passes to the abdominal brain where it is recognized and emitted over the cranial nerves (vagus which aids in inducing nausea and vomiting). These reflex pains in ureteral calculus confuses by involving the sympathetic, spinal and cranial nerves of distant regions, and also because other condi tions of the ureters than ureteral calculus my duplicate or simulate the reflex pain.

6. Pain simulating that of ureteral calculus is a common symptom of many diseases of the abdominal viscera.

7. Ureteral calculus may exist without pain (post-mortems are rich in this testimony).

8. Calculus may exist with the manifestation of pain in some adjacent visceral tract only, for example, pain in testicle, or ovary (genitals).

9. Other diseases of the urinary tract than ureteral calculus may simulate or duplicate a pain (ureteritis, malignancy, hematuria tuberculosis, vesical calculus, growth, cystitis).

10. Reno-ovarian reflex, reno-testicular reflex, or reno-uterine reflex pains are not signs of ureteral calculus, but are simply intensified localizations of pain along the ureter, which may exist from numerous conditions.

11. Unilateral pain, stabbing pain, muscular trauma pain (Jordan Lloyd), stamping muscular pain (Clement Lucas), pain from corporeal trauma (muscular), pain from the sensitive ureteral proximal isthmus or pelvis, may arise from various conditions other than ureteral calculus.

The sudden acute abdominal pain arising from the genitals is more easily interpreted and managed. The pain can be more definitely located by the patient; and sudden disorganization of viscera, being accessible in the pelvis, is much more within control of the gynecologist. The sudden acute abdominal pain from the genitals is generally due to a ruptured ectopic pregnancy, or the very rare matter of the rupture of a pyosalpinx into the peritoneal cavity. Most of the pains are of slower origin and almost diagnosable. Sex and the reproductive age aid in the interpretation of the case.

With a ruptured pregnant oviduct the pa

tient complains of sudden excruciating, terrible pain which at first is generally diffuse, but rapidly localizes in the pelvic region. The sudden pain is persistent, muscular rigidity is intense, the abdomen is tender and the patient's face is anxious, with the impending crisis vomiting is not conspicuous. If the hemorrhagic peritoneal extravasation is ample the pain is excruciating and faintness, syncope, shock with extreme anemia occurs. Death frequently occurs from hemorrhage.

Lawson Tait used to advocate that the oviduct would rupture not later than the fourteenth week. However, it may rupture or abort at any time previous to that. To the experienced gynecologist a bimanual vaginal and rectal examination reveals in most cases ample evidence for an operation. In sudden abdominal pain, rapid rise of pulse with lowering of temperature indicates (hemorrhage) gravity and demands surgical intervention. It may be stated that during a decade of attendance in the Mary Thompson Hospital for Women and Children Dr. Lucy Waite and myself have operated on considerable numbers of ruptured gestating oviducts in which the patient could not furnish a clinical history of very much pain or exact date of rup

ture.

PYOSALPINX,

In pycsalpinx the pain may be sudden and excruciating (involving the peritoneum).

The patient enforces upon herself extreme physical quietness, breathing with the proximal end of the abdomen only. The thighs are flexed, the face flushed, the abdomen tender, sensitive and rigid, the expression that of impending crisis. Bimanual vaginal examination reveals a large uneven mass, which is excruciatingly painful.

At

The mass should be palpated gently for fear of rupture. One of my patients with a very large pyosalpinx strained at stool, causing rupture and death from peritonitis. the autopsy I found perhaps a quart of pus, free in the peritoneal cavity. She died from excruciating pain and shock in some ten hours.

In regard to the character of sudden abdominal pain arising from the genitalis is more easily interpreted and managed. The pain can be more definitely located by the patient; and sudden acute abdominal pain, it varies as to its mode of attack, and as to vis. cera attacked.

AXIAL TORSION OF PEDICLES OR VISCERA.

Torsion of style or rotation of pedicle of a viscus is characterized by sudden severe abdominal pain. The intensity of the pain de

pends on the completeness of the constriction in the pedicle.

The tumor rotated on its axis gradually enlarges because the venous blood can not return, while the arterial blood continues to pass into the tumor. Ovarian tumors rotate on their axis or pedicles perhaps the most frequently subsequent to parturition. The initial pain is generally severe but not excruciating like extravasation in the peritoneal cavity. As usual the pain is first diffuse, and later becomes localized in the region of the increasing tumor from accumulating venous blood and nerve trauma.

Hyper-rigidity of abdominal muscles and hyperesthesia of abdominal skin accompanies, exists (on account of reflex irritation in the spinal cord).

One of the most important aids to diagnosis is that the women possess a tumor, and that with accompanying abdominal pain the tumor gradually enlarges because the rotating pedicle easily constricts the thin walled veins, while the rigid walled artery persists in injecting its continuous stream into the tumor.

I have witnessed torsion of pedicles in ovarian tumors, oviduct sigmoid, ileocecal apparatus, myoma, enteron, omentum and kidney. Torsion of pedicles may apply to tubular viscera (ureter, intestine, oviduct) as well as vessels.

I have operated on subjects with mycmata rotated to such an extent that the entire original blood supply was completely obliterated, the tumor being nourished by newly formed blood vessels from adjacent viscera, especially from the omentum majus. Rokitansky of Vienna, first called attention to the axial rotation of tumors some forty years ago.

The facility of pedicular torsion depends on the elongation and limited dimension of the pedicles. Volvulus is but axial torsion facilitated in the sigmoid by a narrow foot or base (due mainly to mesosigmoiditis).

Axial torsion of the digestive tract constitutes about one-fortieth of intestinal obstruction. Perhaps 6% of ovarian and parovarian tumors experience axial torsion. Mr. Lawson Tait saw some 70 cases, and as his pupil I witnessd with admiration his amazing acumen in diagnosing and successfully operating on axial rotated tumors. My assistant, Dr. A. Zetlitz, operated on a patient with almost complete torsion of the uterus, and in examining the specimen evidence demonstrated itself that it was a slow chronic process and closely associated with peristalsis.

Axial torsion of viscera may be acute or chronic, complete (pathologic) or incomplete (physiologic), hence the manifestations of pain will vary.

Axial torsion of abdominal viscera (tumors) are no doubt rotated by the peristalsis of the viscus itself or that of adjacent viscera, especially the colon (sigmoid), which by its rhythmic movements rotates the ovarian tumor the omentum and the ilium about the cecum. Tumors with axial torsions should be at once removed, while vital viscera with axial torsion should be reduced, untwisted, detorsioned, and sutured in situ for axial torsion tends to recur. It may be due to the constriction, to the blood vessels, to the peristalsis cr adjacent peritonitis.

CHIEF FACTORS INVOLVED IN SUDDEN ABDOMINAL PAIN.

The accompanying table presents a bird'seye view of some of the practical factors involved in sudden abdominal pain. Indelible opinions must be entertained in the diagnosis as to the signification of the abdominal pain whether it be from peritonitis (septic lesion from adjacent viscera) or pain from violent peristalsis (colic) or tubular viscera (due to mechanical irritation, calculus, stricture, flexion or from inflamed parietes). For practical purposes I will present a skeletal table of sudden pain of the six visceral tracts, intestinal, urinary, vascular, lymphatic, nervous, and genital. vous, and genital. It is evident that abdominal pain rests on some common factors, as (a) flexion (b) stricture; (c) calculus (violent peristalsis, colic) of tubular viscera, in which the danger and pain are limited. Perforation (extravasation into the peritoneum) of tubular viscera in which danger and pain are unbounded. A decade ago it was thought sufficient to remember the three dangerous peritonitis regions, viz, pelvic, appendicular, and gall-bladder. With the present accumulated knowledge of the abdominal viscera the field presents problems of increasing complexity as presented in the following bird'seye view of numerous causes of abdominal pain in the several visceral tracts:

I. There are three kinds of sudden abdominal pain, viz: (a) that of peritonitis, perforation (inflammatory, septic lesions from adjacent visceral peritoneal extravasation, continuous excruciating pain (pain, continuous, unlimited, and life in jeopardy), as 1, perforation of the tractus intestinalis (gastrium, enteron, colon, appendix-its appendages, biliary or pancreatic channels).

2. Perforation of the tractus genitalis (oviductal gestation, pyosalpinx, hydrosalpinx, uterus, ovary).

4. Perforation of the tractus urinarius (kidney, ureter, bladder).

4. Perforation of the tractus lymphaticus (chyle duct, chyle cysts, chyle channels).

5. Perforation of the tractus vascularis (aneurism, hemorrhage, embolus, oviductal gestation, is hemorrhage). (The tractus intestinalis, urinarius, genitalis, vascularis, lymphaticus may perforate, intraperitoneal or extraperitoneal. In extra peritoneal perforation, the pain is similar to intraperitoneal perforation except in degree, however, the danger of the extraperitoneal visceral perforation is limited); (b) that of viotent peristalsis (colio, non-inflammatory) of lubular viscera, as in mechanical irritation,

calculus, stricture, obstruction, volvulus, flexion, oviductal gestation, parturition, constipation, aneurism, invagination, hernia, strangulation by band (inflammatory) (pain limited, periodic, life not in jeopardy); (c) that from painful peristalsis (colic inflammatory) from inflamed parietes of tubular viscera, as ureteritis, choledochitis, salpingitis, cholecystitis, cystitis, myometritis, myocorditis, enteritis, colitis, appendicitis (pain periodic, inflammatory, life not in jeopardy). First and foremost for practical purposes it will be instructive to consider sudden abdominal pain from perforation of the three excretory mucous visceral tracts, viz: intestinal, genital and urinary (as they not only perforate but develop immediate sepsis and jeopardizes life). Second, sudden abdominal pain should be considered from perforation of the two non-excretory, non-mucous visceral tracts, viz., vascular and lymphatic (as they perforate, but do not develop immediate sepsis nor place life in immediate danger).

II. In making a diagnosis of sudden abdominal (constant) pain probability is the rule of life, e.g., (a) sudden abdominal pain (constant) pain accompanied with vomiting, abdominal rigidity, rise of pulse and temperature, tympanitis, is peritonitis (perforative), as appendicular, genital, biliary, gastro-intestinal, hemorrhagic pancreatitis. (b) Sudden (inconstant) abdominal pain with prac tically negative pulse temperature, abdominal rigidity, tympanitis and perhaps vomiting, is violent peristalsis (colic), as flexion, stricture, calculus, inflammation, strangulation, invagination, volvulus, axial torsion.

III. Extravasation in the peritoneal cavity is accompanied by agonizing, excruciating pain.

IV. The leading symptoms should not be obscured by opiates until its complete clinical history as possible is obtained.

V. The clinical history is frequently a pencil of light in the diagnosis of sudden abdominal pain.

VI. Examine the patient completely from head to foot (especially per rectum and per vaginum).

VII. Exploratory peritonotomy is chiefly justified only in ascertaining the extent of visceral diseases and rarely justified to determine a diagnosis.

VIII. Delay in deciding the diagnosis of sudden severe abdominal pain should be avoided. Prompt diagnosis is the sheet anchor for immediate successful medical or surgical treatment.

IX. It must be remembered that sudden severe abdominal pain is a matter of gravity, and prompt investigation with prompt decisions should occur so that the patient's