The Abdominal and Pelvic Brain
Byron Robinson, M. D.



"Give me liberty or give me death." - Patrick Henry, American. (1736-1799.)

Truth should be constantly advocated because the majority constantly advocate error.

    Abdominal surgery is no longer a pioneer work.  It is the result of the accumulated experience of the past fifty years.  Its success is based on well tried practices.  It is a jealous field, filled with battles lost and won, marked here and there with sad regrets, chagrin from unavoidable mistakes, however often brightened by the light of success.  A master-hand in abdominal surgery is a hard-earned reputation.  However, accumulative experience of fifty years has still left obscure points in abdominal surgery which the genius of Lawson Tait has attempted to set at rest by the exploratory and confirmatory incisions misused and abused field.
    During the past fifteen years I have been specially interested in gynecology and abdominal surgery, and during these years has risen the question of abdominal pain and its signification.  To interpret abdominal pain requires the best skill of the finest head.
    Sudden, severe abdominal pain is the one significant early symptom sounding the hope for relief or the knell of doom.  In the interpretation of sudden appearance of abdominal pain lies the physician's chance of success or failure - usefulness or disaster.  This cry of sudden pain may come from multiple lesions or sources - it may be the appeal of a strangulated loop of intestine on the verge of gangrene; the demand of an agonizing ureter afflicted with a bristling calculus; the disaster of a perforated appendix in the dangerous peritonitic enteronic area; the horrible, grinding, hopeless pain of a biliary calculus; the calamity of a ruptured gestating oviduct; or from the beginning painful perforative peritonitis of impossible diagnostic origin accompanied by excruciating pain.
    Abdominal pain belongs to the domain of the nervus vasomotorius, the sympathetic nerve, and should be interpreted according to its life and habits, in relation to its anatomy, distribution to viscera and physiology (rhythm) peristalsis.  Rhythm is a physical accompaniment of life.
    Severe abdominal pain is the appeal for prompt, efficient assistance.  In the first place, in my experience, the natural manifestation of sudden abdominal pain is too frequently obtunded, dulled, lulled into a treacherous quietude by the general practitioner's employment of large hypodermic injections of morphia, which obscures diagnosis.  Frequently it is the mode of onset, the sudden appearance and localization of the pain that affords the sharpest aid to diagnosis, and if the sharpest, delicate symptoms are obscured by morphia it may jeopardize the patient's life.
    Sudden pain in the abdomen is frequently the guiding, suggestive means to a diagnosis.  Pain in any location is the conscious expression of nerve trauma, whether it be macroscopic or microscopic.

     Fig. 85. This is an illustration of a peritoneal band of a the sigmoid from a woman physician operated by Dr. Lucy Waite.  I assisted Dr. Waite and saw the elongated band attenuated in the middle.  Its rupture allowed the gas to rush through the sigmoid with recovery.  The termination of the band (1) is at 2 and 4 on the right side and at 3 on the left side.

    Pain is an objective as well as a subjective symptom.  Its subjective character forces us to depend on the patient's statement for its location, severity, duration.  Pain is the most constant beginning feature and frequently the most constant, persistent characteristic.  For this reason the practitioner should secure a complete clinical history, mode of onset, location of pain, rhythmic or constant, before he obscures its most delicate and valuable aid to diagnosis by narcotics.  Abdominal pain is Nature's warning that mischief is afoot in the abdominal viscera, and its manifestations should not be obscured by opium until sufficient evidence is secured to diagnose the cause.  The successful diagnosis depends on the most careful analysis of every available symptom in severe abdominal pain, which is defective in a narcotized patient.
    A characteristic of sudden abdominal pain is that at first it is diffuse or mainly in the umbilical region ( the abdominal brain, the sensorium of abdominal vicera).
    Gradually, with the lapse of time - hours - it becomes more and more localized in the region of the affected organ (beginning local peritonitis).
    A suggestive symptom is that almost all patients with sudden abdominal pain especially beginning peritonitis, vomit.  The failure of the general practitioner in appreciating the significance of sudden severe abdominal pain results in late, and too frequently disastrous, surgery, also in disastrous treatment by administrating cathartics, the enemy of visceral quietude.
    In sudden abdominal pain the pulse in general is of more practical value than temperature.  In some advanced, grave abdominal diseases the pain is limited or absent. Overwhelming profound sepsis has obtunded sensibility.  In sudden abdominal pain the first and foremost matter is its diagnosis - the rock and base of rational treatment.  The diagnosis is absolutely required in order to attempt rationally to remove the cause.
    Probability is the rule of life and it is just as applicable in diagnosing sudden abdominal pain as in other matters.  For example, when a man is attacked by sudden abdominal pain and vomiting with rise of temperature, pulse and respiration, the probability is that it is appendicitis - not perforation of the gastrium, enteron or colon, for that occurs perhaps one hundred times less than perforation of the appendix.

     Fig. 86.  This occurred in a woman about 35 years of age.  The 8 feet of enteronic loops lying in the fossa duodeno-jejunalis were reduced with facility.

    Observation.  - I was called to attend a physician who was attacked with sudden abdominal pain while riding in his buggy.  The abdominal pain from the beginning was located several inches to the left of the medium line of the abdomen.  The diagnosis was ruptured appendicitis from a potential appendix, i. e., one with an elongated meso-caecco-appendicular apparatus capable of extending or moving to locations distant from the usual appendicular site.  The improbable diagnosis was intestinal perforation, because the appendix per forates perhaps a hundredfold more than the intestine.  In operating on the physician forty hours subsequent to the attack I found the peritonitis localized to the left of the medium line of the abdomen in the enteronic coils located in the left iliac fossa.  The potential appendix was during operation practically in its usual location, however, surrounded by peritonitis.  The explanation was evident.  He had a potential appendix, which while wandering amongst the intestinal loops in the left half of the abdomen had become perforated and immediately, before adhesions formed, returned to its usual location in the right iliac fossa.  The extensive, varying mobility of the cecum and appendix should be included in the anatomic diagnosis.
    Anatomy is the solid ground of nature on which to build a rational diagnosis of sudden abdominal pain.


    We should study the history of the abdominal pain in each patient for aid in diagnosis.
    A clinical study of abdominal pain is of the utmost importance to both general physician and abdominal surgeon.  Has the patient experienced similar sudden abdominal pain previously?  What was the length of time elapsed between the previous attacks of pain?  If the pain is recurrent it is probably from the same original cause, e. g., repeated perforated appendicitis or repeated attacks from calculus. Has the pain any regular persistent relation to the ingestion of food or fluid?  If so we examine the proximal end of the tractus intestinalis, as for gastritis, ulceration, biliary passages, pancreatic disease and perhaps appendicitis.  If the pain persistently precedes or follows defecation, search for rectal disease - hemorrhoids, fissure, ulceration, carcinoma.  If the pain recurs with menstruation, one examines the genitals.  If the pain be sudden and occurring for the first time, we should scrutinize its history and every visceral function.  Pain following extra exertion may be due to hernial strangulation, ruptured pregnant oviduct, breaking of peritoneal adhesions, formation of volvulus, rupture of a cystic tumor, an ovarian cyst, or other tumor or viscus, rotated on its pedicle.  Pain following extra trauma may be ruptured bladder, stomach, intestines or other viscera.  In gestation an impending miscarriage may cause sudden abdominal pain.  Clinical history is the most valuable in acute abdominal pain - not in chronic.  Repeated rough rides with repeated abdominal pain is suggestive of calculus.  The repeated abdominal pains due to painful peristalsis in inflamed ducts-biliary, ureteral, intestinal, genital-is still difficult to diagnose.
    It should be distinctly remembered that sudden recurrent abdominal pain following peritonotomy or peritonitis is mainly due to peritoneal bands checking peristalsis, or painful peristalsis from inflamed viscera.  Sudden abdominal pain in a patient who had had hernia is liable to be from constrictions of peritoneal bands.  The clinical history is frequently a pencil of light in the diagnosis of sudden abdominal pain.


    Age and sex are of extreme value in diagnosing sudden abdominal pain.  In woman, in the maximum sexual phase, the lesions of the tractus genitalis surpass those of the tractus intestinalis.      Still a differential diagnosis between appendicitis and right-sided inflamed oviduct, peritoneum and ovary, is frequently difficult.
    Sudden pain in anemic young women may be perforating round ulcer of stomach.
    In children lesions of the tractus intestinalis preponderate, gasteroenteritis, invagination, enterocolitis, appendicitis.
    In senescence malignancy may attack the gastrum, colon, rectum, gall bladder and pancreas, as well as ulceration of the intestinal tract usher in pain.


    Abdominal pain may be acute or chronic, it may be tolerant or excruciating (peritoneal extravasation).  It may be due to intra-abdominal or extra-abdominal disease.  It may arise from violent peristalsis (colic) in tubular viscera or from inflammation.  Abdominal pain may be due to disease or trauma.

     Fig. 87.  I secured this specimen from an autopsy.  The subject had numerous recurrences as was demonstrated by the marked cicatricial strictures at various points of the enteron.  Also saccular dilatations (9) of the enteron demonstrated repeated recurrences.

    If one will closely watch the sudden acute abdominal pain, it will be quite apparent that the character of the pain in most of the acute affections is very similar.  We only observe a reality in difference of degree of pain from the bearable to the agonizing.  In perforation the character of the pain is the same in all viscera.  In invagination it is paroxysmal and periodic, at least at first, due to irregular and violent peristalsis.  In internal strangulation it is generally intense and periodic, due to violent peristalsis; later continuous and of an aching, dragging, character, due to paralysis of the intestinal segments.  In appendicitis the pain is nearly always sudden and intense, i. e., the perforative variety.  The variety of appendicitis with slowly increasing pain is likely lymphatic in invasion and not dangerous, simply medical, though of course the appendicular mucosa may be perforated.  Sudden, acute abdominal pain of a lancinating character, and quite continuous, is very likely to be due to perforation of the appendix or digestive tube, and the continuous, agonizing character of the pain is a heraldic symptom of diffuse peritonitis - the knell of life.  It may be remembered that the character of sudden acute abdominal pain will depend on the capacity of any viscus for peristalsis, i. e., its capacity to cause colic by violent, wild, irregular muscular action.  In peristalsis periodicity must not be forgotten, and the etiology which gives rise to the irritation, inducing the peristalsis.  It may be transitory in character, as food irritation, rapidly forming and inducing imagination, or a calculus attempting to enter a duct.  Or the pain may be continuously periodic, as a calculus lodged in some canal, appendix, ureter, enteron, colon, or binary.  Head and Sherren claim that the body is endowed witb three forms of sensibility conducted by three series of fibers in the efferent nerves, viz.:
    1.  The nerves which subserve deep sensibility.  The fibers of deep sensibility or "deep touch" course chiefly with the motor nerves to the muscles, aiding muscular protection of viscera, and also supply the fibrous structures connected to the muscles - muscular sense.

     Fig. 88. This was drawn from a child about 10 months old. At the operation, which was on the 4th day, I could not disinvaginate the ileum without inflicting irreparable damage. The child died 12 hours later.

    2.  The n e r v e s which respond to painful impressions and to extreme heat and cold responding to light touch - skin s e n s e. This second system of n e r v e s Head and Sherren term proto-phatic."
    3.  The nerves which enable light touch and the minor degrees of temperature to be appreciated and two points to be discriminated.
    To the third system of sensibility the name "epicritic" is applied - temperature and location sense.    The sensibility of the abdomen is a significant matter in sudden abdominal pain.
    The abdominal cutaneous sensibility must be distinguished from the sensibility of the abdominal musculature and also the condition as to whether the hyperesthenia be unilateral or bilateral, symmetrical or non-symmetrical, e. g., McBurney's point is frequently simply a nervous point.  At this point the nerves of the coecum correspond with the nerves of the abdominal wall immediately ventral to it, i. e., the appendicular nerves being irritated transmit sensations to the spinal cord where reorganization occurs and the impulses are emitted over the intercostal nerves to the abdominal wall at McBurney's point.  The same condition will occur relative to other viscera, e. g., the kidney.
    Pain may be reflex or sensitive, hyperesthesia, neurasthenia, hysteria.
    Gastric ulcer is especially liable to manifest pain from cold drink, solid food.
    In the diagnosis the pain is the most important element to both patient and physician.
    The anatomic and physiologic side must be studied, analytically.
    It may be remembered that the dorsal and ventral (parietal) peritoneum is sensitive to trauma according to individuals.  The healthy visceral peritoneum is not sensitive to trauma.  The healthy viscera may be handled without pain.
    Pain on abdominal palpitation may arise from radiation.
    Subjects vary as to their susceptibility of pain.
    Pain manifests certain characteristics as facial expression, position of body, muscular tension.
    Sudden abdominal pain depends on definite cause and it behooves the physician to discover it.
    On account of the multiple viscera, complex nerve supply, and numerous functions the abdomen presents the most abundant and varied pain of any body region.

     Fig. 89.  Drawn from a woman about 38 years old.  At the first operation I could easily disinvaginate.  The ileo-coecal invagination recurred some two months later and at the second operation I resected the coecum and reunited the ileum and colon.  The patient died some 10 days later.  Autopsy demonstrated that invagination was due to an enormous coecal ulceration and the colon was beset with perhaps a dozen ulcers from the dimension of a dime to that of a silver dollar. 1, Coecum and appendix.  II, ileum.

    The sudden beginning of severe abdominal pain is frequently significant of serious trouble.
Gastric Crisis.  So-called abdominal crises should be studied with care that life may not be placed in jeopardy or disastrous treatment instituted.  First and foremost is the gastric crisis of locomotor ataxia in which the patient is attacked with paroxysmal vomiting and severe gastric pain enduring from some hours to several days and may recur after days or weeks.  In such cases the symptoms of tabes dorsalis will aid the diagnostician.
    Nephritic Crisis, or the so-called "Dietl's crisis," perhaps should be considered as a trauma on the nerves, vessels and ureter of a dislocated kidney.  Torsion of the nephro-neuro-vascular pedicle with flexion of the ureter doubtless accounts for this rare phenomenon.  Dietl's crisis is followed by local tenderness in the renal region, hence, infection occurred in the peritoneum.
    Gas in the tractus intestinalis is a frequent accompaniment of abdominal pain.  However, the presence of the gas does not produce the pain, as that is mainly due to trauma, stretching of the inflamed nerves in the peritoneal sheet.


    How far can we diagnose abdominal pain by its locality?  Only to a limited degree.  Associated circumstances must aid in the diagnosis.  There are three common localities of acute abdominal pain or peritonitis, viz., pelvic, appendicular and that of the gall-bladder region; and as probability is the rule of life, it is well to diagnose acute abdominal pain as a disturbance in one of these three localities of the peritoneum until proved otherwise.
    Acute abdominal pain in general is referred to the umbilicus - in other words, the region immediately over the solar plexus or abdominal brain, the receiver of the impressions of abdominal viscera.  Acute abdominal pain is generally due to a disturbance of the peritoneum, owing to a lesion of an adjacent viscus; but since the peritoneal lesion can arise from many organs and from several points of the same organ, it demands the most experienced diagnostic acumen and the most mature judgment to interpret the significance of the lesion through the abdominal wall.  No one can decide what kind of wood lies under a table cloth.  I have repeatedly observed in appendicitis that patients say the acute pain, especially in the beginning, is over the whole middle of the abdomen (solar plexus).  This may be due to excessive and violent peristalsis of the enteron.  As regards locating the pain at any point of the enteron, it cannot be done, first, because the loops of intestines have no distinct order as to locality; second, the patient cannot discriminate a point of pain at any given locality, perhaps from lack of practical experience.
    Pain in a particular area does not invariably signify that the cause of the pain is located in that region.  The absence of pain in regions is significant.
    Though pain in the umbilical region be indeterminate of location, it is frequently the knell of distress in peripheral visceral lesion as appendix, oviduct, invagination, axial relation.
    However, a kind of sudden severe abdominal pain may arise from violent irregular peristalsis (rhythm) in non-inflamed (or slightly inflamed) tubular viscera, as foreign bodies (hepatic, pancreatic, ureteral, intestinal calculus) as strictures (intestinal, ureteral, biliary, pancreatic ducts, appendix, oviducts).
    In sudden abdominal pain (especially peritonitic extravasation) four factors may be observed, viz.:  (a) (Sympathetic), First, diffuse pain in the central abdomen, umbilical region, solar plexus, the three abdominal sensory areas, cutaneous, peritoneal and muscular are affected, shocked.  The bed clothing cannot be tolerated (sensory, skin) and the abdominal muscles are rigid - muscular visceral protection.
    (b)  Later localization of the pain occurs over the affected viscera (peritonitis).
    (c)  (Spinal nerves) Rigidity of abdominal muscles arise over affected viscus (somatic muscular, protection of viscera).
    (d)  Hyperesthesia of the skin over the affected viscus (somatic cutaneous, protection of viscera).
It must be noted that cutaneous or sensory manifestations of somatic spinal and visceral nerves may extend over their entire periphery, e. g., in appendicitis, hyperesthesia or supersensitiveness of the skin may be found in the right iliac fossa, over the pubis, pudendum, Poupart's ligament, and the testicle.
     Fig. 90.  An illustration to expose the progressive steps of uterine invagination (intussusception or inversion) from the depression at 1, to the completed process at 2. 1, is where the invagination begins. 2, presents the progressive steps of the fundal progress through the os uteri. 3, the vaginal fornices subsequent to the uterine invagination; the cervix presents a vigorous rigid ring, resembling a giant anal sphincter, with steady, continuous, vigorous pressure on the invaginated portion of the uterus; the rigid cervical ring gradually yields, dilates and the uterus disinvaginates like a spring.  The uterus becomes reduced like a dislocated joint.  Hence, like intestinal invaginations and volvulus, the uterus may tend to reinvaginate.

    In regard to the location of sudden acute abdominal pain we have to consider (a) the seat of pain as felt by the patient; (b) the pain elicited by pressure (tenderness); (c) local rigidity of the abdominal muscles; (d) anesthetic or hyperesthetic condition of the skin of the abdomen.
    As to local tenderness of pain elicited by pressure, it indicates a pathologic condition of viscus or of the peritoneum (inflammatory).  The pain is induced by motion or disturbance communicated to a sensitive inflamed area, peritoneum.
    Local rigidity of abdominal muscles indicates adjacent disease of organs supplied by the same nerves as the muscles which exercise a protective agency, to preserve rest for damaged tissue, to assume repair, and to prevent further damage from motion, e. g., distribution of sepsis by peristalsis.  Hyperesthesia or sensitiveness of the skin due to transmitted irritation, is often present, but is not very reliable as to locality, for it is dependent on peculiar symptoms and accompanies, more or less, though irregularly, most acute abdominal affections.  Of course it would be expected that the severe sudden onset of pain in the renal and biliary ducts, being very near the abdominal brain, would be difficult to separate from the solar plexus.  Lead colic may deceive the most elect as to its etiology or seat.
    With few exceptions, to locate the seat of lesion in acute abdominal pain, we call to aid the pain elicited by pressure.  Pressing the abdominal walls produces a distinct localized tenderness or pain which suggests localized pathology.  Again, rigidity or tension of the abdominal wall is suggestive of pathologic locality.  The symptom is simply purely reflex, due to irritation passing from the involved viscera to the spinal cord, whence its irritation is transmitted to the periphery of the distal intercostal nerves which control the abdominal muscles over the seat of pain.  Dashing cold water on the belly will produce similar protective muscular rigidity.  Hence, in general, the location of the disease in the abdomen from the patient's feeling of sudden acute pain, is quite indefinite.  But local tenderness and local pain on pressure aid much.  Localized rigidity of the abdominal wall is suggestive that such tension is protecting the seat of disease from motion, further bacterial or fecal invasion.  In short the rigid muscles are plating the pathologic parts to anatomic and physiologic rest.
    Vomiting is a general characteristic of sudden acute abdominal pain.  In sudden acute abdominal pain, from visceral lesion, Nature makes profound effort to manifest its distress, however to diagnose the seat of pathology and its nature from localization of the pain requires much reading between the lines from experience and judgment.
    Again, a vast difference exists between sudden acute abdominal pain and that which progresses gradually.  Much depends on the stage of the disease in which the physician first visits the patient.
The signification of sudden acute abdominal pain may be more actually realized by a short consideration of some of the principal conditions which occasion it.
    In some cases the physician is unable to localize the pain in any visceral tract under such conditions, the apt remark is that probability is the rule of life; hence an exploratory operation in the region of the appendix and gallbladder is justifiable in subjects jeopardized by imminent danger.  The most frequent point of pain or pressure is the epigastrium, the abdominal brain or plexus coeliacus.


    In general, sudden acute abdominal pain is referred by the patient to the umbilical region, to the solar plexus, directly over the abdominal brain.  This, in my opinion, is a nervous center, possessing the power of reorganization, of receiving and transmitting forces, controlling visceral circulation and inducing reflex or referred pain.  The irritation of peripheral visceral nerves is transmitted to the abdominal pain, when reorganization may localize the pain over the abdominal brain, at the seat of disease, or at a remote abdominal point, due to a supersensitive nervous system.  Anal fissure, or ulcer, is one of the most typical examples to produce reflexes in the abdominal viscera, especially in the tractus intestinalis.  Short trauma of viscera, as hernia, acute flexion of tubular viscera, induces abdominal pain and especially by reflexes.


    Reflex pain from distant areas may simulate severe abdominal pain, multiplying the difficulties in differential diagnosis.
     Fig. 91.  An illustration presenting complete uterine invagination.  The oviducts and ovaries may be entirely included within the invaginated uterus. 1, ovary; 2, oviduct; 3, round ligament; 4, uterine fundus with diamond-shaped aperture resected from its wall; 5, vaginal lumen.  Drawn from subject dying from trauma, shock, due to uterine invagination 2 1/2 hours subsequent to labor.  I performed the autopsy 4 hours after death.

    Obscure symptoms of abdominal pain arise from the invasion of the peritoneum from pneumonia.  In fact I have seen a half dozen physicians in consultation advise and perform peritonotomy in a case of pneumonia, so deceptive were the abdominal symptoms - pain, tenderness, tympanitis, temperature, muscular rigidity and respiration.
    Pleurisy or intercostal neuralgia extending over a large area of intercostal nerves which supply the abdominal wall may simulate sudden abdominal pain - for the trunk of a nerve being irritated manifests its sensation, pain, at its periphery which, in the case of the intercostal, end in the abdominal wall.
    Abscess in the abdominal wall may simulate abdominal, peritoneal or visceral pain, from irritation of the intercostal (abdominal wall) nerves.  Dr. Lucy Waite had in her charge in the hospital a child with an abscess in the abdominal wall which simulated extremely abdominal visceral (peritoneal) disease.
    Amygdalitis mastitis and hysteria may simulate abdominal pain.
    In post-operative peritoneal hemorrhage (peritoneal extravasation) the pain is obscure, as the previously traumatized, and consequently obtunded, sensibility of the peritoneum does not manifest recognition of the bleeding, while peritoneal hemorrhage (peritoneal extravasation) from ruptured pregnant oviduct produces excruciating pain.
    Spinal cord lesions may simulate abdominal pain by a diffuse sensitiveness over the affected intercostal nerves, e. g., the girdle, constricting pain in tabes dorsalis or locomotor ataxia.

     Fig. 92.  Drawn from a subject with physiologic or incomplete sigmoid volvulus.  Z, Sigmoid. The Yolvulus is rotated about 360 degrees.

    Uremia may be accompanied by persistent vomiting.  Pain in right shoulder may refer to hepatic disease.
    Spinal caries may produce pain in portions of the abdomen from pressure on dorsal or lumbar nerves, as sensory areas or rigid muscular areas.
    Testicular pain may refer to a ureteral calculus.  Crushed testicle may induce severe abdominal pain, vomiting and shock, as its route to the abdominal brain is direct and rich in nerves.
    Hyperesthesia of the iliac regions are deceptive, because these regions are supplied by the cutaneous branches of the ileo-hypogastric nerve (first lumbar).  McBurney's point is practically a skin hyperesthesia, a super-sensitiveness of skin area included in the peripheral region of cutaneous twigs of the last dorsal (twelfth intercostal) nerve and the ileo-hypogastric (first lumbar) nerve.
    In short, if any sensory intercostal or lumbar nerve be affected (by somatic diseased viscera) it will manifest sensory skin areas at its corresponding periphery.
    Muscular rigidity of the abdominal wall will be manifest in the somatic area of the spinal nerves corresponding to the diseased viscera (simulating the cutaneous area).   In short, if any motor intercostal or lumbar nerve be affected (by somatic diseased viscera) it will manifest motor (muscular rigidity) area at its corresponding periphery.
    A feature of obscurity in the diagnosis in abdominal muscular rigidity is that when a part of an abdominal muscle becomes irritated, the whole (and not part) of the muscle becomes rigid.  Hence the muscular rigidity is the same for perforated appendix or gall-bladder.  For general peritonitis the whole abdominal muscular apparatus is rigid.

     Fig. 93.  Drawn from a subject with physiologic or incomplete sigmoid volvulus which is 360 degrees rotated.

    In the tractus nervosus the neuroma of intercostal or lumbar nerves must not be overlooked.  I have observed three subjects of neuroma on the ileo-hypogastric or ileo-inguinal nerve.   One in Prof.  Senn's clinic where a neuroma on a nerve in the abdominal wall in the region of the appendix was exquisitely tender inducing a diagnosis of appendicitis.  The analytic, searching diagnostic methods of Prof.  Senn soon discovered the tender neuroma, which he removed instead of the appendix.  One subject, a female, 24 years of age, was sent to me with a diagnosis of appendicitis.  I found a typical neuroma on the lumbar nerve in the region of the appendix.  A third case of neuroma of a lumbar nerve in the appendicular region I saw in consultation with Dr. I. Washburn, of Rensselaer, Indiana.  Abdominal pain is the surface indication of various pathologic states of the abdominal organs (or abdominal wall).  In abdominal pain the chief skill is in the diagnosis, for the correct treatment depends on the diagnosis.  The more correct the diagnosis the less "neurosis" will occur in abdominal pain.  The abdominal wall, including the cutaneous and muscular layers. receives its (chief) nerve supply from the spinal cord, which contains sensory and motor nerves.  The viscera receive their (chief) nerve supply from the sympathetic, which contain sensory and motor (rhythmic). (The parietal peritoneum has a mixed nerve supply.) The spinal cord emits nerves through the rami communicantes to the viscera and receives nerves from the viscera.  The spinal cord emits nerves to the abdominal wall (muscle and skin).  Hence the viscera and abdominal wall are in direct, harmonious, balanced relations and consequently of vast value in diagnosis.  Any visceral disorder is reported to the spinal cord which is at once emitted to the abdominal wall for protective purposes (muscular rigidity).  The visceral walls are the thoracic and abdominal and cannot be divided - they are supplied by the spinal nerves which overlap, extending from clavicle to pelvic floor.
    Man's breathing apparatus consists of the thoracic and abdominal wall.  The thoracic visceral rhythm (sympathetic) dominates in the thoracic wall.
    All the visceral tracts except the nervous may manifest painful peristalsis from inflamed ducts or canals.

     Fig. 94.  Drawn from subject with physiologic or incomplete volvulus of the ileo-coecal apparatus. I, presents the state of the volvulus - about 200 degrees.


    Strangulation by bands and through apertures constitutes one third of all intestinal obstructions.  If the bowel loops glide through an inguinal or femoral aperture, digital examination will detect the cause of sudden, acute abdominal pain.  Obturator and sacro sciatic hernia are seldom diagnosed, so that they would practically be included in internal strangulation by peritoneal bands.  Sex does not aid in diagnosis, for males and females about balance in peritonitis during life, hence will possess about the same amount of peritonitic bands.
    A history of previous peritonitis tells a significant story of strangulation by bands.  Vomiting is violent, pain from peristalsis is periodic and general over the abdomen.  The pain is not due to checking of the fecal current, but to reflex irritation of the bowel at the seat of obstruction.  Temperature is not conspicuous and the pulse is not much changed.  Tympanitis arises in exact proportion to the peristalsis of the bowel wall proximal to the seat of obstruction.  At first the pain is violent, but it subsides with the progress of the case, becoming more continuous and generally diffused.  If the patient be quiet, The pain is so slight that it deceives the most elect.  No stool, no gas per rectum, no detectable swelling at any hernial aperture with continuous abdominal pain and vomiting, demand surgical notice.  The temperature and pulse are not reliable.  Strangulation by bands will generally give no tender location on pressure and no detectable swelling; and, in fact, I have watched cases with the abdomen quite soft and pliable, with no possible physical point of diagnostic value, not even tympanitis, yet with obstruction which proved gangrenous on

     Fig. 95.  Drawn from a child 14 months old, referred to me by Dr. Walter Fitch.  I operated on the third day and found the pedicle, foot or style, of the volvulus to be located at the coecurn, the constriction being due to the rotation of the distal end of the ileum and proximal end of the jejunum around each other as an axis.  On opening the abdomen the colon was collapsed while the enteron was enormously distended.  After releasing the volvulitic pedicle the gas rapidly distended the entire colon and large volumes with ample stool passed per rectum.  The child died of peritonitis 3 days later. 4,  Volvulitic pedicle of enteron.

peritonotomy.  In one case the pain was at first severe, general, and almost subsided the day before the operation, yet fifteen feet of intestine was as red as sunset.  The sudden. acute abdominal pain is not due to the constricting band. but to reflex irritation transmitted to the abdominal brain, where reorganization occurs, whence it is emitted to the whole digestive tract, inducing violent, disordered and wild peristalsis (colic).

     Fig. 96.  Drawn from subject with physiologic or incomplete volvulus of ileo-coecal apparatus.  X, shows the state of the volvulus almost 360 degrees.  Z, presents a large pouch in the mesosigmoid.

    Acute, sudden abdominal pain, due to a constricting peritoneal band, is one of the most obscure to interpret.  To explore the abdomen in the proper time for such a case requires a wise diagnostician and a bold surgeon.  The matters to bear in mind by strangulation by bands are, the acute, sudden abdominal pain with a violent onset, vomiting, and the distinct colicky, peristaltic, periodic character of the suffering, not forgetting a previous history of peritonitis.  However, the sudden, acute abdominal pain, arising from a strangulation of a loop of bowel by peritonitic bands, is difficult to interpret and seldom diagnosed.  It may be asserted, that when a patient is suffering from some grave disease, manifest by sudden acute abdominal pain, the nature of which cannot be interpreted, an early exploratory laparotomy is justiflable and demanded.  Such obscure cases require an experienced surgeon, skilled in abdominal work, to meet any emergency, to enter the peritoneum and retire rapidly.  I remember very distinctly the case of a man, about 40, who gave consent to my colleague, a general practitioner, who was entirely untrained by experience or observation in abdominal surgery.  The doctor told me he opened the abdomen and found a band stretching tightly across the right colon.  But he said "the colon was black, and I did not know what to do with it, so I closed the abdomen." It is needless to say that the man made a prompt, fatal exit.  But most cases die undiagnosed.  The d a n g e r of strangulation by bands is gangrene and perforation.
    The starting point of peritoneal bands are - (a) local peritonitis, (b) hernial apertures (inguinal, femoral, abturator, fossa duodeno-jejunelis, intersigmoid fossa, Winslow's foramen), (c) peritonitis from muscular trauma (psoas, lateral abdominal), (d) infective mesenteric glands, (e) operative sites, the mesosigmoid. (f) fimbriated ends of oviducts, (g) Meckel's diverticulum.  A history of typhoid fevor, hernia, peritonitis is suggestive.
    The intensity of the abdominal pain in intestinal obstruction depends on the completeness of the obstruction.  The pain not being inflammatory is paroxysmal, rythmical, due to trauma on the nerve periphery in the intestinal wall.
    It should be noted that reduction by taxis of a strangulated intestine in the hernial rings ought to be practiced with care.  The danger is reduction in mass (without relief) and the return into the peritoneal cavity of pathological intestinal segments.  In strangulation, internal, it is well to inquire whether a patient has suffered from peritonitis or experienced peritonotomy.
    In strangulation of an intestinal loop the symptoms will practically simulate perforation or extravasating peritonitis only after the sepsis has begun.

     Fig. 97.  Pelvic position (woman 47 percent - man 37 percent). 2, Retro-coecal position (20 per cent). 3, Potential position (23 per cent). 4, Right of psoas (18 per cent). 4, Resting on the psoas (46 per cent).

    Hernia which may involve several visceral tracts (digestive, genital, urinary) not infrequently presents unsuspected irritation from the natural hernial rings from the inimical supraumbilical hernia in the linea alba.  I have observed much distress and suffering in patients afflicted with hernia which had been overlooked for years.
    I assisted Dr. Lucy Waite to operate on a woman some 35 years of age, on whom a previous peritoneal section had been performed.  She had suffered from obstruction of the bowels for several days with continuous vomiting.  Dr. Waite found an organized peritoneal band of some fifteen inches in length extending tensely across a loop of intestine producing almost complete obstruction.  Rupture of the band afforded complete relief with recovery.
    Sudden obstruction may arise from intestinal loops gliding to and fro through apertures in the mesentery, omentum.


    Invagination constitutes about one-third of all intestinal obstruction, and the sudden, acute abdominal pain arising from this cause is more easily interpreted.  Age signifies much in this case, for one-fourth of all invagination occurs before the end of the first year of extrauterine life, and one-half before the end of ten years.  Invagination is a disease of childhood.  Its mode of onset is sudden and frequently violent.  From some twentv-five experiments in invaginating the bowel of the dog, I am sure the pain is periodic at first.  The griping, colicky peristalsis is rhythmic, depending on irritation.  At stated times the dog suddenly spreads wide his four feet and arches his back, appearing in severe distress, then gradually recovers his natural attitude.  In invagination blood occurs in the stool in 80 per cent of cases (especially children), and the vomiting is not violent, nor even always conspicuous, for the bowel is only partially occluded.  Seventy per cent occur at the ileocecal apparatus, that landmark in man's clinical history, 15 per cent in the enteron and 15 in the colon.  Invagination manifests abdominal pain similar to an elongated enterolith in the bowel, which in rotating leaves small spaces at its side for the passage of gas and some liquid stool.  I have, unfortunately, watched a case of enterolith day after day, with some half dozen physicians, not becoming able to interpret the abdominal pain or to diagnose the case, until gangrene of the bowel occurred at the seat of the enterolith, when nature asserted manifestation to induce us to explore the abdomen, but with a fatal result.  The most skilled of abdominal surgeons repeatedly examined this case, but could not interpret the acute abdominal pain, which came on suddenly, though as the days glided it quietly subsided.  The patient was a physician, but could not localize any abdominal pain; it was diffuse.  Temperature was about 99 1/2 deg. and 100 deg.  F., and the pulse was 85 to 95, almost the whole week of illness.  The abdomen was generally soft and not tympanitic.  Very seldom can abdominal tumor be palpated in bowel invagination.  Shock in young children is quite conspicuous, yet I personally know of two autopsies in infants, who were attended in life by three of the most skilled abdominal surgeons, yet the postmortems revealed invagination as the cause of death.  A skilled and experienced physician, such as the late Dr. Jaggard was called to an eight months infant and he stripped the clothing to be more thorough in examination, and yet after all his diagnostic skill, failed to locate disease in the digestive tract from lack of symptoms.  The child was very pale, cried a little, and died thirty hours after the attack.  The autopsy revealed ileocecal invagination.
    Sudden acute abdominal pain in a child may with high probability be interpreted as invagination, especially if one can detect the periodic, peristaltic character, its colicky nature.  Blood following in the stool is almost pathognomonic.  A tumor will rarely be found, and pressure on it will not generally elicit tenderness, it is not at all likely the patient can locate the seat of the disease from pain.  Tympanites and vomiting are not conspicuous, and the temperature and pulse are not reliable.  The danger of invagination is sloughing of the apex or neck and consequent perforation and peritonitis.
Invagination presenting at the anus interprets easily the cause of pain.
    Tenesmus is a prominent feature.  In quite a number of cases of invagination during the last fifteen years I could palpate a tumor but twice, and that was once in an adult, spare woman where the ileocecal invagination had progressed to the Rexura coli lienalis.  The cause of her invagination was a large ulcer of the cecum, which extensively hypertrophied the cecal wall.  I disinvaginated the cecum; however, reinvagination occurred some weeks later when resection of the cecum was practiced with fatal result.  Once I could palpate an invaginated tumor in a child.

     Fig. 98.  The appendix rests among the enteronic coils; however, on rupture it would be protected by the omentum.

    In actual practice we found at the Mary Thompson Hospital for women and children that shock was the chief fatal factor - the children entering the hospital with advanced invagination, when peritonitis had begun and the pulse was uncountable.
    From fifteen years of observation on infant invagination, as they enter the hospital in an advanced or late stage of the disease, I am convinced that on the average, more infants will recover from intestinal invagination without an operation than with one.  I think actual cases by number will prove this claim - sound unsurgical as it may.
    Slowly progressing stricture may suddenly become closed.


    Volvulus is so rare that it constitutes about one-fortieth of all intestinal obstructions, and occurs mainly in men, as women and children are practically free from sigmoid volvulus.  As in invagination so in volvulus, I was always compelled to suture them in position in a dog.  But I never succeeded in establishing a permanent volvulus in the dog.  Volvulus is characterized by tympanites, and it is said by periodic pain.  Volvulus occurs at the sigmoid in 60 per cent of subjects, at the ileocecal valve in 30 per cent, and in the small intestines in 10 per cent.  It is so rare that though I have seen several cases of partial (physiologic) volvulus, however only one case of complete (pathologic) volvulus in man.  The subject of enteronic volvulus was in a male child brought to me by Dr. Walter Fitch.  He was in the third day of illness.  I operated and relieved the volvulus of the enteron but the child died of shock and infection three days later.  Nicholas Senn operated successfully on a man, on the eighth day, for sigmoid volvulus.  He introduced a tuck placation in the mesosigmoid for prophylaxis.      Seven years later another physician operated on the same man for volvulus, recurrence, with fatal result.  The man had enormous tympanites; his pain is not described as severe, but no doubt the suffering is severe.
    At first the pain is periodic but as time advances it becomes more constant, with now and then exacerbations.  Vomiting, though not conspicuous, must arise more or less from trauma to the peritoneum.  Perhaps the sudden pain, chronic constipation, and rapid rise of tympanites would aid in interpreting volvulus, bul seldom can one diagnose such a disease from its rarity.  Pain no doubt would be referred to the abdominal brain.  Most clinicians note tympanites as a conspicuous feature of volvulus.
    Weller Van Hook treated successfully a case of sigmoid volvulus of eight days' standing.
    From observation of the sigmoid and mesosigmoid in hundreds of autopsies I am convinced that the chief etiology of volvulus of the sigmoid is elongated sigmoid located in the proximal abdomen and possessing a narrow foot accompanied by mesosigmoiditis due to vigorous action of the left psoas muscle which traumatizes the sigmoid, inducing migration of germs or their products through mucosa, muscularis into the serosa, inciting plastic peritonitis in 80 per cent of adults.
    The plastic peritonitis in general ends in two conditions, viz.: 1. The most frequent, the plastic sigmoiditis binds the left surface of the mesosigmoid to the ventral surface of the psoas muscle.  Such subjects cannot have sigmoid volvulus from mechanical condition. 2. The second state of the mesosigmoid arising from the mesosigmoiditis is a progressive shortening, a contraction of the base of the mesosignioid, that is, the base or pedicle of the mesosigmoid becomes a very narrow pedicle from the progressing, contracting mesosigmoiditis, so that peristalsis of the sigmoid induces a rotation or torsion of its base.  In autopsies I have found partial (physiologic) rotation of the mesosigmoid, especially during the existence of mesosigmoiditis - as far as 180 to 360 degrees.

     Fig. 99.  Drawn from female, aged 50 years.  The diagnosis in this case would be uncertain.

    Sigmoid volvulus is due to the torsion, rotation, of the narrow pedicle of a mesosigmoid contracted at its foot by mesosigmoiditis.  When one untwists, detorsionizes, the volvulus and releases it, the sigmoid recedes, rotates, like a spring into its original volvulitic condition.  To prevent the volvulus from returning to its original torsion in dogs I sutured it in situ.  Resection may be required to overcome the acute torsion.  Puncture may be required to reduce its dimension.  Most subjects have ample time to acquire sigmoid volvultis, as they  are generally over 40 years of age.  There is frequently physiologic sigmoid volvulus in autopsy which is partial tor-sion of the mesosigmoid; however, obstruction is incomplete.  The marked tympanitis or meteorism of sigmoid volvulus is at first localized in the left iliac fossa - a slight diagnostic point.  The sigmoid is the most varied of any segment of the colon in location and capacity of its lumen.  The tymp-anitis may be located in the right abdomen while the nontympantic enteronic loops may be forced around the constricted foot of the volvulitic sigmoid.  Childhood is not predisposed to sigmoid volvulus, notwithstanding the relatively elongated sigmoid and mesosigmoid, because the angle of mesosigmoid insertion (what I term von Samson's angle) is located well proximalward on the lumbar vertebra.  Why woman is practically free from sigmoid volvulus I am, so far, unable to explain. sigmoid volvulus occurs practically in men possessing what I term the "giant verticle sigmoid" which is located in the proximal abdomen and occurred in perhaps 15 per cent of the autopsies.  The foot of this giant verticle sigmoid is narrow and by the contracting mesosigmoiditis results in a narrow style around which may rotate the sigmoid loop.  This was the condition I found in physiologic volvulus which occurred in perhaps 2 per cent.

     Fig. 100.  This drawing was taken from a subject on whom I operated for a large ab-scess in the right iliac fossa and at the same time I removed a perforated tube 3 inches in length and of the usual appendicular dimen-sion - supposing it to be the appendix.  Three months later the man died from appendicitis, as the postmortem performed by Dr. Arthur MacNeil demonstrated.  The first attack and abscess was from the perforation of Meckel's diverticulum, located in the right iliac fossa.  The second attack and abscess was from per-foration of the appendix, located (retro-coecal) in the right iliac fossa.


    Appendicitis is the most dangerous and treacherous of abdominal diseases - dangerous because it kills, and treacherous because its capricious course cannot be prognosed.  The peritonitis it produces is either enteronic (dangerous - absorptive, non-exudative) or colonic (mild-exudative, non-absorptive).
    A concise clinical history should be obtained when sudden pain arises in the right side of the abdomen for it might be due to perforated appendix, gall-bladder or gestating oviduct.  The right-sided pain may arise from binary, pancreatic or ureteral calculus or ureteral flexion.
Pleurisy or intercostal neuralgia (right) may confuse.  In the right side, so closely adjacent are eight important viscera, momentous in surgery, that a silver dollar will touch the pylorus, gall-bladder, head of the pancreas, kidney, adrenal, duodenum, ureter and possibly the appendix.  Hence differential diagnosis of sudden abdominal pain in the closely adjacent multiple organs of the right side is difficult - frequently impossible.
    The conditions that cause the excruciating, agonizing, shocking pain in appendicitis are perforation and extravasation into the peritoneal cavity.  Right-sided muscular rigidity means that the motor (intercostal) nerves supplying the abdominal muscles are irritated.  It may be any kind of peritoneal infection (extravasation from any viscus, hepatic, intestinal, ureteral or genital).  Right-sided cutaneous hyperesthesia means that the sensory (intercostal) nerves supplying the abdominal skin are affected.  It may depend on any kind of peritoneal infection.  Sudden cessation of severe symptoms, as rapid diminishing of high temperature and pulse and abdominal rigidity, is an evil omen - gangrene of the appendix has probably occurred.  Immediate operation should occur.
    For years I have made it a rule to recommend appendectomy to patients having experienced two attacks.  Fifty percent of subjects who have had one attack experienced no recurrence.

     Fig. 101.  Appendicitis and salpingitis are separate diseases, each arising from its own mucosa.  However, infection emanating from either may compromise the anatomy and physiology of the other by peritoneal adhesions.

    In perforation it is very difficult to interpret the sudden abdominal pain.  Associated circumstances would aid.  In typhoid fever one would naturally suspect perforation if sudden acute abdominal pain arose, and my colleague, Dr. Weller Van Hook, successfully operated on a typhoid perforation diagnosed by his medical friend.  One might think if he was called to a young woman with sudden acute abdominal pain that it was a round, perforating ulcer of the stomach, after excluding pelvic and appendicular disease, but the sudden acute abdominal pain of perforation is so vague and indefinite that only an exploratory incision would interpret it.
    The sudden acute abdominal pain from appendicitis (perforation) is more a,pt to be diagnosed from probability.  Now probability is the rule of life, and when one is called to a boy or man with sudden acute abdominal pain, it is likely appendicitis.  The pain of appendicitis is at first sudden and generally diffuse, and in appendicitis this is, in my experience, a characteristic and conspicuous feature.  The sudden acute pain in appendicitis is doubtless due to violent appendicular peristalsis (colic) of an inflamed appendix, or to the rupture allowing the bowel contents to come in contact with the peritoneum, and also inducing violent irregular peristalsis of the adjacent bowel loops.  It is the agonizing, excruciating pain of peritoneal extravasation.  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 is more or less of a mesenterium commune, the cecum may approach 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 fecal extravasation and - from violent peristalsis.  I see nothing especially worthy of attention in the so-called McBurney point.  It is skin sensitiveness.  Pain over the seat of disease is certainly a natural feature, and generally so over the appendix, which 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 practically a cutaneous byperesthesia.  Then again pain on pressure may be reflex, appearing in remote regions of the abdomen.  The sudden, acute, diffuse abdominal pain arising in appendicitis, generally 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 radiation, transmitted to a sensitive, inflamed peritoneum, and not the dragging of an adhesion, as some assert, for adhesion so newly formed can have no nerves formed in them.  Butman 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.  Contracting adhesions compromises appendicular drainage.  The appendix 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 search for pain in the three great regions of dangerous peritonitis, viz., the pelvic, appeddicular and gall-bladder regions.  In appendicitis the pain on pressure is in the ileo-coecal plexus, i. e., in the ileo-coecal angle, not at the so-called McBurney's point, which is a nerve skin neurosis - a skin hyperesthesia.

     Fig. 102.  The appendix is associated with the liver.  The appendix (coecum) is nondescended in males 9 per cent and in females 5 per cent.  In this case there is an ileo-coecal volvulus. 

    The ileo-colic plexus may be found tender on bi-manual vaginal examination, especially on the right side.  However, these hyperesthetic (tender) points are insufficient to establish a diagnosis of appendicitis.  Palpable anatomic findings are the only reliable data for the diagnosis of appendicitis.


    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 fullness.  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 gallbladder, 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 exists perhaps four times as frequently 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 acuteness, intensity and distinct periodicity, than in invagination, appendicitis or perforation of the digestive tract.  Jaundice is not necessary.  Jaundice or icterus is determined by the color of the eye-ball, and not of the skin.  A feature in gall-bladder pain is that it extends well towards the dorsum.  Age aids in diagnosing 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 occasional 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 gall-stone in the biliary passages.
    The pain of non-perforated biliary colic arises suddenly, is agonizing, and especially intense in the gall-bladder region.  It is generally limited in duration, and frequently associated with jaundice.      Biliary calculus may exist without pain (autopsies are rich in this testimony).


    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 contained 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 a few 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.

     Fig. 103.  This illustration is from a woman physician, death from peritonitis following enteronic obstruction by a biliary calculus, which had become dislodged from Meckel's diverticulum.


    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.


    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.
    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.  Ureteral calculus permits time 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 calculus 70 per cent failed to demonstrate calculus.
    5.  The vast dimensions of the plexus nervosus ureteris in number of ganglia and number of strands permit irritation from the ureter to pass with facility and rapidity to the abdominal brain, whence it becomes the sympathetic nerves of the abdominal reorganized and emitted: (1) over 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 genital 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 reorganized and emitted over the cranial nerves (vagus which aids in inducing nausea and vomiting).  These reflex . pains in ureteral calculus confuse by involving the sympathetic, spinal and cranial nerves of distant regions, and also because other conditions of the ureters than ureteral calculus may 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 (postmortems 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 intense pains 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.
    12.  The characteristic of pain in ureteral calculus is inconstancy, variation or radiation and reflexion.  It has a tendencv to produce sympathetic aching in other abdominal viscera.
    13.  The pain in ureteral calculus depends chiefly on its position (ureteral pelvis and proximal isthmus, sensitiveness) and also on the mobility of the calculus.
    14.  Pain (colic) can arise in the ureter from increased ureteral pressure (calculus, stricture, flexion - obstructing the urinal stream), or from inflamed ureteral wall - ureteritis.
    15.  Ureteral-lithiasis, cholelithiasis, appendicitis, ureteritis, cystitis, nephritis, may p r o d u c e practically identical symptoms.

    Intoxications. - Uremia may be accompanied by abdominal pain, lead colic, blue gum line and occupation.  Food of concentrated nature as meats may produce such concentrated urine that urination is accompanied by pain.
     Fig. 104.  Roentgen ray of the ductus pancreaticus and part of ductus bilis (it contains six hepatic calculi).  From postmortem specimens.  I to II, ductus communis choledochus, dilated to 3/4 inch in diameter and containing four hepatic calculi (A, B) in its distal end; II to IV, ductus cysticus, dilated to 1/3 inch in diameter, yet preserving in form six valvulae Heisterii; II to III, ductus bepaticus, dilated to 1/2 inch, containing a hepatic calculus; C, cholecyst, normal dimension, containing no calculus ; P, ductus pancreaticus (ductus Hofmanii-Wirsungii), ductus pancreaticus accessorius (ductus Santorini,).  Hepatic calculi C, D and B.


    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 patient 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 gynecologists 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 rupture.


    In pyosalpinx 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 an impending crisis.  Bimanual vaginal examination reveals a large uneven mass, which is excruciatingly painful.
    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.  At 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 similar to other sudden acute abdominal pain, it varies as to its mode of attack, and as to viscera affected.
The pain of pyosalpinx is generally that of a local peritonitis; however, it is limited in its reflexion to other peritoneal areas.


    Torsion of style or rotation of pedicle of a viscus is characterized by sudden severe abdominal pain.  The intensity of the pain depends on the completeness of the constriction in the pedicle.
    The tumor rotated on its axis gradually enlarges because the venous blood cannot return, while the arterial blood continues to pass into the tumor.  Ovarian tumors rotate on their axes 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.
     Fig. 105.  Specimen containing pancreatic calculus.  From a postmortem; man about 40 years.  I to II, ductus choledochus; II to III, ductus hepaticus ; III to IV, ductus cysticus; Sa, ductus pancreaticus accessorius; IP, separate exit of ductus pancreaticus in duodenum.  A calculus 1/4 inch in length and 1/6 inch in diameter is incarcerated in the duct of the caput pancreaticum.  The calculus of the pancreatic duct projects into the lumen of the duodenum.  Also six calculi existed in the ductus pancreaticus, as noted in sketch.  The pancreas was in an advanced stage of suppuration and fatty degeneration.  This specimen was kindly presented to me by Dr. A. M. Stober.  B. J. Beuker sketched it from the pathologic laboratory of Cook County Hospital.

    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 sigmold, ileocecal apparatus, myoma, enteron, omentum and kidney.  Torsion of pedicles may apply to tubular viscera (ureter, intestine, oviduct) as well as to vessels.
    I have operated on subjects with myomata 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 per cent of ovarian and parovarian tumors experience axial torsion.  Mr. Lawson Tait saw some 70 cases, and as his pupil I witnessed 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 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 or adjacent peritonitis.


    The accompanying table presents a bird's-eye 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.  It is evident that abdominal pain rests on 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's-eye view of numerous causes of abdominal pain in the several visceral tracts:

    I.  Tractus instestinus
    II.  Tractus Urinarius
    III.  Tractus Genitalus
    IV.  Tractus Vascularis
    V.  Tractus Lymphaticus
    VI.  Tractus Nervosus


    1. 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).
    3.  Perforation of the tractus urinarius (kidney, ureter, bladder).
    4.  Perforation of the tractus lymphaticus (chyle duct, chyle cysts, chyle channels).

     Fig. 106.  Presents hepatic calculus in the usual locations, Hartman's pouch and Vater's diverticulum.  A calculus in Vater's pouch aids to obstruct and infect the ductus pancreaticus. 

    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 extraperitoneal perforation, the pain is similar to  extraperitoneal visceral perforation is limited); (b) that of violent peristalsis (colic, non-inflammatory) of tubular 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 jeopardize 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).
     Fig. 107.  Carcinoma completely obstructing the biliary and pancreatic ducts.  Illustrates an x-ray of enormously dilated biliary passages.  The biliary ducts (excepting the gall-bladder, which was three to four times its normal dimension) had a capacity of 32 ounces, about six or seven times the natural capacity.  The ductus communis choledochus was over 1 1/4 inches in diameter.  The pancreatic duct admitted the index finger.  The man, 69 years old, a giant in stature, weighing some 250 pounds with ordinary limited fat, lost 115 pounds in weight during three months' illness.  The ductus cvstictis. extending from II to IV, had seven Heister's valves, and its lumen would admit a lead-pencil only.  At B the biliary ducts were deficient within the liver substance, but were really dilated on the surface.  T, the carcinoma (divided with the scalpel), completely severing the lumen of the biliary and pan-creatic ducts.  There was enormous gastroduodenal dilatation from the compression of the transverse duodenum by the superior mesenteric artery (A) and vein (V).  D, foldless, gran-ular, proximal 2 1/2 inches of the duodenal mucosi; I, entrance of ductus communis chole-dochus in the duodenum; Sa, ductus Sanitori; P, ductus pancreaticus.  The ductis communis choledochus and ductus pancreaticus, located between the carcinoma and Vater's diverticulum, were normal.  Da, is the normal sized duodenum located distal to the compressing superior mesenteric vein (V) and arterv (A).  Observe the vast dilatation of the duodenum proximal to the superior mesenteric artery, (A) and vein (V).  I secured this rare specimen at an autopsy through the courtesy of Dr. Charles O'Byrne.

    II.  In making a diagnosis of sudden abdominal (constant) pain probability is the rule of life, e. g., (a) sudden abdominal (constant) pain accompanied with vomiting, abdominal rigidity, rise of pulse and temperature, tympanitis, is peritonitis (perforative), as appendicular, genital, binary, gastrointestinal, hemorrhagic pancreatitis, (b) sudden (inconstant) abdominal pain with practically 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 nearly as possible is obtained.
    V.  The clinical history is frequently a pencil of light in the diagnosis of sudden abdominal pain.

     Fig. 108.  This illustrates ureteral calculus in its usual location, viz., (a) in the ureteral pelvis at the proximal isthmus (w), (b) in the pelvic ureter at P. 

    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 life may not be placed in jeopardy by delay, or disastrous treatment be instituted.
    X.  (a) Determine, if possible, the location of the initial pain; (b) inquire if the pain was at first diffuse in the central abdomen for awhile; (c) later and final observe whether the pain localizes itself in the region of the affected organ (peritonitis).
    XI.  The location of the pain may be superficial (hyperesthesia of the skin) or deep in the muscularis (rigidity).  McBurney’s point is a skin hyperesthesis (from the cutaneous branches of the twelth dorsal and first lumbar nerve - ileo-hypogastric).
    XII.  The location of sudden abdominal pain is indicated by the segment (somatic) of the spinal nerves in adjacent abdominal muscles (rigidity), skin (hyperesthesia).  The diseased abdominal viscus is protected, fixed by muscular and nerve mechanism similar to the muscular protection fixation of an inflamed joint.
    XIII.  The topographic anatomy mastered, for, it is the solid ground of nature on which rests rational diagnosis.  This can be accomplished by study in the cadaver and at autopsy.
    XIV.  R e m e m b e r the major regions of peritonitis - appendicular, pelvic and that of the gall-bladder.
    XV.  Remember the major regions of violent peristalsis, colic (calculus), binary, ureteral, oviductal and pancreatic.
    XVI.  Call the most available and competent abdominal surgeon early in consultation.
    XVII.  Remember that operations do not kill - it is disease that tolls the funeral bell.
    XVIII.  Operations on the dying are unsatisfactory.

     Fig. 109.  Calculus at 3 which I removed in 1898 and in 1906 I removed a calculus from the same (left) kidney which was atrophied to one-third of its normal dimensions.  Patient is, six months after the second operation, well.

    XIX.  As a general idea it may be stated that it is difficult to determine with precision the cause of sudden abdominal pain.  One must frequently ask Jupiter to guide them in the greatest field of probability (appendicitis, salpingitis, chole cystitis).
    The operator who performs peritonotomy for abdominal pain should be prepared for any emergency for the toxion of pain within the abdomen sounds an alarm, the course of which can not with certainty be determined externally.  One can not determine the kind of wood that lies under a table cloth.
    XX.  Abdominal pain as a single symptom is frequently delusive.
    XXI.  The more accurate the diagnosis in sudden abdominal pain the less neuroses," "neuralgia" or "indigestion" will occur.
    XXII.  A last resort to diagnose sudden abdominal pain is the exploratory and confirmatory incision" of Lawson Tait.
    First and foremost, should be introduced: (a) anatomic rest, which is maximum quietude of skeletal or voluntary muscles.  Retire to bed not to rise for defecation or urination; (b) physiologic rest, which is minimum function of viscera.  Food and fluid are prohibited per mouth.
     Fig. 110.  The arteria uterina ovarica 3 hours subsequent to parturition at term.  Every branch of the artery is ensheathed by a fenestrated plexus of nerves.

    No anodynes or in minimum repeated doses until clinical history and the diagnosis is completed (maximum doses of anodynes obscure the diagnosis).
    [NOTE - The method of treatment for abdominal pain by anatomic and physiologic rest was especially advocated by the distinguished English physician, Wilkes, in 1865 (living at present), continued by the celebrated American, Alonzo Clark (1807-1887), by the "opium splint, " and established forever in 1888 by one of the greatest surgical geniuses of his age - Lawson Tait (1845-1900].
    Heat (hot, moist cornmeal poultice, hot water bag, hot bath) aids to relieve pain.
    No cathartics - cathartics stimulate peristalsis, increases pain and distribution of sepsis.  They induce vomiting.  A rectal enema (or two) may be employed - the composition may be equal parts of molasses and milk, soap suds, glycerine, magnesium sulphate.  Rectal injections of air.


John B. Deaver   E. S. Ricketts    E. Babler
J. H. Musser   E. 0. Smith   E. Harlan