Sudden abdominal pain diffused, or in the umbilical region, will in a few hours become localized in the region of the affected organ. Deadening drugs should not be given, for they will mask the affection and obscure diagnosis, Sudden abdominal pain, with vomiting, is indicative of peritonitis. The cause may be volvulus, invagination, internal or external hernia, extension of septicemia, rupture of ectopic pregnancy, or rupture of an abscess into the peritoneum. The abscess may be typhlitic, perityphlitic, appendicular, tubal, pelvic, subperitoneal, cellulitis, perforations of ulcers, ulceration caused by biliary or renal calculus, etc. An operation at once, with drainage, should save most cases. Delay means death. Unfortunately, advantage is taken of this truth to urge people with intestinal indigestion, gas pains, uterine and other pains, to have an operation at once.

Absolute quiet, frequent copious enemas, and abstinence from food, is a safe "watchful waiting." To use cathartics is unnecessary under all circumstances, but to give them where any of these symptoms exist is positively criminal ignorance.

In peritonitis the pulse is of more value than the temperature. The pulse is rapid and small (120 to 150); the temperature may be normal, subnormal, or high; the breathing is costal and rapid (30 to 40); the urine is usually highly charged with indican. Collapse threatens early. The face is anxious, the skin cold, and the mind clear. Often the intoxication is so great that the patient talks and acts as if there were little the matter. This, however, depends on the cause. Puerperal cases are liable to act in this way. I have seen cases dying; yet they were hopeful and believed in an early recovery. When the organ involved in causation is the liver, pessimism is present.

Pain that precedes or follows bowel movement indicates rectal disease, hemorrhoids, fissure, ulceration, cancer.

If pain recurs with menstruation, the reproductive organs should be examined.

Sudden pain experienced for the first time should be analyzed carefully. If the same character of pain has been experienced before, time may be taken, if necessary, to find the cause. If pain follows exertion, it may be from hernia, rupture of tubal pregnancy, rupture of peritoneal adhesions with hemorrhage, volvulus, rupture of cystic tumor, or twist of tumor on its pedicle. Pain following trauma may be from rupture of the bladder, stomach, intestines, or other viscera.

Pregnancy, with threatening abortion, may be the cause of pain. Horseback, or rough riding, of any kind, followed with pain, is suggestive of calculus. Repeated abdominal pain due to painful peristalsis in the uterine, fallopian, biliary, ureteral, urethral, intestinal, spermatic, and other ducts, is not often recognized. If it could be, many mistakes would be overcome.

I have seen neuralgia of the spermatic vessels diagnosed appendicitis, and, after the appendix was removed, the pain that came back was diagnosed adhesions. It is no uncommon thing to have the appendix removed, then the right ovary, then operations for adhesions, then operation on the gall bladder, because of genital affections; namely, spermatorrhea, ovarian irritation, endometritis with stenosis of the neck of the womb (a very common cause of abdominal pain in nulliparous women), or urethral tenesmus.

There are many gall bladder operations because of painful peristalsis caused by gastro-intestinal indigestion, and irritation and inflammation of the viscera. After hernial operations, pain may continue because of adhesive bands. I know of one death caused by obstruction from adhesions at the internal ring of partial hernia.

Women of menstrual age should be examined for affections of the genito-reproductive organs.

Sudden abdominal pain in anemic young women should cause the physician to suspect perforating ulcer of the stomach or duodenum. In children, abdominal pain usually means gastro-intestinal derangement, such as gastritis, enteritis, twist, invagination, colitis, appendicitis.

In those past middle life, particularly in old age, cancer is the common cause of abdominal pain

The character of pain should be noticed. In perforation the character of the pain is the same in all viscera.

In invagination the pain is paroxysmal and periodic, due to peristalsis. Strangulation is generally intense and periodic, due to peristalsis; later there is aching and dragging. In appendicitis the pain comes on suddenly, and is intense in fulminating cases. There is a type which comes on slowly, and is easily controlled by fasting and quiet. A sharp, lancinating pain, continuous in character, is possibly due to perforation. A continuous, agonizing pain spells diffuse peritonitis, and means death unless immediately relieved by operation and drainage.

Pain caused by obstructed peristalsis is periodic, and will subside if no food or drink be given. In appendicitis the patient will remain comfortable, but in obstruction from a twist or invagination, discomfort and pain will not leave, the pulse will run high, and the face becomes anxious.