In our effort to work out a symptomatology of this condition, we have reviewed carefully the histories of some two hundred patients, and compared them with the histories of ulcer of the stomach and duodenum and gall bladder disease. Of these two hundred patients, one hundred and fifteen have been operated on a year or longer, and each patient has been written to and the exact condition of health ascertained.

DIFFERENTIAL DIAGNOSIS.

Chronic indigestion is most typically exemplified in chronic peptic ulcer, gall bladder pathology, appendicitis and cancer of the stomach, but we should hold clearly in mind the indigestion of pancreatitis, tuberculosis (especially pulmonary), tuberculous leisons of the ileocecal region, Bright's disease and pernicious anemia. This latter class of sufferers often present themselves solely because of digestive disturbances, and not infrequently it calls for painstaking care to reach a correct. diagnosis.

I. ULCERS.

Chronic ulcer of the stomach and duodenum has a definite, clear-cut and regular symptomatology, and we shall discuss this as the purest type of "indigestion". First, let us note that the histories of those who come to operation cover years of complaint, and that for much of the time the periods of attack and periods of freedom from symptoms alternate. Early in the history of this complaint the appetite remains good, nutrition does not fail, and food brings immediate relief from all symptoms; the pain, distress, gas, sour eructations, nausea or vomiting returning one to four hours after meals. The heartier the meal the more marked and prolonged the relief. During the period of attack this precise relief of symptoms by food or drink and regular return one to four hours later is peculiarly characteristic, and this prevails until complications have arisen that seriously interfere with the gastric function. Another stage of the trouble may be considered to begin after many periods of attack. The peculiar type remains unchanged. The attacks are more severe and prolonged, appetite may fail or food is not taken because of pain, distress, gas, vomiting,

sour eructations and burning stomach. Food and drink relieve, but the time of relief is shortened and the latter pain increased. Vomiting may replace eructations, and gives relief, as does irrigation of the stomach. Nutrition decreased not so often because of lessened appetite or of prescribed diet as because of fear of later distressing symptoms. Relief for a time comes from food or drinks, vomiting, irrigation and alkalies, but the distress returns again when the acid, acrid condition of the stomach contents returns. It is not the chronicity or the periodicity that is peculiar, nor the degree or location of the pain, nor the vomiting, gas, sour eructations or sour burning stomach; these are common to all types of chronic dyspeptic trouble-gall-stones, appendicitis, cancer, etc.; the characteristic point is the time the pain appears, with its accompanying symptoms of vomiting, gas and sour eructations; its regularity after meals or after other means that quiet, and the equally ready control of symptoms by food, vomiting, irrigation, etc. This characteristic regularity day after day, meal after meal during the period of attack, is hardly equaled in any other lesion or functional disorder. Later, when complications have appeared, the symptoms change. Food may not ease, but rather increase the distress, which is often more or less continuous. There are no periods of real relief, vomiting is perhaps less frequent, is more copious, and gives only partial relief; appetite and nutrition fail.

II. GALL-BLADDER DISEASES.

Gall-bladder disease has its peculiar type of digestive disturbances. We distinguish four stages based on the degree of severity of symptoms developed in the history.

I.

1. Those patients with mild disturbance, usually gastric, and often lightly considered by the patients and even more lightly by the physicians. These are light attacks of distress, gas, upward pressure, coming often soon after food, or at irregular times, often of sudden onset and short duration, eased by belching, slight vomiting or regurgitation, or slipping away almost unnoticed and without treatment, though various measures may get credit for their relief. These sudden, irreg

ular, mild dyspeptic attacks are quite as typical of gall-bladder disturbance as are the severe, typical attacks which, as a rule, supplant the mild.

2. There is another class of patients with more or less prolonged, dull (mild or severe) pain in the epigastric area, right hypochondium or whole liver area. This pain may be increased by food, exertion or motion; deep respiration gives pain, and when located posteriorly the trouble may be called pleurisy. These patients pass through prolonged, steady attacks, their distress may alternate with ease, and comparatively good or excellent health may be enjoyed for a time. During an attack dyspeptic symptoms are prone to be present, and but for the irregularity, as compared with ulcer, one might oftenest consider gastric lesions.

3. In the third class is to be found the great number in whom the correct diagnosis is made, and in this class surgery finds its greatest activity. Here we have the so-called typical gall-stone attack-sudden, severe epigastric pain, radiating to the right costal arch (at times to left), through to the back or scapular region, spasm of the diaphragm, upward pressure, gas, nausea, vomiting, and after a longer or shorter terrific. attack comes sudden cessation and, until complications occur, almost immediate return to health. Sudden onset, and sudden cessation without apparent cause or without treatment, are quite peculiar to gall-stone disease when no complications are present. These attacks come irregularly, night or day, and oftenest bear no relation to food, though often called acute indigestion, gastralgia, neuralgic stomach and other equally in

correct names.

4. The fourth condition is that of chronic gall-bladder trouble-adhesion, duct obstruction, perforation, contractions and duct infections-with pancreatitis. Often in this class chronic gastric disturbances predominate, and the picture is so closely related to chronic ulcer with complications, that a differential diagnosis cannot be clearly made if only present symptoms are considered. A correct diagnosis depends on the development of the early history. However, the chief end is obtained when the necessity for surgery is realized, and the

patient is sent for relief with a diagnosis of a surgical abdominal trouble.

III. CHRONIC APPENDICITIS.

In reviewing our histories of chronic appendicitis in which stomach symptoms predominate, we find that there is a neurotic element running through many of the cases. Whether this is an inherited taint or due to the chronic disability we do not know. Sex plays no important part. The average age is less than in either chronic ulcer or gall-bladder sufferers. In the former it is 45, in the latter 40, and in chronic appendicitis 34 years.

CHARACTER OF ATTACKS.

We note in general that the symptoms are irregular when compared with chronic peptic ulcer; prolonged when compared with gall-bladder trouble; the exceptions being, ulcer with complications, gall stones with duct obstruction and infection. If the attacks of chronic appendicitis be short they lack the regularity of ulcer, are usually more severe, unless perforative ulcer be considered. When studied with gall-stones there may be less distinction, but the characteristic radiation of the pain of gall-stones is wanting, and the clear-cut gall-stone attack is poorly simulated. The whole syndrome is blamed to food intake directly more often than in ulcer, and still more frequently than in gall-bladder disturbances.

Exertion is a factor often laid at the door of appendiceal attacks; rarely is this true in peptic ulcers and gall-stones. Then, too, absolute disability, so that the bed is sought, is common during an appendiceal course, and is rare in ulcers, except bad hemorrhages, perforations and other late complications, when nutrition suffers greatly. In gall-stones the bed is seldom taken to except at the crisis, or in common-duct obstruction, infection or severe pancreatitis, and even then, as a rule, we find our patients about. We note the chronicity and theperiodicity in all, but chronic appendicitis lacks the regular relief to all symptoms on taking food, and the regular return of pain in one to four hours. In chronic appendicitis the food instead of bringing ease produces early if not immediate dis

comfort; one meal giving one effect, the next meal quite another. Rarely do meals give ease in appendicitis, except in some hyperacid conditions, and in this relief there is no regularity meal by meal or day by day, as in ulcer. When we turn to gall-stones, there are the short, clear-cut attacks with sudden onset and sudden relief, mild or severe, with the severer cases giving typical radiation, and, when relief comes, perfect health instead of a few or many days of general disability.

PAIN.

Pain in chronic appendicitis is the great prevailing symptom and is often manifested by a queer distress. It does not seem so often to reach the severity it does in gall-stones, but is more prolonged; neither does it so often reach the constancy and intensity during the whole attack as it does in decided cases of chronic ulcer. However, it is not the kind, the degree, the location or the radiation, nor is the time of the pain so great a factor as it is in ulcer. The time of the pain is irregular. During an attack pain oftenest appears soon after, or is caused directly by food, save in those rather rare instances of highly acid condition, or when, from fear of food light diet has heightened the appetite, at which time food gives short respite. Often there is present rather continuous pain or rather a continuous distress which is epigastric, or so indefinitely abdominal that the patient describes it as epigastric, when really it is abdominal. There is not the clear-cut repetition and definite pain of ulcer, nor the clear-cut definite gall-bladder attacks; neither is there so often the definite location of the pain. Nausea, distress, flatulence and a feeling of distention covers the sensations of far more patients with chronic appendicitis than of chronic peptic ulcer or gall-bladder disease. The degree and the kind of pain are not specific, but have a bearing. Severe pain points to acute appendicitis, which we are not considering here.

LOCATION.

Location of pain has a bearing, though we may have only epigastric pain complained of in any or all three conditions. In gastric ulcer the pain is purely epigastric, except in perfora