tion, great dilatation and prolapse conditions. In gall-stones it is epigastric, with radiation to right and to back, or a sore and tender feeling in any part of the liver area. In chronic appendicitis it may be epigastric only, but often indefintely epigastric and abdominal, in low gall-bladder or high appendix area. Then the radiation is usually nil in ulcer, to right costal arch and back in gall-bladder, indefinitely or plainly abdominal in chronic appendicitis.

With attacks of dyspepsia with epigastric pain, with radiation to or about the umbilicus or lower abdomen, hold first and clearly to appendiceal disturbance, keeping in mind peptic ulcer and gall-bladder trouble with possible complications. A tender area is often found at McBurney's point when not at all complained of subjectively.

CONTROL OF SYMPTOMS.

When we come to control of symptoms, we find a clear-cut difference. Food, drink, alkalies and irrigation bring more or less complete and immediate relief in uncomplicated peptic ulcer, the symptoms returning regularly within a few hours at

most.

In chronic appendicitis anything taken into the stomach usually disturbs, and only rarely brings relief, and if some ease is felt it is not regular and complete. Vomiting may bring relief in chronic appendicitis, but rarely so completely as in ulcer, and vomiting is much less constant in chronic appendicitis, and hence is less a factor.

In the usual run of uncomplicated gall-stone diseases food does not give much evidence of being a direct cause of the painful attacks.

EARLY HISTORY.

Before leaving the subject of pain we would call attention to attacks in childhood or early youth of diarrhea or "stomach ache", more commonly termed "belly ache", as these attacks are usually abdominal. The attacks, the histories of which are often clearly recited, are typical appendicitis, and are the logical forerunners of the later dyspeptic attack. Then, too, recall the history of years of indefinite dyspeptic symptoms, followed

by a typical appendiceal attack, with operation and the cure of the dyspepsia. Let us not forget that in any abdominal attack with prominent gastric symptoms, where a history of pain about the umbilicus or lower abdomen is definite, we should hold first and clearly to appendiceal trouble, not forgetting gall-stones, ulcer, pelvic tumors (ectopic pregnancy) and, perhaps general constitutional disease-Bright's disease, tuberculosis, etc.

VOMITING.

Vomiting in ulcer is usually regular (except in complications), one to four hours after meals when all symptoms are at their height. It is sour, acrid, bitter-burning liquid, perhaps with some food. Ease follows the vomiting, and the vomiting is allayed by food taken, as are all other distressing symptoms. In gall-bladder cases the vomiting is only at the crisis, and is a bitter, acrid mucus, unless by chance the spasm follows closely the ingestion of food. In chronic appendicitis vomiting is not so prominent a symptom as in ulcer and does afford a marked degree of relief. It is irregular during the attack, but when it does appear it closely follows food, and consists of food rather than sour liquid, though both may be present. Nausea rather than vomiting is a characteristic.

GAS.

In chronic appendicitis discomfort from gas makes up more the general complaint than it does in ulcer. There is abdominal distention of gas scarcely located by the patient. Gas is belched, but not so much as in ulcer, and there is not the intense feeling of gas distention as is experienced at the height of a gall-bladder attack. The amount of sour eructations is not so great as in ulcer. In chronic appendicitis the patient is conscious of a feeling of slipping of gas in the bowels, and its passage gives a peculiar sense of relief, as at times do bowel movements. In this rather quiet and general way gas aids in the diagnosis.

BOWELS.

Constipation is one of the early symptoms of appendicitis, and may be the only one for a considerable period. It is

usually marked, though spells of diarrhea occur and usher in an attack. Free movements give considerable ease. Mucus is

present though not distinctive.

APPETITE.

In chronic appendicitis the appetite often fails, or it is so variable that this helps in distinguishing appendicitis from ulcer. At other times food is refused because of immediate distress, and when both factors are in action nutrition suffers. In ulcer the appetite rarely fails, except late, and if food is refused it is because of the pain, distress and vomiting that follows one to four hours later. Nutrition, therefore, usually suffers along the whole course of chronic appendicitis as a result of the diminished appetite or lessened intake of food, because of the immediate distress which follows. If nutrition suffers in early ulcer it is because of vomiting or due to diet to avoid late distressing symptoms. Nutrition rarely fails in gallstones until pancreatitis or complications supervene.

TEST MEAL.

The test meal is of value in the diagnosis because it is so negative. In a paper1 on "The Value of the Test Meal in Gastric Diagnosis" we called attention to this fact. There are no food remnants in the meal, hence no obstruction, and this is evidence of value. The stomach is usually normal in size and position and the acids oftenest within the normal limits, though in some cases they may be high. No organic acids, no bacteria or blood, as a rule, are present.

TREATMENT.

Treatment in chronic appendicitis will scarcely bear discussion. In ulcer of the stomach we do have medical cases in greater number than surgical cases. In gall-bladder diseases we may be pardoned for advising some sufferers to take the Carlsbad cure or other methods of treatment that may influence the oncoming of the later stage, but chronic appendicitis can only justly fall to surgery, and other advice when the diagnosis is made must be considered faulty and perhaps dan1 New York Medical Journal, September 4, 1909.

gerous. However, we cannot meet all cases clearly with only gastric symptoms present-pain, vomiting, gas, etc. history is recalled of pain radiating to right costal arch or back, or if no general liver pain be elicited, with no history of sudden, short, mild or severe epigastric attacks, with abrupt cessation and perfect health immediately following, we cannot say gall-stones. If with these same symptoms of pain, gas and vomiting, and with the same epigastric location we can get no early history of periods of attack with regular symptoms one to four hours after food, with clear cessation of symptoms following food, drinks, etc., but only symptoms of chronic complicated ulcer, then we cannot decide. So also with the same signs if we can get no history of childhood or youthful attacks of diarrhea or "belly ache", no radiation of pain to the umbilicus or lower abdomen, no tenderness at McBurney's point, or other local manifestations, but only chronic gastric symptoms, then we cannot diagnose undoubted appendicitis. What we can say is, "you have a serious trouble, perhaps in the upper abdomen, and surgery affords the great chance of relief", and it should be accepted. If at operation the surgeon finds the upper abdomen normal, let him next look to the great likely point, the appendix. This holds out many promises of relief.

SUMMARY OF CASES

Of the patients 58 were females, 57 males. The average age was 34 years and the average duration 71⁄2 years.

All patients have regained normal weight; many are above previously normal weight; none has lost weight.

Condition of the appendix found at operation, classified pathologically:

DR. FELL. I am interested in the differential diagnosis of these cases, as there are many cases the correct diagnosis of which is doubtful. We have learned to place little reliance on snap examination of stomach contents, but to pay considerable respect to the early history and subsequent history of the case. I have operated upon some in which the diagnosis was not clear, many have been relieved, but some have failed. It is certainly of great benefit to us to have the differential diagnosis made more clear and I thank Dr. Guthrie for his paper.

DR. LENAHAN.-I recall one of these chronic stomach cases that developed a sudden acute attack of appendicitis. I operated and three years have passed with no return of any of her former gastric symptoms. Can there be any doubt that this woman's stomach trouble of former years was this type of chronic appendicitis?

DR. MINER. It gives me great pleasure to hear this valuable paper, showing a great deal of research and teaching that in every case there should be a most careful study made.

One is apt to arrive at a diagnosis too quickly.

In my service at the City Hospital thus far we have had one case in which the localized pain led to the immediate conclusion of gastric ulcer. On making a careful stomach examination no positive symptoms were found. The case seemed to gradually grow better but suddenly developed acute appendiceal symptoms and was transferred to the surgical ward.

DR. H. GIBBY.-There is one phase of the subject which Dr. Guthrie did not discuss and that is the causation of the stomach symptoms when the appendix is at fault. The question as to whether it is due to nervous reflex or whether due to hormones circulating in the blood is an open one.