and the patient is not improving. The internist should be rather cautious in these cases, especially in the administration of purgatives, on the one hand, and morphin on the other. We can all see how much harm may be done in a great many cases, by purging, upon the one hand, irritating an already susceptible abdomen, and by the administration of morphin upon the other, só as to later mask the symptoms and allow the patient to go along without proper treatment. Of course, it is our duty to palliate the symptoms in every way possible whenever such palliative measures are not detrimental to our patient as described above. We should advise that all cases of this character be put at absolute rest, preferably in a hospital where they can. be watched. The diet should be limited or withheld entirely. Nausea, if present, should be relieved by the simpler remedies; pain, by external remedies; constipation, by enemata. If improvement is not rapid, our duty to go it single-handed. ends.

What part shall surgery play? The responsibility in cases where diagnosis is withheld to consider the patient's condition a little longer, should be divided between the internist and the surgeon. Immediate action should be taken if the least doubt exists, as, with the nearly perfect technique of latter-day surgery, a minimum of danger exists, even in an unnecessary operation, which is preferable to untimely delay.

These statements may be rather bold, but they are based upon our own experience of several years with abdominal cases, many of which might have been saved, and in others, instead of encountering a grave condition upon operation, a rather acute simpler disease would have been found.

How may we accomplish the best re

sults in these cases? Certainly by cooperation of the internist and the surgeon, but to secure this the conditions which now exist must be changed, for the medical man certainly postpones consultation until the last because of the inequality that now obtains, both in the attitude of the surgeon toward the physician, professionally, and in the great difference in the remuneration received. We are not an advocate of division of fees, and have never been placed in position to accept or decline such a proposition, but it does seem that if the physician and surgeon divide the responsibility in cases such as we have cited, there should be a more equitable basis of remuneration than is at present in vogue.

Paradoxical as the statement may seem, we have come to believe that the medical aspect of the acute abdomen is nearly always surgical.

DISCUSSION.

DR. H. HORACE GRANT: I think Dr. Meyers' view, as to the necessity for cooperation between the physician and surgeon in very grave conditions, is one to. be highly applauded. The differential diagnosis between the conditions that require surgery and those which may be safely treated by medical means are not easily made. In my opinion, the most important guide, and the one which will more frequently enable us to make differential diagnosis, is the pulse, rather than pain or temperature, both of which are very uncertain as indications of the gravity of a condition, which, if it requires surgery, must be relieved within fortyeight hours in order to get a good result. A considerable amount of shock is present in such conditions as fulminating appendicitis, prolonged intestinal strangulation, perforation, etc., accompanied by a marked increase in the frequency of the

pulse. It is true that, in intestinal strangulation, the pulse may be somewhat late in becoming accelerated, but wherever there is a perforation-and this is a condition which demands the most prompt surgery-shock is very marked, and is our best guide as to the indications for surgery. If, in making differential diagnosis, we will endeavor to exclude the milder conditions, those which do not demand surgery, we will more promptly arrive at a conclusion as to whether or not surgery is indicated. Grave acute abdominal conditions can scarcely be confounded with anything except the colic of gallstones or kidney stones, or perhaps acute indigestion, but none of these conditions give rise to shock and they are not sufficiently severe to keep the patient from walking about were it not for the intense pain, and they are not attended by any elevation of temperature unless there is ptomaine poisoning in connection with an acute indigestion, Thus, by excluding those conditions which may be relieved by simple measures, a definite conclusion is more easily arrived at. Where simple measures do not give relief, and a positive diagnosis cannot be made, an exploratory laparotomy is indicated. In the presence of vomiting, the possibility of intestinal obstruction or beginning peritonitis should not be overlooked, and when persistent it constitutes a positive indication for some surgical interference.

It seems to me to be very unwise to either give these patients opium, administer a purgative, or even to wash out the stomach. The temptation to do these things in cases where the diagnosis is obscure is very great, and the attending physician is apt to administer a purgative where there is constipation, or to give morphin where there is intense pain, but such measures are almost certain to re

sult in carrying the patient beyond the proper time for operative interference..

To sum up, I believe that, in endeavoring to arrive at a diagnosis, the most important points are to exclude the simpler conditions, and to be on the lookout for grave conditions as manifested by the presence of shock. Whenever the attending physician is in doubt as to the proper course to pursue, he should, as Dr. Meyers has advised, withhold all palliative measures which may tend to obscure the diagnosis until the proper time. for operative interference has passed. For example, where we have perforation, in only a few instances will the patient recover under surgical interference after twenty-four hours have elapsed, and in cases where there is actual mechanical obstruction of the bowel, sufficient to interfere with the circulation, thirty-six to forty-eight hours is as long as we can reasonably expect to wait and still afford relief by surgical measures. Consequently, operative interference to be effective must be practiced as early as possible in perforation, and within thirty-six to forty-eight hours in intestinal obstruction.

There are no more important questions to be decided between the physician and the surgeon than those brought up by Dr. Meyers. While I agree with him that diagnosis is sometimes a difficult question, I believe that exploratory operation will frequently simplify it, and will tend to overcome the hesitancy which the physician sometimes feels in submitting a case to a surgeon.

DR. AP MORGAN VANCE: I wish to say only a few words in regard to the question of remuneration.

In my opinion, the comparatively smal! compensation received by the attending physician has been, in a great measure, due to his lack of courage; he hesitates

to demand what he deserves for fear of scaring the patient off. Just as soon as the general practitioner learns to correctly estimate the worth of his services, and demand it, the justice of his claims will be recognized, but I have found, for instance, that as a rule, they hesitate to make a charge for attending an operation equivalent to what the surgeon would charge for making a diagnosis. Very few of them have the courage to make a charge commensurate with the services. rendered and the responsibility undertaken. The general practitioner usually charges two dollars a visit, but if he sees a case of "acute abdomen," calls a surgeon and helps him, he is entitled to more than the charge for a visit, according to the circumstances of the patient. The physician is the only one who can remedy this condition of affairs; he is the only one who has a right to do it, and I believe the best solution of the problem is for him to demand what he feels he de

serves.

DR. LOUIS FRANK: I am very much in accord with Dr. Vance as to the question of remuneration. The physician could get more adequate compensation in many of these cases if he had the courage to demand it.

The treatment of an acute abdomen is a tremendously broad subject. First, I would ask, what shall we term an "acute abdomen?" Generally speaking, after three or four days have elapsed an abdomen is no longer acute in the strict sense of the word, and I believe that the proper time for the physician to call in the surgeon to share the responsibiltiy, if it is done at all, is immediately after the doctor's first visit. In my opinion, this is sufficient time to enable the attendant to determine upon what method of procedure he proposes to adopt. If he decides to carry the patient along and

make the "acute abdomen" a "chronic abdomen," so to speak, and if this plan of treatment proves unavailing, and the physician waits until he sees that there is no further chance for his patient except by operative interference before calling a surgeon, the latter should not be expected to share the responsibility, because the case has probably, by that time, passed beyond the time when operative interference would be productive of the best results.

In speaking of an "acute abdomen," the picture we have in mind and upon which the whole question hinges, is that of a peritonitis, or an infection of the peritoneal cavity. This, as is true of all inflammations, is not in itself an acute condition; it is the end result of bacterial invasion. Some of the symptoms mentioned by the essayist and by Dr. Grant in his discussion are not symptoms of acute infection of the abdomen; they are terminal symptoms-symptoms that follow in the wake of a widely diffused infection and which, in many cases, indicate that the case is going rapidly on to a fatal termination. Therefore, unless the physician decides, in any given case, that he is dealing with an acute abdomen which may get through without an operation, he should advise immediate operation, and the surgeon would then be willing to assume his part of the responsibility. I believe that the best results would be achieved under this plan.

Many different forms of infection occur in the peritoneal cavity, and that due to perforation of the stomach or intestines does not necessarily mean a fatal termination without surgical interference. It is a well known fact that infections in the upper part of the abdomen are more or less innocuous, and several days may elapse before the patient develops symptoms of peritonitis. However, that is

immaterial; the question is, what plan of treatment will result in the greatest good to the greatest number. For my own part, I believe that immediate operation should be carried out in all these cases.

Although the paper was very short, the topic includes such a tremendous field that if we take the time necessary to consider all of its phases, we would be here all night. Therefore, I will not attempt it.

It

I would say, however, that, if there is one intra-abdominal condition in which absolutely no delay is permissible, it is intestinal obstruction. To delay operation in order to make an accurate diagnosis, or in attempts to relieve the patient, is the worst thing that can be done, because conditions may arise which will cause the death of the patient irrespective of any surgery we may do. In the case presented by Dr. Baldauf to-night we have an example of what may occur. This woman undoubtedly had an "acute abdomen" at one time, and the symptoms which Dr. Baldauf described were recrudescent or recurring symptoms. had become a case which might be termed a "chronic abdomen," and it is a very beautiful illustration of what may occur if we wait too long. In the vast majority of cases, while I agree that accurate diagnosis cannot always be made, still I think the attendant can arrive at a definite conclusion as to what plan of procedure he will adopt in a given case. If he waits until the patient has chills, temperature, vomiting, etc., he will have waited too long. As I understand it, there is no one symptom, unless it be the sudden onset of intense pain, that determines an acute abdomen. If one pins his faith to the temperature or pulse, he will lose out every time. Some of the most widely diffused purulent abdomens I have ever

seen showed absolutely no acceleration of the pulse, and no elevation of temperature. We have all seen cases of peritonitis and appendicitis without much acceleration of the pulse or elevation of temperature. Therefore, in my opinion, there is no one symptom upon which a great deal of stress can be laid in determining an acute abdomen aside from the sudden onset of severe pain. This is the one and only early symptom which is absolutely dependable.

DR. J. G. CECIL: There seems to me to be one phase of this subject that deserves a little more attention than has been given to it in the short paper presented by the essayist. A close study of the preceding symptoms will very often determine whether the abdomen is what might be termed acute, or whether the condition is the result of a disease process that has been going on for some time, and I think it is obligatory upon the attending physician to make a very careful analysis of the preceding history. Of course, very often a history of preceding symptoms is not obtainable, and it is not always reliable when it is obtained, but in a great many instances it will help to clear up the diagnosis, and will put the physician in position to defend his course, either in treating the case medicinally, or in giving it up and turning it over to the surgeon.

There are a great many symptoms which are either overlooked entirely, or are not considered important, but which, when studied closely and given their due significance, may aid materially in clearing up the diagnosis.

I am glad to have heard this paper and the discussion, because it opens up a subject which is so often a matter of controversy between physicians and surgeons.

DR. J. ROWAN MORRISON: This is a very

interesting subject from the standpoint of the medical man. It seems to me that, when a physician is confronted with what Dr. Meyers has termed an "acute abdomen," his first duty is to exhaust every means at his command to arrive at a positive diagnosis before he leaves that patient, and if he is still unable to reach a definite conclusion, he should call in some one to help him. If a history can be obtained of previous symptoms, or similar attacks, it should be given full consideration. Under no circumstances, however, should he simply attempt to tide the patient over and avoid surgical interference for the time being. If he cannot arrive at a positive diagnosis by himself, he should call in some one to help him, and if it is apparent that the question of time is paramount, a definite conclusion should be reached as quickly as possible. As to the question of remuneration, I am inclined to agree with Dr. Vance and Dr. Frank that the average general practitioner hasn't got the nerve to charge as much as he really deserves for his services in guiding a patient through an attack of typhoid fever, for instance, or a pneumonia. I think after all, it is largely a question of nerve.

DR. SIDNEY J. MEYERS (closing): I thank the gentlemen for their discussion of the paper.

Dr. Grant discussed the subject from a general standpoint, and did not dwell upon the symptoms of any particular condition.

In regard to Dr. Cecil's remarks, I stated in the paper that our errors were of omission rather than commission. By that I meant that we do not always go into the previous history of the patient as fully as we should, and we do not make our examinations sufficiently thorough to enable us to arrive at a diagnosis.

By the term "acute abdomen," I do

not mean those cases in which the physician is able to make diagnosis-where he can say to himself, definitely, "Here is a case of ectopic gestation," or ruptured gall-bladder, or appendicitis, as the case may be. The term is meant to cover those cases in which there is a symptom complex from which we are unable to arrive at a diagnosis. It is an "acute abdomen" from the standpoint of the physician because he sees it for the first time.

I stated in the paper that, in many of these cases, we can better afford to err on the side of surgery by opening the abdomen and finding nothing, than we can to err on the other side by allowing the case to go along, perhaps to the point where any surgery that may be done will be of no avail.

Just a few days ago I saw a case in which I made diagnosis of appendicitis, called a surgeon and the case was operated upon for appendicitis. However, the appendix was found to be normal, and the patient still has the same trouble as before the operation. In another case, a surgeon agreed with me that we had to deal with an empyema of the gallbladder. Operation was done and the gall-bladder drained, but the patient continued to suffer and it later developed that he had the crises of locomotor ataxia.

I could go on and cite quite a number of cases in which surgeons made mistakes as well as the internist, but these will suffice to bring out the point I intend to make.

Dr. Cecil stated that just as soon as we have made diagnosis, we should turn the case over to the surgeon. I object to that way of putting it. Any surgeon or consultant who has ever done any work for me knows that I do not delay in seeking their advice or assistance in