a temporary improvement, and I explained to him in the beginning that he had a mechanical condition present, as I believe he has a duodenal ulcer with adhesions, and suggested from the start that he should consider an exploratory operation.

I would not be understood that all ulcers should be operated. I have always tried to distinguish, by case history and examination, an old ulcer from the new. In either event I place the case in bed and by rest and diet endeavor to give them relief. If it is a recurrence, and the symptoms do not improve within three or four weeks, I advised surgery; in the acute cases, I keep them in bed for four weeks, allowing a gradual return to ordinary diet; should the old symptoms recur, I place them in bed again and go over the treatment again. I have seen quite a number of acute cases and I think I have had very good success; at present I have three cases under treatment in all of whom the first evidence have developed within three to eight months, and all are doing well; no pain, no occult blood, with gradual disappearance of all symptoms.

How should "chronic dyspepsia." so called, be treated?

First-A careful and complete history should be made; this history searched for every and any evidence that would lead us to believe that any organ than the stomach is involved, and this should be gone over again and again, if necessary, until all possible information has been secured.

Second-A careful physical examination should be made; all tender points or areas of increased resistance noted; examinations should be made regularly; gastric analysis at various intervals under the same and different circumstances; a systematic and regular test for occult. blood in both gastric contents and stool.

Third-All this should be done in a hospital or infirmary; in fact, it is an absolute necessity to clear up many cases. Rest itself is of prime importance and a most necessary adjunct to treatment.

Fourth-After all this has been done and tentative treatment shows but little or no result, surgical interference should be urged. The time has been well spent ; every effort has been made toward a perfect diagnosis and the rest and diet has placed the patient in the best possible condition to get full benefit from an operation.

After all, it is not such a large proportion of our cases that need operation. Certainly it is to the credit of the careful diagnostician if an operation is needed. to be the one to suggest it, and have it done before so many complications develop that we so often see. The best interests of the patients is served by the surgeon and internist working in harmony and what praise is better than that of the grateful patient whose case has been thoroughly studied out and the decision reached that medicine will not dissolve gall-stones, break up adhesions nor restore a twisted appendix, but an exploratory operation reveals the source of trouble-this is removed and he is once more restored to normal, bewailing not the money spent on treatment, but the time lost in his chronic invalidism?

DISCUSSION.

DR. AP MORGAN VANCE: It has been my fortune to have done a good many exploratory operations in this class of cases, and I must say that the results have been very satisfacttory in the vast majority of them. We find all sorts of symptoms in these cases, in addition to those related by Dr. Lucas. A number of my cases had intense jaundice, and yet no stone was found in the bile ducts. These

patients are often cured by the separation of adhesions, and sometimes we find miliary tuberculosis. I saw a case with Dr. Lucas, in a young man, who had suffered all these symptoms for a year or two, and upon operation they were found to be due to miliary tuberculosis and adhesions of the gall-bladder, stomach and colon, and separation of these restored him to health. I believe in exploratory operation, and relieving whatever condition is found to exist. I believe I have operated on at least twenty cases where all the signs pointed to gall-stones, and yet none were found. I believe that we can often relieve these patients by the separation of adhesions, or by exposing the viscera to the air, thus curing tuberculosis, if it is present.

DR. LOUIS FRANK: I am very glad indeed to have heard this paper by Dr. Lucas, as it opens up a subject that is of very great interest to us all, and one to which our attention has been called very frequently in the past two years. I am especially glad to have heard this paper because of the weight I am sure it will have with a great many internists. Most of the discussions along this line in the past few years have emanated from surgeons, and there have been very few contributions from men doing special work of this character, as Dr. Lucas is doing, that have come out so plainly and forcibly in favor of what we know should be the treatment in this class of cases. Therefore, I am sure that Dr. Lucas' paper will do much good in calling attention to this phase of the subject, because a paper of this sort, coming from a man who does special work, will necessarily have more weight than a similar paper coming from a man who does surgery.

I am in hearty accord, as are all of us who have paid attention to gastric symptoms, with everything the essayist has

said. I will preface my remarks by saying that I agree with Dr. Lucas that every case of gastric ulcer does not demand operation. As he has said, if these patients do not recover or show marked improvement after a thorough and conscientious course of treatment, then the question of exploratory operation should be very carefully considered. I am sure that all of us who are doing surgery could cite numerous instances in which we have seen just the relief secured after surgical operation that Dr. Lucas has reported. It has been well said that if any case of neurotic dyspepsia, or functional stomach disturbance, does not recover under a careful course of treatment extending over several months or a year, the possibility of an organic lesion in the stomach, duodenum, kidney, appendix, or even the uterus itself, should be considered. I have seen very marked gastric symptoms entirely relieved by the removal of fibroid tumors. I have seen the same relief follow the fixation of a movable kidney. We see numerous instances of this kind in kidney mobility of a certain type. I do not mean those cases in which the kidney mobility is just a part of a general gastroptosis. The appendix, we know, is a frequent source of chronic dyspepsia. particularly hyperacidity, and we should never fail to interrogate this region in a study of these cases.

As the essayist has said, more is to be learned from a careful study of the history of the patient than from anything else; in fact, I believe that a careful study of the history of past illness, going back over a number of years, will throw more light upon the case than will a physical examination, or even repeated physical examinations. We should spend days in securing such history, if necessary, and in bringing out points which the patient neglected to give us on his first visit, and

in this way we can usually arrive at a fairly accurate conclusion as to the cause of the complaint. If it is not clear then, of course, an exploration should be done with the idea of removing any pathology which may be found to exist. Sometimes in the presence of the most marked symptoms we may operate and find no lesion of any organ. Only recently I had a case of this kind; Dr. Lucas also saw the patient, who gave a most typical history of gastric ulcer, including hematemesis. She had been undergoing treatment, consisting of stomach washing and dieting, for three or four years, and had suffered so long and so persistently that she demanded relief. Exploration revealed absolutely nothing abnormal. The tubes and ovaries were healthy; no mobility of the kidneys; appendix absolutely normal, and I may say in passing that I do not believe in the removal of a normal appendix any more than in the removal of a normal gallbladder or stomach. This patient was completely relieved. She was operated upon during one of these attacks. After the first few hours she had no nausea following the operation, and has had no disturbance since. Whether this was purely a neurosis, relieved by operation, I do not. know, but I do know that we frequently have patients who have very marked gastric symptoms and upon operation show very little, if any, pathology.

DR. J. GARLAND SHERRILL: I wish to thank Dr. Lucas for the pleasure of hearing this most excellent paper; and, also, on behalf of the profession, to thank him for coming out into the open and taking the stand he has taken. I believe that, in the main, every man in the profession, whether he be a medical man or a surgeon, has at heart the desire to cure his patient, and, having that desire, he should employ all the means at his command to obtain that result. I believe that the so

called confliction between the internist and the surgeon is more imaginary than real, yet it is a subject which has been discussed in detail in many societies.

Dr. Lucas mentioned several classes of cases which produce symptoms of indigestion, and undoubtedly a great many of these patients have lesions which are not located in the stomach, and yet produce symptoms which seem to be referred to that organ. It is only by very careful study of each individual case that we can hope to determine whether or not the stomach is involved. In a number of cases we will be able to isolate the organ that is causing the symptoms, while in many others we will not be able to make so accurate a diagnosis. Many of these cases in which we are not able to arrive at a satisfactory conclusion will, as has been mentioned by Dr. Frank, clear up when subjected to operation, although no distinct pathology may be found.

I have always considered that, in these cases of men and women who are subject to so-called neuroses, there must be some actual pathology, if it can only be found. Some patients suffer from extreme nervousness where there is simply a diseased rectum, with co-incident irritation. Others suffer from nervous influences where a floating kidney is present, and suffer repeated attacks of abdominal crises and other phenomena. And again where we have chronic recurring peritonitis with adhesions, and where the gall-bladder becomes adherent to surrounding structures. We have all seen such cases and know that the symptoms may be relieved by surgical interference.

I wish to endorse Dr. Lucas' statement that not all gastric ulcers are operative cases. I do not believe that any one here would make the claim that every case of gastric ulcer should be subject to surgical interference. The first object of medicine

is to relieve the patient, if possible, without disfiguring the body; the second object is to afford relief by surgery if we are unable to do it otherwise. To illustrate this, I will mention a case referred to me by Dr. Rash, of Owensboro. Dr. Lucas also saw this patient, and we agreed, independently, that it was a case for medical treatment. Diagnosis was made of ulcer of the stomach and the patient referred back to Dr. Rash, and we were pleased to learn a few months later that the patient had made a perfect recovery. Where there is persistent recurrence of the symptoms, with a marked tendency to bleeding, we should subject these patients to operative interference.

The progress made in the treatment of this class of cases has been very great indeed in the past few years.

DR. IRVIN ABELL: I am very much in accord with what has been said, and I merely wish to endorse the views of previous speakers.

The group of dyspeptics that come under the classification of neurotics and neurasthenics form one of the most difficult classes of patients with whom we have to deal. I, for one, have been rather loath to approach, surgically, any of these neurasthenic patients unless I could demonstrate a distinct lesion in the abdomen as the possible cause of the neurasthenia. Both of the cases that I saw, whose case reports Dr. Lucas has given you to-night, were seen many months before they were operated on, and in both instances I was unable to satisfy myself upon the first examination whether they had a distinct lesion in the abdomen as the cause of the symptoms. Therefore, they were referred back to their physician for further treat ment. Dr. Lucas has given you in detail the extent of the treatment to which these patients were subjected, and yet, previous to the time of operation, we had rather

indefinite ideas as to what might be present in the abdomen, with the exception of a movable kidney and a displaced stomach. Those were the only pathological lesions of which we felt satisfied. Cystoscopic examination of the bladder, when the patient first came under my care, showed a perfectly normal bladder in each instance. The findings within the abdomen proved conclusively that the irritation was due to the enormous sigmoid. While the patient was rather a small woman, the total length of the sigmoid must have been twenty-two inches, and it was easily larger than my wrist. Even while lying on the table, a great portion of it rested in the pelvis. This explained the accumulation of gas which occurred within the sigmoid. During the times that she complained of this distention, a mass upon the left side could easily be made. out, and massage of this mass always produced a rumbling with gradual disappearance of the enlargement. We were unable to explain this until we saw this large sigmoid.

Since operation the patient has been perfectly free of gas formation until within the last few days. I have not seen her, but she telephoned me that she had one little attack following a visit to the home of one of her friends where she indulged in an unusual diet.

My experience in this case, as well as in others, has led me to the conclusion that, in these neurotic and neurasthenic cases, while prolonged examinations, repeated history takings, and analysis of secretions, will oftentimes lead us to the conclusion that the patient must have some demonstrable lesion within the abdomen as the cause of these symptoms, we all dislike to approach these patients. surgically. Nevertheless, I believe it is the proper thing to do in this class of cases, because, while we may not relieve

some of them, the greatest proportion will secure relief from correction of such lesions as present themselves.

DR. J. ROWAN MORRISON: I wish to say a few words in appreciation of this excellent paper. Whenever we have symptoms of marked dyspepsia, I think it is the duty of the physician or surgeon, whichever sees the patient, to inquire very carefully into the history, extending over days and even weeks, to determine whether or not there is some lesion within the abdomen to account for the symptoms. If it is absolutely impossible to find such a lesion, the case might be considered one of neurosis. We should keep the patient in mind, however, and if the symptoms recur, go over all this again. In many instances in taking histories important facts will be brought out which were not mentioned on the first occasion.

DR. LUCAS (closing): I think we are gradually educating the general public upon the subject of exploratory operations, and as a result we do not now have near the trouble in getting patients to submit to operation that we formerly had. Last Sunday I saw a young girl who works in a laundry, and who has been having a great deal of trouble. I suggested to her that the proper thing to do would be to open her up, and she said she was perfectly willing.

There was so much to say on the subject of chronic dyspepsia that I left out the genito-urinary tract entirely. I have seen a great many movable kidneys and I am not such a firm believer in reflex disturbances in the stomach from this cause as many of the rest of you are. I have in mind one case in which both kidneys were fixed, and that patient's stomach condition did not improve. I have another case in which both kidneys were fixed, but they are loose again now,

and the patient's condition is worse than before.

I make it a rule to take the history of every patient who comes to see me. I keep all the current cases in a desk file, and every time the patient comes to see me, I take the history out and go over it again. It is astonishing how little the average white man knows about himself, and the negro knows nothing. On the second visit I get a great deal more information, the third time a little more, and pretty soon the histories are written on side-ways and cross-ways, and oftentimes it is necessary to turn them over and write additional information on the backs.

The patient that Dr. Frank referred to was a great disappointment to me. That patient not only had a typical history, including typhoid, but she had tenderness in the median line, and exquisite pain in the gall-bladder, and I do not think I ever was so disappointed as when she was opened up and nothing was found. In reading a work on differential diagnosis the other day, I noticed a case recorded in which the patient was operated on, very much under the same circumstances, by a Boston surgeon. Nothing was found, but the patient got entirely well.

A couple of months ago a patient, whom I had not seen for three years, came to see me, and told me that she had consulted two surgeons. This woman is in splendid health now, looks well and is in good flesh. She is one of those kind that has everything. If a friend of hers. has pleurisy, she gets it. She has had tuberculosis four or five times. She has been vomiting for a good many years. She told me that she had consulted two surgeons, one of whom said it was her gall-bladder and the other her appendix. She asked me what to do, and I told her that in a case of that kind I would consult