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THE MEDICAL FORTNIGHTLY

A Cosmopolitan Biweekly for the General Practitioner

The Medical Fortnightly is devoted to the progress of the Practice and Science of Medicine and Surgery. Its aim is to present topics of interest and importance to physicians, and to this end, in addition to a well-selected corps of Department Editors, it has secured correspondents in the leading medical centers of Europe and America. Contributions of a scientific nature, and original in character, solicited. News of Societies, and of interesting medical topics, cordially invited.

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Subscriptions may begin at any time; volumes end with June and December.

Contributors should understand that corrected typewritten copy is essential to clean proof and prompt publication, and is much more satisfactory than manuscript. Original articles should be as condensed as justice to the subject will allow.

ST. LOUIS PHARMACISTS AND THE LIQUOR LICENSE.-Many local druggists have determined to give up the sale of alcohol and those. medicines classed as intoxicating beverages by the internal revenue collector, with a view of fighting the $624.00 a year license demanded by the excise commissioner from those who sell intoxicating liquors. It is interesting to note that the St. Louis West End Grocers' Club has an opinion from Lieutenant-Governor Charles P. Johnson to the effect that this saloon license should not be de

manded from grocers. His opinion in full is given in the Eli Grocer and General Merchant, of St. Louis, for April 14, page 5.

NATURE'S BEST TONIC.-Laughter is undoubtedly one of Nature's greatest tonics. It brings the disordered faculties and functions into harmony, it lubricates the mental bearings, and prevents the friction which

Editorial offices in St. Louis, Jacksonville, and St. Joseph monotonous, exacting business engenders.

where specimen copies may be obtained, and subscriptions will be received.

Contributions and books for review should be addressed to the editors, 319 and 320 Century Building, St. Louis, Mo.

MEDICAL MISCELLANY

THE establishment of a state tuberculosis sanatorium in Iowa has been facilitated by the passage of a bill in the legislature appropriating $50,000 for the purpose.

A BULLETIN issued by the Interstate Commerce Commission shows that during the months of July, August and September last 1053 were killed and 16,386 injured among passengers and employees of steam roads in the United States.

PRICE OF RADIUM.-Henri Farjas, of Paris, in his latest list of radium preparations, quotes the following prices: Pure radium bromide, one milligramme, $80; one centigramme, $800; one decigramme, $8,000; one gramme, $80,000.

To this must be added the import duty of twenty-five per cent. At this rate the commercial value of one grain of radium in the United States would be more than $5,000.

In response to a suggestion from the National Association for the Study and Prevention of Tuberculosis, President Roosevelt has appointed a committee to investigate the sanitary condition existing in the government offices and workshops, with a view to recommending measures for the prevention of tuberculosis. The members of the committee are: Surgeon-General Robert M. O'Reilly, of the U. S. Army; Surgeon-General P. M. Rixey, of the U. S. Navy; and Surgeon-General Walter Wyman, of the Public Health and Marine Hospital Service.

It is a divine gift bestowed upon us as a life preserver, a health promoter, a joy generator, a success maker. Life with the average man is too serious at best. Never lose an opportunity for relaxation from the stress and strain of your business or profession. Every draught of laughter, like an air-cushion, eases you over the jolts and the hard place on life's highway. Laughter is always healthy. It tends to bring every abnormal condition back to the normal. It is a panacea for heartaches, for life's bruises. It is a life prolonger.

A

THAT

ereal diseases.

SYSTEM OF VENEREAL PROPHYLAXIS IS PRODUCING RESULTS.-G. Shearman Peterkin (Seattle, Wash.) says the education of the individual in the law of sex is the only feasible means, at our present stage of evolution, of lessening or preventing venFrom sociologic, economic, ethic and physiologic laws, etc., scientific facts are taken as premises, and from these conclusions drawn to prove that this fact must be recognized. With these principles as a working basis, pamphlets-five in number-have been issued by a Committee on Prophylaxis of Venereal Diseases of the Washington State Medical Association. The pamphlets are appended in full, and Dr. Peterkin gives the reason for using them as a means of disseminating such knowledge. and for presenting the amount and character of knowledge they contain. The position is taken that business principles of today can be ethically applied in leading man, who must and will make his own morality, to the next succeeding evolutionary stage of his morality.-American Medicine.

MEDICAL MEMORANDA.

For Sale. First-class surgical chair and fine improved nebulizer. Both will be sold cheap if taken at once. Address "Removed," care Medical Fortnightly, St. Louis, Mo.

Entero-Colitis.-Dr. O. W. Cobb, Easthampton, Mass., reports case of an eight months' old boy who was said to be dying of cholera infantum. "I found the patient almost moribund and displaying all the symptoms of entero-colitis. I ordered high enemas of glyco-thymoline in 25 per cent solution and warm. Used four ounces at a time with a soft rubber catheter once every three hours. The child could retain nothing, was in frightful pain and passing constantly thin, foul smelling discharges tinged with blood. For nourishment I ordered several combinations to be administered, an ounce at a time, as a rectal clyster following the enemas of glyco thymoline. I know it is not good practice to give hypodermics to an infant, but this was a grave case. My predecessor had ordered gr. 1 64 morphine, gr. 1-960 atropin, sub. q. every four hours if needed, with strychnine 1-240 gr. if necessary. I continued this as the baby was often in intense pain and there seemed to be no other way The baby improved from the first, but so slowly that it was scarcely discernible to the parents, but the nurse and myself saw it. After three days the child could take some nourishment per oram. I then gave 2 m. of glyco-thymoline in one ounce of water every two hours before feeding. It began to have short periods of natural rest and the discharges were in every way improved. At the end of a week, Aug. 14th, the improvement was quite marked but we did not relax our vigilance. The enemas were continued fifteen days, once every three hours, then at less frequent intervals for a month, then once a day for six weeks. The recovery of the little patient was long and slow but uneventful.* The mother and nurse were devoted and

It

ably seconded my efforts. At this time the baby is a strong, rosy youngster.
gives me great pleasure to tell you of this case. The experience may be of value
and it certainly proves to my satisfaction at least, the potential possibilities of glyco-
thymoline in gastro-intestinal work."

The Modern Treatment of Nephritis.-If we will consider Renault's idea, that the kidney is not a filter, but a gland of secretion, as well as excretion, and that this secretion passes into the blood, where its action brings about such changes that the kidney is better able to eliminate the toxins, then will we get an idea of the action of nephritin, the unchanged primary elements of the cell of the cortex and the convoluted tubules of the kidneys. This idea has been worked out exhaustively, but in a crude way, for three years in the hospitals of France, where they have been making daily macerations of fresh kidneys and treating various cases of nephritis with remarkable results. For some time we have been trying to produce a product that could be used successfully by physicians in cases of nephritis, overcoming the nausea and repugnance, as well as the gastric irritation, which usually accompanies crude products, and also secure a product of a definite standard. so that the dose can be graduated according to the requirements of each individual case. Taking Renault's macerations as a standard, we make many experiments, the result showing that glycerine extracts were extremely weak, desiccated kidneys showed that the primary substances were injured by the heat and no favorable results obtained, solutions, extracted by normal saline solution, required alcohol to keep them, which is irritating, other extracts showed no value, and no active principles could be precipitated that would give the results as shown in France. Nephritin alone maintained a definite action throughout all these experiments, and if we still keep Renault's macerations as a standard, nephritin is found to be fifty times as potent, or in other words, ten tablets of nephritin equal the maceration of one pig's kidney. Nephritin is made from the fresh pig's kidney, uninjured by any preservatives, is perfectly stable and does not irritate the stomach; laboratory and clinical tests have confirmed the remarkable results by this method abroad. A case of albuminuria in a whisky drinker. Sp. gr. 1011 urea 0.5 per cent, albumin 1 gm. per liter, sediment showed hyaline casts in abundance. Given 4 tablets four times a day. On third day sp. gr. 1022, urea 2 per cent, albumin 0.75 gm. per liter. Careful examination of the sediment failed to show casts. He is showing rapid improvement without change of diet. The treatment of nephritin will, we think, bring a new era in the treatment of Bright's and other diseases of the kidney, while not a cure, where permanent changes have taken place in the histological structure of the cells, yet its aid in relieving the diseased kidney and helping the overburdened heart, will rightfully place it as a necessity in all cases of nephritis. The reports and conclusions, observed by many of the clinicians of France and printed in the most prominent medical journals of that country, are worthy of our attention. Page and Dardelin, in the Presse Medicale, Paris, report 18 cases of nephritis treated by giving a maceration of fresh pig kidneys. They say the results have been so remarkable that they do not hesitate to recommend the treatment. We would urge our readers to send for descriptive literature and samples of nephritin, and give same a careful trial. Reed & Carnrick, whose products are already so well known to the professioual world as to need no comment here, are the manufacturers.

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Papers for the original department must be contributed exclusively to this magazine, and should be in hand at least one month in advance. French and German articles will be translated free of charge, if accepted.

A liberal number of extra copies will be furnished authors, and reprints may be obtained at cost, if request accompanies the proof.

Engravings from photographs or pen drawings will be furnished when necessary to elucidate the text. Rejected manuscript will be returned if stamps are enclosed for this purpose.

COLLABORATORS.

ALBERT ABRAMS, M. D., San Francisco.
M. V. BALL, M. D., Warren, Pa.
FRANK BILLINGS, M. D., Chicago, Ill.
CHARLES W. BURR, M. D., Philadelphia.
C. G. CHADDOCK, M. D., St. Louis, Mo.
S. SOLIS COHEN, M. D., Philadelphia, Pa.
ARCHIBALD CHURCH, M. D., Chicago.
N. S. DAVIS, M. D., Chicago.

ARTHUR R EDWARDS, M. D., Chicago, Ill.
FRANK R. FRY, M. D., St. Louis.

Mr. REGINALD HARRISON, London, England.
RICHARD T. HEWLETT, M. D., London, England.
J. N. HALL, M. D., Denver.

HOBART A. HARE, M. D., Philadelphia.
CHARLES JEWETT, M. D., Brooklyn.
THOMAS LINN, M. D., Nice, France.
FRANKLIN H. MARTIN, M. D., Chicago.
E. E. MONTGOMERY, M. D., Philadelphia.
NICHOLAS SENN, M. D., Chicago.
FERD C. VALENTINE, M. D., New York.
EDWIN WALKER, M. D., Evansville, Ind.
REYNOLD W. WILCOX, M. D., New York.
H. M. WHELPLEY, M. D., St. Louis.
WM. H. WILDER, M. D., Chicago, Ill.

LEADING ARTICLES

SUDDEN ABDOMINAL PAIN-ITS SIGNIF

ICANCE.

BYRON ROBINSON, B. S., M. D.

CHICAGO.

We do well what we do automatically. Truth should be constantly advocated because the majority constantly advocate error.

Abdominal surgery is no longer a pioneer work. It is the result of the accumulated experience of the past fifty years. Its success

is based on well tried practices. It is a jealous field, filled with battles lost and won, dotted here and there with sad regrets, chagrin from unavoidable mistakes, but often brightened by the light of success. A masterhand in abdominal surgery is a hard-earned reputation. However, the accumulative experience of fifty years has still left obscure points in abdominal surgery which the genius of Lawson Tait has attempted to set at rest by the exploratory and confirmatory incision.

During the past fifteen years I have been particularly interested in gynecology and abdominal surgery, and all along these years has risen the question of abdominal pain and its signification. To interpret abdominal pain requires the best skill of the finest heads. Sudden, severe, abdominal pain is the one

No. 12

significant, early symptom sounding the hope for relief or the knell of doom. In the interpretation of sudden appearance of abdominal pain lies the physician's chance of success or failure-usefulness or disaster. This cry of sudden pain may come from multiple lesions or sources-it may be the appeal of a strangulated loop of intestine on the verge of gangrene; the demand of an agonizing ureter afflicted with a bristling calculus; the disaster of a perforated appendix in the dangerous enteronic peritonitic area; the horrible, grinding, hopeless pain of a biliary calculus; the calamity of a ruptured gestating oviduct; or from beginning painful perforation peritonitis of impossible diagnostic origin-accompanied by excruciating pain.

Abdominal pain belongs to the domain of the sympathetic nerve and should be interpreted according to its life and habits, in relation to its anatomy, distribution to viscera and physiology (rhythm) peristalsis.

Severe abdominal pain is the appeal for prompt, efficient assistance. In the first place, in my experience, the natural manifestation of sudden abdominal pain is too frequently obtunded, dulled, lulled into a treacherous quietude by the general practitioner's employment of heavy hypodermic injections of morphia, which obscures diagnosis. Frequently it is the mode of onset, the sudden appearance and location of the pain that affords the sharpest aid to diagnosis, and if the sharpest, delicate symptoms are obscured by morphia it may jeopardize the patient's life.

Sudden pain in the abdomen is frequently. the guiding, suggestive, means to a diagnosis. Pain is the most constant beginning feature and frequently the most constant, persistent characteristic. For this reason the practitioner should secure a complete clinical history, mode of onset, location of pain, rhythmic or constant, before he obscures its most delicate and valuable aid to diagnosis. Abdominal pain is Nature's warning that mischief is afoot in the abdomen, and its manifestations should not be obscured by opium until sufficient evidence is to diagnose the cause. The successful diagnosis depends on the most careful analysis of every available. symptom in severe abdominal pain, which is defective in a narcotized patient.

A characteristic of sudden abdominal pain is that at first it is diffuse or mainly in the umbilical region (the abdominal brain, the sensorium of the abdominal viscera).

Gradually, with the lapse of time-hoursit becomes more and more localized in the region of the affected organ (beginning local peritonitis).

A suggestive symptom is that almost all patients with sudden abdominal pain, especially beginning peritonitis, vomit.

The failure of the general practitioner in appreciating the significance of sudden severe abdominal pain results in late, and too frequently disastrous surgery, also in disastrous treatment by administrating cathartics, the enemy of visceral quietude.

In sudden abdominal pain the pulse in general is of more practical value than temperature. In some advanced, grave abdominal diseases the pain is limited or absent. Overwhelming profound sepsis has obtunded sensibility. In sudden abdominal pain the first and foremost matter is its diagnosisthe rock and base of rational treatment. The diagnosis is absolutely required in order to attempt rationally to remove the cause.

Probability is the rule of life and it is just as applicable in diagnosing sudden abdominal pain as in other matters. For example, when a man is attacked by sudden abdominal pain and vomiting with rise of temperature, pulse and respiration, the probability is that it is appendicitis-not perforation of the gastrium enteron or colon, for, that occurs perhaps one hundred times less than perforation of the appendix.

Observation.-I was called to attend a physician who was attacked with sudden abdominal pain while riding in his buggy. The abdominal pain from the beginning was located several inches to the left of the median line of the abdomen. The diagnosis was ruptured appendicitis from a potential appendix, i. e., one with an elongated meso-coeco-appendicular apparatus capable of extending or moving to locations distant from the usual appendicular site. The improbable diagnosis was intestinal perforation, because the appendix perforates perhaps a hundredfeld more than the intestine. In operating on the physician forty hours subsequent to the attack I found the peritonitis localized to the left of the median line of the abdomen. The potential appendix was practically in its usual location, however, surrounded by peritonitis. The explanation was evident. He had a potential appendix, which while wandering amongst the intestinal loops in the left half of the abdomen had become perforated and immediately, before adhesions formed, returned to its usual location in the right iliac fossa. The extensive, varying mobility of the cecum and appendix should be included in the anatomic diagnosis.

Anatomy is the solid ground of nature on

which to build a rational diagnosis of sudden abdominal pain.

PATIENT'S HISTORY.

We should study the history of the abdom. inal pain in each patient for aid in diagnosis. A clinical study of abdominal pain is of the utmost importance to both general physician and abdominal surgeon. Has the patient experienced similar sudden abdominal pain previously? What was the length of time elapsed between the previous attacks of pain? If the pain is recurrent it is probably from the same original cause, e. g., repeated perforated appendicitis or repeated attacks from calculus. Has the pain any regular persistent relation to the ingestion of food or fluid? If so we examine the proximal end of the tractus intestinalis, as for gastritis, ulceration, biliary passages, pancreatic disease and perhaps appendicitis. If the pain persistently precedes or follows defecation search for rectal disease-hemorrhoids, fissure, ulceration, carcinoma. If the pain recurs with menstruation one examines the genitals. If the pain be sudden and occurring for the first time we should scrutinize its history. Pain following extra exertion may be due to hernial strangulation, ruptured pregnant oviduct, breaking of peritoneal adhesions, formation of volvulus, rupture of a cystic tumor, an ovarian cyst rotated on its pedicle. Pain following extra trauma may be ruptured bladder, stomach, intestines or other viscera. In gestation an impending miscarriage may cause sudden abdominal pain. Clinical history is the most valuable in acute abdominal pain-not in chronic. Repeated rough rides with repeated abdominal pain is suggestive of calculus. The repeated abdominal pains due to painful peristalsis in inflamed tubes or ducts-biliary, ureteral, intestinal, genital-is still diffioult to diagnose.

It should be distinctly remembered that sudden recurrent abdominal pain following peritonotomy or peritonitis is mainly due to peritoneal bands checking peristalsis. Sudden abdominal pain in a patient who had had hernia is liable to be from constrictions of peritoneal bands. The clinical history is frequently a pencil of light in the diagnosis of sudden abdominal pain.

AGE AND SEX.

Age and sex are of extreme value in diagnosing sudden abdominal pain. In woman, in the maximum sexual phase, the lesions of the tractus genitalis surpass those of the tractus intestinalis. Still a differential diagnosis between appendicitis and right-sided inflamed oviduct, peritoneum and ovary, is frequently difficult.

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