"Biliousness," (by S. A. Clement, M. D., Baltimore, Md.)-The world is full of biliousness. Now I am free to admit that the term "biliousness" is not the least bit of scientific but the laity know what it means and when they are given something to help it and that something does help it they want more of that something which fact increases the demand for that something which, in this case, is felsin. I report results in four cases. In each one of these cases I used felsin and nothing else. I wished to test the value of the preparation so that these cases show bona fide results from the use of the tablets, and that is what physicians want.

CASE NO. 1. Mr. G. aet 40; occupation, patrolman. This patient is so situated that his meals are taken very irregularly and, as a rule, hurriedly. Natural result-dyspepsia. On January 18, 1903, called for prescription; complained of accumulation of much gas and rumbling in abdomen, pyrosis, bad taste in mouth, a sensation of "a rock in my stomach," bowels irregular and slight frontal headache. Gave felsin tablets, one after each meal and one at bedtime. February 1st,reported that he had received considerable relief. Continued the prescription. February 7th, reported that all symptoms cleared up with the exception of the constipation, which was improving. Ordered felsin, one tablet after meals, for an indefinite time.

CASE NO. 2. Mr. M. aet 53; no occupation. He belongs to what I term the "hot bird and cold bottle" class of dyspeptics. Imprudent both in eating and drinking. His main complaint was excessive flatulence, bilious headache and constipation. Gave felsin tablets every four hours for three days, then one tablet after each meal and one at bedtime. The flatulence disappeared in two days, the headache in three and the bowels are beginning to act as they should. If he will be careful with his diet and continue the use of the tablets for a couple of months I am confident he will get well, but such cases are hard to manage, The tablets acted in this case very nicely as, from the patient's description, he has about run through the list of digestives. Now he is grateful to felsin.

CASE NO. 3. Mrs. C., aet 65. For three months past has noticed that if she takes anything more for supper than a cup of tea and cracker or two she would awaken next morning with headache and more or less nausea. Also reported chronic constipation. Ordered felsin tablets after each meal and on going to bed. The first two mornings after using the tablets awakened with headache but no nausea. Has now been using tablets two weeks and can eat a moderate meal at night with no bad results next day. Will continue use of tablets.

CASE NO. 4 Mrs. D., aet 24. Four months advanced in first preg. nancy, complains that "everything she eats fills her full of wind and she can't get rid of it." Complaints of pregnant ladies must be taken with a grain of salt, but prescribed felsin, one tablet after meals. After eight days treatment she reported that she had no more difficulty with the wind but now she can't get enough to eat. Evidently felsin in this case relieved the gas and stimulated the appetite.

Felsin is a new preparation manufactured by the Viskolein Co,, 210 Fulton Street, New York, who will no doubt send samples to physicians upon request.

Issued Tenth and Twenty-fifth of Every Month by the Fortnightly Press Co.

UNDER THE EDITORIAL DIRECTION OF

FRANK PARSONS NORBURY, M. D. AND THOS. A. HOPKINS, M. D. Secretary: CHArles Wood Fassett, M. D.

A COSMOPOLITAN BIWEEKLY FOR THE GENERAL PRACTITIONER

Editorial Offices in St. Louis, Jacksonville and, St. Joseph, where specimen copies may be obtained and subscriptions will be taken.

Address all business communications to the Fortnightly Press Company.

Address all contributions and books for review to the Editors, Suites 318, 319, 320 Century Building, St. Louis.

Volume XXIV

JULY TWENTY-FIFTH

Editorial Department.

Number 2

THE editors of the FORTNIGHTLY take great pleasure in announcing that arrangements have been completed which assure a resumption of our De

Announcement.

partment of Progress, and that under the auspices which insure that it will quite equal the Original Department in importance and interest. We have purposed in the selection of a new department staff, making each section active and thoroughly up-to-date; the men who have joined us as heads of the departments are especially fitted for this work, each is a specialist in the line of work, of which he takes editorial charge, each has in addition to work in college, in hospitals and in practice in this country enjoyed the privilege of extended post-graduate study in Europe, and each of them is a medical enthusiast of the best sort. The development of this work will necessitate some changes in the FORTNIGHTLY; We anticipate a considerable enlargement and, possibly some change in form later.

With the exception of one department, the surgical, for which an eeditor will be selected within a few days, the departments will be conducted as follows:

Internal Medicine by Dr. O. E. Lademann.

Pathology and Bacteriology by Dr. R. B. H. Gradwohl.

Obstetrics and Gynecology by Dr. W. H. Vogt.

Ophthalmology by Dr. Waldemar Fischer.

Pediatrics by Dr. A. Levy.

Therapeutics by Dr. W. T. Hirschi.

Dermatology by Dr. A. S. Wolf.

Otology by Dr. A. F. Koetter.

Laryngology by Dr. F. C. W. Printz.

The departments of Nervous and Mental Diseases and of Genito-Urinary diseases will be conducted by the editors.

APPENDICITIS is a subject of perennial interest and one which even in the light of accumulated experience and knowledge seems to offer a field for

Appendicitis
Questions.

discussion of certain points which are not yet definitely settled in the general opinions prevailing among members of the profession. To the physician who has followed the literature and discussions during these formative periods of our knowledge of this disease it seems almost inevitable that the result of his study and observation should be that appendicitis is a surgical disease. Such a conclusion would be first founded upon the facts regarding its physiology which have been elaborated by Sajous (Cyclopedia of Medicine and Surgery, June, 1903, editorial) Eccles, Craig and others. The consensus of opinion of these observers is that "the vermiform appendix supplies a bactericidal and antitoxic secretion to the coecal contents.'

Again, Kilbourn in his embryological, histological and pathological study of the appendix says: An enormous amount of microbic fermentation is constantly going on, as is shown by the hydrogen and marsh gas generated. Of late a great deal is written about intestinal sepsis and antisepsis. In specific diseases, such as typhoid fever and dysentery, the idea is not recent, for therapeutics have long aimed at intestinal antisepsis in combating them. But in the vague cases associated with neuralgias. myalgias, headache, lassitude, light fever and lethargy, a great deal of stress is being laid upon the absorption of the toxins from the alimentary canal, especially the large intestine. There must be some protection normally, against this condition, and I think we find it in the appendix. The germicidal properties of the tonsils and their protection to the pharynx are well realized. And in the appendix we must recognize an organ hav ing similar work in its own territory. "Its situation is particularly adapted to act upon the contents of the colon, its secretion being able to act immediately upon the food as it passes through the cecum.

Sajous says the bactericidal and antitoxic process is due to local phagocytosis and trypsis digestion.

Under normal conditions the vermiform appendix performs functions similar to those of lymphatic glands elsewhere in the intestinal canal, and affords protection to the region over which it presides. It is not a useless organ, and in the light of this inquiry it should not be removed unless diseased because it is doing preventive service. Sajous says, "Quite another state of things appear, however, when an inflammatory process invades the appendix, for it suddenly assumes a degree of importance out of all proportion with its position in the economy as an accessory structure, and exposes the patient's life as much as if it were a major organ. Reliable statistics show that under these circumstances an early and skillfully performed appendicectomy is indicated, even though localized discomfort, constipation and other of the smaller ailments follow.

Robert T. Morris (Medical Brief, July, 1903) considers this and other questions in admirable form, showing that indeed appendicitis is a surgical disease and should be considered as such. The following extracts from this valuable paper explain his position.

"The Removal of Normal Appendices.-Should the normal appendix be removed when it happens to be exposed in the course of operation for some other trouble?

"It has been my policy to leave the appendix untouched under these circumstances, believing that while operation for its removal entails trifling risk, the chances of the patients having trouble with the appendix, introducing the question of comparative risk only, there is still just enough danger connected with excision of the appendix to make it seem advisable to leave the organ untouched until we really and definitely have an infec-. tion to deal with. This has always been my position, both in speaking and in writing upon this subject, although it is not the common belief.

"The Treatment of Involution Appendices.-Senn and Ribbert called attention to the fact that the appendix is prone to undergo a normal involution change, with replacement of its lymphoid and mucous layers by connective tissue. These cases have been believed to be without interest for the surgeon, but my recent report upon a study of cases of this sort shows that in a certain proportion of patients the involution process is productive of complicated disturbances, not severe in character, but sufficiently important to receive accurate and detailed attention. The contracting connective tissue which replaces the lymphoid and mucous layers apparently engages nerve filaments in such a way as to cause a disturbance similar to that seen in other kinds of contracting scar tissue, and in the case of the appendix it leads to local pain and discomfort in the appendix region, persistent in character, and to a disturbance of the intimate sympathetic ganglia of the bowel wall. These patients suffer from intestinal indigestion with its commonly recognized features. The involution appendix cases are recognized by a few physicians, and when seen by the surgeon are apt to be passed on as cases not requiring operation, on the ground that there is not sufficient evidence of infection to warrant surgical procedure. The involution appendix on palpation is found to be harder than normal. It may or may not be tender on pressure, but we have the constant association of symptoms of pain or discomfort located at the site of the appendix, together with the history of intestinal fermentation. There is opportunity for error in diagnosis in these cases when one's attention is first attracted to them, but after a moderate degree of experience one is apt to get them right without much difficulty.

"Shall we advise removal of the appendix in these cases?

"I make it a rule to leave the question entirely to the patient, stating to him that he is not likely to have an acute infection of the appendix, and, in fact, is probably less in danger of having an infection of the involuting appendix than of a normal one. I say to him that if the intestinal fermentation is sufficiently amenable to medical treatment, and if the local discomfort in the appendix region can be put aside as a matter of small moment, there is no need for having the appendix removed. On the other hand, if the disturbance is enough to keep his general health continually below par, it is worth while to have the appendix removed, as the operation in cases of this sort is one not meaning very much from our present

day point of view. In these cases of involution appendix it is often more important to follow Abernathy's advice, "to treat the patient rather than the case.

"A neurasthenic patient inclined to be a valetudinarian will have symptoms out of all proportion to the lesion, and yet these symptoms may be controllable by a physician who is expert in the management of patients of this class. I personally confess to a certain degree of failure in managing them, and have referred them to physicians in whom they expressed a feeling of confidence.

"Acutely Progressing Cases of True Infective Appendicitis.-In cases of this sort, I believe in operating as soon as the diagnosis is made, on the ground that the patient is being operated upon any way by bacteria, whose intentions are unknown. The question resolves itself into the simple one as to which shall be allowed to operate in the case, the bacteria or the surgeon.

"My position in this matter is stated as a principle which assumes that the patient is within reach of competent surgical services. In the exceptions in which the patient is not in reach of competent surgical ser- · vices it is better perhaps to leave the patient in charge of the bacteria than in charge of an operator who has not learned out of experience to make his statistics better than the statistics of the bacteria.

In "an acutely progressing infective appendicitis which has gone on to well defined abscess formation, it is better for even an inexperienced operator to open the abscess, and to drain, instead of leaving the case to Ñature. 'Leaving the case to Nature'is accepted in curious interpretation by Homo Sapiens, who assumes that Nature is especially interested in him, but biologists believe that Nature is just as much interested in the welfare of the fine colony of bacteria which are at work in a case, as she is in a patient who may not even be considered by his acquaintances to be a very desirable member of society.

"Cases in which Evidence is Clear that the Infective Process is Subsiding when the Patient is First Seen by the Surgeon. -My advice in reference to this class of cases has changed within the past three or four years. It formerly seemed desirable to operate at once, even in cases of this sort, on the ground that it avoided a tedious recovery, and the dangers of portal embolism, and of pylephlebitis which might occur as a late complication. It always avoided the danger of acute exacerbations which not infrequently occur during the course of a case apparently proceeding to recovery.

"At the present time I believe that in a case without abscess, we may to advantage wait for some two or three weeks after the acute symptoms have subsided before considering the question of operation, and the question of operation in the interval is then determined by palpation findings, and by the subjective history of the case. If on palpation we find the appendix clearly abnormal, if the patient is suffering from adhesions, the appendix should be removed in the interval. If he has had more than one acute attack previously, even though the appendix is found on palpation