THE PAIN AND TENDERNESS OF APPENDICITIS. The cecum occupies no fixed position in the pelvis, consequently the location of the appendix varies, and when inflamed may be so situated as to cause either a localized or referred pain. The early pain and cutaneous hyperalgesia of appendicitis radiates about the umbilicus or is referred to the epigastrium, because of the distribution of the eighth and tenth dorsal nerves. Intra-abdominal pain corresponds to the distribution of the superior mesenteric plexus. In the usual case of appendicitis the pain corresponds to the location of the appendix, the attached portion of which is found on a line drawn from the right anterior superior spine of the ilium to the umbilicus, and about half way between these two points. This point (McBurney's) invariably marks the cecal end of the appendix, and is painful on pressure because the right rectus muscle is pierced by a twig of the twelfth dorsal nerve in this location. The distal end of the appendix may be displaced to any part of the abdomen. When the appendix extends across the belly cavity pain will be complained of to the left of the linea alba. If the organ overhangs the brim of the pelvis pain is not infrequently referred to the bladder, or to the liver, the gall bladder or the kidney when the appendix is post-cecal and displaced upward. Constant or paroxysmal pain may be confined to the right testi. cle. This results when the appendix occupies the pelvis and gives rise to irritation of the iliohypogastric nerve, which sends branches to the skin covering the pubes. Pain is occa sionally referred along the anterior crural nerve and becomes localized to the inner side of the right knee. The incipient pain of appendicitis is paroxysmal, transitory and colickylike, or it may be lancinating, and is more intense when the serous coat is involved. Pain may be preceded by chilly sensations; frequently nausea and vomiting mark the beginning of an attack, which is characterized by the symptom-complex of shock. The cessation of acute pain during the acme of an attack of appendicitis is suggestive of rupture of the organ. Tenderness is the most important, and a more constant symptom than pain. It is always present, and in the absence of general peritonitis is limited to the inflamed appendix. Occasionally tenderness will be diffused, but is invariably localized at McBurney's point. "If tenderness exists on the right side and then develops on the left side, severe spreading peritonitis usually exists."-W. Meyer. "When the appendix becomes gangrenous, local tenderness for a time disappears, because the peritoneum of the involved region has become anesthetic; later, however, it returns, spreads, and becomes general."-Da Costa. "In view of the fact that tenderness in the right iliac fossa is often demonstrable in tubal and ovarian disease, the sign in males is of greater significance than in females."-Tubby. "Firm, deep, continuous pressure at McBurney's point will usually elicit tenderness and often pain of the most exquisite character. If the appendix is postcecal tenderness can be demonstrated by palpation through the rectum or vagina. After the advent of suppuration tenderness in the right iliac fossa becomes more general. Frequently after a remission following the sudden, sharp, primary attack of appendicitis, tenderness and rigidity alone remain to tell the attending physician that trouble still exists."-Deaver. STATE MEDICAL EXAMINATION-RESULT. F. F. The Ohio State Board of Medical Registration and Ex amination held its semi-annual examination of candidates for licenses to practice in Ohio January 2, 1905, at Columbus, O. The total number of graduates examined was 32, of whom 25 passed and 7 failed. The following is a list by numbers of those examined, together with their school and the average grade of each. Unless otherwise designated the year of graduation is 1905: PASSED Cleveland U. of Medicine and Surgery.... ..(1897) 803, 75 .... Starling Medical College, Columbus, Ohio,. 811, 80 Western Res. Med. Col., Cleveland....812,88; (1882) 824. 86 Medical College of University of Munich......(1903) 813, 84 Ohio Medical University....814, 93; 820, 81; 821, 95; 822, 86 Cleveland College of Phys. and Surg. Western U. Med. Col., London, Can... Rush Medical College, Chicago, Ill. Illinois Medical College, Chicago... College of P. and S., Baltimore, Md.... ....817, 84; 818, 75 ...(1904) 823, 83 ..825, 85 826, 80 .. 820, 89 S. S. Still College of Osteopathy, Des Moines, Ia.... 834, 75 FAILED Cooper Med. Col., San Francisco, Cal... Medical College of Ohio, Cincinnati. Helsingfors University, Finland... (1887) 813,65 .(1893) 816, 68 . (1898) 819, 64 .(1904) 829, 71 .(1904) 830, 73 Am. S. of Osteo., Kirksville, Mo.. (1901) 832, 66; (1904) 833, 60 MANUAL OF MEDICINE. By Thomas Kirkpatrick Monro, M. A., M. D., Fellow of and Examiner to the Faculty of Physicians and Surgeons, Glasgow; Physician to Glasgow Royal Infirmary and Professor of Medicine in St. Mungo's College; formerly Examiner in the University of Glasgow and Pathologist to the Victoria Infirmary. Philadelphia and New York, W. B. Saunders & Co. London, Balliere, Tindall & Cox. Dr. Munro's book should serve admirably the purpose for which it is primarily intended, that of a text-book for students. He has accomplished successfully the difficult task of condensing into a volume of moderate size the enormous mass of facts which makes up our present knowledge of internal medicine. The work throughout shows painstaking care in the classification and arrangement of these facts and in their concise and lucid presentation. In arrangement it does not differ materially from the usual plan of the larger treatises. The space has been judiciously divided, and each section receives its due consideration. This same sense of proportion is seen also in the space alloted to the individual diseases and to their subdivision of etiology, morbid anatomy, symptomatology, diagnosis and treatment. THE COLUMBUS MEDICAL JOURNAL VOL. XXX. MARCH, 1906. No. 3. A NOTE ON THE SO-CALLED CHRONIC JAUNDICE AND ITS TREATMENT. BY WOODBRIDGE HALL BIRCHMORE, M. D. Brooklyn, New York City. The practitioner of medicine is sometimes consulted by men, more frequently by women, on account of a trivial symptom which but too often betokens a most serious pathological state. No definite lesion can be said to exist, yet all the tissues are more or less assailed and the functions of all the organs interfered with. The lesion which caused the patient to seek advice may be described as "important for cosmetic reasons," and no physician can have been long in the profession without experience of the mental perturbation of his "lady friends" if they chance to be thus assailed by ill fortune. This lesion on which stress is laid is the discoloration of the skin, a dull yellowish brown, with darker spots usually upon the cheeks, sometimes upon the forehead, sometimes upon the neck and shoulders. The patient seeking aid will be sure to explain that she does not do so because she is sick, but because of her mental distress at her appearance. The young practitioner may not recognize the seriousness of the case, but to him who has had a few years' experience, or good clinical teaching, such a patient is indeed a problem. As has been said, the patient is in most cases a woman, and the physician has no easy task before him to decide his course of action. Shall he tell her how serious is the state of her health? Shall he say to her that at any time and without warning mental disturbances ending in suicide or murder may follow if a systematic treatment of the condition existing is not at once begun, or shall he begin the systematic treatment and say nothing? This he must decide for himself, but if he does not at once and seriously set about the task before him, he will be wanting in judgment. The teaching of the schools will naturally suggest to the physician that at some previous time this condition, to which he will probably apply the overworked word "chronic-biliousness," was preceded by an attack of acute jaundice. The patient may tell him so and assure him that it was (may be) ten years before, and that from that time until now a complexion which had been, as we say, "peaches and cream," but now become "coffee colored," was gradually getting darker, and that at last, to crown her distress, these dark spots have appeared. Having had opportunity to study a most unusual number of these cases, and to watch the developments, permit me to suggest that the connection with the bilious attack and the jaundice is purely hypothetical, but to assure the reader that there is nothing hypothetical about the serious prognosis. The real condition of the patient. The real condition of the patient should rouse the anxiety of any physician who has maintained his position as one in touch with the development of medical thought, which is just beginning to waken to the seriousness of the probable future. The cause of this discoloration is the invasion of the cell contents of every anatomical element of the whole body with those substances which are commonly known as "bile-green" or "bile-red." Every cell in the body is at this time more or less distinctly poisoned by them, and the amount is increasing towards that point when intoxication will lead to actions of such sort that the sanity of the patient may be questioned. The great importance of this condition is due to the mis conception of the causation. As this condition is confused with acute and chronic jaundice, physicians commonly assume that the liver is to blame, and may even tell the patient that the liver is "torpid." In any given case this may be true, but that torpidity, while coincident in time with the more serious disorder, is coincident only, and beyond this accidental coincidence in time the two have no connection. Examination by the |