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COPYRIGHT DEPOSIT
STATE BOARD
EXAMINATION
QUESTIONS & ANSWERS
OF THE
aniteD States ant) CattaDa
A PRACTICAL WORK GIVING AUTHENTIC QUESTIONS
AND AUTHORITATIVE ANSWERS IN FULL THAT WILL
PROVE HELPFUL IN PASSING STATE BOARD EXAMI-
NATIONS. REPRINTED FROM THE MEDICAL RECORD
f iftfj €Hition
Altogether New Matter
Every Question Answered in Full
NEW YORK
WILLIAM WOOD & COMPANY
Mncrccxvui
Copyright, 1918
By WILLIAM WOOD & COMPANY
First Edition, November, 1907
Second Printing, April 1908
Second Edition, September, 1908
Third Edition, October, 1910
Second Printing, February, 1912
Fourth Edition, September, 191 2
Fifth Edition, January, 1918
m 101918
>GI.A481347
r
CONTENTS
PAGES
Questions Answers
Alabama 5 9
Arkansas 38 44
California 78 84
Colorado 125 128
Connecticut 163 167
Georgia 194 198
Illinois 232 237
Indiana 264 269
tucky 291 295
:siana 333 337
yland 364 369
sachusetts 398 401
dssippi 425 428
Hampshire . 449 452
Jersey 470 474
York 499 503
h Carolina 530 534
556 560
loma 586 591
sylvania 624 627
ouutn Carolina 652 657
Tennessee 703 706
Texas 736 741
Virginia , . 776 781
Washington 807 813
West Virginia 861 865
Ontario 902 904
Medical Council of Canada 938 941
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PREFATORY NOTE
The present is the fifth edition of the Medical Record
series of State Board Questions and Answers, the first
having been published in November, 1907. The fact
that 13,800 books of the first four editions have been
distributed — an average of over 3,300 of each edition-
is an evidence that the work is appreciated. The
Medical Record began the publication of answers to
the examination questions of the State Licensing Boards
in December, 1906, and they have appeared in every
second issue of the Journal since that time.
The work was undertaken in the hope that it would
prove useful to the recent graduate in familiarizing
him with the nature of the examination to which he
must submit before obtaining the right to practise
medicine, but unexpectedly it has proved interesting
and profitable to many older members of the profession
who have thereby kept themselves posted regarding
recent discoveries, and have also found entertainment
in testing themselves as to their continuing knowledge
of the elementary branches.
As was explained when the series was begun, eleven
years ago, these answers open no short and easy road
to success in the examination, for the candidate is not
likely to come across the identical question in his
examination paper. The object of publishing them is
only to acquaint the student with the general character
of these examinations and to inspire him with con-
fidence in the result of his trial. Of the 19 per cent,
who fail each year, it is safe to say a third meet disaster
by reason of fright which would have been averted by
a study of the examination papers answered in this
department of the Medical Record. In the hope that
this new edition will prove to be as useful as its prede-
cessors in thus giving confidence to the recent graduate
and removing from his ordeal, trying enough in itself,
the terror of the unknown, the book is offered in the
service of the junior members of the medical profession.
ALABAMA.
&tat* Mitral 2to using Soarta.
STATE BOARD EXAMINATION QUESTIONS.
Alabama State Board of Medical Examiners.
anatomy.
i. How are cervical, thoracic, and lumbar vertebrae dis-
tinguished? Give the characteristics of the seventh cer-
vical vertebra.
2. To what class of joints does the elbow belong? What
bones enter into its formation and name three of its liga-
ments.
3. Name the muscles of the anterior tibial region, and
describe the tibialis anticus.
4. Describe a nerve fiber.
5. Give the origin and course of the musculospiral nerve.
6. Describe briefly the structure of arteries and veins.
7. Name the branches of the external carotid artery.
Give the origin, course, and distribution of the lingual
artery.
8. Give in a general way the flow of blood through the
systemic veins.
9. Name the terminal lymphatic vessels, and locate "and
describe the receptaeulum chyli.
10. Give the structure of the stomach.
PHYSIOLOGY.
1. Discuss at length the means and methods employed
by the human organism in protecting itself against infec-
tious diseases.
2. What phenomena follow injury to and section of the
pneumogastric nerve?
3. Discuss the function of the mucosa of the respiratory
tract.
4. Discuss the distribution and function of the cerebro-
spinal fluid.
5. Discuss aphasia.
6. Discuss hunger and thirst.
7. How is the automatic action of the heart muscle sup-
posed to be maintained?
8. Discuss the absorption of ingested fats.
9. What general conditions influence blood-pressure and
blood-velocity ?
10. Discuss the origin and significance of urea.
chemistry.
1. Define "chemical change" and "physical change/'
5
MEDICAL RECORD.
2. Name, describe, and give source of two elements used
in their elementary forms in medicine.
3. Describe hydrogen— how does it occur and how may
it be prepared ?
4. Describe carbon dioxide — give formula and state what
relation it bears to the respiratory changes.
5. What is phenol—-give properties and source?
6. In what tissue is iron an important constituent, and
how is it combined therein?
7. Define "proteid" and name three proteids found in the
human body.
8. Describe the method for the quantitative determina-
tion of urea.
9. How may occult blood be detected in the feces?
10. What are ptomaines and how may they be intro-
duced into the body?
ETIOLOGY, PATHOLOGY, SYMPTOMATOLOGY, AND DIAGNOSIS.
i. Give the etiology of mucous colitis.
2. Give the etiology of scurvy.
3. Give the pathology of endocarditis.
4. Give the pathology of abscess of liver.
5. Give the symptomatology of erysipelas.
6. Give the symptomatology of heat-stroke.
7. Give the diagnostic symptoms of pellagra.
8. Name one variety of pernicious malarial fever and
give its diagnosis.
9. Give the diagnosis of diabetes mellitus.
10. Give the differential diagnosis between appendicitis
and ovaritis.
PHYSICAL DIAGNOSIS.
1. Name points for observation in the inspection of the
thorax.
2. Name points for observation in the inspection of the
abdomen.
3. Give the varieties or kinds of respiratory (breath)
sounds and the explanation of each (adventitious sounds
not asked for, such as rales, for example).
4. Give the varieties or kinds of voice sounds and the
explanation of each.
5. Give the physical signs of bronchial asthma and their
explanation.
6. Give the differential physical signs between a thor-
oughly compensating cardiac hypertrophy caused by mitral
stenosis and one caused by aortic insufficiency, and the
reasons for same.
7. Give the physical signs of pericarditis with consid-
erable effusion and their explanation.
6
ALABAMA.
8. Give the physical signs of arteriosclerosis.
9. Give the method for the physical examination of the
spleen.
10. Give the physical signs of a bladder distended with
fluid.
(Optional, to be answered or not, as the applicant pre-
fers) : Make a diagnosis in the following hypothetical
case: Right side — Absent movement; bulging intercostal
spaces ; absent fremitus lower three-fourths, increased
upper fourth ; flatness lower one-third ; tympany middle
and part of upper third, dullness remaining upper
third ; absent respiratory and vocal sound lower third ;
amphoric breathing and egophony middle and part of
upper third ; bronchial breathing and bronchophony re-
maining upper third; succussion positive. Left side —
Exaggerated movement and respiratory sound and apex
of heart to left of mammary line.
OBSTETRICS.
1. What changes take place in the circulatory apparatus
of the fetus after birth?
2. What conditions may be mistaken for pregnancy?
3. How would you diagnose the death of the fetus in
uterof
4. What are the results of retroflexion of the gravid
uterus with incarceration?
5. What are the premonitory symptoms of eclampsia?
6. What precaution should be taken in the management
of face presentations?
7. What precautions should be taken against septic in-
fection during labor and in the puerperal state?
8. Describe the internal method of performing podalic
version and what are the dangers to the fetus?
9. (a) Give the diagnostic points of value in breech
presentation prior to rupture of the membranes. (b)
Name and describe positions of breech presentation.
10. Describe briefly the operation of cesarean section.
GYNECOLOGY.
1. Give the etiology of metrorrhagia.
2. Give the effects of oophorectomy.
3. Give the names of the two most important muscles
of female perineum.
4. What is meant by fibrosis of the uterus?
5. Describe the endometrium.
6. Name the conditions that cause sterility in the female.
7. What pathological conditions are caused by posterior
displacement of the uterus?
MEDICAL RECORD.
8. Classify tumors of the uterus.
9. Describe one operation for procidentia uteri.
10. Give the contraindications for curettage.
SURGERY.
1. Give the cardinal rules for treatment of wounds.
2. Give the treatment of shock and the precautions that
may be taken for its prevention.
3. Name the different forms of peripheral aneurysms
and give treatment for different varieties.
4. Name the varieties of fistula in ano and give treat-
ment for same.
5. Describe the treatment of a compound fracture of
the femur.
6. Give the diagnosis and tell how to reduce a backward
dislocation of the head of the femur.
7. Give diagnosis and treatment of empyema or pus in
the pleural cavity.
8. Give symptoms and treatment of gallstones.
9. Give diagnosis and treatment of perforation of the
intestine in typhoid fever.
10. Give symptoms of suppurative pyelitis.
HYGIENE AND MEDICAL JURISPRUDENCE.
i. Define hygiene.
2. What is immunity and how developed? What is
susceptibility?
3. Give the differential diagnosis between scarlet fever
and measles.
4. What effect does excessive exercise have on the
heart? What effect does insufficient exercise have on the
heart?
5. What is the difference between parasites and sapro-
phytes?
6. If on examination colon bacilli are found t<§ be pres-
ent in the general water supply of a community, what
fact does it establish? What steps, if any, should be taken
to protect the community?
7. Give the prophylaxis of uncinariasis.
8. What are the methods of self-purification of large
bodies of water?
9. What are the symptoms of acute poisoning from bi-
chloride of mercury and the antidote?
10. Found, the dead body of a newborn infant How
can it be positively determined that the child was born
alive?
DISEASES OF THE EYE, EAR, NOSE AND THROAT.
I. In complete ptosis how is the eye, or its appendages,
8
ALABAMA.
affected, and why? In complete facial paralysis how is
the eye, or its appendages, affected, and why?
2. Give the differential diagnosis between acute catarrhal
conjunctivitis and gonorrheal ophthalmia, and the general
principles of management of each. Write two prescrip-
tions for each.
3. Explain the normal reaction of the pupil. What is
the condition of the pupil in iritis, and what the remedy?
What is the condition of the pupil in glaucoma, and what
the remedy?
4. State some conditions that would demand enucleation
of the eyeball, and describe the operation.
5. Give the symptoms of complete obstruction of the
Eustachian tube, of some standing, and explain briefly the
measures to be employed for relief.
6. Give the symptoms, dangers, and management of
acute purulent otitis media.
7. How would you diagnose and manage abscess of
the antrum of Highmore?
8. Give the symptoms, diagnosis, and management of
adenoids of the pharynx.
9. A person is eating and suddenly begins to struggle
for breath and turns bluish in appearance; what would
you suspect, and what would you do?
10. Give some of the indications for laryngotracheotomy
and describe the operation.
ANSWERS TO STATE BOARD EXAMINATION
QUESTIONS.
Alabama State Board op Medical Examiners.
ANATOMY.
I. The cervical vertebra are distinguished by possessing
a foramen in the transverse process. Further, they are
smaller than those in the other regions; they have no
facets for the ribs; the spinous processes are generally
short and bifid ; the spinal foramen is large and trian-
gular; the superior articular process is directed upward
and backward, and the inferior articular process is directed
downward and forward.
The thoracic vertebra have a heart-shaped body with a
facet or demi-facet on each side for articulation with a
rib ; the laminae are broad and deep ; the spinous process
is long and points downward; the transverse processes are
long and articulate with the tubercle of a rib; the supe-
rior articular process is directed backward and slightly
outward ; the inferior articulate process is directed for-
9
MEDICAL RECORD.
ward and slightly inward; the spinal foramen is smaller
and circular.
The dorsal vertebra have a large body, wider trans-
versely, and with no facet or demi-facet; the laminae are
hort and thick; the spinous process is horizontal; the
transverse processes are "rudimentary" ; the superior ar-
ticular process is directed inward and slightly backward;
the inferior articular process is directed outward and
slightly forward; the spinal foramen is larger, and tri-
angular.
The seventh cervical vertebra is characterized by pos-
sessing a very long and prominent spinous process which
is thick, not bifurcated, and is nearly horizontal.
2. The elbow- joint is a. ginglimus or hinge-joint. The
bones which enter into its formation are the trochlea of
the humerus, the greater sigmoid of the ulna, and the head
of the radius. Three of its ligaments are : Anterior, pos-
terior, and internal lateral.
3. Muscles of the anterior tibial region are : Tibialis
anticus, Extensor proprius hallucis, Extensor longus dig-
itorum, and the Peroneus tertius.
The Tibialis Anticus is situated on the outer side of the
tibia. It arises from the outer tuberosity and upper two-
thirds of the external surface of the shaft of the tibia,
from the interosseous membrane and from the intermus-
cular septum; it is inserted into the inner and under sur-
face of the internal cuneiform bone and the base of the
metatarsal bone of the great toe. It is supplied by the
anterior tibial nerve; it flexes the foot at the ankle-joint.
4. Nerve Fibers. — 1. Medullated Fibers. — "Medullated
nerve fibers usually consist of three parts: (a) axis cylin-
der, (b) medullary sheath, (r) neurilemma. An axis
cylinder is a cell process that carries an impulse away
from the nerve cell. It is a slender cytoplasmic process
and may be very long, as is the case with the motor fibers
that come from nerve cells in the anterior horn of the
spinal cord and extend, without interruption, to muscles
in the distal parts of the limbs. The axis cylinder pre-
sents a longitudinal striation, a fibrillar structure, that is
supposed to be continuous with the cytoplasmic striation
of the cell body. The fibrils are imbedded in a fluid pro-
toplasmic substance, the neuroplasm, and the whole sur-
rounded by a delicate membrane, the exolemma. Im-
plantation cone is an elevation that is sometimes present
at the junction of the axis cylinder and cell body. The
medullary sheath (white sheath of Schwann) is a cover-
ing to the axis cylinder. This sheath never extends to
the nerve cell, but begins a little distance from it. Nodes
of Ranvier are constrictions of this sheath at regular in-
10
ALABAMA.
tervals. The smaller the fiber the greater the distance be-
tween these nodes. Long fibers are slender, with long
distance between the nodes; short fibers are coarse, with
short distance between nodes. The neurilemma is a thin
structureless membrane that surrounds the medullary
sheath. An oval nucleus is present in this sheath, mid-
way between the nodes of Ranvier. At each node the
neurilemma is constricted and touches the axis cylinder,
which in turn may be slightly thickened at this point and
may give off a collateral. Medujlatednerv^fibers^ wJLtJtL_
neurilemma are found in the^cranTal and spinal nerves.
Medullated fibers without a neurilemma are found in the
brain and spinal cord. The neurilemma gives great
strength to the fibers. Its absence in the brain and cord
accounts for the pulpy soft nature of this tissue."
' Non-medullated nerve fibers with a neurilemma, but
without a medullary sheath, mingle with the medullated
fibers. The sympathetic system consists largely of non-
medullated TTBers.' Terminal branched endings of an axis
cylinder, called neuropodia, have neither medullary sheath
nor neurilemma. The axis cylinder, just as it leaves its
nerve cell, is likewise uncovered." (Hill's Histology.)
5. The musculo spiral nerve is derived from the posterior
cord of the brachial plexus, and originates from the sixth,
seventh, and eighth cranial nerves. At first it is behind
the axillary and brachial arteries ; it winds around the
humerus in the musculospiral groove with the superior
profunda artery; it pierces the triceps muscle. At the
elbow joint it divides into the radial and posterior inter-
osseous nerves. It supplies the Triceps, Anconeus, Supina-
tor Jongus, Brachialis anticus, and Extensor carpi radialis
longior muscles.
6. An artery consists of three coats: The tunica in-
terna, or internal coat; the tunica media, or middle coat,
and the tunica adventitia, or external coat. The internal
coat consists of a basement membrane, on which is a layer
of endothelial cells. The middle coat consists of involun-
tary muscle fibers, between the layers of which are some
elastic fibers. The external coat consists of connective
tissue (white fibrous and yellow elastic). Between the two
outer coats is an elastic membrane.
The veins also have three coats, but the external coat is
thicker than the middle coat (the opposite condition pre-
vails in the arteries) : the veins often have valves. *
7. The branches of the external carotid artery are: Su-
perior thyroid, lingual, facial, occipital, posterior auricular,
ascending pharyngeal, superficial temporal, and internal
maxillary.
The Ungual artery arises from the external carotid
11
MEDICAL RECORD.
artery; it runs upward and inward to the great cornu of
the hyoid bone, then downward and forward beneath the
hyoglossus muscle; it then runs perpendicularly to the
tongue, and turns forward on the under surface of the
tongue, going almost to the tip of the tongue under the
name of the ranine artery."
8. "The systemic veins return blood to the right auricle
of the heart through the superior vena cava, the inferior
vena cava, and the coronary sinus. The two first named
receive blood from the veins of the body and limbs and
from most of the solid viscera. The coronary sinus re-
ceives blood from the veins of the walls of the heart alone.
The veins of the body wall and limbs form two groups —
(i) the superficial veins; (2) the deep veins. The super-
ficial veins, which commence in the capillaries of the skin
and subcutaneous tissues, lie in the superficial fascia, and
are very numerous. They frequently anastomose with one
another, and they also communicate with the deep veins,
in which, after piercing the deep fascia, they terminate.
They may or may not accompany superficial arteries. The
ndeep veins accompany arteries, and are known as venae
comites. The large arteries have only one accompanying
vein, but with the medium-sized and small arteries there
are usually two venae comites, which freely anastomose
with each other by short transverse branches of com-
munication. Visceral veins usually accompany the arteries
which supply viscera in the head, neck, thorax, and abdo-
men. As a rule there is only one vein with each visceral
artery, and, with the exception of those which enter into
the formation of the portal system they terminate in the
deep systemic veins. ,, (Cunningham's Anatomy.)
o. The terminal lymphatic vessels are the thoracic duct
and the right lymphatic duct.
The receptaculum chyli is a triangular pouch-like struct-
ure which forms the commencement of the thoracic duct.
It is situated on the front of the bodies of the first and
second lumbar vertebras, to the right of and a little behind
the aorta, and by the side of the right crus of the
diaphragm.
10. "The wall of the stomach consists of four coats,
which, enumerated from without in, are: serous, muscular,
areolar, or submucous, and mucous membrane. The serous
coat is a layer which is derived from the peritoneum. It
is deficient only along the lines of the lesser and greater
curvatures. The muscular coat consists of three layers of
plain muscular fibers. Of these the bundles of the outer
layer run longitudinally, those of the ^ middle layer cir-
cularly, and those of the inner layer obliquely. The longi-
tudinal and circular bundles become thicker and stronger
12
ALABAMA.
toward the pylorus, at which they pass into the correspond-
ing layers of the small intestine; at the pylorus itself the
circular layer is greatly thickened to form the sphincter
muscle. The oblique fibers are only present in the left or
cardiac part of the stomach. The areolar or submucous
coat is a layer of areolar tissue, which serves to unite the
mucous membrane loosely to the muscular coat; in it
ramify the larger branches of the blood vessels and
lymphatics. The mucous membrane is a soft thick layer,
generally somewhat corrugated in the empty condition of
the organ. Its inner surface is covered by long columnar
epithelium cells, all of which secrete mucus. They are
prolonged into the ducts of the glands, but when these
divide to form the tubules the cells become shorter
(cubical). The thickness of the mucous membrane is due
to the fact that it is largely made up of long tubular
glands the mucous membrane is formed of retiform with
glands, which open upon the inner surface. Between the
some lymphoid tissue. Externally it is bounded by the
muscularis mucosae, which consists of an external longi-
tudinal and an inner circular layer of plain muscular
fibers." (Schafer's Essentials of Histology.)
PHYSIOLOGY.
i. The acidity of the gastric juice, the urine, and the
vaginal secretion; the alkalinity of the blood; the bacte-
ricidal action of the blood and lymph; the agglutinating
action of the blood; and the general power of the body to
produce antitoxins.
2. Injury to or irritation of the pneumogastric nerve
may cause: Palpitation, vomiting, coughing, a sense of
suffocation, hoarseness, aphonia, laryngeal paralysis.
Division of one pneumogastric nerve may cause few or no
symptoms; but division of both nerves is followed by death
due to paralysis of the laryngeal muscles.
3. The mucosa of the respiratory tract serves : To warm
the inspired air, to moisten the inspired air, to remove in-
jurious substances from the inspired air.
4. The cerebrospinal fluid is present in the ventricles of
the brain, in the central canal of the spinal cord, and in
the subarachnoid space surrounding the brain and the
spinal cord. Its function is to protect the brain from in-
jury and the circle of Willis from compression; it forms
a water cushion on which the middle and posterior parts
of the brain may rest; it minimizes shocks.
5. "The speech areas, four in number and in kind, are in
the left hemisphere in righthanded persons and in the
right in lefthanded persons. There are two types of
aphasia, which is the loss of the power of speech, known
13
MEDICAL RECORD.
as motor and sensory aphasia. The motor speech center
lies in the posterior part of the third frontal convolution
(Broca's convolution), just in front of the center of the
muscles of speech (hypoglossal and facial nerve centers).
A lesion of the motor speech center causes motor aphasia,
in which there is a loss of the word- forming power,
although the tongue is movable and the patient may un-
derstand spoken and written language and knows what he
wants to say. It is as if memory of the motor combina-
tions essential to produce speech were lost.
"The power of writing is usually lost with motor speech.
The probable location of its cortical center is in the poste-
rior two-thirds of the first, and perhaps in the second,
temporal convolution. A lesion here causes 'word deaf-
ness/ a sensory aphasia in which the memory of the
sounds of words is lost so that they are not understood,
though hearing may be normal.
"The visual speech center lies in the posterior part of
the angular gyrus in the outskirts of the higher visual or
the visuopsychic field. Word-blindness (alexia), or the
loss of memory of printed or written language is caused
by a lesion here, though sight itself may be normal.
"Thus the basis of language is a series of memory pic-
tures (i) of the sound of words; (2) of their appear-
ance; (3) of the effort necessary to enunciate them, and
(4) to write their symbols. As these memory pictures are
connected with each other and with others that make up
the concept by subcortical association fibers passing be-
tween them, a lesion in any of these association tracts also
leads to a defect of speech." (Woolsey, Applied Surgical
Anatomy.)
6. Hunger and Thirst. ''The seat of sensations of
hunger is located in the epigastrium. The seat of sensa-
tions of thirst is located in the pharynx, and is quieted by
intravenous injections of water. In every case it is ad-
mitted that hunger and thirst are but localized expressions
of a general need of the blood for food and drink. The
true seat of hunger and thirst is not known. In all cases
it is acknowledged that thirst is more painful than hunger,
and it is more urgent to satisfy thirst than hunger. A
dog without food but supplied with water lives twice as
long as a dog deprived of both food and water." (Ott's
Physiology.)
7. Automaticity of the Heart.— "The question of the
cause or causes of the automatic rhythmical contractions
must be sought for whether the phenomenon turns out
to be a property of the muscular tissue or of the nervous
tissue of the heart. When we say that a given tissue is
automatic we mean that the stimuli which excite it to
14
ALABAMA.
activity arise within the tissue itself, and are not brought
to it through extrinsic nerves. In the heart, therefore,
we assume that a stimulus is continually being produced,
and we speak of it as the inner stimulus. Experiment
and speculation have been directed toward unraveling
the nature of this inner stimulus. Most of the physiol-
ogists who have expressed an opinion upon the subject
have sought an explanation in the composition of the
blood or lymph bathing the heart tissue, or in the products
of metabolism of the tissue itself. Regarding this latter
view there is nothing of the nature of direct experimental
evidence in its favor. No product of the metabolism of
the heart tissue capable of exerting this stimulating effect
has been isolated. In regard to the former view, that the
inner stimulus is connected with a definite composition of
the blood or lymph, there has been considerable experi-
mental work which is of fundamental significance. While
the older physiologists paid attention mainly to the or-
ganic substances in the blood, it has been shown in recent
years that the inorganic salts are the elements whose
influence upon the heart beat is most striking. These
salts are in solution in the liquid of the tissue, and are
therefore probably more or less completely dissociated.
Attention has been directed mainly to the influence of the
cations, of which three are especially important, namely,
the sodium, the calcium, and the potassium/' (Howell's
Physiology.)
8. Absorption of fat.^ "Fat is not absorbed as fat, but
as glycerin and fatty acid or soap. It is generally accepted
that the fatty acid set free in the intestine is dissolved by
the bile salts, and in this way, together with the glycerin,
is absorbed by the columnar cells, but that during absorp-
tion a lipase which is contained in the columnar cells
re-synthesizes, by reverse action, the glycerin and fatty
acid. In this way minute fat particles are found near the
bases of the columnar cells, and these may be demon-
strated by staining with a I per cent, solution of osmic
acid. The fat globules are further taken up from the
columnar cells by some of the lymphocytes, which are
capable of exhibiting ameboid movements, and which are
found in the lymphoid tissue between the columnar cells
and the central lacteal. The fat is then deposited in the
central lacteal by these ameboid cells, and in this way it
gets into the general lacteal stream, and thence into the
thoracic duct. The bile salts, which have been absorbed
by the columnar cells, in all probability get into the portal
vein radical, and in this way are taken back to the liver
to be excreted again in the bile. After a fatty meal
minute globules of fat may be demonstrated in the blood
15
MEDICAL RECORD.
plasma of an animal; but they disappear rapidly, possibly
existing in a solution and invisible form adsorbed to the
blood proteins before they are deposited in the fat depots
of the body." (Lyle's Physiology.)
g. Blood-pressure is influenced by several factors, such
as: The quantity of blood in the circulation, the force
of the ventricular systole, the elasticity of the arterial
walls, and the peripheral resistance.
^lEART.
ARTERIOLES.
BL00D-
BLOOD-
press're
FLOW.
Force constant . .
Resistance increased
+
—
Force constant . .
Resistance diminished
+
Force increased. '.
Resistance constant
+
+
Force diminished
Resistance constant
Force increased..
Resistance diminished
+ -
+ +
Force diminished
Resistance increased
- +
Force increased..
Resistance increased
+ +
+ -
Force diminished
Resistance diminished
h
The velocity of the blood flow is largely influenced by
the same factors as the blood-pressure, particularly the
force of the ventricular systole and the peripheral resist-
ance. The possibilities of the variations in these factors
are shown in the preceding table from Waller, in which
the plus sign denotes an increase, and the minus sign a
decrease in effect.
10. Urea is the end-product of proteid metabolism, and
is the most important of the nitrogenous excreta of the
body. The quantity of urea excreted is an index of the
amount of protein which has been broken down in the
body. Most of the urea is formed in the liver, from (i)
the amino acids which have been absorbed from the small
intestine, and which are not needed by the body; and (2)
from the ammonium carbonate which is derived from the
tissues, and from the action of a uricolytic enzyme upon
uric acid. These two sources give respectively what is
known as exogenous urea and endogenous urea.
CHEMISTRY.
1. In a physical change the composition of the matter
acted upon is not altered; in a chemical change the com-
position of the matter acted upon is altered.
2. Two elements used in their elementary form in medi-
cine: (1) Iodine is a bluish gray solid occurring in scales;
it is volatile, the vapor has a violet color and a peculiar
odor. It may be prepared by burning kelp, extracting the
ashes with water, removing the other salts and removing
the iodine from the compounds in the mother liquor by
16
ALABAMA.
chlorine. (2) Iron, when pure, is a silver white, soft solid,
and crystallizes in cubes or octahedra. Reduced iron is
prepared by heating ferric oxide in hydrogen:
Fe 2 3 + 3H 2 = Fe a + 3H 2 0.
3. Hydrogen is a colorless, odorless, tasteless gas; it is
the lightest substance known, and is a good conductor of
heat and electricity; it does not support combustion or
respiration. It occurs free in volcanic gases and in the
gases of the stomach and intestines ; also in combination
in water, ammoniacal compounds, and many organic sub-
stances. It can be prepared by the action of diluted sul-
phuric acid on zinc:
Zn + H 2 S0 4 + x H 2 = x H 2 + ZnS0 4 + H,.
4. Carbon dioxide is a colorless, suffocating gas, with a
faintly acid taste. It will neither burn nor support com-
bustion; it is soluble in water. Its formula is COa. There
is 0.04 per cent, of it in atmospheric air; but in expired
air this is increased to 4.4 per cent.
5. Phenol, CeH 6 OH, is commonly called carbolic acid. It
is a crystalline solid, occurring in long, colorless needles.
It has a peculiar odor, and a burning taste; it is soluble
in water, alcohol, and ether. It occurs in coal and wood-
tar. It is made by heating phenyl iodide with potassium
hvdroxide :
GH«1 + KHO = Kl + GH5OH.
6. Iron is an important constituent of the blood; it is
found in the hemoglobin of the red corpuscles.
7. Proteids are nitrogenous organic substances of very
complex composition and of unknown constitution. They
all contain carbon, hydrogen, oxygen, and nitrogen; and
some contain, in addition, sulphur, iron, phosphorus, or
some other element.
Three proteids found in the body: Hemoglobin, keratin,
and mucin.
8. Quantitative determination of urea: "The specific
gravity of the urine is carefully determined, as well as
that of the liquor sodae chlorinatae. One volume of the
urine is then mixed with exactly seven volumes of the
liquor sodae chlorinatae, and, after the first violence of the
reaction has subsided, the mixture is shaken from time to
time during an hour, when the decomposition is complete;
the specific gravity of the mixture is then determined. As
the reaction begins instantaneously when the urine and
reagent are mixed, the specific gravity of the mixture must
be calculated by adding together once the specific gravity
of the urine and seven times the specific gravity of the
liquor sodae chlorinatae, and dividing the sum by eight.
From the quotient so obtained the specific gravity of the
mixture after decomposition is subtracted; every degree
17
MEDICAL RECORD.
of loss in specific gravity indicates 0.7791 gram of urea
in 100 c.c. of urine. The specific gravity determinations
must all be made at the same temperature ; and that of
the mixture only when the evolution of gas has ceased
entirely." (Witthaus* Manual of Chemistry.)
9. Detection of occult blood in the feces: "Soften a por-
tion of the stool with water, shake with an equal volume
of ether to remove fat, and discard the ether. Treat the
remaining material with about one-third of its volume of
glacial acetic acid and extract with ether. Then apply the
guaiac test (mix equal parts of ozonized turpentine and
fresh tincture of guaiac which has been diluted with
alcohol to a light sherry-wine color. In a test tube or
conical glass overlay the liquid to be tested with this
mixture. A bright blue ring will appear at the zone of
contact within a few minutes if hemoglobin be present)/'
(Todd's Clinical Diagnosis.)
10. Ptomaines are basic, nitrogenous compounds pro-
duced from protein material body by the bacteria which
cause putrefaction. They are generally introduced into
the body as food.
ETIOLOGY, PATHOLOGY, SYMPTOMATOLOGY, AND DIAGNOSIS.
1. Etiology of mucous colitis: Dysentery, diseases of
the liver or heart, tuberculosis, nephritis, exhausting dis-
eases, and indigestion.
2. Etiology of scurvy: Improper diet, the absence of
fresh vegetables with the salts normally contained in them,
3. "Acute simple endocarditis may be prenatal as well as
postnatal. In the former class of cases, the right side of
the heart is usually involved, while in those instances ob-
served after birth, the disease is most often limited to the
left side. While the disease may attack the entire lining
membrane of the heart it is especially marked at the
valvular portions of the endocardium. The earliest change
is that of hyperemia of the membrane rendering it red and
swollen. As the inflammatory exudate is thrown out the
surface of the valves become roughened and warty ex-
crescences are formed. These verrucose formations are
to be found on the auricular surface of the mitral valve
and on the ventricular surface of the aortic valve at the
line of contact of their leaflets, usually from 1 to 2 mm.
from their free margin. These vegetations are produced
by a proliferation of the cells of the adventitia and of the
external connective tissue; fibrin from the blood is de-
posited on the formations, thus serving to increase their
size. The excrescences are friable and may be easily de-
tached or broken off and carried in the blood stream as
emboli, to various parts of the body, particularly the left
18
ALABAMA.
side of the brain, the kidneys, and the spleen. If retained
in position, fibrous tissue is eventually formed ; the valves
become thickened and contracted, producing chronic endo-
carditis. The leaflets may then become the seats of
various infiltrations." (Hughes' Practice of Medicine.)
4. Pathology of abscess of the liver. "The liver is en-
larged, swollen, and opaque, and presents the ordinary
evidences of parenchymatous degeneration or cloudy swell-
ing. In addition, in the cases of so-called multiple pyemic
abscesses it exhibits a number of variously sized abscesses
— usually small, but often coalescing to form larger, some-
times many-chambered cavities, with purulent contents.
The so-called single, tropical, or amebic abscess of the
liver is described by Manson as consisting at first of one
or more grayish, ill-defined, anemic, circular patches, half
to one inch or thereabouts in diameter, in which the
lobular structure of the liver cannot be made out. A drop
or two of reddish, gummy pus may be expressed from the
necrotic patches. Later the center of these patches lique-
fies, and distinct but ragged abscess cavities are formed.
An abscess thus commenced extends partly by molecular
breaking down ; partly by more massive necrosis of por-
tions of its wall; partly by the formation of additional
foci of softening in the neighborhood and subsequent
breaking down of the intervening septa. These may involve
almost if not an entire lobe, usually the right. The pus
is usually thick, viscid, chocolate-colored and streaked with
blood, and often contains large pieces of necrotic liver
tissue. Entameba dysenteric? may be found in more than
one-half of the cases (in some of the other cases in the
wall of the abscess). The ordinary pyogenic organisms
are rarely encountered. A large abscess may consist of
a suppurating hydatid cyst." (Kelly's Practice of Medi-
cine!)
5. Symptoms of erysipelas: Sudden onset ; high tempera-
ture; a sharply defined red patch on the skin which
spreads in all directions, the edges being raised and hard;
variable constitutional disturbance.
6. Symptoms of heat-stroke: Dizziness, feeling of op-
pression, nausea, headache, vomiting, high temperature,
sometimes diarrhea, relaxation of muscles, loss of con-
sciousness and convulsions. It generally occurs during ex-
posure to the rays of the sun,
7. Diagnostic symptoms of pellagra: Anemia, gastric
pain, diarrhea, salivation, mental and physical depression;
an erythema that is bilateral and occurs on the exposed
parts of the body; muscular spasms, neuromuscular pains,
vertigo, headache, paralysis, melancholia, spinal tenderness.
8. Pernicious estivo autumnal malarial fever is diagnosed
19
MEDICAL RECORD.
by finding the specific protozoon in the blood of the pa-
tient. This form is caused by the Plasmodium prcecox.
g. Diabetes mellitus is diagnosed by the large quantity
of urine, with sugar in it, great thirst, enormous appetite,
muscular weakness, emaciation, and the acetone odor of
the breath.
10. In appendicitis the pain is of sudden onset and is
localized in the right iliac fossa; there is abdominal rigid-
ity, chiefly of the right rectus muscle, and tenderness at
McBurney's point; there are usually fever, nausea, vomit-
ing, and constipation.
In inflammation of the right ovary the pain is not local-
ized, but may be bilateral, and spreads to the vagina and
rectum; there is no tenderness at McBurney's point; it
is usually worse, just before the menstrual period, which
sometimes affords relief ; on vaginal examination the ovary
is found to be tender.
PHYSICAL DIAGNOSIS.
1. In inspection of the thorax, one should note: The
size, shape, and symmetry of the chest; the movements
during respiration; the rhythm, force, and frequency of
the heartbeat; the position of the apex; any pulsations or
enlargements; beading of the ribs; the color of the skin,
and any eruptions.
2. In inspection of the abdomen, one should note: The
general nutrition, size, shape, movements, pulsations, re-
tractions; color of skin, and eruptions; the presence of
white or colored lines; enlarged superficial blood-vessels;
peristaltic movements; distention, or new growths; and
general retraction.
3. The respiratory sounds. "The respiratory murmur
may be modified in intensity, rhythm, and quality. The
modifications of intensity are puerile, exaggerated, or
feeble respirations. The modifications of rhythm are asth-
matic, emphysematous, and cogged-wheel or jerky respira-
tions. The modifications of quality are bronchial, cav-
ernous, and amphoric breathing. Bronchial breathing oc-
curs in lobar pneumonia, phthisis, compensatory emphy-
sema, tumor, syphilis, and infarct. Both inspiration and
expiration are harsh and have a high-pitched (tubular)
character. Cavernous breathing is low-pitched and blow-
ing in character and is heard over cavities. Amphoric
breathing is similar to the sound produced by blowing
gently over the mouth of an empty jar. It is present in
phthisical cavities, pneumothorax with patulous opening,
and localized consolidation near a large bronchus."
(Pocket Cyclopedia.)
4. The voice sounds. "Vocal resonance is increased over
20
ALABAMA.
the apex of the right lung in health and in phthisical and
pneumonic consolidations. It is diminished in thick chest-
walls, pleural effusions, emphysema, and pulmonary
edema. Bronchophony, or exaggerated vocal fremitus, oc-
curs in phthisis. Pectoriloquy, the complete transmission
of the whispered words to the ear, is heard over phthisical
cavities and in pneumothorax when the lung is patulous.
Egophony, in which the voice has a nasal, trembling
sound, is heard at the upper border of dullness in pleural
effusions." {Pocket Cyclopedia.)
5. Bronchial asthma. "Physical examination during the
attack reveals a distended chest, as the lungs are overfull
of air which cannot be expired. Moreover, as the thorax
is thus in the inspiratory position, its movements, in spite
of the violent respiratory efforts, are extremely limited,
and the diaphragm is lowered and almost immobile. The
respirations are normal or decreased in frequency; inspira-
tion is short and quick; the expiration is prolonged and
wheezy because of the difficulty in expelling the previously
inspired air through the narrowed tubes — an expiratory
dyspnea. Percussion is normal or hyperresonant. On
auscultation a multitude of sonorous and sibilant rales
are heard, during both inspiration and expiration. Toward
the close of the attack, and during its course if bronchitis
coexists, moist rales of various sizes are perceived." (But-
ler's Diagnostics of Internal Medicine.)
6. In initial stenosis there will be observed a presystolic
thrill ; the hypertrophy will be right sided ; the left side
of the heart will be of normal size; the second pulmonic
sound may be accentuated.
In aortic insufficiency the murmur is diastolic; the left
ventricle is hypertrophied ; the arteries will be found
throbbing ; and the characteristic Corrigan pulse is present.
7. Pericarditis with effusion. "The physical signs are:
Marked increase of the cardiac dullness; displacement of
the apex beat; muffling of the heart sounds; displacement
of other organs (if effusion be great). The shape of
the dullness is characteristic. It is conical, the apex of
the cone being truncated and situated at the level of the
second rib, owing to the close attachment of the pericar-
dium to the great vessels at this point. The apex beat is
generally pushed upward and to the left. It lies, when it is
palpable at all, distinctly within the left border of cardiac
dullness, not, as in enlargement due to valvular disease, in
close relationship to it. The marked distention of the
pericardial sac surrounds the heart with fluid, and causes
a dullness extending much beyond the limits of the organ
itself. The amount of bulging and displacement of or-
gans will, of course, vary with the amount of fluid prss-
21
MEDICAL RECORD.
ent. As resolution takes place the friction returns, and
may be very coarse in character. Muffling of the heart
sounds is not always present, and is not entirely due to
the presence of fluid, for the fetal heart is quite distinctly
heard through an amount of fluid greater than is usually
present in pericarditis. The muffling is therefore due
mainly to weakness of the cardiac muscle from accom-
panying myocarditis, although where the quantity of fluid
is very great, in serous and chronic pericarditis, this may
in part account for it/' (Wheeler and Jack's Handbook
of Medicine.)
8. Physical signs of arteriosclerosis. The arteries are
tortuous and feel like a pipe-stem ; the apex beat of the
heart is powerful and may be displaced to the left; car-
diac dullness is increased downward and to the left, owing
to hypertrophy of the left ventricle; the first sound of
the heart is apt to be loud and booming, and the second
sound accentuated.
9. Examination of spleen. "A greatly enlarged spleen
and more rarely one scarcely more than palpable may be
seen to move with the respiration; furthermore, in any
case of splenomegaly a marked prominence of at least
the left upper quadrant is produced. Auscultation may
reveal friction sounds in the presence of perisplenitis, or
the organ may be anchored by adhesion, but it is ordin-
arily freely and directly movable with respiration, and
palpation is the only method yielding important results.
The position of the patient should be right lateral if minor
enlargements are to be noted, as in typhoid fever or other
acute infections, and the right hand should make pressure
posteriorly while the left makes palpation. Abdominal
distention defeats palpation save in great enlargement, and
the normal spleen is not palpable. If greatly enlarged the
dorsal position is to be preferred and the condition can
hardly be overlooked, unless with a tense wall the careless
or hurried examiner fails to get below the actual border
or to distinguish between muscular resistance and the
splenic mass." (Greene's Medical Diagnosis.)
10. In the case of a bladder distended with fluid there
will be a tumor in the hypogastric region, dullness on per-
cussion over the tumor, and the introduction of a catheter
will cause the tumor to disappear.
Optional. Right-sided pleurisy with effusion.
OBSTETRICS.
1. Changes that take place in the circulatory apparatus
at birth: The hypogastric arteries dwindle and become
impervious; the Eustachian valve atrophies; the foramen
ovale closes; the ductus arteriosus and ductus venosus be-
22
ALABAMA.
come obliterated; the umbilical vein becomes obliterated
and is afterward known as the round ligament of the
liver.
2. Conditions that may he mistaken for pregnancy:
Amenorrhea, ascites, fibroids, ovarian tumors and cysts,
obesity, tympanites, subinvolution of the uterus, and pseu-
docyesis.
3. Symptoms of death of fetus in utero: Cessation of
the signs of pregnancy, the abdomen and uterus are both
diminished in size, the fetal heart sounds and movements
are absent, there is no pulsation in the cord, the mother's
breasts become flaccid and occasionally secrete milk. If
the fetus has been dead for some time, crepitus of its
cranial bones may be elicited.
4. Retroflexion of the gravid uterus, with incarceration,
may result in: Constipation, irritability of the bladder,
retention of urine, cystitis, pyelonephritis, rupture of blad-
der, sloughing of the uterus, peritonitis, exhaustion, and
shock.
5. Premonitory symptoms of eclampsia are: Dizziness,
disturbances of vision, flashes of light before the eyes,
vertigo, headache, diminished secretion of urine with less-
ened output of urea and some albumin, and pain in the
epigastric region.
6. If the chin is presenting anteriorly, expectant treat-
ment may suffice; but care must be taken to observe that
the chin does not rotate backward. Spontaneous version
may occur, and the presentation becomes a vertex one.
Failing this, or as a means of favoring this, postural treat-
ment, such as Walcher's position, has been recommended.
If, in spite of this, engagement has not occurred, cephalic
version is indicated, care being taken not to rupture the
membranes. If this is not successful, podalic version
should be tried. If, after all these manipulations the child
is still alive and the head is engaged, symphyseotomy is
indicated; if the child is dead, craniotomy should be per-
formed.
7. The aseptic management of normal labor aims to pre-
vent infection. The prophylaxis consists in thorough dis-
infection of the patient, the physician, and the instruments
and appliances employed. The simplest method is as fol-
lows : "The patient, at the beginning of labor, takes a tepid
bath and is well scrubbed all over with soap and water.
Then an enema of soap and water to empty the bowel;
after the action of which the external genitals, thighs, but-
tocks, and abdomen are carefully washed with a 1 12000
bichloride solution, special attention being given to over-
look no fold or fissure of the surface. The vaginal douche,
of 2 per cent, creolin solution, or the weak solution- of
23
MEDICAL RECORD.
bichloride of mercury formerly used before labor, has been
abandoned, unless there be some already existing infection,
when it may be used. The normal vaginal mucus is itself
germicidal in some degree, as well as a useful lubricant,
and should therefore be allowed to remain undisturbed.
Moreover, washing out the vagina exposes the woman to
some danger of infection from an unclean syringe. The
physician, before making any examination or doing any
operation, removes his coat, bares the arms to above the
elbows, when the hands and arms are thoroughly scrubbed
with soap, water, and a stiff nail-brush. Scrape the under
surface of the nail-ends and the fissures surrounding the
nails with some pointed instrument, not sharp enough to
scratch, and having washed off all soap in some clean
water, immerse the hands and leave the arms in a 1 12000
bichloride solution, and continue this last washing for ten
minutes." (King's Obstetrics.)
Nothing should come in contact with the genitals of the
patient that is not sterile; and examinations should be as
few as possible.
8. "Internal version is done by passing one hand into
the uterus, seizing and bringing down one or both feet.
The cervix must be sufficietly dilated to allow the hand
to pass. It should be done as soon as possible after the
membranes have ruptured. If there is only slight retrac-
tion of the uterus it may be done, by an expert operator,
by deeply anesthetizing the patient, but one who has not
had much experience of the operation should not attempt
it. If the uterus is firmly retracted it should never be
attempted. The patient may lie on her left side, or pref-
erably on her back. The right hand may be used in all
cases, but in some the left one does better. It depends
on which way the child is lying. Use the hand which will
most easily reach the front of the . child. Thus, if its
back is toward the mothers right side, use your right
hand, and if the back is toward her left, the left hand;
but if you are not accustomed to working with your left
hand always use the right. The hands and arms should be
thoroughly sterilized, and well washed in lysol solution.
Pass the hand in a cone shape to dilate the cervix, if it is
not sufficiently dilated already, and pass the hand on to
the front of the child, rupturing the membranes, if they
are unruptured. As much of the liquor amnii as possible
should be retained in the uterus by damming it back with
the wrist. If a contraction comes on, spread your hand
flat on the front of the child and wait until the uterus
relaxes. If you do not do this the pressure upon your
closed hand will almost paralyze it, and may cause rupture
of the uterine wall. Catch one or both feet, making sure
24
ALABAMA.
it is a foot and not a hand. As soon as you get a foot,
pull the leg down steadily into the vagina, if the uterus is
quiescent, but if a contraction comes on, wait, spreading
your hand out as before. The child's body usually rotates
quite easily, unless the uterus is retracted round it. If
version is attempted when the uterus is retracted, as in
a transverse case, care must be taken to unhitch the shoul-
der from under Bandl's ring, if it is caught, but only an
expert should undertake such a risky operation, and it
should only be undertaken if there is a chance of saving
the child's life. The final part of the delivery is carried
out in exactly the same way as when the breech presents. ,,
(Jardine's Delayed and Complicated Labor.)
The dangers to the fetus, are: — Injury from the trac-
tion, asphyxia, and death.
9. In breech presentation the back of the fetus may be
palpated to one side of the mother's abdomen, the head is
found at the fundus of the uterus, and auscultation gives
the heart sounds above the umbilicus. The breech is
either above the brim of the pelvis, or else it fills up the
pelvis so that pelvic palpation is impossible.
The positions of breech presentation, are: — Left sacro-
anterior, right sacro-anterior, right sacro-posterior, and
left sacro-posterior.
jo. Cesarean Section. "Fluid extract of ergot, Tl^xx, is
injected into the thigh muscles just as the anesthesia is
begun. The operator assures himself that there is no loop
of intestine between the uterus and abdominal wall, be-
neath the field of incision. Should a coil of intestine be
found there, it is pushed above the fundus. An assistant
holds the uterus in central position. The skin incision ex-
tends one-third above and two-thirds below the level of
the umbilicus. It is best made through the right rectus
muscle. The external layer of the rectus sheath is
divided, the muscular bundles separated with handle of
scalpel and the fingers, and the deep layer of the sheath
and the peritoneum divided after lifting them with tissue
forceps. Bleeding vessels are controlled by gauze sponge
pressure, or held by catch-forceps before opening the
peritoneum. A short longitudinal median incision is made
in the uterine wall beginning at the fundus, avoiding the
membranes if still unbroken. This is extended downward
with fingers, scissors, or scalpel to a total length of about
six inches. The hand is thrust through the membranes
and the child is extracted by the head or the feet, which-
ever is most accessible. In case of anterior implantation
of the placenta, usually the hand may best be passed
directly through it. The cord is clamped at two points
with catch-forceps, cut between them, and the child is
25
MEDICAL RECORD.
passed to an assistant. The uterus slips out of the abdo-
men as the child is extracted, and the intestines are kept
back with hot sterilized towels placed over the upper part
of the incision. The coverings help also to protect the
peritoneum from soiling. The uterus is wrapped in hot
moist cloths. As a rule, it is better not to wholly even-
trate the uterus. The placenta, if not spontaneously sep-
arated, may be peeled off by grasping it with one hand
like a sponge. If the cervix is not sufficiently open for
drainage, a large rubber tube or gauze strip is passed
down through it and withdrawn from below. Irrigating
or mopping the uterine cavity is unnecessary. Asepsis is
promoted by leaving it as nearly as possible untouched.
The peritoneum is sponged dry with the least possible
friction or handling. The uterine wound is closed with
deep No. 2 chromated catgut sutures at intervals of about
1/3 inch. They are given a wide sweep laterally through
the muscular wall, falling short of the decidua. The peri-
toneal coat of the uterus is closed with a No. 1 continuous
plain catgut suture, forming a welt over the deep suture
line. The hemorrhage is inconsiderable and usually ceases
with the introduction of the first sutures — a hypodermic
of ergotole should be given before beginning the opera-
tion, and one of ergotole and pituitrin on the delivery
of the child. Retraction of the uterus is ensured by
manipulating it, if necessary, through a hot towel, or by
faradism. When there has been much blood lost, a quart
or two of warm sterilized 0.9 per cent, salt solution may
be left in the peritoneum. The parietal peritoneum is
closed with a plain running No. o catgut suture. Inter-
rupted silkworm-gut sutures are then passed at intervals
of about Y\ inch; through all but the peritoneum, from
within outward. The fascia is brought together with in-
terrupted No. 2 plain catgut sutures, or with a continuous
suture. ^ The silkworm-gut sutures are now tied. The ab-
domen is cleansed, and the wound covered with a dressing
of several thicknesses of dry sterile cheesecloth; over this
is placed a thick compress of sterile absorbent cotton.
The dressings are secured with strips of zinc oxide ad-
hesive plaster, and held in place by a Scultetus binder."
(Polak's Obstetrics.)
GYNECOLOGGY.
i. Causes of Menorrhagia. Constitutional: Purpura,
scorbutus, hemophilia, hepatic cirrhosis, over indulgence in
food and alcoholic drinks. Local and Vascular: Uterine
congestion and displacement, endometritis, subinvolution,
fibroids, and other tumors.
2. Effects of Oophorectomy: — "The operation, if thor-
26
ALABAMA.
oughly performed, is followed generally by atrophy and
consequent arrest of function in the uterus, and the pre-
cipitation of the menopause. The artificial production of
this critical period gives rise to phenomena quite similar
to those which characterize the natural menopause, except
in most cases menstruation is arrested permanently at
once. The popular impression that the operation unsexes
the woman in a mental sense or renders her masculineis
a mistake. The effect of the operation upon sexual desire
is variable, but probably no more so than that of the nat-
ural menopause. The question of insanity as a result of
the operation has been raised; it probably occurs no more
frequently than after other operations of equal gravity,
probably not oftener than with the natural meonopause."
(Dudley's Gynecology.)
3. Two important muscles of the perineum: — The trans-
versa perinei and the levator ani.
4. Fibrosis of the uterus. — "This is a morbid condition
of the uterus which presents the following characters:
The patients are usually multipara between thirty-five and
forty-five years of age, but the condition is also metwith
in younger women, and in nulliparae. They complain of
menorrhagia which lasts from fourteen to eighteen days.
At times the bleeding is so profuse as to place life in
danger. The uterus is enlarged, and the cervix is hard to
the touch. When the cervical canal is dilated the tissue
of the cervix tears rather than stretches; the endometrium
is quite smooth, but the walls of the uterus are hard and
resisting, and the curette makes a harsh grating sound
in passing over it, and brings very little tissue away. The
structural changes are very striking; the uterus is larger
than usual, and its walls are thick and tough. On section
the arteries stand out prominently, exposing their thick-
ened walls. On microscopic examination the muscle tissue
of the uterus is seen to be replaced by an abnormal
growth of fibrous tissue. The walls of the uterine arteries
are very thick, and the lumina of the vessels much nar-
rowed and sometimes obliterated. The glands of the en-
dometrium are markedly atrophied, so that the mucosa
presents a much thinner layer than the normal. The
changes in the tissues of the uterus are analogous to the
curious fibrotic changes which occur in the walls of the
cardiac ventricles as a sequel of syphilis. In the uterus
the changes are probably a remote consequence of septic
endometritis." (Sutton and Giles* Diseases of Women).
5. "The mucous membrane of the uterus is thick, and
consists of a lining of ciliated epithelium, supported on a
vascular and very cellular fibrous tissue. Long tubular
glands extend down into the muscular coat invading its
27
MEDICAL RECORD.
deep layer. In the cervix the glands are shorter, but
more branched, and are lined by columnar mucus-secret-
ing cells. Near the os uteri the epithelium becomes colum-
nar, and passes at the orifice into the stratified squamous
type. During menstruation the mucous membrane becomes
congested, the surface becomes partially disintegrated, and
an escape of blood takes place from the surface/' (Aids
to Histolopy).
6. The most common causes of sterility in woman are :
Gonorrhea, absence or errors in development of any part
of the genital tract, malformations of genitals, fistula,
lacerations, obesity, alcoholism, pelvic inflammations,
dyspareunia, inflammations of uterus, tubes, or ovaries,
elongated cervix. The cause may not be in the woman,
but in the man.
7. Posterior displacements of the uterus may cause:
Menstrual irregularities (such as amenorrhea, dysmenor-
rhea, or uterine hemorrhages), abortion, leucorrhea,
sterility, constipation or pain on defecation, neurasthenia,
hysteria, and various reflex symptoms. The ovaries and
tubes may be displaced or pressed upon; the uterus may
be compressed, or dilated.
8. Tumors of the uterus may be classified as follows:
I. Malignant: Carcinoma, sarcoma, deciduoma malig-
num, endothelioma.
II. Benign: Fibromyoma, adenomyoma, polypi.
9. Operation for procidentia uteri. "An incision two or
three inches in length is made immediately above the
symphysis, and the fundus uteri is drawn forward by a
volsellum. Three silkworm gut stitches are inserted
through the abdominal parietes and peritoneum, and also
through the body of the uterus just posterior to its axis.
The stitches should include about Y^ inch of the uterine
wall in their grasp, and go about l /% inch deep. On draw-
ing them tight, the uterus is fixed forward against the
abdominal wall and contracts adhesions. In some cafes
it may be desirable to scarify the uterine wall before
tying the stitches, so as the better to determine adhesions.
As a general rule the adhesions stretch somewhat, and
hence allow a certain degree of play, but without the like-
lihood of a return of the displacement." (Rose and Car-
less' Surgery.)
10. The contraindications to curettage are : The possi-
bility of pregnancy and malignant tumors. _
SURGERY.
I. The general rules for treatment of wounds: Stop the
bleeding ; remove foreign bodies ; make the part as aseptic
as possible; coapt the edges; drain when necessary;
28
ALABAMA.
dress, and secure rest to the part; bring about reaction ;
ease the pain.
2. Treatment of shock: Place the patient in the recum-
bent position, with the head low, apply warmth to the
bod)', administer a stimulant, and give a hot saline in-
fusion ; morphine, hypodermically, may be necessary for
the relief of pain. Adrenalin solution is administered into
the arterial system.
In surgical operations shock may be largely prevented
by reassuring nervous patients, keeping the patient warm,
the avoidance of the excessive catharsis, and semi-starva-
tion that often prevail before operations, the administra-
tion of strychnine and atropine before operation, the avoid-
ance of delay and undue handling of parts during the
operation, prompt checking of hemorrhage, and by using
the utmost gentleness.
3. Aneurysms are described as : Fusiform, sacculated,
and dissecting.
For fusiform aneurysm, constitutional treatment alone
is indicated.
For sacculated aneurysm there are several methods of
treatment : Constitutional ; compression of the artery ;
ligature of the main artery; Matas* operation of aneurys-
morrhaphy.
For dissecting aneurysm, there is no treatment.
4. Fistula in Ano. — Classification: There are four va-
rieties: (1) The complete, which opens into the rectum
internally and on the perineum externally; (2) the ex-
ternal incomplete, or blind external, which opens on the
perineum, but not into the rectum; (3) the internal incom-
plete or blind internal, which opens into the rectum but
not on the perineum ; (4) the horseshoe fistula, which ex-
tends around the rectum and opens on each side. The
internal opening is generally between the two sphincters,
but may be above the internal sphincter and below the
external sphincter. There may be several pockets or
side tracts extending in different directions.
Treatment: This consists in "the conversion of the
fistula into an open wound so that it may heal from the
bottom. A grooved director is passed through the fistula
into the rectum, and the overlying tissues severed with a
bistoury. The sphincter should never be cut more than
once, because of the danger of incontinence. All branch-
ing sinuses likewise should be opened, and all fibrous tis-
sue, with undermined skin, cut away with scissors. The
bleeding is then checked, and the wound packed with
iodoform gauze. If the fistula is lined with mucous mem-
brane it must be completely excised. A blind external
fistula may be excised and the wound sutured. A blind
29
MEDICAL RECOjRD.
internal fistula may be converted into a complete one and
treated as above. The bowels are confined for the first
three or four days, and the wound dressed after each
defecation, being irrigated with creolin and repacked with
iodoform gauze." (Stewart's Surgery.)
5. "In the treatment of compound fractures the main
object is to render the wound aseptic and to give efficient
exit to the discharges. For this purpose the patient should
in all cases be anesthetized, the limb shaved, and thor-
oughly purified, and the wound enlarged and thoroughly
washed out with some reliable antiseptic. It may be ad-
visable to excise torn and dirty fragments of skin, muscle,
and tendon, especially when dirt has been ground into
them. Loose fragments of bone are removed and portions
'denuded of their periosteum may be taken away lest
necrosis should ensue; where fragments retain any con-
siderable connection with the soft parts they may be left
without fear. When a sharp end of one of the frag-
ments is protruding through a small opening in the skin
it is first purified thoroughly before attempting its reduc-
tion and then replaced, after enlarging the wound in the
skin, or a portion sawn off. Hemorrhage is dealt with in
the usual way, and the fragments are placed as nearly as
possible in their normal position. If the fragments can be
brought accurately into position it is well to fix them by
some mechanical appliance; but where the ends of the
bone are much comminuted the small portions must be ar-
ranged in position as well as possible, and no attempt
made to wire them. A good-sized drainage tube is in-
serted, and, if need be, counteropenings are made; the ex-
ternal wound is closed or not, according to circumstances,
and dressed, and suitable splints are then applied. Under
such a regime the majority of cases do well. Immovable
apparatus may be used after a time, windows being left
in the plaster casing to allow wounds to be dressed."
(Rose and Carless* Manual t of Surgery.)
6. In a backward dislocation of the head of the femur
(on to the dorsum ilii), the head of the bone lies on the
dorsum ilii ; the acetabulum is empty ; the great trochanter
will be found above Nelaton's line; the leg is considerably
shortened, and is also flexed, inverted, and adducted; the
toes rest on the instep of the other foot, the femur
crosses the opposite thigh at its lower third.
Treatment: The patient is placed on a mattress on the
floor and anesthetized. The leg and thigh are flexed in
the position of adduction. This rolls the head of the bone
down to the lower part of the acetabulum. The leg is then
circumducted outward and brought down straight ; this car-
ries the head through the rent into the acetabulum. Fail-
30
ALABAMA.
ing success by this method, the body must be fixed and
direct upward traction must be exercised upon the flexed
thigh. As a rule these maneuvers are successful; if not,
extension by pulleys must be made use of.
7. Empyema. Symptoms: Fever, sweats, chill, dimin-
ished breath sounds and vocal fremitus, impaired mobility
of chest, dullness on affected side, heart displaced to oppo-
site side, leucocytosis. Diagnosis is made by respiration,
showing the fluid to be^ pus. Treatment: Aspiration,
drainage, irrigation, resection of ribs (Estlander's opera-
tion), or resection of chest wall (Schede's operation).
8. Gallstones. Symptoms: "While the calculus re-
mains free in the gall-bladder, usually there are no symp-
toms. Impaction of the stone in the common duct gives
rise to intermittent jaundice, following sharp pain in the
right hypochondriac or epigastric region, frequently
radiating toward the right scapula, nausea, vomiting,
sweating, depression, and often intermittent fever (Char-
cot's intermittent fever). When the stone is impacted in
the cystic duct, jaundice is less common, but the hepatic
colic is severe, and dropsy of the gall-bladder may occur.
The diagnostic points are the age, sex, history of previous
attack, with jaundice and intermittent fever, location of
the pain, dark, amber colored urine, containing bile, and
sometimes the finding of the stone in the feces."
Treatment "'includes the relief of pain by morphine
(g r - Va) and atropine (gr. 1/125), hypodermically, inhala-
tions of chloroform, hot applications, and blisters over
the seat of pain, and, later, a saline purgative. During
the interval the diet should be largely liquid, and drugs
such as sodium phosphate, sweet oil, chloroform, pipera-
zin, and mineral waters should be administered. Consti-
pation should be avoided by giving fluidextract of cas-
cara (3j4) and glycerine (3^4) every night. Lavage and
rectal irrigation may be practised. If the attacks become
more frequent and severe and medical treatment fails,
surgical interference (cholecystotomy) is indicated."
{Pocket Cyclopedia.)
9. Perforation of the intestine in typhoid fever. Symp-
toms: "When perforation occurs, violent pain develops.
As a rule there are tenderness, rapid pulse, costal respira-
tion, abdominal rigidity, vomiting, and shock. Usually
there is temporary reaction from shock, the subnormal
temperature giving way to a normal or to an elevated
temperature. The vomiting in some cases becomes ster-
coraceous. ^ There is constipation and sometimes dullness
on percussing the flanks. The face is Hippocratic. The
patient may die of the preliminary shock or may react
and die subsequently of blood poisoning."
31
MEDICAL RECORD.
Treatment: "Death is practically certain without opera-
tion. Operation should be done at once, proper means being
adopted to combat shock. In many cases a general anesthetic
should not be given, but a local anesthetic should be em-
ployed. The incision should be made in the right iliac
region and the colon should be first located and then the
end of the ileum. By locating the colon we obtain a
fixed point from which to begin our search for perfora-
tion, and by opening the abdomen in the right iliac region
we come down at once onto the perforated gut in the vast
majority of cases. When a perforation is found, it should
be inverted with two layers of Halsted sutures. It is
not wise to excise the ulcer. If the bowel is very badly
damaged, resection can be considered, but it is usually
wiser to make a temporary artificial anus. After finding
a perforation and closing it, examine to see if there are
others. Close every perforation, and if a point is found
where the thinning of the bowel wall indicates that per-
foration is liable to occur, protect this point by inverting
the area of ulceration by sutures. Clean the peritoneum
by flushing with hot salt solution. Leave the wound open,
insert strands of iodoform gauze, and establish tubular
suprapubic drainage. Elevate the patient a little in bed
and employ continuous proctoclysis of salt solution." (Da
Costa's Modern Surgery.)
10. Symptoms of suppurative pyelitis: Chill, tenderness,
and pain in kidney, fever, vomiting, headache, scanty
urine containing pus, exhaustion, and uremia.
HYGIENE AND MEDICAL JURISPRUDENCE.
1. Hygiene is the science and art of all that concerns
the preservation, promotion, and improvement of health,
and the prevention of disease.
2. Immunity is the power of resistance of cells and tis-
sues to the action of pathogenic bacteria. Immunity may
be either natural or acquired.
Natural immunity is this power of resistance, natural
and inherited, and peculiar to certain groups of animals,
but common to every individual of these groups.
Acquired immunity is this resistance acquired: (i) By
a previous attack of the disease caused by the bacteria, or
(2) by the person being made artificially insusceptible.
The conditions which give immunity from the pathogenic
action of bacteria are: (1) A previous attack of the dis-
ease; (2) inoculation, with small quantities of bacteria, so
as to produce a mild attack of the disease; (3) vaccina-
tion; (4) the introduction of antitoxins; (5) the introduc-
tion of the toxins of the bacteria.
Active immunity follows an attack of a certain disease
ALABAMA.
and secures immunity for that alone; or it follows inocu-
lation of a virus weaker than necessary to cause the typi-
cal disease ; or it follows inoculation by bacterial products
apart from the organisms themselves.
Passive immunity is the term applied to the effect of a
serum derived from an immunized animal and injected into
one not immune.
Susceptibility is liability to infection; a loss or absence
of immunity.
3. Scarlet fever: Period of incubation, from a few hours
to seven days. Stage of invasion, twenty-four hours.
Character of eruption, a scarlet punctate rash, beginning
on neck and chest, then covering face and body ; desqua-
mation is scaly or in flakes. The eruption is brighter, is
on a red background, punctiform, and is more uniform;
the temperature is higher, the pulse quicker; the tongue
is of the "strawberry" type, the lymphatics in the neck
may be swollen., and there is sore throat; Koplik's spots
are absent.
Measles: Period of incubation, ten to twelve days.
Stage of invasion, four days. Character of eruption,
small dark red papules with crecentic borders, beginning
on face and rapidly spreading over entire body ; desqua-
mation is branny. The eruption is darker, less uniform,
more shotty; the temperature is lower, pulse slower, the
tongue is not of the "strawberry" type; coryza, coughing,
and sneezing may be present; Koplik's spots are present.
4. Excessive exercise leads to irregular action of the
heart, hypertrophy of the heart muscle, increased rate of
heart beat, and disturbance of the rhythmic action of the
heart.
Insufficient exercise leads to degeneration of the heart
muscle, and general weakening of the heart's action.
5. A parasite is an organism which lives in or on an-
other living organism.
A saprophyte is an organism which derives its nourish-
ment from dead matter.
6. The presence of the colon bacilli in a water supply
denotes the presence of sewage in that water and indi-
cates the possibility and probability of an epidemic of
typhoid as soon as the first typhoid case (or typhoid car-
rier) comes to that locality. Proper arrangements for the
hygienic disposal of sewage should be made at once; and
the inhabitants should be instructed as to the danger, and
as to the proper disposal of sewage.
7. Prophylaxis of uncinariasis: Children and adults
should be made to wear shoes; proper toilet facilities
should be provided, and their use enforced; bathing or
wading in shallow water should be forbidden; a proper
33
MEDICAL RECORD.
water supply should be available for drinking purposes,
and prompt recognition and treatment of all cases should
be encouraged.
8. Methods of self- purification of large bodies of water:
Sedimentation, precipitation, oxidation, dilution, the action
of bacteria, and the action of water plants.
9. Bichloride of Mercury. Symptoms of acute poison-
ing: "The nauseous, metallic taste is experienced during
the act of swallowing. Within a few moments this is fol-
lowed by an intense, burning pain in the mouth, throat,
and stomach. The mouth and tongue are whitened and
shriveled. There are vomitings of a white material, con-
taining shreds of mucous membrane, and tinged with
blood, and bloody stools. Salivation occurs if life be suffi-
ciently prolonged. Death sometimes occurs early from
collapse, accompanied by convulsions, or in deep coma;
but in most fatal cases life is prolonged for from three
to six days."
Antidote: "White of egg. The following precautions
should be observed in its administration: Too much
should not be given at one time, lest the precipitate be
dissolved in the excess; the antidote should be followed
by an emetic, to remove the precipitate before it shall
have been dissolved by the acid and chlorides of the gastric
juice." (Witthaus* Essentials of Chemistry and Toxi-
cology.)
10. If respiration has taken place, the lungs will float on
being put into water; if respiration has not taken place,
the lungs will sink. Further, the lungs before respiration
are situated at the back of the thorax and do not fill the
cavity; whereas, after respiration they fill the whole cavity.
DISEASES OF THE EYE, EAR, NOSE, AND THROAT.
I. Ptosis is due to paralysis of the third cranial nerve.
"The eyeball is almost immobile, the limitation of move-
ment being upward, downward, and inward, with the upper
end of the vertical meridian inclined inward, especially
upon looking downward; the face is directed upward and
toward the sound side, and the head inclined to the
shoulder of the paralyzed side. There is slight exophthal-
mos on account of the paralysis of the three recti which
normally draw the eyeball backward ; the pupil is dilated
and is immobile; accommodation is paralyzed; there is
crossed diplopia — the false image is higher, and its upper
end inclined toward the paralyzed side." (May's Diseases
of the Eye.)
"In paralysis of the facial nerve the eyelids cannot be
shut, and the cornea remains more or less exposed. When
a strong effort is made to close the lids the eyeball rolls
34
ALABAMA.
upward beneath the upper lid. Epiphora is a common re-
sult of facial palsy. Severe ulceration of the cornea may
result from the exposure." (Nettleship's Diseases of the
Eye.)
2. Acute catarrhal conjunctivitis. Symptoms: "Hy-
peremia, profuse lacrymation, epiphora, a profuse dis-
charge, sensation of sand in the eye, and sometimes photo-
phobia. Treatment: Astringent and antiseptic washes are
of value. Ascertain the underlying cause, if possible, and
remove it. Anointing the lids with pure or medicated
vaseline every evening is necessary. Alum, tannic acid,
silver nitrate, and zinc sulphate are valuable as astrin-
gents. In intractable cases a 50 per cent, solution of
boroglycerid in glycerin should be applied once daily."
(Pocket Cyclopedia.)
Gonorrheal ophthalmia. Symptoms: Swelling and
redness of the eyes, the presence of a discharge which
soon becomes purulent, the conjunctiva of the lids be-
comes thickened, the eyelids are edematous, pain is severe,
and there is some fever.
Management: Protect the sound eye. Wash the eye
carefully every half hour with a saturated solution of
boric acid; pus must not be allowed to accumulate. Two
drops of a 2 per cent, solution of nitrate of silver must
also be dropped onto the cornea every night and morning.
The eyes must be covered with a light, cold wet compress.
The patient must be isolated, and all cloths and com-
presses used must be burned. In adults the irrigation must
be frequent, about every half hour or hour.
3. The normal pupil is circular, regular in outline, and
the two pupils are equal in size.
The pupil in iritis is contracted, sluggish, and irregular.
The pupil in glaucoma is dilated, oval, and immobile.
Treatment of iritis: Atropine, dionine, the application
of leeches to the temples, hot fomentations, absolute rest
in bed, protection from the light, light diet, purgatives,
abstinence from alcohol, avoidance of all use of the eyes
for near work, constitutional treatment varying according
to the etiology, paracentesis, and iridectomy.
Treatment of glaucoma: Myotics, such as eserine or
pilocarpine; massage of the eyeball^ mydriatics are contra-
indicated; operative treatment may include paracentesis,
iridectomy, or sclerotomy.
4. The indications for enucleation of the eye are: "(1)
Injuries of the ciliary region when the eye is completely
blind, or the traumatism so extensive that the form of
the eyeball cannot be preserved; (2) traumatic irido-
cyclitis, to prevent or cure sympathetic ophthalmia; (3)
severe pain in a blind eye; (4) iridocyclitis, phthisis
85
MEDICAL RECORD.
bulbi, and glaucoma, when accompanied by severe pain or
inflammatory symptoms, and when the eye is blind or is
certain to become so; (5) malignant tumors, either intra-
ocular or epiocular, if they cannot be removed with reten-
tion of the eyeball; (6) anterior staphyloma, if the eye
is blind, troublesome, and disfiguring; (7) panophthal-
mitis, after the suppurative stage is passed; (8) foreign
bodies in the eye when they cannot be removed and cause
irritation, or the eye is blind." (May's Diseases of the
Eye.)
Enucleation of the eyeball is performed as follows:
"A general anesthetic is generally given. After introduc-
tion of the speculum, the conjunctiva is divided all around
the cornea, as close to its border as possible, and dissected
back as far as the insertions of the recti muscles. A squint
hook is passed beneath the tendon of the internal rectus,
and the latter is divided with the strabismus scissors close
to its insertion; then the other straight muscles are cut
in the same way, together with the subconjunctival con-
nective tissue for some distance beyond the equator. The
points of the scissors must always be directed toward the
eyeball and the latter stripped as clean as possible to avoid
any unncessary removal of orbital tissue. Instead of
commencing with a circumcorneal division of the conjunc-
tiva, we may begin with a tenotomy of the internal rectus
and then divide the conjunctiva as we pass from tendon to
tendon. The hook is passed around the globe to make
sure that the attachments of the muscles have been com-
pletely divided. The eyeball is then dislocated forward
by pressing the speculum backward, and thus the optic
nerve is put on the stretch. A pair of enucleation scissors,
closed, are passed between sclera and conjunctiva, feeling
for the optic nerve; they are withdrawn, slightly opened,
and the nerve is divided close to the sclera. The eyeball
is held between the thumb and index finger of the left
hand, and the oblique muscles, and other unsevered attach-
ments are divided. The orbit is plugged for a few minutes
to control hemorrhage, and the conjunctiva is usually closed
with a single suture, which is passed through its edge at
intervals and tied like the string of a pouch. The eye is
bandaged and the patient kept in bed for a day." (May,
Diseases of the Eye.)
5. The mouth is apt to be kept open ; mouth-breathing is
common ; enlarged tonsils or adenoids or both are prob-
ably present; the patient suffers from deafness, or partial
deafness. Treatment : Remove adenoids and enlarged ton-
sils ; inflate with a Politizer bag or use a Eustachian
catheter.
6. In active suppurative otitis media: "Pain (lessened
36
ALABAMA.
when drum perforates), fever (ioo° to 104 R), tinnitus,
deafness (usually partial only), and purulent discharge
(after perforation). Treatment: Dry heat allays the pain.
Warmed water or warmed carbolic acid solution (1:40)
may be used. Inflations, aspirations, etc., should be
avoided. If the nares are filled with tough secretions, a
spray of Dobell's solution may be used. If the pain con-
tinues over six hours in a child or over twelve hours in
an adult without spontaneous perforation of the tympanic
membrane, paracentesis of that structure should be per-
formed. The concha and meatus should be smeared with
petrolatum to avoid chapping, and the secretions should be
gently mopped off as they appear. Under this treatment
the ear usually returns to normal in two to three weeks/'
(Pocket Cyclopedia.)
7. "Abscess or empyema of the antrum of Highmore is a
collection of pus within the maxillary antrum. It results
from inflammation of the jaws, the teeth, or the mucous
membrane of the nose. It causes pain, edematous swelling
of the overlying soft parts, and crepitation on pressure
upon the superior maxillary bone. Pus may escape from
the nostril of the diseased side when the head is bent in
the direction of the healthy side. A rhinoscopic examina-
tion discloses the fluid passing into the nares. The antrum
on the side of the abscess cannot be transilluminated by an
electric light in the mouth. The constitutional symptoms
of suppuration usually arise. Treatment : Bore a gimlet-
hole through the superior maxillary bone, above the canine
tooth, or perforate the bone by means of a trocar. Irri-
gate daily with boiled water or normal salt solution. Keep
the opening from contracting by inserting a small tent of
iodoform gauze. In persistent cases it may be necessary
to draw a tooth, break through the socket of the first or
second bicuspid into the antrum, and insert a silver or
hard-rubber tube, and also to perforate the antrum from
the inferior meatus and keep the opening patent. In
very persistent cases osteoplastic resection of a portion
of the upper jaw will be demanded." (Da Costa's Sur-
gery.)
8. The symptoms of adenoids are : Mouth-breathing,
snoring, open-mouth, a vacant, dull expression of the face,
modification of the voice (nasal twang), with inability to
pronounce certain letters. Effects: Earache and other
ear affections, mental deficiency, frequent attacks of coryza.
nose-bleed, stunted growth, convulsions, laryngismus
stridulus, and various other neuroses may also be noticed:
Diagnosis is made by rhinoscopy, and by feeling the ade-
noids with the forefinger behind the palate. As the
growths bleed easily, the examining finger will be found
37
MEDICAL RECORD.
covered with blood. Treatment consists in thorough re-
moval by a curette.
9. A piece of meat (or other food) is probably impacted
in the pharynx or esophagus.
First of all, an attempt may be made to dislodge it by
means of the fingers. If it is beyond the reach of the
fingers forceps may be used. If suffocation seems immi-
nent laryngotomy must be done at once. If unsuccessful
with the forceps, an attempt may be made to push the
mass into the stomach, with a probang. If these methods
fail and the impaction is in the upper part of the esophagus,
esophagotomy is indicated; if in the lower part of the
esophagus, gastrotomy is necessary, and the foreign body
may be reached and removed by forceps or fingers intro-
duced through the cardiac orifice of the stomach.
10. Laryngotracheotomy is indicated in diphtheria when
intubation does not relieve and the symptoms are urgent;
to remove foreign bodies from the larynx that cannot be
treated by simple methods; to provide passage for air, in
growths, tumors, or abscesses pressing on the larynx and
interfering with the proper supply of air, and for edema
of the glottis when the intubation tube cannot be intro-
duced. ^ "Laryngotracheotomy consists in making an in-
cision into the air-passages by dividing one or two of the
upper rings of the trachea, the cricotracheal membrane, the
cricoid cartilage, and the cricothyroid membrane. This
operation is employed in cases where, from the age of the
patient, the cricothyroid space is too small to admit of a
sufficient opening, or in those in which, for any reason,
the surgeon does not deem it advisable to attempt to open
the trachea lower down. The incision in the skin and
superficial fascia of the neck is made in the same manner
as in the operation of laryngotomy, but is carried a little
further downward. It may be necessary to displace the
isthmus of the thyroid gland downward to expose the
upper portion of the trachea, and when the trachea is ex-
posed the incision should be made through this and the
cricoid cartilage from below upward. A tracheotomy tube
is introduced through the wound and secured by tapes tied
around the neck." (Wharton's Minor and Operative Sur-
gery.)
STATE BOARD EXAMINATION QUESTIONS.
Arkansas State Medical Board.
anatomy.
1. In the anatomy of the brain, what is the corpus
callosum? Describe its connection.
38
ARKANSAS.
2. Describe the esophagus as to (a) location, (b)
dimension, (c) arterial supply.
3. Give the anatomy of the bladder, including blood
and nerve supply.
4. Give origin, course, and distribution of the great
sciatic nerve.
5. Name the bones of the head.
6. Describe the prostate gland and give blood and
nerve supply.
7. What muscles assist in (a) mastication, (6) de-
glutition?
8. Give the gross and topographic anatomy of the
pancreas.
9. Describe the triangle of the elbow and name the
structures that pass through it.
10. Give the distribution of the radial nerve below the
wrist.
PHYSIOLOGY.
1. Describe (a) the hemoglobin of the blood, (b)
Give its function, (c) State what takes place from the
inhalation of coal gas upon the hemoglobin of the blood.
2. Define (a) the term "blood pressure." (b) What
factors govern normal blood pressure?
3. Compare flow of blood through an artery and vein.
4. Why is respiration stopped during the act of swal-
lowing?
5. Name four necessary constituents of food essen-
tial to health.
6. During the absorption of carbohydrates, in which
set of blood vessels is the percentage of sugar the
highest?
7. Under what circumstances may the quantity of
urine, in health, fall considerably below the average?
8. Give the number of layers of the wall of the small
intestine and describe each layer.
9. Give location, structure, and function of the pituit-
ary body.
10. Name the principal columns of the spinal cord
and give functions of each.
CHEMISTRY.
1. Define (a) matter. (6) Name three properties of
matter.
2. Define (a) a molecule, (b) Define an atom.
3. Define (a) an element, (b) Name five, giving
symbol of each.
4. Name (a) elements comprising halogen group.
(b) Give one equation for producing chlorine.
5. Give (a) symbol, atomic weight, and valence of
MEDICAL RECORD.
oxygen, (b) Give one equation for producing oxygen.
6. Name (a) two alkali metals. (6) Give symbol
for a salt of each.
7. Give symbol, properties and one method of obtain-
ing mercury.
8. Name the different forms in which carbon exists
in the free state.
9. Describe three tests for detecting albumin in urine.
10. Describe Fehling's test for sugar in urine.
GYNECOLOGY.
1. Give treatment for chronic endometritis.
2. What advice would you give a young woman re-
garding dress?
3. Describe surgical treatment for umbilical hernia.
4. Give symptoms of carcinoma of cervix.
5. Give symptoms and treatment of acute pelvic cel-
lulitis.
6. Give reasons for dilatation of cervix.
7. Indications for and technique of uterine curette-
ment.
8. Name conditions which justify an operation dur-
ing pregnancy.
9. Give symptoms following malpositions of uterus.
10. Give technique of repairing a lacerated perineum.
MATERIA MEDICA.
1. What is (a) the source of carbo animalis? 6)
Carbo ligni? (c) How are they prepared? (d) Give
dose and uses of each.
2. Give properties and untoward effects of sulphonal.
3. Give properties of potassium chlorate, potassium
carbonate and potassium acetate, (b) What is the
composition of potassa cum calce (Vienna paste) ?
4. Name four antiperiodics.
5. What do you understand (a) by physiological an-
tagonism of drugs? (b) Give two examples.
6. From what is (a) phosphorus obtained? (6) Give
its properties.
7. Name (a) the official chlorides of mercury; (b)
the iodides.
8. What are (a) protectives? (b) Give several ex-
amples.
9. Give properties and physiological action of ethyl
alcohol.
10. Why should we not keep morphine in solution?
THERAPEUTICS.
1. What remedies would you use (a) in mucous diar-
rhea? (b) In serous diarrhea? (c) In diarrhea due
to glandular deficiency?
40
ARKANSAS.
2. Give therapeutics of argentum nitrate.
3. How would you use (a) iodine in goiter? (6)
What other remedies may be used?
4. How would you use (a) pilocarpine in erysipelas?
(b) What other remedies would you use?
5. What precautions should we use in administering
quinine intravenously and intramuscularly?
6. What remedies do you use, and how do you apply
them in puerperal infection?
7. What foods would you prescribe for the nursing
mother (a) to increase milk fat? (b) to decrease milk
fat?
8. Give therapeutics of phenol.
9. What remedies are usually used (a) in insolation?
(b) Why is venesection beneficial?
10. How is biniodide of mercury best administered in
chronic paludism?
PATHOLOGY.
1. What is Pathology?
2. Name the diseases from which pleuroempyema
may result.
3. Describe the abnormal structural changes that may
occur in the prostate gland and assign cause for same.
4. Define (a) toxemia, (b) Give symptoms and ex-
plain how toxins are disposed of in the animal body.
(c) Differentiate intoxication and infection.
5. What pathological conditions of bone may result
(a) from a fracture or contusion? (6) Name the pos-
sible sequels of a -severe contusion of the cranium.
6. Give cause and pathology of a follicular ovarian
cyst.
7. Describe and give cause of adenoid development in
children.
8. Give causes of deafness, and explain how it is pro-
duced pathologically.
9. Give significance of indican and skatol in the urine.
10. Describe the symptoms and explain the patho-
genesis of acute anterior poliomyelitis.
BACTERIOLOGY.
1. What is Bacteriology?
2. How are bacteria recognized?
3. Explain the effects of age upon a culture of bac-
teria.
4. Describe the chief morphological characteristics
(a) of the organism producing cerebrospinal meningitis.
(6) Describe method of diagnosing miscroscopically,
give culture-media, time for growth, stains used, and
41
MEDICAL RECORD.
technique of staining, (c) Name the varieties of men-
ingitis from a bacteriological standpoint.
5. What is meant (a) by the term "physiological
leucocytosis?" (6) Give a few examples of same.
6. Give technique of staining malarial Plasmodium.
7. Define ptomains and toxins.
8. Name and describe the organisms that produce the
following diseases : Furunculosis, diphtheria, syphilis,
and pneumonia.
9. Describe in detail the examination of sputum for
tubercle bacilli.
10. Discuss the reliability of the following tests:
Widal test for typhoid; Wassermann reaction for syph-
ilis; Von Pirquet's test for tuberculosis.
THEORY AND PRACTICE.
1. Define (a) malaria. (6) Give best method of pre-
vention and treatment for an ordinary case.
2. Give the symptoms and treatment of acute ton-
silitis.
3. Name three complications of typhoid fever and give
treatment of each.
4. Give symptoms, complications, and treatment of
chronic interstitial nephritis.
5. Differentiate between follicular tonsilitis and diph-
theria.
6. Give cause and treatment of tetany.
7. Differentiate between tuberculosis with consolida-
tion and pleurisy with effusion.
8. Give dietetic and medicinal treatment of ileocolitis.
9. Define acidosis and name diseases in which it may
occur.
10. Give symptoms, complications, and treatment of
otitis media.
OBSTETRICS.
1. Define fecundation and describe its physiology.
2. State the most important signs of pregnancy up to
the fourth month.
3. Name the various diameters of the fetal head.
4. What is the placenta? From what is it formed,
what is its structure and what are its functions?
5. What preliminary preparation would you suggest
for a case of labor?
6. How would you diagnose the death of the fetus in
utero?
7. Define abortion, miscarriage, and premature labor.
8. How would you diagnose and manage a case of
occipitoposterior presentation?
9. How should a hand presentation be managed?
42
ARKANSAS.
(What course would you pursue if you found a hand
projecting from the vulvar orifice?)
10. Give the varieties, symptoms, and treatment of
puerperal mastitis.
SURGERY.
1. Give symptoms, diagnosis, and treatment of Pott's
disease.
2. Differentiate intussusception from acute appen-
dicitis? Give treatment for intussusception?
3. Give causes, symptoms, and treatment of ischio-
rectal abscess.
4. In what diseases is splenectomy indicated? Give
the characteristic blood picture of any one of these
pathological conditions, and describe the operative tech-
nique for removal of spleen.
5. What pathogenic microorganisms are more fre-
quent causes of wound infections? State in detail how
you would treat an infected wound of the soft parts.
6. Give causes of delayed union in fractures. State
how you would determine that such existed and the best
method of treatment.
7. What are some of the dangers of injuries which
penetrate the knee joint. How would you avert them?
8. Give indications for decompression operation on
skull. State in detail operative technique.
9. Give causes and treatment of chronic osteomyelitis.
What degenerative condition of the kidney arises in long
continued suppuration of bone? Also give treatment
for this complication.
10. Describe how you would ligate the common caro-
tid artery in superior carotid triangle, the structures
you would go through, and what complications may
arise from ligation.
HYGIENE.
1. State the dangers of excessive weeds and shade
about dwellings.
2. What advice would you give a community in regard
to obtaining pure drinking water?
3. Name precautions that should be observed around
all public drinking places.
4. Name (a) five preventable diseases, (o) State
why preventable.
5. Name (a) the diseases to which the negro is com-
paratively insusceptible, (b) Name diseases to which
the negro is more susceptible than the whites, (c)
State reason for above.
6. Why is the prevalence of smallpox and diphtheria
considered greater in cold than in warm weather?
43
MEDICAL RECORD.
7. What hygienic precautions should be observed with
patient and community during an epidemic of polio
myelitis ?
8. What hygienic means should be employed in a
house where there is pellagra?
9. From what are (a) ptomains derived? (b) What
disorders are produced by them?
10. Name precautions that should be observed as to
food and drink by those working under the direct rays
of the sun in the summer.
ANSWERS TO STATE BOARD EXAMINATION
QUESTIONS.
Arkansas State Medical Board.
ANATOMY.
1. The corpus callosam is the great transverse com-
missure which unites the two cerebral hemispheres. It
is situated at the bottom of the great longitudinal fis-
sure, its upper surface forming the floor of this fissure ;
its under surface is connected in front with the septum
lucidum, and behind with the fornix; the posterior
end lies over the mesencephalon and extends back-
wards as far as the highest point of the cerebellum.
It forms the roof of the lateral ventricles.
2. The esophagus extends from the pharynx to the
stomach; it begins at the lower border of the cricoid
cartilage opposite the sixth cervical vertebra, and
passes down along the front of the spine, behind the
trachea and pericardium to end in the stomach at a
point opposite the eleventh dorsal vertebra. It is about
ten inches long, and from half an inch to an inch in
diameter. Its arterial supply is derived from the in-
ferior thyroid branch of the thyroid axis, the descend-
ing thoracic aorta, bronchial arteries, from the gastric
branch of the celiac axis, and from the left inferior
phrenic of the abdominal aorta.
3. The male bladder is a musculo-membranous pouch,
situated in the pelvis, behind the pubes and in front
of the rectum. It has a superior surface, anteroin-
ferior surface, two lateral surfaces, a base or fundus,
and a summit or apex. It is retained in its place by
the two anterior ligaments, two lateral ligaments, and
the urachus; there are also five false ligaments formed
by folds of the peritoneum. Internally, on the floor,
is the trigone, between the openings of the two ureters
and the urethra. The anterior part of the bladder is
uncovered by peritoneum, and is in relation with the
44
ARKANSAS.
triangular ligament, the symphysis pubis, and the
puboprostatic ligament. Above it is covered with
peritoneum and is in relation with the rectum and
small intestines. The base is in relation with the rec-
tovesical pouch, vasa differentia, and seminal vesicles,
all of which separate it from the rectum. It is sup-
plied by the superior, middle, and inferior vesical ar-
teries; and the pelvic plexus of the sympathetic, and
the third and fourth sacral nerves.
4. The great sciatic nerve arises from the sacral
plexus, and passes out of the pelvis through the great
sacrosciatic foramen, below the pyriformis muscle; it
extends down the back of the thigh, passing between
the great trochanter of the femur and the tuberosity
of the ischium; at the lower third of the thigh it di-
vides into the internal and external popliteal nerves.
It supplies the hip-joint and the biceps, semitendinosus,
semimembranosus, and adductor magnus muscles.
5. The bones of the head are: Occipital, two
parietal, frontal, two temporal, sphenoid, ethmoid, two
nasal, two superior maxillary, two lacrymal, two malar,
two palate, twx) inferior turbinated, vomer, and inferior
maxillary.
6. Prostate gland is about 1% x % x % inches, and
weighs about three-quarters of an ounce. It resembles
a chestnut in size and form. It is situated at the neck
of the bladder, and surrounds the first part of the
urethra. It consists of fibromuscular (unstriated)
tissue with imbedded follicular pouches, the whole en-
closed in a firm fibrous capsule, continuous in front
with the triangular ligament, and behind with the pos-
terior layer of the deep perineal fascia. Arteries are
from the vesical, hemorrhoidal, and internal pudic.
Nerves are derived from the hypogastric plexus.
7. Muscles of mastication: Masseter, temporal, ex-
ternal pterygoid, internal pterygoid, and buccinator.
Muscles of deglutition: Buccinator, hyoglossus, stylo-
glossus, palatoglossus, palatopharyngeus, azygos uvulae,
tensor palati, levator palati, stylopharyngeus, stylo-
hyoid, geniohyoid, mylohyoid, thyrohyoid, digastric,
constrictors of pharynx, and the intrinsic muscles of
the tongue.
8. The pancreas is long and irregularly prismatic in
shape; it has been compared to a human or dog's
tongue. The right extremity is called the head, which
fits into the curve of the duodenum; the left end is
called the tail and reaches to the spleen. The stomach
lies in front of the body of the pancreas, and the
transverse colon and its mesentery cross the lower end
45
MEDICAL RECORD.
of the head, which is also in relation to the superior
mesenteric vessels. Behind the pancreas are the su-
pei ior mesenteric artery and vein, portal vein, inferior
vena cava, aorta, crura of diaphragm, left kidney with
its suprarenal capsule. Below are the jejunum, the
duodenojejunal junction, and the splenic flexure of the
colon. Above the neck is the pyloric end of the stom-
ach. The pancreas lies across the front of the first f
and second lumbar vertebrae, behind the stomach, and
in the epigastric and left hypochondriac regions. Its
canal is the duct of Wirsung, which extends trans^-
versely from left to right and opens into the duodenum
in common with the ductus communis choledochus.
9. The triangle at the elbow is bounded above by an
imaginary .line between the tw«> condyles of the
humerus, externally by the inner edge of the supinator
longus, internally by the outer margin of the pronator
radii teres; the floor is formed by the brachialis anticus
and supinator brevis. The space contains the brachial
artery with its accompanying veins, the radial and
ulnar arteries, the median and musculospiral nerves,
and the tendon of the biceps.
10. Below the wrist, the radial nerve supplies the
skin of the radial side of the ball of the thumb, and the
back of the index, middle, and adjoining half of ring
fingers (except the terminal phalanx).
PHYSIOLOGY.
1. The hemoglobin is the coloring matter of the red
corpuscles; it is a crystalline body of complex struc-
ture, whose exact percentage composition has not
been determined. It contains carbon, hydrogen, nitro-
gen, oxygen, sulphur, and iron. It constitutes over 90
per cent, of the red blood corpuscles, and it is owing
to this substance that these corpuscles are capable of
carrying oxygen to the tissues of the body. It has a
great affinity for oxygen; this is due to the presence
of iron. Its function is to carry oxygen from the lungs
to the tissues. When coal gas is inhaled, the hemo-
globin promptly takes up the carbon monoxide, for
which it has a much greater affinity than for oxygen,
and with which it forms a much more stable compound;
the carbon monoxide also makes the blood of a cherry
red color.
2. Blood pressure is the force exercised by the blood
against the walls of the blood vessels. It is regulated
by the force and frequency of the ventricular systole,
the quantity of blood contained in the vessels, the elas-
ticity of the walls of the arteries, and the resistance
in the capillaries.
46
ARKANSAS.
3. The flow of blood in the arteries is intermittent,
at higher pressure, and at a greater velocity than in
the veins; in the veins it is more continuous, at a lower
pressure and at a slightly lower velocity than in the
arteries; in the veins it is also assisted by the con-
traction of muscles, the action of the valves, and the
aspiration of the thorax.
4. The inhibition of respiration during swallowing
is the result of a reflex, the afferent nerve involved
being the glossopharyngeal.
5. Four necessary constituents of food essential to
health: Proteins, fats, carbohydrates, and inorganic
salts.
6. During the absorption of carbohydrates, the per-
centage of sugar is highest in the portal vein.
7. The quantity of urine, in health, may be decreased
in amount: In hot weather, during exercise, after pro-
fuse sweating, when much fluid is lost by the bowel,
when there is a diminished intake of fluid.
8. "The small intestine has four coats, mucous, sub-
mucous, muscular, and serous. The mucous membrane
is characterized by the presence of long finger-like
processes, the villi. Between the villi are numerous
depressions, the crypts or glands of Lieberkiihn. The
villi are covered by columnar epithelium, showing a
striped free border, and interrupted at frequent in-
tervals by goblet cells. The epithelium is set on a
basement membrane. The core of the villus is sup-
ported by retiform tissue. In this there is a central
lacteal, a network of capillaries, and some visceral
muscle fibers prolonged into the villus from the muscu-
laris mucosae. A good many leucocytes, especially
lymphocytes, are present in the villi. The Lieberkiihn's
follicles are lined by epithelium continuous with that
of the villi. At the base of the follicles the cells have
a specially granular character, and frequently show
mitotic figures. These are cells of Paneth. In the
reticular tissue are lymphoid nodules, the solitary
glands of the intestine. At the lower end of the ileum
the lymphoid nodules run together and form large
masses. These may rupture through the muscularis
mucosae, and proliferate in the submucosa. These are
the Peyer's patches. The muscularis mucosae, bound-
ing the mucous membrane, consists of an inner cir-
cular and an outer longitudinal layer of visceral
muscle. The submucosa is a loose fibrous tissue con-
taining the plexus of Meissner. In the duodenum there
are glands of Brunner in the submucosa. There are
racemose glands lined with epithelium of the serous
47
MEDICAL RECORD.
type. Their ducts pierce the muscularis mucosae, and
open either into or between the glands of Lieberkiihn.
In the ileum, at its lower part, there are masses of
lymphoid tissue, the Peyer's patches. The muscular
coat is composed of a thick layer of circular plain
muscle fibers internally, and a thinner longitudinal
layer externally. Between them is a small amount of
loose fibrous tissue in which Auerbach's plexus lies.
The serous coat is derived from the mesentery."
(From Aids to Histology.)
9. The pituitary body is situated on the floor of the
skull, on the sella turcica of the sphenoid bone. It
consists of two lobes, an anterior and a posterior, and
is connected, by the infundibulum with the third
ventricle of the brain. The posterior lobe originates
from the brain, and is composed of neuroglia; the
anterior lobe is derived from the buccal epithelium.
Between these two lobes is the pars intermedia which
invests the posterior lobe but is itself developed from
the anterior lobe. Function: Complete removal of
whole gland or of anterior lobe is followed by death;
the anterior lobe is connected with growth, if the gland
hypertrophies there follows overgrowth of the skeleton,
and partial removal leads to failure of development of
the body as a whole and of the sexual glands. The
posterior lobe is believed to cause constriction of ar-
terioles, rise of blood pressure, contraction of the in-
voluntary muscles in many viscera, increased flow of
urine, and increased secretion of milk.
10. Principal columns of the spinal cord. 1. In
the posterior column, are (a) Posterointernal column
(or column of Goll), which conducts to the brain
special sensations from muscles, tendons, and joints
of the same side; (b) Posteroexternal column (or col-
umn of Burdach), which conducts to the brain tactile
sensations from the opposite side and also contains
association fibers. 2. In the lateral column, are (a)
Anterolateral tract of Gowers, which conducts to the
brain sensations of touch, pain, and temperature from
the opposite side of the body; (6) Anterior and lateral
ground bundles, which connect different levels of the
spinal cord with each other, and also connect the cord
with the medulla and cerebellum (they contain both
motor and sensory fibers) ; (c) Crossed or lateral pyram-
idal column, which is the chief motor tract from the
brain; (d) Direct cerebellar tract, which conducts to
the brain" sensations from the viscera and also assists
in the maintenance of equilibrium. 3. In the anterior
column, are (a) Direct pyramidal tract, which is a
48
ARKANSAS.
motor tract from the brain; (b) Anterolateral ground
bundle, which connects different levels of the cord.
CHEMISTRY.
1. Matter is that which occupies space.
Three properties of matter: Indestructibility, divisi-
bility, impenetrability.
2. A molecule is the smallest quantity of any sub-
stance (element or compound) which can exist in the
free state.
An atom is the smallest quantity of an element which
can enter into the composition of a molecule.
3. An element is a substance which cannot by any
known means be split up into other dissimilar sub-
stances.
Five elements, with symbols: Carbon, C; Silver,
Ag; Arsenic, As; Hydrogen, H; Potassium, K.
4. The elements in the halogen group are: Fluor-
ine, chlorine, bromine and iodine.
To produce chlorine:
Mn0 2 + 4HC1 = MnCl 2 + 2H 2 + CI,.
5. Oxygen. Symbol, O; atomic weight, 16; valence, 2.
To produce oxygen: 2KC10* = 2KC1 + 30 2 .
6. Two alkali metals: Sodium and potassium.
Sodium chloride, NaCl; potassium iodide, KI.
7. Mercury. Symbol, Hg; Properties: A bright,
metallic liquid, volatile at all temperatures, is not al-
tered by the air at ordinary temperature, it alloys with
most metals to form amalgams, it is insoluble in water
but does not decompose water. One method of obtain-
ing mercury: By distilling cinnabar in a current of
air: HgS + 2 = SO* + Hg.
8. Carbon exists free as: (1) Diamond; (2) graph-
ite, and (3) coal.
9. Three tests for albumin in the urine: "The urine
must be perfectly clear. If not so, it is to be filtered,
and if this does not render it transparent, it is to be
treated with a few drops of magnesia mixture and again
filtered."
I,— The heat test: "The reaction is first observed.
If it be acid, the urine is simply heated to near the
boiling point. If the urine be neutral or alkaline, it is
rendered faintly acid by the addition of dilute acetic
acid, and heated. If albumin be present, a coagulum
is formed, varying in quantity from a faint cloudiness
to entire solidification, according to the quantity of al-
bumin present. The coagulum is not redissolved upon
the addition of HNOs."
II. — The trichloracetic acid test: Add a crystal of
49
MEDICAL RECORD.
trichloracetic acid to the suspected urine; the acid dis-
solves, forming a layer underneath the urine. A white
band at the junction shows the presence of albumin.
III. — Heller' s modification of the nitric acid test:
"Place in a test-tube a layer of HN0 3 about 2 c.c. in
thickness; then, with a pipette, carefully float upon
the surface of this a layer of the urine in such a man-
ner that the liquids do not mix. If albumin be present,
a cloudy ring appears at the point of juncture of the
two layers, the borders of the cloud being sharply de-
fined. A cloudy ring may be formed by the presence
of an excess of urates, but in this case it is not at,
but above, the point of junction of the layers, and its
upper border is not sharply defined, but fades off grad-
ually." — {Witthaus* Essentials of Chemistry.)
10. Fehling's test for sugar in the urine: Place in
a test-tube a few c.c. of the liquid prepared as stated
below, and boil; no reddish tinge should be observable,
even after five minutes' repose. Add the liquid under
examination gradually, and boil after each addition.
In the presence of sugar a yellow or red precipitate
is formed. In the presence of traces of glucose, only
a small amount of precipitate is produced, which ad-
heres to the glass, and is best seen when the blue liquid
is poured out.
[The reagent must be kept in two solutions, which
are to be mixed immediately before use. Solution I
consists of 34.653 gms. of crystallized CuS0 4 , dissolved
in water to 500 c.c; and Solution II of 130 gms. of
Rochelle salt dissolved to 500 c.c. in NaHO solution of
sp. gr. 1.12. When required for use equal volumes of
the two solutions are mixed, and the mixture diluted
with four volumes of water.]
GYNECOLOGY.
1. Treatment of chronic endometritis. The general
health must be attended to; rest is indicated; constipa-
tion must be avoided; tonics are of slight use; ergot
is useful for the menorrhagia or metrorrhagia ; vaginal
douches, pessaries, hip baths, and counter-irritation
have all been recommended; curettage may help; and
one or both lips of the cervix may be amputated.
Foreign bodies, such as polypi and fibroids, must be
removed; and any causative factors must be treated.
2. The clothing should be evenly distributed and not
(as is now the fashion) leave nearly half the body
uncovered; there should be no unnecessary constriction
about the waist, and corsets should be made to suit
the individual and not be selected merely because they
50
ARKANSAS.
are the "style"; the clothes should not exert undue
traction; garters are injurious; the shoes are too often
high-heeled, stilt-like contrivances with a minimum of
protection against cold combined with the greatest
amount of compression; the extremities are too often
left almost bare while the waist and hips are unduly
covered and compressed. These errors in dress should
be corrected.
3. Operation for radical cure of umbilical hernia.
"(1) Incise at first through skin and fascia only; the
incision is elliptical, with upper and lower ends in
the median line, and widest part opposite the greatest
width of the hernia. (2) Carefully deepen the wound
on one side until the abdominal aponeurosis (sheath of
the recti) is reached, aiming to come down upon it a
short distance to the outer side of the hernial neck. (3)
Having once reached the rectal aponeurosis, similarly
expose this aponeurosis and the neck of the hernial
sac all around the outline of the ellipse. All bleeding
is controlled by clamp and ligature. (4) The hernial
sac is now incised and its contents dealt with as indi-
cated. Adhesions are separated. Excess of omentum
is ligated and excised. All remaining contents of the
sac are returned to the abdomen — and kept in place
by a large, anchored gauze pad — which is removed just
before closure of the abdomen. (5) The entire sac,
with the umbilicus and the coverings included in the
ellipse, is now excised — dividing the peritoneum in an
elliptical manner about the neck of the sac. (6) The
peritoneum — or the peritoneum and transversalis fascia
together — is sutured with interrupted or continuous
gut sutures. (7) The borders of the abdominal ring —
formed by the sheaths and margins of the recti muscles
— are freshened with curved scissors. The edges of
the ring are then brought together with interrupted
sutures of kangaroo tendon or chromic gut— using
either the plain interrupted suture, or the mattress
type. (8) The skin and fascia (unless the fascia be
thick enough to require separate gut suturing) are
sutured with interrupted silkworm-gut sutures. (9)
The part is then well supported by an abdominal dress-
ing." (Bickham's Operative Surgery.)
4. The symptoms of carcinoma of the cervix are pain,
hemorrhage, and discharge; the cervix is hard and
nodular and the mucous membrane seems immovably
fixed to the underlying tissue. These nodules break
down, and the entire cervix becomes ulcerated, or large
cauliflower-like masses may fill the upper part of the
vagina. The diseased tissue is friable and readily
51
MEDICAL RECORD.
bleeds when touched. A microscopical examination of
a piece of excised diseased tissue may aid in the diag-
nosis.
5. Pelvic cellulitis. Symptoms: The onset of
pelvic cellulitis is usually marked by a rigor, followed
by pain in one or both flanks; febrile symptoms super-
vene, and, as the exudation increases, troubles during
micturition or defecation are experienced. These signs
are of greater significance when they follow within
twenty-four or thirty-six hours an abortion, delivery,
or an operation on the uterus. On examining through
the vagina, a hard mass will be found on one or both
sides of the cervix; in many cases the hard masses are
conjoined by a ring of hard tissue surrounding the
neck of the uterus. When the whole extent of the
ligaments is infiltrated the swelling is perceptible at
the brim of the pelvis and in the hypogastrium. When
suppuration occurs, the temperature, pulse, and gen-
eral condition of the patient are those accompanying
large collections of pus. The local signs are as fol-
lows: the previously hard masses become softer, fluc-
tuation is detected, or the overlying skin is edematous
and perhaps red. The abscess is then said to point.
Treatment: The patient is confined to bed, the bowels
are kept regular by means of saline purgatives, and
warm vaginal douches should be frequently adminis-
tered by a careful nurse. Glycerin tampons help to
relieve the pelvic congestion. When there is much
abdominal pain, warm fomentations to the hypo-
gastrium give great relief. When suppuration occurs
and the pus can be localized, an incision should be
made into it and the abscess drained," (Sutton and
Giles's Diseases of Women.)
6. Indications for dilatation of the cervix: For
diagnostic purposes in suspected cases of cancer or
polypus of the body of the uterus; to remove retained
products of conception; for dysmenorrhea; as a pre-
liminary to curettage; for removal of a polypus; in
cases of uterine hemorrhage to allow of other thera-
peutic or operative procedures; and in cases of cervical
stenosis.
7. Curettage is indicated: (1) For removal of
placental debris, (2) in hemorrhagic endometritis, (3)
in some forms of dysmenorrhea (membranous), (4)
for diagnostic purposes, (5) in some cases of puerperal
sepsis, (6) sometimes to check hemorrhage, due to
fibroids. Contraindications: (1) The least suspicion
of even the possibility of pregnancy; (2) menstrua-
tion; (3) acute endometritis; (4) malignant disease
52
ARKANSAS.
of the uterus or vagina; (5) acute pelvic inflammation.
Technique: All antiseptic and aseptic precautions
are necessary, the patient should be in the dorsal posi-
tion, the vagina is to be disinfected, and the cervical
canal dilated; a speculum is introduced into the vagina
and the cervix is drawn down with volsella; the uterine
cavity is irrigated with creolin or lysol; a curette is
inserted to the fundus and moved down to the internal
os; the operator should begin at one cornu and go in
the same direction all around till he reaches the start-
ing point, and if necessary repeat till no more spongy
or hyperplastic tissue appears; the fundus should be
scraped separately by moving the curette along it from
side to side; in going toward the fundus no scraping
should be done, and care must be taken not to perforate
the uterus; should this happen no fluid must be in-
jected; otherwise the uterus and vagina are again irri-
tated, and one or more strips of iodoform gauze are
inserted into the cavity to act either as a hemostatic
plug or as a drain, which is diminished with two days'
interval and withdrawn on the sixth day. A hemo-
static tampon should be placed in the vagina and with-
drawn the following day. If any fever arises, the
tampon is at once removed and the vagina douched
with antiseptic fluid every three hours. If not, the
vagina is only swabbed with the same every day, and
packed loosely with iodoform gauze. After the final
removal of the gauze the antiseptic douche is given
twice a day until there is no more discharge. The
patient should remain in bed for a week.
8. Operations during pregnancy "should be restricted
to cases of immediate and urgent necessity. Plastic
operations, as a rule, may be deferred. Tumors con-
nected with the reproductive organs, such as carcinoma
of the cervix uteri, ovarian cysts, uterine polypi,
vaginal tumors, vulvar and rectal tumors, may have to
be removed. The danger of abortion following opera-
tions during pregnancy is due chiefly to possible sepsis
or to some other form of toxemia; even the toxemia
of diffusible poisons and drugs, such as iodine, carbolic
acid, bichloride of mercury, quinine, and the bromides,
may induce abortion; hence the use of such drugs
should be limited and judicious." (Dudley's Gyne-
cology.)
9. The following symptoms may follow displacements
of the uterus: Backache, bearing-down pains, a feel-
ing of pressure in the pelvis, constipation, hemorrhoids,
frequent or painful urination, leucorrhea, menstrual
disturbances, as dysmenorrhea or menorrhagia, ster-
53
MEDICAL RECORD.
ility; there may also be general symptoms, as headache,
indigestion, nausea, anorexia, neurasthenia, and gen-
eral malaise.
10. Operation for old laceration of the perineum.
"Lateral tears are best repaired by the Emmett opera-
tion. With the patient in the lithotomy position, guide
sutures or tenacula are passed through the apex of
the rectocele and through each labium majus at the
lowest carunculse myrtiformes. By drawing on the lat-
eral suture and pulling the central suture downward
and to the opposite side, the lateral sulcus appears as
a triangle with the apex up in the vagina. This tri-
angle is denuded of mucous membrane by cutting off
long strips by means of forceps and scissors, or by
dissecting the mucous membrane off in one piece. The
triangle on the opposite side is treated in the same
manner, and the denudation completed by removing
the mucous membrane between the bases of the tri-
angles and below the central suture. Each lateral tri-
angle is closed by interrupted sutures of chromicized
cate-ut or silkworm gut, the latter being shotted. The
needle, which should be curved, is entered near the
margin of the wound on the outer side, passed deeply
to catch the fibers of the levator ani, and brought out
at the bottom of the sulcus, at a point nearer the oper-
ator; it is then reinserted at the bottom of the sulcus,
and passed upward and backward in the rectocele, to
emerge opposite the point of the original insertion.
The opposite triangle is treated in the same manner,
which leaves a small raw area externally to be closed.
The upper or "crown stitch" passes through the skin
of the perineum below the lateral guide suture, then
through the rectocele below the central guide suture,
and finally through the tissues below the opposite guide
stitch. As many sutures as may be necessary are in-
serted below this. If silkworm gut is used, the stitches
should be removed on the tenth day. The external
genitals are irrigated with weak bichloride of mercury
solution after each urination; catheterization should,
if possible, be avoided. The bowels are moved on the
second day. Internal douches are not needed unless
there be infection. The patient should be kept in bed
two weeks, and heavy work and sexual intercourse for-
bidden for three months." (Stewart's Surgery.)
MATERIA MEDICA
1. Carbo animalis is made by subjecting bones to a
red heat in close vessels. It is used to deprive sub-
stances of color.
Carbo ligni is made by burning soft wood without
54
%J ARKANSAS.
- — 4 — ■
free access of air. It is used as an absorbent and
disinfectant; and is given internally in doses of from
10 to 20 or 30 grains.
2. Sulphonal occurs in colorless prismatic crystals,
soluble in 15 parts of boiling water, and very soluble
in boiling alcohol; very slightly soluble in cold water.
It is used as a hypnotic in 15 or 20 grain doses. It
was once believed to be harmless, but it is now known
to be capable of producing headache, vertigo, noises
in the ears, weakness, and incapacity for mental or
physical exertion; edema, cyanosis, skin eruption, dis-
turbances of digestion, ataxia, and abnormal conditions
of the urine have resulted from its use.
3. Potassium chlorate occurs as colorless prisms or
plates with a cool and salty taste, neutral reaction,
and is soluble in 1 to 2 parts of boiling water.
Potassium carbonate is a white, granular, deliques-
cent powder, of caustic taste, and alkaline reaction,
freely soluble in water, but insoluble in alcohol.
Potassium acetate occurs as a white powder or in
crystalline masses, it is deliquescent, odorless, and has
a salty taste; it is soluble in 0.4 part of water and in
2 parts of alcohol.
Vienna paste, potassa cum calce, is a mixture of
equal parts of potassium hydroxide and lime.
4. Four antiperiodics : Cinchonea, and its alkaloids,
arsenic, salicylic acid, and bebeeru bark.
5. Physiological antagonism of drugs means a bal-
ance of opposed actions on particular organs or tissues
excited by drugs; example: the action of morphine and
atropine; also the action of atropine and muscarine.
6. Phosphorus is obtained from bones; it occurs as
a translucent, waxy solid, nearly colorless; insoluble
in water, freely soluble in chloroform and in carbon
disulphide; with a disagreeable odor and taste, and
emitting luminous fumes in the dark.
7. Official chlorides of mercury.- Hydrargyri chlor-
idum corrosivum, and Hydrargyri chloridum mite; the
official iodides, are: Hydrargyri iodidum rubrum, and
Hydrargyri iodidum flavum.
8. Protectives are agents which are used to cover and
protect a part from air, water, friction, etc. Ex-
amples: Collodion, gutta-percha, cotton, plasters of all
kinds, and splints.
9. Ethyl alcohol is a thin, colorless, transparent
liquid, with a sharp burning taste and a spirituous
odor; it mixes readily with water, and attracts moist-
ure from the air; it is a useful solvent. Physiological
action: Alcohol, externally, acts as a refrigerant, an
55
MEDICAL RECORD.
astringent, a disinfectant, an anhidrotic; it also hard-
ens the skin. Internally, it sharpens the appetite, is
a digestant, a diuretic, a diaphoretic, is slightly antipy-
retic, it increases the force and rate of the heart beat
and pulse, it is a vasodilator especially to the vessels
of the skin, it causes an increase in the blood pressure,
it is at first a slight nervous stimulant, but afterwards
is a depressant; in large doses it is a narcotic, and
then causes a reduction of body temperature.
10. Morphine salts will keep in solution if there is
only a small quantity of the salt present. Thus the
liquor mcrphinaB sulphatis of the U. S. P. of 1870, con-
taining one grain to the ounce, used to keep well; but
the Magendie's solution, containing 16 grains to the
ounce, did not keep well, but decomposed. The alka-
loid itself is less soluble than the salts.
THERAPEUTICS.
1. For mucous diarrhea: Regulate the diet, give
milk or whey, then give castor oil or magnesium sul-
phate with bicarbonate of sodium and a little lauda-
num; a mustard plaster may be put on the abdomen;
tonics and astringents as nitrate of silver, hyoscyamus,
lead acetate and opium may be given.
For serous diarrhea: Give opium, volatile oils, cam-
phor, spirit of chloroform, sulphuric acid; mercury
with chalk or calomel may be of service; phenyl salicy-
late, thymol, or bismuth may be tried; the diet must
be regulated, and tonics may be given.
For diarrhea due to glandular deficiency: Give pep-
sin, hydrochloric acid, podophyllin, nitrohydrochloric
acid and ipecac.
2. Therapeutics of argentum nitrate. Nitrate of sil-
ver is used externally for: Conjunctivitis; granular
lids; pruritus of genitals or anus; inflammations of
the mouth, pharynx, fauces; orchitis and epididymitis;
and to provent the pitting of smallpox; it is also said
to abort bedsores and boils.
Internally, it is used: In chronic gastric catarrh,
gastritis, and gastric ulcer; intestinal ulceration,
epilepsy, and chorea.
3. Iodine has been used internally, and by injection,
and also by inunction in exophthalmic goitre; it is not
used much now. Other remedies are: Mental rest,
hydrotherapy, fresh air, belladonna, electricity, organo-
therapy (thyroids and iodothyrin), serum of thyroid-
ectomized animals, rodagen, anthithyroidin, and surgi-
cal measures (partial thyroidectomy, ligature of two
or three of the thyroid arteries).
56
ARKANSAS.
4. Pilocarpine was used hypodermically (in dose of
gr. Vs) in the early stage of erysipelas. Other reme-
dies are: Tincture of chloride of iron, stimulants and
tonics, ichthyol or bichloride of mercury as a dressing;
nitrate of silver has also been applied; collodion,
phenol, iodoform, bichloride of mercury and serums
have been used.
5. Intravenous injections of quinine should be given
very slowly, and a vein of the leg should be selected,
because quinine in a concentrated form is a powerful
depressant of the heart. Intramuscular injection
should be given in the buttock.
6. Remedies used in puerperal infection: Tepid
sponging to reduce body temperature; vaccines and
antistreptococcus serum are of great value; vaginal
douches, posture (Fowler's position), antiseptics ap-
plied locally, tonics, opium, given with caution, for the
pain, and ichthyol applied locally, are the most fre-
quently used remedies.
7. To increase the milk fat, the nursing mother
should have a diet rich in nitrogenous substances or in
fats; merely enlarging the diet may have the same
effect. To decrease milk fat, reduce the diet both in
quality and quantity.
8. Phenol. — Therapeutic action: "As a disinfect-
ant for surgical instruments, soiled linen, hospital ap-
paratus, drains, privies, etc.; as an application for
burns, carbuncle, endocervicitis, lupus, condylomata,
and various other conditions; as an injection for leu-
corrhea and gonorrhea in the female; as a local anes-
thetic. Its antipruritic and parasiticidal qualities ren-
der it useful in many cutaneous affections; and it is
employed locally in hay fever influenza, and nasal ca-
tarrh. In the treatment of wounds it has been largely
superseded by more powerful germicides. Internally:
gastrointestinal irritation; malarial fever, typhoid
fever, scarlet fever, and other zymotic diseases; in-
fluenza; by hypodermic injection in tetanus and bu-
bonic plague." — (Wilcox, Materia Medica.)
9. In insolation, cold water may be used to reduce
the body temperature; cardiac stimulants are needed.
For convulsions, inhalation of chloroform or hypo-
dermic injections of morphine may be used. Venesec-
tion is used to relieve the asphyxia and distension of
the right side of the heart.
10. If the chronic paludism is accompanied by an en-
larged spleen, the unguentum hydrargyri biniodidi may
be administered by inunction in the splenic area.
57
MEDICAL RECORD.
PATHOLOGY.
1. Pathology is the study of life in its abnormal re-
lations; it is the science which treats of disease in all
its aspects.
2. Pleuroempyema may result from: Lobar pneu-
monia, bronchopneumonia, pulmonary tuberculosis, ab-
scess or gangrene of the lung. It may follow fracture
of a rib, a penetrating wound, disease of the esophagus,
abdomen, pericardium, and infectious diseases (par-
ticularly scarlet fever).
3. The prostate may show indications of atrophy,
hypertrophy, concretions, inflammation, tuberculosis,
and tumors. Hypertrophy is quite common in old men;
the entire gland or one lobe may increase in size, ob-
struction of the urethre with retention of urine re-
sults. Inflammation is generally secondary to gonor-
rheal infection of the posterior urethra. Concretions
occur late in life; they generally show concentric ar-
rangement and are called corpora amylacea. Tubercu-
losis is generally secondary to tuberculosis of the vas
deferens or epididymis. Tumors are not common.
4. Toxemia is the condition of blood-poisoning, or the
presence in the blood of the poisonous products of any
pathogenic microorganism. The symptoms are fever,
chills, irregular pulse, increased respiration, diarrhea,
unrest, dry tongue, delirium. The toxins may be de-
stroyed by the secretions of the body (gastric juice,
etc.), by the phagocytic action of the leucocytes, by the
antitoxins which are produced.
Intoxication and infection: "In one class of diseases
the infecting microbe remains localized at the point of
inoculation, and is never or only exceptionally found
in the fluids of the body, the general symptoms of the
disease being due to the absorption of the toxic prod-
ucts. Such are true intoxications. In other cases the
microbe is found circulating in the blood throughout
the body, and finds lodgment in most of the organs.
These are called infections." — (Stengel's Pathology.)
5. Fracture of bone may result in the formation of
a blood clot which fills up the spaces between the ends
of the bones. The blood clot becomes infiltrated with
leucocytes and then becomes absorbed. The connective
tissue cells in the surrounding parts proliferate, the
bone undergoes osteitis of a rarefying type, so that the
blood clot is replaced by granulation tissue. The gran-
ulation tissue becomes calcified and is then replaced by
bone tissue. The periosteum is stripped up, becomes
hyperemic and thickened, and callus is formed.
Contusion of the cranial bones may result in osteo-
68
ARKANSAS.
myelitis or chronic sclerosis and overgrowth of the
bone; syphilitic or tuberculous manifestations may be
lighted up if the patient is the subject of either of these
conditions; subcranial abscess may form; meningeal
hemorrhage, with separation of the dura, may occur;
inflammation and infection may spread from bone to
membranes and from membranes to brain.
6. Follicular Ovarian Cysts. — Causes: They are
due to the failure to rupture and the subsequent dis-
tention of a Graafian follicle. This condition may be
brought about by the deep situation of the vesicle, by
chronic ovaritis causing a thickening of the surface of
the ovary or a hyperplasia of its stroma, and by an
acute inflammation of the organ, producing deposits
of lymph upon it. The disease may occur any time
between puberty and the menopause. Pathology:
These cysts vary in size from a hemp seed to that of a
small lemon, and in exceptional cases they may grow
as large as a man's head. The ovary may be occupied
by a great number of small cysts, or there may be one
large cyst associated with several small ones, or the
distended follicles may coalesce and form a single large
cyst cavity. The contents of the cyst are composed of
a clear, alkaline, serous fluid having a specific gravity
of 1,005 to 1,020, and does not coagulate on exposure
to the air or by heat. Sometimes the fluid may be a
chocolate color from the presence of blood, or it may
be purulent if the cyst becomes infected. An ovum is
often found in small cysts, and in exceptional cases
even in large sacs. The cyst wall, as a rule, is thin and
transparent, but in some cases it is hypertrophied and
densely opaque. The disease is usually bilateral." —
(Ashton's Gynecology.)
7. Adenoids consist in a hyperplasia of the lymphoid
tissue in the nasopharynx. They occur in masses which
grow from the roof or posterior walls, or as peduncu-
lated tumors which hang down into the posterior nares.
They are soft and vascular, and bleed readily. They
are found in infants and children, chiefly those with
poor hygienic surroundings; they are often associated
with enlarged tonsils; rickets and the status lymphati-
cus are believed to predispose to adenoids; damp and
variable climates are most favorable to the development
of adenoids.
8. Causes of deafness: Heredity, consanguinity of
parents, injuries to the head during birth or in infancy,
acute infectious diseases, diseases of the middle ear, in-
flammatory conditions within the cranium, obstructions
of the Eustachian tube, diseases of the auditory nerve
59
MEDICAL RECORD.
or internal ear. There may be congenital absence of
some part of the ear; deformities or atresia of the
meatus may be present; intratympanic changes may
prevent vibration of the labyrinthine fluid; the rouna
or oval windows may be occluded; there may be a lesion
in the auditory nerve, nuclei, fibers, or cortical areas
or in the labyrinth.
9. The presence of indican in the urine is a measure
of the putrefactive changes occurring in the intestine.
It occurs in hypochlorhydria, also in hyperchlorhydria ;
in conditions in which there is diminished intestinal
peristalsis, as in ileus and peritonitis ; also when putre-
factive changes are occurring elsewhere in the body, as
in empyema, gangrene of the lungs, putrid bronchitis.
Skatol occurs in the urine in much the same conditions
as indican.
10. Symptoms of acute anterior poliomyelitis : Some
fever, chills, and convulsions may precede the attack,
or the onset may be sudden; certain groups of muscles
(generally in the extremities) are paralyzed; hemiple-
gia is rare; the reflexes are generally lost; the paraly-
sis is irregular in its distribution, and tends to ameli-
orate, but the recovery is only partial; the affected
muscles waste, and the limb is cold and livid.
The primary changes are in the vessels of the an-
terior horn and in the gray matter; the changes in the
cord are accompanied by round cell infiltration of the
pia and arachnoid; the meningitis is most marked in
the lumbar and sacral regions of the cord, next in the
cervical; the inflammation is responsible for the irrita-
tive symptoms of the disease. The neuroglia becomes
increased and the anterior horn is sclerosed and shrunk-
en. The virus is found in the brain, cord, tonsils, naso-
pharynx, lymphatic and salivary glands, and else-
where. The nasopharynx is probably the site of entry
and of egress of the disease.
BACTERIOLOGY.
1. Bacteriology is that branch of science which is
concerned with the study of unicellular vegetable or-
ganisms and with their relation to medicine, agricul-
ture, and the arts.
2. Bacteria are recognized by their size, shape,
groupings, staining reactions, and cultural character-
istics; also by their ability to produce disease.
3. "Under constant and favorable conditions of life
each kind of bacterium generally exhibits a true con-
stancy of form. Long continued growth in artificial
culture media, however, appears to have an injurious
60
ARKANSAS.
effect upon certain varieties of bacteria. In old cul-
tures or in cultures kept under relatively unsuitable
conditions many bacteria pass into unusual forms which
are plainly the result of degeneration and indicate that
the cell has received some damage from untoward phys-
ical and chemical influences. These degenerative or in-
volution forms often depart very widely from the typ-
ical form, and sometimes give to a pure culture the ap-
pearance of being contaminated by a foreign organism.
Certain bacteria are especially prone to induce involu-
tion forms, and in at least one case, that of the plague
bacillus, the occurrence of involution forms upon a par-
ticular culture medium (nutrient agar, containing 2,5
to 3.5 per cent. NaCl) has been thought to be charac-
teristic and to serve as a valuable aid to the differential
diagnosis of the organism." — (Jordan's Bacteriology.)
4. The diplococcus intracellularis meningitidis is a
diplococcus similar to the gonococcus, but may appear
as tetrads ; the cocci vary in size, are nonmotile, and do
not form spores ; they stain readily with the usual anilin
dyes, but not by Gram's method. The diplococcus grows
upon meat infusions; upon agar, colonies appear in
from eighteen to twenty-four hours; growth occurs
best and most rapidly upon media to which ascitic fluid
or blood serum has been added; Loeffler's blood serum
is also a good medium. Its optimum temperature is
about 37° C. It is extremely sensitive to heat and cold,
and is killed by exposure to sunlight or to drying with-
in twenty-four hours. Organisms that may be mis-
taken for it are the gonococcus (the history of the case
should prevent this error) , micrococcus catarrhalis
(distinguished by fermentation tests and its growth at
23° C), pneumococcus (which is Gram-positive). Be-
sides the usual type, caused by the diplococcus, menin-
gitis may be due to the pneumococcus, bacillus tubercu-
losis, various staphylococci and streptococci, typhoid
bacillus, influenza bacillus, diphtheria bacillus, and
gonococcus.
5. Physiological leucocytosis is an increase in the
number of the white blood corpuscles occurring under
normal or physiological conditions, such as: Digestion,
exercise, after a cold bath, or during pregnancy.
6. To stain the malarial Plasmodium. — A film is
made in the usual way and is allowed to dry spon-
taneously; it is then fixed by immersion in a mixture
of equal parts of absolute alcohol and ether. It is then
stained with Loeffier's methylene blue. Or Jenner's blood
stain may be used (without fixation) ; the film is placed
in the stain for five minutes and is then washed in dis-
tilled water.
61
MEDICAL RECORD.
7. Ptomaines are substances which are produced by
saprophytic bacteria from protein matter during putre-
faction.
Toxins are the poisonous products of bacteria.
8. Furunculpsis is generally produced by the Staphy-
lococcus pyogenes aureus, which is a coccus occurring
in clusters, nonmotile, nonflagellate, nonsporogenous,
liquefying, pathogenic, aerobic, and optionally anaerobic,
which stains by the usual methods and also by Gram's
stain. Its diameter is about 0.8 to 1 mikron.
Diphtheria is caused by the Bacillus diphtherias,
which is a rod-shaped microorganism about 2 to 6
mikrons in length and from 0.2 to 1 mikron in breadth;
the rods are slightly curved and often have clubbed or
rounded ends; they occur either singly or in pairs, or
in irregular groups, but do not form chains; they have
no flagella ; are nonmotile and aerobic ; they are noted for
their pleomorphism ; they do not stain uniformly, but
stain well by Gram's method and very beautifully with
Loeffler's alkaline methylene blue.
Syphilis is caused by the Treponema pallidum, which
is a slender spirillum with regular turns, about 4 to 20
mikrons long, with a fine flagellum at each pole; it is
actively motile, flexible, hard to stain, and has not been
cultivated on artificial media. How it divides is not
known. It stains best with Giemsa's eosin solution and
azur.
Pneumonia is caused by the Micrococcus lanceolatus
or diplococcus of Fraenkel, which is a snherical or oval
coccus, often pointed at one end, usually in pairs, oc-
casionally forming chains of three or four; sometimes
a capsule is visible. It is nonmotile; stains readily with
anilin dyes and also by Gram's method. It grows best
at about 37° C, and is both aerobic and facultative an-
aerobic.
9. To demonstrate the existence of tubercle bacilli in
the sputum: The sputum must be recent, free from
particles of food or other foreign matter; select a
cheesy-looking nodule and smear it on a slide, making
the smear as thin as possible. Then cover it with some
carbolfuchsin, and let it steam over a small flame for
about two minutes, care being taken that it does not
boil. Wash it thoroughly in water, and then decolorize
by immersing it in a solution of any dilute mineral
acid for about a minute. Then make a contrast stain
with solution of Loeffler's methylene blue for about a
minute; wash it again and examine with oil immersion
lens. The tubercle bacilli will appear as thin red rods,
while all other bacteria will appear blue. The tubercle
62
ARKANSAS.
bacillus is rod-shaped, is from 1V 2 to SV 2 mikrons in
length and about one-third to one-half a mikron in
breadth, is a strict parasite, is not motile, and has no
flagella. It is slightly curved, does not form spores, is
not liquefying, and nonchromogenic ; is aerobic; it re-
sists acids; it grows well on blood serum; stains well
by Ehrlich's, Ziehl-Neelsen's, or Gabbett's method; it is
Gram-positive.
10. The Widal test for typhoid is satisfactory, but
not universally reliable. It is not obtained till the sev-
enth day of the fever, and is rarely absent throughout
the disease; it may persist for years after an attack;
a negative reaction is of no value unless repeated two
or three times.
The Wassermann reaction for syphilis is of value in
the secondary stage ; a negative reaction is of little or no
value, particularly in the primary stage; positive re-
sults have been obtained in nonsyphilitic conditions.
The von Pirquet test for tuberculosis is not absolutely
reliable, as it gives positive results in healed cases of
adults as well as in those where the disease is active.
It is said to be more reliable in children than in adults.
THEORY AND PRACTICE.
1. Malaria is an infectious disease caused by the
hemocytozoon, transmitted by the bite of the anopheles
mosquito, and characterized by paroxysms of intermit-
tent fever of quotidian or tertian or quartan type, and
remissions. The specific for malaria is quinine, which,
properly given, destroys the parasite in the blood. It
should be given promptly in doses up to 30 grains in
twenty-four hours and continued in doses sufficient to
keep up a moderate singing in the ears for a week after
the parasites have disappeared from the blood. The
dose may then be reduced, but should be continued for
three months. It is best given in capsule or in acid
solution. In pernicious cases it may be injected intra-
muscularly in 10-grain doses three times a day. Pro-
phylactically quinine may be taken in doses of 5 to 10
grains every morning. Mosquito nets, wire screens,
etc., must be employed; anopheles and their larvae must
be killed, and a system of drainage and covering pools
must be inaugurated.
2. Acute tonsillitis has a sudden onset, with hot and
dry throat, fever rapidly rising to 103° F. or higher,
and severe headache; the breath is fetid, the tongue is
foul, the glands below the jaw are swollen, there is pain
on swallowing; there may be exudation or yellowish
patches on the tonsils. Treatment consists in rest in
63
MEDICAL RECORD.
bed, purgation with calomel and a saline, reduction of
the fever by salicylates or aconite; locally glycerin
and belladonna or sucking tablets of potassium chlorate
may be of great benefit. Antiseptic sprays are useful.
3. Three complications of typhoid, with treatment: —
Intestinal perforation requires surgical treatment;
laparotomy, with suture of the intestine should be done
as soon as possible. In the meantime morphine may
be administered. Intestinal hemorrhage requires
opium, lead acetate, or calcium lactate every three or
four hours, a hypodermic injection of morphine or
ergotin, and the application of an icebag over the
cecum. Constipation, if severe, demands enemata;
don't give purgatives after the first week.
4. Chronic interstitial nephritis. Symptoms: —
Insidious onset, frequency of urination, especially at
night; languor, headache, and thirst, the urine is
pale and clear, and is increased in quantity; blood or
albumin may be detected in it, but albuminuria may be
absent for a long time. Later on, cardiac symptoms
appear, such as pallor, dyspnea, asthma, dimness of
vision, dropsy, and hypertrophy of the heart. Com-
plications are arteriosclerosis, cardiac failure, dropsy,
and threatened uremia. Treatment should be directed
to causative factors, and diet and hygiene should re-
ceive attention. The food should be largely of milk,
fruit and vegetables. Meat should not be allowed
more than once a day. Nitroglycerin or aconite may
relieve the high arterial tension; the bowels must be
kept free; as a rule, alcohol should be prohibited. The
patient should be protected against cold, and tepid
baths and friction are of benefit.
5. Tonsillitis has a sudden onset, with chill and high
fever (103° to 105° F.) ; the tonsils are considerably
enlarged; the pseudomembrane is not adherent, is
easily removed, is limited to the tonsil, does not bleed
when removed, and does not reform; bacteriological ex-
amination shows staphylococci and streptococci, but not
the Klebs-Loeffler bacilli.
Diphtheria has a more gradual onset, chill is gen-
erally not present, and the fever rarely reaches
103° F.; the tonsils are not much enlarged; there is
a thick membrane, which is adherent, is removed with
difficulty and with bleeding, tends to reform, and is
not limited to the tonsil; bacteriological examination
shows the Klebs-Loeffier bacilli.
6. Tetany is probably due to a toxin acting on the
peripheral motor neurones. It occurs chiefly in the
young, and is often associated with some general 4is-
64
ARKANSAS.
order, such as rickets, diarrhea, pregnancy, gastric
dilatation, extirpation of the thyroid, or some specific
fever (such as typhoid). Treatment consists in at-
tending to any real or apparent cause; hot and cold
baths and potassium bromide are of benefit for the
spasm, so, too, is inhalation of chloroform: massage,
galvanism, icebag to the spinal column, and chloral
are said to be useful.
7. In tuberculosis with consolidation, the lung shows
dullness on percussion, bronchial breathing is heard,
the breath sounds are intensified, and the tubercle
bacilli may be detected in the sputum. In pleurisy
with effusion, the lung gives flatness on percussion,
there is no bronchial breathing over the fluid, the
breath sounds are diminished or absent, and the tubercle
bacilli are not found in the sputum. •
8. In ileocolitis, the patient should be placed in bed,
and the diet restricted to milk, limewater, or mutton
and chicken broths, to which w T ell-boiled rice has been
added. A mild laxative, as calomel, magnesia or Ep-'
som salt should be given to relieve the bowel of the
irritant; opium is of help; salol and bismuth salicylate
have proved of service. Locally, warm fomentations
and poultices, or camphorated oil, are beneficial and
agreeable.
9. Acidosis means an increased elimination of acids
by the urine, and is a precursor of acid-intoxication.
It may occur in diabetes, starvation, and poisoning by
phosphorus, salicylates or chloroform.
10. Acute catarrhal otitis media is frequently caused
by acute coryza and the infectious fevers. There is
a painless obstructed sensation in one or both ears, im-
pairment of hearing and tinnitus. The inflamma-
tion causes closure of the eustachian tube. Inflation
and aspiration of the middle ear and syringing and
douching the nares and nasopharynx must be avoided.
A moderate spray of Dobell's solution may be used.
If pain is present, dry heat, in the form of hot-water
bottle, hot stone wrapped in flannel, etc., may be ap-
plied. A few drops, warmed, of a carbolic acid
solution (1:40), or one of formalin (1:2000), may be
instilled into the ear.
Acute purulent otitis media: Acute catarrhal otitis
media, instead of undergoing resolution, may pass into
acute purulent otitis media (especially in exanthemata)
from the passage of pathogenic germs from the naso-
pharynx into the middle ear. The pain will become
more intense, the hearing dull, tinnitus will become
louder and more distressing, and fever usually sets in.
65
MEDICAL RECORD.
Dry heat allays the pain. Warmed water or warmed
carbolic acid solution (1:40) may be used. Inflations,
aspirations, etc., should be avoided. If the nares are
filled with tough secretions, a spray of DobelPs solu-
tion may be used. If the pain continues over six hours
in a child or over twelve hours in an adult without
spontaneous perforation of the tympanic membrane,
paracentesis of that structure should be performed.
The concha and meatus should be smeared with petrola-
tum to avoid chapping, and the secretions should be
gently mopped off as they appear. Under this treat-
ment the ear usually returns to normal in two to
three weeks.
Chronic purulent otitis media is due to the perma-
nent lodgment of staphylococci in the acutely in-
flamed middle ear. This unfortunate result is usually
brought about by improper — i.e. excessive — treatment
of acute otitis media, generally by the patient, but
sometimes, regrettably, by the physician.
Chronic catarrhal otitis media results from acute
catarrhal otitis media that has failed to undergo resolu-
tion. Nasopharyngeal catarrh is usually associated
with this condition. The onset is gradual and is char-
acterized by repeated attacks of the acute form, each
one increasing in severity. As the symptoms of tin-
nitus and deafness increase there may be attacks of
ear vertigo of tympanic origin. These may be mis-
taken for neurasthenia, epilepsy, apoplexy, etc. Early
in the case there are contraction of the tensor tympani,
retraction of the chain of auditory ossicles, and con-
sequent impaction of the stapes in the oval window.
Complications are inflammation of the mastoid cells,
caries and necrosis, phlebitis, meningitis, and brain
abscess. — {Pocket Cyclopedia.)
OBSTETRICS.
1. Fecundation is the result of the meeting of a live
and healthy spermatozoon, with a live and healthy
ovum, in a suitable medium (generally the Fallopian
tube). During coitus the seminal fluid is ejected into
the upper part of the vagina and against the cervix
of the uterus; the spermatozoa enter the uterine cavity
(either by the suction of the uterus or by their own
vibratile motion) and so pass on to the Fallopian tube
Several spermatozoa may surround an ovum,, or even
pierce the peri vitelline space ; but only one spermatozoon
enters the vitellus. This spermatozoon loses its tail ; and
its head becomes the male pronucleus. The male pro-
nucleus and the female pronucleus now fuse together,
and fecundation is completed.
66
ARKANSAS.
2. Up to the fourth month there are no certain sign^
of pregnancy, but the following are presumptive: —
Cessation of menstruation, nausea and morning vomit-
ing; increased size and fullness of the breasts, with
darkened areola and enlarged Montgomery's follicles,
colostrum may be present; the abdomen and umbilicus
may appear flatter than usual, there may be pigmenta-
tion; the uterus may be felt to be enlarged; the cervix
is softened, and the cervix and vagina are of a pur-
plish hue; Hegar's sign of softening of the lower
uterine segment may be elicited.
3. Diameters of the fetal head: — The occipitomental
is approximately 5% inches: the occipitofrontal, about
iVz inches; the biparietal, bimastoid, suboccipitobreg-
matic, and frontomental, about 3% inches.
4. At full term the placenta is a soft, spongy mass,
roughly saucer-shaped, from six to nine inches in di-
ameter, about three-quarters of an inch in thickness at
the central point, and weighs about one pound. It is
formed, partly from the mucous membrane of the
uterus, and partly from the chorionic villi. Its func-
tions are: (1) To supply nourishment to the fetus;
(2) to act as a respiratory organ for the fetus; (3)
to act as an excretory organ for the fetus; (4) it is
also supposed to provide an internal secretion. Its
usual location is on the anterior or posterior wall of
the uterus, near the fundus.
5. In addition to the bath, clean clothes, and other
details which may be taken for granted in persons of
refinement, the physician should, before making a
vaginal examination, carefully cleanse his hands, as
scrupulously as if he were about to undertake a majoi
operation. The hands should be scrubbed for at least
five minutes with hot water, soap, lysol, and a nail
brush that has been boiled or soaked for some time in
an antiseptic. Special care must be given to the nails
and nail-folds. The hands should then be soaked for
three minutes in an antiseptic solution such as bichlo-
ride of mercury 1:1000. This is followed by another
washing in sterile water. Rubber gloves that have
been boiled and kept sterile and a sterile gown add to
the safety of the patient.
The patient should receive a full bath before labor
begins and all bed clothing and personal clothing should
be clean. If there are any pathological discharges from
the genitals, the vagina should be thoroughly scrubbed
with tincture of green soap and hot water, followed by
a mercuric chloride douche (1 :2000) ; this is followed by
a douche of sterile water. The physician's hands should
67
MEDICAL RECORD.
be scrubbed for ten minutes with tincture of green soap
and hot water, followed by alcohol, and immersion in
mercuric chloride (1:100). All instruments should be
boiled for ten minutes or immersed in mercuric chloride
1:1000 for half an hour. Examinations should be
made when necessary to determine the position, pres-
entation, size of the fetus, etc.
6. Symptoms of death of the fetus during the later
months of pregnancy are: — Cessation of the signs of
pregnancy, the abdomen and uterus are both dimin-
ished in size, the fetal heart sounds and movements
cease, there is no pulsation in the cord, the mother's
breasts become flaccid and occasionally secrete milk.
If the fetus has been dead for some time crepitus of
its cranial bones may be elicited.
7. Abortion is the expulsion of the ovum during the
first three months of pregnancy. Miscarriage is the
expulsion of the fetus prior to the seventh month.
Premature labor is the birth of a viable fetus before
the termination of pregnancy.
8. A diagnosis of occipito-posterior position may be
based on: — Finding the sagittal suture in the oblique
diameter of the pelvis, the posterior fontanelle in the
posterior half of the pelvis, the anterior fontanelle is
easily accessible; the fetal heart sounds are heard far
back in the flank, between the ribs and the crest of
the ilium; the fetal head may be felt above the pelvic
brim, and the fetal small parts are felt through the
anterior abdominal walls of the mother, while the
fetal back is not felt.
The normal course of delivery in occipito-posterior
positions, is the same as in occipitoanterior positions,
except that the head must rotate to the front through
three-eighths of a circle; of course, this takes longer
and is more tedious.
In abnormal cases, the management is as follows:
"(a) When diagnosed while the head is at the brim.
(1) Leave it alone. The occiput will probably rotate
to the front all right if it is given plenty of time. (2)
If flexion appears to be deficient, try to increase it by
pushing up the sinciput with the fingers in the vagina
during a pain, at the same time pressing down upon
the fundus with the other hand. (3) The head may be
rotated by passing the hand into the vagina and grasp-
ing it between the fingers and thumb. At the same
time the shoulders must be rotated by abdominal palpa-
tion, or else the head will at once go back to its original
position. This maneuver generally requires an anes-
thetic.
' 68
ARKANSAS
"(6) When diagnosed after the head has entered the
pelvis. (1) Leave it alone. After exercising the pa-
tience of all concerned, it will probably rotate spon-
taneously. Only about one case out of twenty fails to
do so. (2) An attempt may be made to increase flexion
as before. (3) Manual rotation may be attempted as
before, but the head must first be flexed and gently
pushed back out of the pelvis. (4) If the pains are
weak, forceps should be applied well back on the head,
so that when traction is applied, flexion will be pro-
moted. The head should then be pulled w T ell down on
to the pelvic floor. If it begins to rotate, take off the
forceps and leave the rotation to nature, merely keep-
ing the head on the pelvic floor by pressure on the
fundus. After rotation the forceps may, if necessary,
be reapplied and delivery completed.
"(c) When the occiput has definitely rotated into
the hollow of the sacrum, and the case has become a
persistent occipitoposterior, forceps should be applied
and the head delivered with the occiput posterior. The
perineum should be guarded as much as possible, and
any tears stitched up at once. In extreme cases crani-
otomy and pubiotomy may require to be considered. "
— (Johnstone's Textbook of Midwifery.)
9. // the hand prolapses in a head presentation,
and the condition is diagnosed before rupture of the
membranes, nothing should be done until the cervix
is completely dilated. Then the hand may be pushed
up to allow the head alone to engage in the brim. If
this fail, forceps may be applied to the head if there
be no risk of catching the arm, or version may be
carried out. In extracting with forceps the arm may
slip up. When the case is made out only after the
arm is w r ell engaged in the brim, the head should be
delivered with forceps. In breech presentations the
hand sometimes presents; nothing need be done the
hand may or may not slip up. — (Jewett's Practice of
Obstetrics.)
10. Acute mastitis. "Symptoms. The breast is
swollen, painful, and tender, and, owing to the sore-
ness of the nipple, the breast is not relieved of its
secretion, so that it is distended. If suppuration fol-
lows, redness, edema, and fluctuation occur over the
site of the abscess. The abscess may be — (1) su-
pramammary, the pus lying between the skin and
breast; (2) intramammary, or the common form, in
which the pus is in the substance of the breast; (3)
submammary, which is beneath the breast, and may
spread from the deep lobules, but more frequently is
69
MEDICAL RECORD.
due to disease of the underlying ribs. Treatment be-
fore suppuration occurs consists in supporting the
breast with a bandage, emptying the gland regularly
with a breast pump, and applying a belladonna plaster
over the gland to stop the secretion and allay the pain.
When pus is present an incision should be made at
once, or the abscess may burrow extensively and riddle
the breast. The incision should be made in a line radi-
ating from the nipple, so as not to cut the ducts; it
should be free, and all pockets opened up with the
finger. Then a large drainage tube is inserted and
shortened daily, as the wound heals by granulation.
If necessary, several incisions are made."
Chronic mastitis. "Symptoms: — There may or
may not be pain in the breast, but a number of small
scattered lumps are usually found. Both breasts are
usually affected. The skin is seldom attached over
the lumps, but the lymphatic glands may be slightly
enlarged. Distinct cysts may be felt in some cases.
The disease slowly progresses and ends in atrophy
of the breast or general cystic formation. It
is said that cancer is likely to follow interstitial
mastitis. Treatment consists in supporting the breast
and applying a belladonna plaster. Single cysts should
be removed, but if the whole gland is cystic complete
removal is better."— (A ids to Surgery.)
SURGERY.
1. The symptoms of Pott's disease of the spine are
pain, tenderness on pressure, rigidity of the back, and
a sense of weakness, which may usually be recognized
by the child's actions. When suppuration occurs, the
pus may enter the sheath of the psoas, destroying the
muscle, and presenting in the iliac fossa or groin as an
iliac or psoas abscess or it may pass backward through
or external to the quadratus lumborum, and point in
the loin, when it is known as lumbar abscess. In the
cervical region retropharyngeal abscess may occur.
Spinal paralysis may come on at any time and myelitis
develops in the later stages. Treatment: — "Rest in
bed, using sand bags as splints, is the first considera-
tion. After the acute symptoms have subsided a
Thomas splint, Sayre's plaster cast, or Cocking's felt
jacket may be applied to the back and the patient grad-
ually allowed to move about. To apply the plaster -of-
Paris case, the patient should be suspended so that the
heels are just off the ground. A skin-fitting vest is
then applied to the trunk, under which a stomach pad
is inserted, which should be removed after the plaster
70
ARKANSAS.
has become dry. Plaster bandages should now be ap-
plied in the usual manner, extending from the level of
the axilla to just below the crest of the ilium. When
the case is dry, it may be divided down the front
and perforated, so that it can be laced up or removed
at any time. Abscesses should be opened early and
freely, and injections of iodoform emulsion w T ill be
found very beneficial. Laminectomy is sometimes ad-
visable." — (Pocket Cyclopedia,)
2. Intussusception occurs most frequently in child-
hood, is accompanied with tenesmus and frequent
diarrhea with passage of bloody mucus, the body tem-
perature is normal or subnormal, the pulse is weak,
the trouble is in the small intestine, and the bowel
frequently protrudes at the rectum.
Appendicitis generally occurs in early adult life,
there is no tenesmus, the stools are infrequent, there
is moderate fever, 102° to 103° F., the pulse is of good
volume, pain is located in the right iliac fossa, and
there is dullness on percussion in this region.
Treatment of intussusception: — "The reduction of
the intussusception at the earliest possible moment is
the only treatment admissible, and this can only be
done with certainty by operation. The abdomen should
be opened over the tumor if it can be felt; if not, in
the mid-line below the umbilicus. The intussuscep-
tion is then reduced by squeezing out the entering por-
tion, beginning at the lowest part. The intestine
should never be pulled out, for fear of tearing it. If
there is any difficulty, the wound must be enlarged and
the lump brought out. If, owing to adhesions, reduc-
tion cannot be done, the intussuscepted portion must
be excised through an incision in the ensheathing layer,
but the outlook is bad in these cases. If the bowel is
gangrenous, the condition is so bad that nothing more
can be done than to bring out the coil and establish an
artificial anus. If, owing to any reason, an operation
is not possible, non-operative procedures must be tried.
These consist of attempting to reduce the invagina-
tion by inflation with air, or, better still, by fluid.
A catheter is passed into the rectum, and fluid poured
in from a funnel raised not more than two feet. A
hand is placed over the tumor to feel when the lump
disappears. The objections to this are, that after
twelve hours reduction cannot be obtained by this
method; that valuable time is wasted if it fails;
that you cannot tell if the last inch has been reduced
(and if it has not, recurrence is certain) ; that it is
no use in the enteric or ileo-colic forms; and that the
bowels may be ruptured." — (Aids to Surgery,)
71
MEDICAL RECORD.
3. Acute ischio-rectal abscess is due to infection of
the fat of the isehio-rectal fossa with pyogenic organ-
isms. It occasionally results from skin infection, but
usually spreads from the rectum. The mucous mem-
brane is abraded by a constipated motion, and the
Bacillus coli then invades the wall and spreads to
the fossa. A fish bone or pin occasionally causes the
wound in the rectum. An abscess forms alongside the
rectum, and may burst into the rectum, on the sur-
face, or both, a fistula being likely to follow. Treat-
ment: — A free incision should be made at once, open-
ing up every part of the abscess, including the com-
munication with the bowel if it can be found. Cel-
lulitis of a gangrenous type may also occur, and must
be promptly treated by free incisions and stimulants.
Chronic ischio-rectal abscess is met with in phthisical
patients. A caseating focus is found in the fossa,
which breaks down and discharges by several sinuses,
which may be at a distance from the anus. Treatment
consists of a free incision, scraping out the tuberculous
area, and applying pure carbolic acid.
4. "Splenectomy has been performed for: — Injuries;
spontaneous rupture in typhoidal and other splenic
enlargements; splenoptosis; abscess; tumors, which
are rare, the most frequent being sarcoma; cysts,
hemorrhagic, serous, lymph, or most frequently hy- •
datid; malarial hypertrophy; idiopathic splenomegaly;
splenic anemia, in which there is enlargement of the
spleen, with diminution in the number of white and
red blood cells, and a reduction in the percentage of
hemoglobin; Banti's disease (hypertrophy, with cir-
rhosis of the liver) ; and certain other affections, such
as tuberculosis, syphilis, and amyloid disease. The
operation is contraindicated in leukemia and in the
presence of marked cachexia and dense universal ad-
hesions. An incision is made in the left semilunar
line, the phrenosplenic ligament tied and divided, the
spleen delivered through the wound, and each vessel of
the pedicle severed between ligatures." — (Stewart's
Surgery.)
5. Pathogenic microorganisms which cause wound in-
fections .—Staphylococcus pyogenes aureus, albus, and
citreus; streptococcus pyogenes gonococcus; pneumo-
coccus; bacillus coli communis; tubercle bacillus ;' ac-
tinomyces; and anthrax bacillus.
Treatment of infected wound of soft parts. The
wound is covered with gauze while the skin around it
is cleaned up to the edge; the wound is held open and
enlarged if necessary; it is flushed with sterile water
72
ARKANSAS.
and with an antiseptic lotion; bleeding is checked; for-
eign matter is removed; loosely attached or crushed
tissues are snipped off; pockets where dirt, blood, or
bacteria might lodge are opened; the wound is then
packed with antiseptic gauze and left open (or closed
with temporary sutures). The packing is removed in
three days, when stitches may be tightened; where
there is a thick discharge, moist dressings should be
applied, but they must be frequently changed; drain-
age is necessary.
6. Delayed union in fracture is caused by: — 111
health, want of approximation of the end of the bone,
want of blood supply in the bone, defective innerva-
tion of the bone, disease of the bone, lack of rest, and
immobility.
Delayed union is detected by finding movement of
the fragments after the recognized period for such
union (in case of humerus or tibia this is six or seven
weeks).
Treatment is given by DaCosta as follows: — "When
delayed union exists, seek for a cause and remove it,
treating constitutionally if required, and thoroughly
immobilizing the parts by plaster. Orthopedic splints
may be of value. Use of the limb while splinted, per-
cussion over the fracture, and rubbing the fragments
together, thus in each case producing irritation, have
all been recommended. Blistering the skin with iodine
or firing it has been employed. If the case be very long
delayed, forcibly separate the fragments and put up in
plaster as a fresh break. If these means fail, irritate
by subcutaneous, drilling or scraping, or, better, by
laying open the parts and then drilling and scraping at
many places."
7. Penetrating wounds of joints:— If the wound is
aseptic, only a small amount of inflammation follows;
if septic, acute arthritis develops. If glairy synovial
fluid is seen escaping from the wound, it is certain
that the joint is opened; if it is doubtful as to whether
or not a wound leads into the joint, the skin should be
purified, the opening enlarged, and a careful examina-
tion made to settle the point. If the joint is opened,
the aperture should be enlarged, the joint washed out,
and drained with a rubber tube, which can be removed
in a day or two if no septic inflammation supervenes.
8. "The decompression operation (decompressive
trephining) : — This operation is employed particularly
in cases of inoperable brain tumor. It differs from
palliative trephining in the fact that the dura is in-
cised and an opening left to permit of bulging of the
73
MEDICAL RECORD.
brain. The bulging relieves pressure. By Cushing's
method we get a hernia of the brain, but not a fungus
cerebri. Cushing and Bordley have performed it in
cases of uremia, and improvement has followed. They
suggest that the operation be used in certain cases oi
renal disease when medical treatment and lumbal
puncture have failed to abate uremic symptoms, or
when blindness is impending. The effect of the opera-
tion in cases of brain tumor is sometimes extraor-
dinary. Its most prominent benefit is in abolishing
choked disk. It must not be done directly over a tumor,
because the bulging tumor might become the seat of
hemorrhage. It is, of course, useless in relieving
blindness, for blindness means atrophy, but it is often
very valuable in preventing blindness. When choked
disk exists, operation should be done early, even if
there is good vision. If in advanced cases any sight
remains, it should be performed. Now and then there
is an unfavorable result, which was good previous to
operation. The permanence of the relief to the choked
disk is variable. It is not always permanent. Cush-
ing's subtemporal decompression is done upon the righi
side as a rule, but in some cases on the left side. An
objection to doing it on the left side is that the bulg-
ing of the left temporal lobe may cause word deafness.
A curved incision is made through the skin and sub-
cutaneous tissue, the flap is turned down, the tem-
poral fascia is incised in the direction of the muscle
fibers beneath it, the temporal muscle is split and
not cut, the periosteum is separated from the bone,
the soft parts are retracted, the boije is opened as the
surgeon prefers, and the opening is enlarged with a
rongeur. The dura is opened, and radiating incisions
are made through it toward the edges of the bone gap.
The wound is closed by four layers of fine silk sutures."
— (DaCosta's Surgery.)
9. Chronic osteow/yelitis "follows an acute attack, or
begins of itself. In the former case, after pus obtains
exit, a slow, rarefying, and at the same time osteo-
plastic, inflammation continues for months. The
sinuses discharge thin pus, and at times particles of
necrosed bone; but they may at intervals become
blocked by exuberant granulations, or dried pus, when
a sharp pain ensues in the bone, accompanied by
feverish symptoms. Any injury may set free bacteria
from the granulations, and cause local cellulitis. Mean-
while the bone becomes irregularly thickened, either
at one spot, or all over. The other form often begins
with a short acute stage, which may be altogether over-
looked. It may not show itself for years, and then
74
ARKANSAS.
commences with aching in the bone. There is usually
unnatural thickness of the bone, and this becomes more
marked in one place, and an abscess may be formed
in the soft tissues. It takes three forms — (1) central
necrosis; (2) localized abscess; (3) sclerosing osteo-
myelitis, without suppuration.
Treatment consists in removal of sequestra (seques-
trotomy) and suppurative centers. The limb is made
bloodless; an incision is carried down to the bone,
and the periosteum stripped back; a wide layer of
new-formed bone is chiselled off, and the cavity laid
bare. The sequestrum is removed, and the cavity
scooped out with a sharp spoon. Healing takes place
slowly by granulations under simple tamponade; and
in order to hasten it, the wound may be closed with a
flap of skin loosened from the sides while the cavity
may be filled up with blood clot, or with iodoform
paste (iodoform, 60, sesame oil, 40, spermaceti, 40),
which are ultimately absorbed, and replaced by new-
formed bone. For the same purpose, the periosteum
may be left in contact with the cortical layer, which is
chiselled off as an osteoplastic flap, and is replaced
in position, after the cavity is cleared out; or a piece
of living, or decalcified, bone may be engrafted." —
(Buchanan's Surgery.)
Amyloid, kidney may occur in cases of long-con-
tinued suppuration of bone. The treatment lies in the
early treatment of the primary condition, and, besides
the recognized surgical measures, includes fresh air,
sunshine, nourishing food, tonics; iron, arsenic, potas-
sium iodide and bismuth are often of service.
10. Ligation of common carotid artery in superior
carotid triangle:— Make an incision three inches long
in the line of the artery (from the sternoclavicular ar-
ticulation to a point midway between the angle of the
jaw and the mastoid process), so that the center of the
incision is on a level with or very little higher than the
cricoid cartilage. This incision goes through the skin,
superficial fascia and platysma. The deep fascia is
then cut through, and the edge of the sternomastoid
is exposed, and then drawn outward. The omohyoid
is then exposed by cutting through a dense fascia.
Here there is usually a plexus of veins in front of the
artery. Draw aside the lateral lobe of the thyroid
body, and look for the deep guide to the vessel, namely
the angle formed by the anterior belly of the omohyoid
with the anterior border of the sternomastoid (the
artery bisecting this angle) . Draw the omohyoid down-
ward, and then expose the sheath so that the descendens
75
MEDICAL RECORD.
hypoglossi nerve and the sternomastoid branches of the
superior thyroid artery are not injured. The sheath
is opened on its tracheal side; then clear the artery
and pass the needle from the outer side to avoid the
risk of wounding the internal jugular vein and vagus
nerve.
Complications which may arise from ligation: —
Twitchings, tremblings, convulsions, syncope, giddi-
ness, loss of sight, hemiplegia all probably due to di-
minished supply of arterial blood. Softening of the
brain, stupor, and apoplexy may occur from venous
congestion; the lungs may become congested; death
may occur from cerebral disease due to sudden inter-
ference with the cerebral circulation.
HYGIENE.
1. Excessive weeds arid shade about a dwelling keep
out sunshine and fresh air, favor dampness and the*
multiplication of molds and bacteria, and aid in har-
boring insects, mosquitoes, etc. Vegetation prevents
the sun's rays from reaching the ground, so excess
of weeds makes the climate lass equable and the soil
more damp, and at the same time restricts the' move-
ments of the air.
2. Pure water is colorless, odorless, cool, without dis-
agreeable or salt or sweetish taste, and is free from
bacteria, poisons, foreign bodies, etc.
Characteristics of a good drinking water: — (1) It
should be clear and limpid. Cloudy and muddy waters
should be avoided. (2) It should be colorless. A
greenish or yellowish color is usually due to vegetable
or animal matter in solution or to organisms, (3) It
should be odorless; especially free from sulphuretted
hydrogen or putrefactive animal matter. (4) It should
not be too cold, but should have a temperature of
from 46°F. to 60° F. (5) It should have an agreeable
taste; neither flat, salty, nor sweetish. A certain
amount of hardness and dissolved gases give a spar-
kling taste. It should contain from 25 to 50 c.c. of
gases per liter, of which 8 to 10 per cent, is carbon
dioxide and the rest oxygen and nitrogen. (6) It
should be as free as possible from dissolved organic
matter, especially of animal origin. (7) It should not
contain too great an amount of hardness. A certain
quantity of saline matter is necessary, however, to give
it a good taste. It should not contain over three or
four parts of chlorine in 100,000 parts of water.—
(From Bartley's Chemistry.)
Contaminated water is purified by: — Distillation,
76
ARKANSAS.
boiling, filtration, precipitation, and various chemical
processes.
In collecting and storing rain water for drinking:
The first flow should be allowed to run to waste; this
is to ensure cleanliness. The cisterns for storage
should allow of easy inspection and cleansing; they
should be kept covered so as to exclude dirt, dust, in-
sects, animals, and light overflow pipes should dis-
charge into the open air and not into the sewer, and the
opening should be covered to keep out small animals
and foreign matter; the cisterns should be well ven-
tilated, and regularly and thoroughly inspected.
3. The water must be' the purest obtainable, and
fixtures must be as simple as is compatible with effi-
ciency. There must be no public or stationary drink-
ing cups; paper cups are the best. There must be no
means, of drinking direct from the faucet. There must
be no means of interfering with the water supply or
with the proper care of fixtures, etc. There must be
proper and constant inspection to see that there is no
undue waste of water, and that everything is as clean
as possible.
4. Five preventable diseases: — (1) Smallpox, which
can be prevented by compulsory vaccination and prompt
isolation of all cases; (2) malaria, which can be pre-
vented by the destruction of anopheles mosquitoes and
their breeding places; (3) bubonic plague, which can
be prevented by the complete destruction of rats; (4)
Malta fever, which can be prevented by avoiding the
milk or meat of goats imported from the Mediter-
ranean countries or from the endemic center in
Texas; (5) hydrophobia, which can be prevented by
the long-continued and systematic muzzling of all dogs.
5. (a) The negro is comparatively insusceptible to
yellow fever and dysentery, (b) The negro is more
suceptible than the whites to tuberculosis, venereal
diseases and keloids. The reason for (a) is prob-
ably an acquired immunity. The reason for (b) is
probably lessened resistance and lowered vitality com-
bined with inferior hygienic surroundings.
6. In the cold weather there are greater and more
frequent changes of temperature, and ventilation is
poorer; hence the vitality of the body is lowered, and
there is a greater liability to take disease.
7. During an epidemic of poliomyelitis, "the patient
must be isolated except for the necessary attendance;
he must also be screened from flies. All utensils com-
ing in contact with the patient's mouth must be im-
mediately disinfected. All nasal or buccal secretions
77
MEDICAL RECORD.
must be immediately destroyed by burning or by effi-
cient chemical germicides. The physical condition of
other members of the family must be carefully looked
after. The case must be reported at once to the author-
ities, who will see that the latest information is placed
in the hands of the physician. Both the profession
and public must be educated to a knowledge of the
dangerous infectiousness of the disease."— (Gardner
and Simonds* Practical Sanitation.)
8. In pellagra: — Spoiled corn should be avoided, and
the corn should be replaced by other grains ; salt should
be given with the food; rest is necessary; diet must be
nutritious and properly balanced; eggs and milk are
valuable, but a milk diet is not recommended; hydro-
therapy, massage, and fresh air are valuable ; if pos-
sible, a trip to a cool climate should be advised. Ice
applications have proved beneficial.
9. Ptomaines are derived from protein matter (by
the action of bacteria). Disorders produced by them
are intestinal intoxication; food poisoning (canned
meats, sausages, decomposing fish, cheese, ice-cream,
and milk) ; gangrene.
10. Diet presents a serious problem. Prolonged heat
exerts an unfavorable influence on digestion* hence too
much of a burden should not be placed on the digestive
system. No more food should be taken than can be
comfortably digested. Vegetables and fruit are prefer-
able to meat; the latter should be taken only once a
day; fish, if fresh, is good; the same applies to milk.
Fruit should be quite ripe, and sound. Cold tea or lime-
juice makes a refreshing beverage. Pure water is
the best thing to drink. Alcohol should be let alone,
or taken only if there is a distinct indication for it,
and then only with food.
STATE BOARD EXAMINATION QUESTIONS.
Board of Medical Examiners, State of California.
anatomy and histology.
1. (a) What structures are derived from the epi-
blast; hypoblast; mesoblast? (b) Simple tissues of the
human body may be divided into five classes. Name and
define each class.
2. Briefly describe the heart; location; relation to
chest wall and vertebrae; composition and arrangement
of walls; nerve and blood supply; valves and endo-
cardium.
78
CALIFORNIA.
-~"&. Describe the mandible (inferior maxillary bone).
4. Give the histology of lung tissue.
5. Briefly describe the ovary. Give its relations;
blood and nerve supply. Define ovulation; graafian
follicle; corpus luteum.
6. If the abdominal aorta be ligatured two inches
superior to its bifurcation, how may a collateral circu-
lation be re-established below the ligature?
7. Describe the hip joint, naming muscles passing
across the joint.
8. Differentiate bursa mucosa and bursa synovial.
Locate five important examples of each kind.
9. Name and locate the ganglia that communicate
with the branches of the fifth cranial nerve ; give the
anastamoses of the branches of the first and second
divisions of the fifth cranial nerve.
10. Give the insertion and nerve supply of the follow-
ing muscles; soleus; tibialis postius; pronator radii
teres; scalenus anticus; quadratus femoris; biceps
femoris; sartorius; obturator internus; platysma;
temporal.
11. Give the origin and nerve supply of the following
muscles; trapezius; gastronemius ; latissimus dorsi;
biceps cubiti; sterno mastoid; omo-hyoid; pectoratis
minor; brachio-radialis ; rectus femoris; internal
oblique.
12. Give the action of any ten muscles of the fore-
going groups.
Answer ten questions.
PHYSIOLOGY.
1. Describe how the distribution of blood is regulated
on change of position.
2. Explain the influence of the vagus nerve on res-
piration.
3. In what does the peristalsis of the esophagus differ
from other parts of the alimentary canal?
4. How do the movements of the large intestine differ
from those of the small intestine?
5. Discuss causes, mechanical and nervous, in the call
to defecation.
6. Why is it that living tissue resists many influences
which attack dead tissue with disastrous effect?
7. Discuss the maintenance of the rhythmical beat of
the heart.
8. Describe by diagram and text the growth and de-
velopment of a nerve cell.
9. What effect will transfusion of. a moderate amount
of fluid have upon the blood pressure? Explain why.
79
MEDICAL RECORD.
10. Why do we not have coagulation of blood within
the living vessels?
11. Outline a normal pulse tracing and explain the
elevations and their relations.
12. Explain how the blood retains its alkalinity
against an excessive acid diet.
Answer ten questions only.
MATERIA MEDICA, THERAPEUTICS, PHARMACOLOGY AND
PRESCRIPTION WRITING.
1. Write a complete prescription for a 120 c.c. soln.
containing tincture of nux vomica (0.5 c.c. to the dose)
for internal use, and describe the therapeutic indica-
tions and the contraindications for the same.
2. Discuss the medical treatment of constipation in a
woman fifty years of age.
3. Give the dosage of strychnine sulphate and of
opium and discuss the action of each on the alimentary
tract.
4. Discuss the dosage and mode of using calcium in-
ternally and its therapeutic action.
5. Discuss the dosage, modes of administration and
therapeutic action of sodium phosphate.
6. Discuss fully the precautions to be taken in the
use of mercury in the treatment of syphilis.
7. Discuss the general principles that should guide
one in the therapy of typhoid fever.
8. Discuss the treatment of ancylostomiasis (un-
cinariasis), also the prophylaxis.
9. Discuss the therapy of rabies.
10. Discuss the medical treatment of diabetes mel-
litus.
11. Discuss the medical and dietetic treatment of
early arteriosclerosis.
12. Discuss the therapy of mercurial stomatitis.
Answer ten questions only.
CHEMISTRY AND TOXICOLOGY.
1. (a) What is organic chemistry: (b) What are
the general characteristics of organic compounds?
2. Name the principal derivatives of hydrocarbons.
3. Give general characteristics of metals of the iron
group.
4. What does illuminating gas contain generally, and
why is it toxic?
5. Give by volume, by weight, and by molecular
weight, the components of water.
6. Write equation- showing action of sulphuric acid
on sodium chloride.
80
CALIFORNIA.
7. Give a test for sulphuric acid in vinegar.
8. Name five elements used in pure state in medicine.
9. What is the chemical treatment for creosote
poisoning?
10. Mention antidotes for iodine poisoning.
11. Give a test for determining the presence of strych-
nine.
12. What metallic chemical substances are found in
the body?
Answer ten questions only.
BACTERIOLOGY AND PATHOLOGY.
1. Define three varieties of cysts and give an example
of each.
2. What forms may hemorrhage take and what is
the fate of the effused blood?
3. What are ptomaine, toxalbumin, leucomaine?
4. Discuss arrhythmias of the heart, with special
reference to heart block and fibrillation.
5. What is a parasyphilitic condition?
6. Of what help is embryology in the study of path-
ological conditions of the male genital tract?
7. Mention four diseases of protozoan origin and give
short description of the causal organisms.
8. Discuss serum sickness.
9. Discuss chromogenic bacilli.
10. Discuss artificial immunization against typhoid
fever and smallpox.
11. Discuss the pneumococcus of Frankel and the
pneumobacillus of Friedlander.
12. Differentiate gonococci from other cocci in pus
from the urethra.
Answer ten questions only.
GENERAL MEDICINE.
1. What are the causes of hemorrhoids? Tell how
the causes named produce them.
2. What complications may develop during or fol-
lowing acute gonorrheal urethritis?
3. Discuss empyema.
4. Upon what would you base a diagnosis of a tumor
of the cerebellum?
5. Discuss tuberculosis of the spine.
6. Describe an attack of acute lobar pneumonia.
7. Describe the lesion of secondary syphilis.
8. Differentiate chancre, chancroid and herpes. When
would you consider the case with the chancre cured?
9. What is the significance of a systolic blood pressure
of 165 in a man of fifty? What should be done for him?
81
MEDICAL RECORD.
10. Diagnose and treat a case of acute anterior polio-
myelitis.
11. Give etiology and treatment of a case of la
grippe.
12. What is the significance: (a) of a tarry stool;
(b) a clay colored stool; (c) a greenish frothy stool;
(d) a hard lumpy stool?
Answer ten questions only.
OBSTETRICS AND GYNECOLOGY.
1. Describe syphilitic ulcer of the cervix uteri.
2. Give causes and treatment of cervical stenosis.
3. Discuss the merits of cesarean section compared
with other methods of relieving dystocia.
4. Describe the operation of csesarean section.
5. What structures are divided in a complete lacera-
tion of the perineum? Describe in full operation for
repair. •
6. (a) Discuss non-specific cystitis in its relation to
gynecology, (b) Discuss constipation in Its relation to
gynecology.
7. Give treatment of severe erosion and eversion of
cervix with excessive mucopurulent discharge in woman
pregnant at three months.
8. (a) Describe the fetal circulation and indicate
changes occurring at birth, (b) What is a blue baby?
9. Give preventive treatment of: (a) Mastitis ;
(6) Ophthalmia neonatorum; (c) Puerperal infection;
(d) Postpartum hemorrhage.
10. Gives differential diagnosis of pregnancy and dis-
tention of uterus due to retained menses.
11. When and how would you employ the following
drugs in labor; Ergot, pituitrin; quinine; scopolamine;
lobelia; gelsemium.
12. (a) When first consulted by a primipara, what
should be the scope of your examination: (6) Why
should an examination be made six to eight weeks fol-
lowing delivery.
Answer ten questions only.
SURGERY.
1. Describe in detail treatment of lacerated wound of
scalp involving periosteum, and discuss possible dangers
of improper treatment
2. What are the most important factors concerned in
extensive postoperative thrombosis and embolism? Dis-
cuss the precautionary measures suggested for their
prevention.
3. Classify ileus. Give symptoms and treatment.
82
CALIFORNIA.
4. Give some of the causes of delayed union in frac-
tures and the treatment you would adopt for each of
these causes.
5. Give indications for paracentesis membrani tym-
pani. Describe operation in detail. What structures
should be especially avoided.
6. Describe in detail and give method of reduction of
backward dislocation of the thumb at the metacarpo-
phalangeal joint.
7. How would you treat a penetrating wound of the
:-ornea with incarceration of the iris?
8. Discuss hydronephrosis. Give treatment.
9. Discuss retropharyngeal abscess. Give treatment
in detail.
10. Give symptoms and signs of malignancy of mam-
mary gland. Give surgical treatment in detail.
11. Give causes and symptoms of fracture of base of
skull.
12. Give etiology, pathology, symptoms, differential
diagnosis and treatment of acquired fiat-toot.
Answer ten questions only.
HYGIENE AND SANITATION.
1. Discuss the sanitation of an encampment of five
thousand soldiers.
2. Define humidity of the atmosphere. What classes
of diseases are most prevalent in a humid atmosphere?
3. What measures should be used on shipboard, or in
camp, to eradicate scurvy?
4. What is sewer gas? How does the inhalation of
sewer gas affect the system?
5. Discuss the agency of ptomaines in inducing
diseases.
6. Name and describe the methods of five important
infections and contagious diseases.
7. Discuss the prophylaxis of typhoid fever.
8. Give the medical and hygienic plan for the inspec-
tion and care of immigrants arriving at a seaport.
9. Discuss the theory of hereditary tendencies as ap-
plied to tuberculosis.
10. Describe the best method for eradication of hook-
worm from a community.
11. Give the prophylaxis of filth diseases.
12. Discuss the care of milk from dairy to customer.
Answer ten questions only.
MEDICAL RECORD.
ANSWERS TO STATE BOARD EXAMINATION
QUESTIONS.
Board of Medical Examiners, State of California.
anatomy and histology.
1. From the epiblast are derived: The skin and its
appendages (hair, nails), and its glands (including the
mammary glands) ; the nervous system (brain, spinal
cord, ganglia, and nerves) ; the epithelial parts of the
organs of special sense.
From the hypoblast are derived: The epithelial lin-
ing of the alimentary canal and its glands ; the epithelial
lining of the respiratory tract, Eustachian tube, thyroid
and thymus.
From the mesoblast are derived: The skeleton; con-
nective tissue; muscles and bones; heart, bloodvessels,
lymphatics and spleen; the urinary and generative
organs.
The tissues are : Epithelial, connective, muscle, nerve,
and blood.
Epithelium consists of cells placed on free surfaces
with very little intercellular substance.
Connective tissue is a general name given to several
forms of tissue which support and connect the other
tissues of the body; it is composed of cells and inter-
cellular material.
Muscle consists of cells and fibres which can con-
tract; three kinds are recognized: visceral, skeletal
and cardiac.
Nervous tissue consists of nerve cells and fibres; the
cells originate or receive nerve impulses and the fibres
transmit the same.
Blood is a tissue in which the intercellular substance
is fluid; the cells are of three kinds: Erythrocytes,
leucocytes, and blood-plates.
2. The heart is located obliquely in the thorax, be-
tween the lungs, and enclosed in the pericardium. A
line from the lower border of the second left costal
cartilage (one inch from sternum) to upper border of
third right costal cartilage (half inch from sternum)
represents the base line; the right side will be a line
drawn from right side of upper limit to seventh right
chondrosternal articulation; the lower limit is a line
from this last point to the apex (in fifth intercostal
space three and one-half inches from mid-line) ; the.
left side from left end of upper border to left of apex.
The heart lies opposite the fifth, sixth, seventh and
eighth dorsal vertebrae.
84
CALIFORNIA.
The aortic valves are behind the third intercostal
space close to the left side of the sternum. Pulmonary
valves in front of the aortic, behind the junction of the
third rib, on the left side, with the sternum. Tricuspid
valves, behind the middle of the sternum, about the level
of the fourth costal cartilage. Mitral valves behind the
third intercostal space, about one inch to the left of the
sternum.
Its walls consist of muscle fibers, with some con-
nective tissue to which many of the fibres are attached
The heart is divided by a septum into a left and right
heart; and each side is further divided into an upper
chamber (auricle) and a lower chamber (ventricle),
connected with valves so arranged that circulation of
the blood only occurs in one direction. In the right
auricle are the Eustachian and coronary valves; the
former is situated between the anterior margin of the
inferior vena cava and the auriculo-ventricular orifice.
In the right auricle are also found the openings of the
superior and inferior venae cavae, coronary sinus, fora-
mina of Thebesius, the auriculo-ventricular opening, the
fossa ovalis, annulus ovalis, tubercle of Lower, and the
musculi pectinati. In the right ventricle are the tri-
cuspid and semilunar valves; also the columnae carneae,
chordae tendineae and the auriculo-ventricular opening
and the opening of the pulmonary artery. In the left
ventricle are the mitral and semilunar valves, the
columnar, chordss tendinege, and the aortic and auriculo-
ventricular opening. The heart is about 5 x 2% x 3%
inches, and weighs about ten ounces. It is supplied
with blood by the right and left -coronary arteries.
The nerve supply is from the superficial and deep
cardiac plexuses, and from the vagus and sympathetic
system. The endocardium is a thin translucent mem-
brane, consisting of a lining of endothelial cells which
rest upon a fibroelastic tissue. The endothelial cells
are flattened and nucleated, and are of an irregular
outline. The subendothelial tissue consists of a net-
work of white fibrous and yellow elastic tissues. A few
involuntary muscle fibers (non-striated) may also be
present.
3. The mandible consists of a body and two rami.
The body is horse-shoe shaped and contains the lower
teeth; externally it presents the symphysis, mental
process, mental foramen, incisive fossa, and external
oblique line; internally it presents the four genial tu-
bercles, sublingual fossa, internal oblique line, submaxil-
lary fossa. The alveolar border has sixteen cavities
for teeth. The ramus is quadrilateral, and presents the
85
MEDICAL RECORD.
inferior dental foramen and a spine. Above it has. the
coronoid and condyloid processes, separated by the
sigmoid notch. The muscles attached are: Levator
menti, depressor labii inferioris, depressor anguli oris,
platysma myoides, buccinator, masseter, orbicularis
oris, geniohyoid, geniohyoglossus, mylohyoid, digastric,
superior constrictor of pharynx, temporal, internal and
external pterygoids.
4. The histology of lung tissue: "In the lungs the
bronchi branch in a tree-like manner, the final ramifi-
cations opening into the pulmonary cells. The larger
intrapulmonary bronchi are lined by columnar ciliated
epithelium resting on a basement membrane. Lying
under this basement membrane are longitudinally
disposed elastic fibers with loose connective tissue.
More externally is a layer of smooth muscle fibers ar-
ranged circularly, the bronchial muscle. External to
the bronchial muscle is a fibrous coat containing scat-
tered, irregular plates of hyaline cartilage. The smaller
bronchi (bronchioles) have no cartilaginous plates, but
their muscular coat is well marked. Each bronchiole
leads into a small number (three or four) of wider
thin-walled spaces, lined by flattened epithelium, and
called atria. Out of each atrium open two or three
blind diverticula, each of which is called an infundibu-
lum. The walls of the infundibula are studded with
hemispherical sacs known as alveoli, which are lined
by flattened, non-nucleated, epithelial cells. Between
adjacent alveoli there is a dense network of capillaries,
supported by a small amount of fine connective and
elastic tissue; the network of capillaries is thus com-
mon to the two adjacent air cells, and the blood in the
capillaries is separated from the air in the alveoli
merely by two thin layers of epithelium. In birds, even
the alveolar epithelium appears to be absent, the blood
and air being separated solely by the capillary wall. ,,
(Bainbridge and Menzies', Essentials of Physiology.)
5. The ovaries are two in number, and correspond to
the testes in the male; they are of a flattened ovoid
form, vertically placed in the posterior part of the broad
ligament. By its anterior border the ovary is connected
to the broad ligament, and by its lower pole to the
uterus by a proper ligament, extending to the superior
angle of the uterus, and called the ligament of the
ovary. The lateral surfaces and posterior borders are
free. The superior pole and posterior border are em-
braced by the Fallopian tube; on its inner surface it
is in relation with small intestine in Douglas* pouch,
and externally lies in a peritoneal fossa between the
CALIFORNIA.
external and internal iliac vessels as they diverge. The
vessels enter the hilum at the attached anterior border.
— (Aids to Anatomy,) The arteries are the ovarian,
from the aorta; the nerves are from the ovarian
plexus and the aortic plexus.
Ovulation is the escape of a ripe ovum from a
Graafian follicle.
Graafian follicle is a spherical body or vesicle, found
in the outer part of the ovary, and which contains the
matured ovum.
Corpus luieum is the scar on the surface of the ovary
which marks the site of a ruptured Graafian follicle.
6. After ligation of the abdominal aorta, the col-
lateral circulation is carried on by: (1) Internal mam-
mary with deep epigastric; (2) internal mesenteric
with internal pudic; (3) if above the inferior mesen-
teric, by superior mesenteric with inferior mesenteric.
7. The hip-joint is an enarthrodial joint, formed by
the head of the femur and the acetabulum. The artic-
ular surfaces are covered with cartilage. Near the
center of the head of the femur is attached the liga-
mentum teres. The ligaments are: (1) The capsular,
which embraces the margin of the acetabulum above,
and the neck of the femur below. (2) The ileofemcral
or Y ligament, which passes obliquely across the front
of the joint, and is attached above to the anterior
inferior spine of the ilium, and below to the anterior
intertrochanteric line. (3) The ligamentum teres. (4)
The cotyloid ligament, which deepens the acetabulum,
and bridges over the cotyloid notch, being there called
(5) the transverse ligament. The joint has a very ex-
tensive synovial membrane. It is capable of the follow-
ing movements: Flexion, extension, abduction, adduc-
tion, circumduction, and rotation.
The muscles in immediate relation with the capsule
are: (1) Above, the rectus femoris and gluteus mini-
mus; (2) in front, the iliopsoas; (3) on inner side, the
pectineus and obturator externus; (4) behind, the
pyriformis, obturator internus, two gemilli, obturator
externus, gluteus minimus and quadratus femoris.
Synovial bursas and bursse mucosas are identical.
Five examples: Suprapatellar bursa, ischiogluteal
bursa, olecranon bursa, bursa of tendo Achillis, and
prepatellar bursa.
9. Ganglia in connection with the fifth cranial nervei
(1) Gasserian ganglion, situated in Meckel's cave neay
the apex of the petrous portion of the temporal bone;
(2) lenticular ganglion, situated in the back part of
the orbit; (3) Meckel's ganglion, in the sphenomaxil-
87
MEDICAL RECORD.
lary fossa; (4) otic ganglion, situated immediately be-
low the foramen ovale; (5) submaxillary ganglion,
situated above the deep portion of the submaxillary
gland.
Of the first division, the lacrimal inosculates with the
facial; the supratrochlear with theinfratrochlear; the
supraorbital with the facial; the nasal with the facial;
infratrochlear with supratrochlear.
Of the second division, the temporal inosculates with
the facial; the malar with the facial; the posterior
superior dental with the middle superior dental; the
inferior palpebral with the facial and malar; the nasal
with the nasal from the first division.
10 and 12, Soleus; insertion, by tendo Achillis into
posterior surface of os calcis; nerve supply, internal
popliteal and posterior tibial ; action, extends ankle.
Tibialis posticus; insertion, scaphoid, cuboid, cunei-
form, second, third and fourth metatarsals, and sus-
tentaculum tali; nerve supply, posterior tibial; action,
extends ankle, flexes tarsal joints, and inverts foot.
Pronator radii teres; insertion, middle of outer sur-
face of radius; nerve supply, median; action, flexes
elbow and pronates forearm.
Scalenus anticus; insertion, scalene tubercle on
upper surface of first rib; nerve supply, branches of
lower cervicals; action, raises ribs, flexes spine, and
bends neck to same side.
Quadratus femoris; insertion, posterior intertro-
chanteric ridge and below on shaft of femur as far as
insertion of adductor magnus; nerve supply, sacral
plexus; action, external rotator and adductor of thigh.
Biceps femoris; insertion, outer side of head of
fibula; nerve supply, great sciatic; action, flexes knee,
extends thigh and rotates leg outward.
Sartorius; insertion, inner side of upper part of
tibia, by side of tubercle; nerve supply, middle cutane-
ous, or anterior crural; action, flexes hip and knee,
abductor and external rotator of thigh.
Obturator internus; insertion, upper and front
part of great trochanter of femur; nerve supply, sacral
plexus; action, external rotator of thigh.
Platysma; insertion, mandible, and opposite pla-
tysma ; nerve supply, facial ; action, moves skin of neck,
slight depressor of lower jaw.
Temporal; insertion, front and internal surface of
coronoid surface of mandible; nerve supply, inferior
maxillary; action, muscle of mastication, closes mouth,
and protrudes and retracts lower jaw.
11. Trapezius; origin, spinous processes of seventh
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CALIFORNIA.
cervical and all thoracic vertebrae, supraspinous liga-
ment, ligamentum nuchae, and inner third of superior
curved line of occipital bone; nerve supply, spinal ac-
cessory, and cervical plexus.
Gastrocnemius; origin, posterior part of inner
condyle and line above it, and lateral surface of outer
condyle of femur; nerve supply, internal popliteal.
Latissimus dorsi; origin, spinous processes of lower
six thoracic vertebrae, supraspinous ligament, lumbar
and sacral spines, and outer edge of crest of ilium;
nerve supply, long subscapular.
Biceps cubiti; origin, upper border of glenoid cavity
of scapula, glenoid ligament, and apex of coracoid
process of scapula ; nerve supply, musculocutaneous.
Sternomastoid ; origin, upper and anterior part of
manubrium, and inner and upper surface of clavicle;
nerve supply, spinal accessory.
Omohyoid; origin, upper border of scapula behind
the notch, and transverse ligament; nerve supply, first,
second and third cervicals.
Pectoralis minor; origin, outer surface of third,
fourth, and fifth ribs, just external to the costal carti-
lages; nerve supply, internal anterior thoracic.
Brachioradialis ; origin, lower half of outer and
inner surfaces of shaft of humerus, all inner intermus-
cular septum and outer part of outer intermuscular
septum; nerve supply, musculospiral and musculocu-
taneous.
Rectus femoris; origin, anterior inferior spine of
ilium, and groove above the acetabulum; nerve supply,
anterior crural.
Internal oblique; origin, outer half of Poupart's
ligament, anterior % of middle crest of ilium, and
fascia lumborum; nerve supply, lower intercostals and
iliohypogastric.
PHYSIOLOGY.
1. The regulation of the distribution of blood on
change of position is brought about by the vasomotor
system. This system causes a dilatation of the vessels
in those parts requiring more blood and a constriction
of the vessels in those parts requiring less blood.
"2. The vagus nerve contains two sets of fibers; one
set inhibits inspiration and causes expiration and is
stimulated in ordinary inspiration by the expansion of
the lungs; the other set of fibers causes inspiration and
inhibits expiration, and is excited in strong expiration
by collapse of the lungs.
3. Peristalsis in the esophagus is more closely con-
nected with the nervous system than is peristalsis in
89
MEDICAL RECORD.
the intestine; and it can pass over any muscular block
caused by ligature, cutting or crushing, so long as the
nervous connection is not involved. Stimulation of the
mucous membrane of the pharynx will also cause peri-
stalsis in the esophagus.
4. The movements of the large intestines differ from
those of the small intestines mainly in the great fre-
quency of antiperistalsis.
5. Defecation is partly voluntary and partly reflex.
In the infant the voluntary control is not developed,
in the adult it may be lost; it is then reflex. As a
rule the rectum is empty till just before defecation;
at that time the feces descend into the rectum from
the pelvic colon, and their passage from colon to rectum
constitutes the call to defecation. The sensation is
due to distention of the rectum. The descent of the
feces from colon to rectum is due to a reflex peri-
stalsis caused by the taking of food into an empty
stomach or to the muscular activity of dressing. The
sphincters are normally in a state of tonic contraction,
but they are relaxed by the inhibition of a center in
the lumbar enlargement of the spinal cord. This re-
laxation is partly voluntary and partly reflex.
6. Living tissues are protected by the body fluids
(chiefly blood and gastric juice) ; and the acidity of
the urine and of the gastric juice, and the alkalinity
of most of the other secretions aid in protection
against evil influences; the phagocytic action of the
blood is similarly a protection ; the blood and lymph are
bactericidal in their action; the agglutinating action
of the blood is a further protection. The living body
is also capable of producing antitoxins.
7. The rhythmical beat of the heart is probably due
to the inherent rhythmicality in the heart muscle; it
is therefore of myogenic origin, but it starts in the
sinus, where this power is best developed, and the
ventricle responds to the stimulus. That the rhyth-
micity is fiot due to nervous influences is proved by
the fact that in some animals if the heart is excised
the rhythmical beat will still continue for many hours.
8. "The growth of a neuron from origin to comple-
tion is a comparatively slow process in the higher
animals. Early in fetal life (about the third or fourth
week in man) certain round germinal cells make their
appearance amid the columnar ectodermic cells sur-
rounding the neural canal. From their division are
formed, in the first months of embryonic life, the prim-
itive nerve cells or neuroblasts. These soon elongate
and push out processes, first the axon or axons, and
90
CALIFORNIA.
then the dendrites. As development goes on, the cell
body grows larger, and the processes longer and more
richly branched. The axon and its collaterals, when
it has any, in the case of the great majority of the
nervous elements of the brain and cord, ultimately ac-
quire a medullary sheath, although the time at which
medullation is completed varies in different groups of
elements, and in some nervous tracts it is even want-
ing at birth. At birth, too, the branches of many of
the cells are less numerous, and the connections be-
tween different nervous elements therefore less inti-
mate than they will afterwards become. For many
years the processes, and particularly the axons, con-
tinue not only to grow longer, but to grow thicker as
well. The cell body also enlarges, and the quantity
of material in it that stains with basic dyes increases.
The cross section of the axis cylinder is, and remains,
almost exactly equal to the area of the medullary
sheath. Even after puberty is reached the anatomical
organization of the nervous system may continue to
advance, although at an ever slackening rate, and the
finishing touches may only be given to its architecture
in adult life. In old age the nervous elements decay
as the body does. The cell body diminishes in size;
the stainable material lessens in amount ; vacuoles form
in the protoplasm and pigment accumulates ; the nucleus
shrinks; the nucleolus is obscured or may disappear
altogether. At the same time the processes of the cell,
and especially the dendrites, tend to atrophy." — (Stew-
art's Manual of Physiology.)
9. Transfusion of a moderate amount of fluid will
increase the blood pressure, but only for a short time,
owing to the rapid adaptability of the peripheral re-
sistance.
10. Why blood does not coagulate within the living
vessels is a question which has not been settled. It
is believed that the liver cells produce an antibody
called antithrombin; this antithrombin neutralizes the
fibrin enzyme or thrombin which is normally present
in the blood stream and which is an essential factor in
the process of coagulation.
11. "In a normal arterial pulse tracing the ascent
or anacrotic limb is abrupt and unbroken; the descent
or catacrotic limb is more gradual, and is interrupted
by one, two, or even three or more, secondary wave-
lets. The most important and constant of these is the
third one, which has received the name of the dicrotic
wave. Usually less marked, and sometimes absent, is
the second wavelet between the dicrotic elevation and
91
MEDICAL RECORD.
the apex of the curve. It is generally termed the
predicrotic wave. Oscillations, due to vibrations of
the recording apparatus, appear on many pulse trac-
ings, and it is important to recognize their cause, so
that no weight may be given to them." — (Stewart's
Manual of Physiology.)
12. "The reaction of the blood to litmus is alkaline,
but when it is determined accurately in terms of H ion
concentrations, it is found to be almost the same as
that of distilled water. Under various conditions the
reaction may alter slightly, and these changes produce
marked physiological effects in the body, although they
are usually too slight to affect an ordinary indicator,
such as litmus. Further, the presence in blood of
proteins and phosphates makes it possible for a con-
siderable amount of acid or alkali to be added to blood
without any appreciable change being produced in the
H ion concentration. The reason is that the acid or
alkali thus added combines with proteins or phosphates
to form compounds which do not undergo ionic disasso-
ciation, and therefore does not alter the concentration
of H ions by which the reaction of the blood is ulti-
mately determined. For example, NasHPO* can be
partly converted into NaEfcPC^ on the addition of acid,
with little or no alteration in the number of free H
ions present in the solution." — (Bainbridge and
Menzies' Essentials of Physiology.)
MATERIA MEDICA, THERAPEUTICS, PHARMACOLOGY AND
PRESCRIPTION WRITING.
1. I£. Tincture nucis vomicae 16.00 c.c.
Tincturse gentianse composite. 60.00 c.c.
Aquae q.s. ad 120.00 c.c. M.
Sig.: Take one teaspoonful in water, half hour be-
fore meals.
This prescription is intended as a tonic, appetizer,
stimulant, or stomachic.
Nux vomica is particularly employed in conditions
characterized by loss of appetite, indigestion, weak-
ness, and other evidences of lowered vitality. It is
further used in cases of gastric catarrh, constipation,
diarrhea, pneumonia, typhoid, hysteria, anemia and
chlorosis, neuralgia. It is contraindicated in acute in-
flammatory conditions of the spinal cord, and when
there is excessive reflex irritability.
2. Medical treatment for constipation should not be
tried till other means have failed. Good and regular
habits, hygiene, exercise, and diet should all be thought
of and suggested. Then purgatives may be tried, with
the object of unloading the bowel. Rhubarb, castor
92
CALIFORNIA.
oil, mercury, senna, or jalap may be given. To cure
the tendency to constipation, cascara, sodium phos-
phate, manna, aloes, and podophyllin have been recom-
mended. All drugs of this type lose their efficacy
after a time, and the dose has to be increased. The
compound cathartic pill and vegetable cathartic pill
are useful. Enemata of soap and water, with a little
turpentine or olive oil, have proved beneficial.
3. Dose of strychnine sulphate is 1/40 grain.
Dose of opium is 1 grain.
Strychnine increases the peristaltic action of the
intestines, is a stomachic tonic, improves the appetite,
aids digestion, stimulates the flow of saliva and in-
creases the flow of gastric juice.
Opium checks the secretion of saliva and the flow
of gastric juice, diminishes the secretion of bile and
pancreatic juice, lessens peristalsis and impairs diges-
tion. Very large or very small doses, however, are
said to increase peristalsis.
4. Calcium itself is not used in medicine. Calcium
bromide is used as a nerve sedative, in doses of 30
grains. Precipitated calcium carbonate is an antacid
and mild astringent, and is used in cases of gastric
acidity, and for controlling diarrhea; dose 20 grains.
Calcium chloride is used in cases of rickets, glandular
enlargement, lupus, purpura, hemophilia and tubercu-
lous conditions; dose 20 grains. Calcium hyphophos-
phite is said to be a stimulant of nerve tissue; it is
used in the treatment of rickets, osteomalacia, tuber-
culosis, ununited fractures; dose 8 grains. Calcium
phosphate is used as a feeble antacid, also in cases of
rickets, ununited fractures, dental caries; dose 20
grains. Calcium oxide is used as an antacid and in
cases in which bone salts are deficient; it is added to
cow's milk to make it more digestible and less inclined
to curdle in the stomach. Chlorinated lime is used for
stomatitis and as a gargle for putrid sore throat; dose
2 grains. Calx sulphurata is used for boils and acne;
dose 20 grains.
5. Sodium phosphate is used as a saline laxative in
20 to 30 grain doses, with plenty of water. It is also
said to be useful in cases of gallstones and diseases
of the liver, as well as in nervous diseases.
6. Precautions to be taken in administer big mer-
cury: "Owing to the marked tendency of mercury to
produce stomatitis, the greatest care should be exer-
cised in the hygiene of the mouth. Before beginning
the administration of this drug the patient should be
sent to a competent dentist and have his teeth treated,
93
MEDICAL RECORD.
including the filling of cavities, the removing of old
stumps, and a thorough cleansing. If pyorrhea exists,
it should be determined by microscopical examination
if the endamoaba huccalis is present, and if so some
emetine should be administered. During mercurial
treatment all particles of food should be removed from
between the teeth with dental floss, and they should
be brushed carefully after each meal with some good
dentifrice. A mouth wash should also be used fre-
quently during the day; this may consist simply of a
4 per cent, solution of potassium chlorate. The urine
should be examined at frequent intervals for evidence
of nephritis."— (Syphilis, by Thompson.)
7. In typhoid fever the patient should be placed in
bed in a quiet and well ventilated room; an intelligent
nurse is necessary. The utmost cleanliness of the
patient, bedding, sick-room requisites, etc., must be
observed. The patient's strength must be conserved in
every way possible; the infection must not be allowed
to reach others; the diet must be suited to the patient,
and must be given frequently ; drugs are only to be
given when there is a distinct need for them; the
patient must be carefully watched for the first sign
of complications; the best method for reducing the
body temperature is the use of the Brand bath; the
patient should be allowed plenty of water to drink.
8. Uncinariasis is best treated by thymol; this is
given in capsules containing 20 grains after the patient
has been purged with sodium phosphate; the thymol is
also followed by a saline purge. Two or three such
capsules may be required. Prophylaxis consists in
boiling the drinking water, washing the hands before
eating, and careful disinfection of feces, or proper
toilet facilities; "carriers" must be treated.
9. Rabies is treated by the Pasteur method; do not
kill the dog, but keep it and watch it, and if it has
rabies give the patient the Pasteur treatment; if at
the end of a week the dog shows no signs of rabies,
there is no need to treat the patient. The wound should
be cauterized with nitric acid and then dressed anti-
septically.
10. Medical treatment of diabetes mellitus: Tonics,
like arsenic, iron and strychnine are often useful.
Opium proves efficacious in some cases. It is best
given in the form of codeine (V2 grain three or four
times a day). Salicylates have been strongly recom-
mended. Bromides are serviceable in subduing nerv-
ous manifestations. Alkaline carbonates and alkaline
mineral waters have long enjoyed a reputation. Upon
94
CALIFORNIA.
the recognition of the early signs of coma, a moderate
amount of readily digestible carbohydrate should be
added to the diet. Absolute rest should be enforced,
saline laxatives and diuretics (theobromine, caffeine),
should be administered, and large doses (1 to 2 ounces)
of sodium bicarbonate should be given daily. Devel-
oped coma is rarely relieved by intravenous injections
of 4 per cent, solution of sodium carbonate (a liter,
if possible, and repeated if necessary at end of six
hours)." — (Stevens' Practice of Medicine.)
11. In early arteriosclerosis the causative factors
of the disease should be treated; the patient must be
saved from mental and physical strain; the diet should
be chiefly vegetarian, and alcohol and red meat must
be avoided. Long hours of sleep and much rest are
beneficial; daily warm baths, massage and passive
exercise have proved of service. Saline laxatives may
reduce the hypertension; iodide of potassium, nitro-
glycerin, amyl nitrite, choral hydrate, and morphine
are the drugs most often used, but they must be se-
lected and prescribed with care and not in a routine
fashion.
12. In mercurial stomatitis the patient must stop the
use of the mercurial; potassium iodide, in small doses,
is serviceable. Solution of potassium chlorate may be
used as a mouth wash, and atropine may be given to
check the excessive secretion of saliva. Tonics are
often necessary.
CHEMISTRY AND TOXICOLOGY.
1. Organic chemistry is the chemistry of the carbon
compounds. Organic compounds may be either gases,
liquids, or solids (crystalline or amorphous) ; volatile
or non-volatile; have any variety of taste, and color;
and are very prone to change when acted upon by heat
or chemical reagents; and the more complex they are
the greater is their liability to change.
2. The principal derivatives of the hydrocarbons are:
The haloid derivatives, various oxidation products (al-
cohols, aldehydes, ketones, carboxylic acids, ethers,
esters), carbohydrates, sulphur derivatives, metallic
compounds, nitrogen derivatives (amines, nitrils,
amides, ammonium derivatives, cyanogen compounds,
compound ureas), and phosphorus, arsenic and anti-
mony derivatives.
3. Metals of the iron group form two series of com-
pounds, as ferrous and ferric. In the former series
the metal is bivalent; in the latter it is quadrivalent,
and two atoms of this quadrivalent element combine
exchanging a valence between them and so forming a
95
MEDICAL RECORD.
hexavalent group. Thus, Fe Cls, ferrous chloride ;
Fe~Cls
I — FesClg, ferric chloride.
Fe=Cl 8
4. Illuminating gas contains: Hydrogen, methane,
ethane, carbon monoxide, carbon dioxide, nitrogen, am-
monia, hydrogen sulphide, hydrocyanic acid, acetylene,
and other compounds.
Its toxic properties are due to the carbon monoxide,
and to the mixture of other ingredients, chiefly carbon
dioxide, hydrogen sulphide, methane and ammonia.
5. Water contains one volume of oxygen and two
volumes of hydrogen; or by weight eight parts of
oxygen and one part of hydrogen ; by molecular weight,
sixteen parts of oxygen and two parts of hydrogen.
6. IfrSO* + 2NaCl =± Na 2 S0 4 + 2HC1,
or H2SO* + NaCl = NaHS0 4 + HCL
7. Test for sulphuric acid in vinegar: Add some
cane sugar and evaporate; if the sugar turns black,
sulphuric acid is present.
8. Five elements used in a pure state in medicine:
Iron, carbon, sulphur, phosphorus, and oxygen.
9. The chemical treatment for creosote poisoning
consists in washing out the stomach with alcohol and
water and the administration of sodium sulphate or
magnesium sulphate.
10. Antidotes for iodine poisoning: Starch, and
sodium thiosulphate.
11. Test for strychnine: It forms a colorless solu-
tion with concentrated sulphuric acid; if a crystal of
potassium dichromate is drawn through this solution
it is followed by a trail of color, blue, violet, rose, and
yellow.
12. Metallic chemical substances found in the body:
Iron, sodium, potassium, calcium, magnesium, lithium,
and occasionally manganese, copper, and lead.
BACTERIOLOGY AND PATHOLOGY.
1. Three varieties of cysts: (1) Retention cysts,
which result from the retention of normal secretions,
such as sebaceous cysts. (2) Exudation cysts, which
result from excessive secretion in cavities which have
no excretory duct, such as hydrocele. (3) Congenital
cysts which may be due to blighted ova, or inclusion
of epiblast; such are dermoid cysts.
2. Forms of hemorrhage: (1) By rhe'xis, when it
occurs from rupture of a blood vessel; (2) by diapede-
sis, when it passes through the vessel walls without
rupture of the latter; (3) very small hemorrhages,
96
CALIFORNIA.
which are called petechiae; (4) larger hemorrhages
into the tissues, called ecchymoses ; (5) infiltration of
a portion of tissue with blood, called a hemorrhagic
infarction; (6) a tumor-like mass of blood, called a
hematoma.
Fate of the effused blood: "The extravasated blood
in the tissues usually coagulates, although exception-
ally it remains fluid for a long time. A certain num-
ber of the white blood cells may wander into adjacent-
lymph vessels, or they may remain entangled with the
red cells in the meshes of the fibrin. The fluid is
usually soon absorbed; the fibrin and a portion of the
white blood cells disintegrate and are absorbed. The
red blood cells soon give up their hemoglobin, which
decomposes and may be carried away or be deposited
either in cells or in the intercellular substance at or
near the seat of the hemorrhage, either in the form
of yellow or brown granules or as crystals of hema-
toidin. Sometimes all trace of extravasations of blood
in the tissues disappears, but frequently their seat is
indicated for a long time by a greater or less amount
of pigment or by new formed connective tissue. Occa-
sionally the blood mass, in a more or less degenerated
condition, becomes encapsulated by connective tissue,
forming a cyst." — (Delafield and Prudden's Path-
ology.)
3. Ptomaines are products which result from the ac-
tion of bacteria upon proteid material.
Leucomaines are similar products formed in the body
as the result of normal proteid metabolism, and are not
due to bacterial action.
Toxalbumins are poisonous substances elaborated by
bacteria during their grow r th; they are capable of pro-
ducing disease.
Arrhythmia is an alteration in the normal cardiac
rhythm. It may depend upon disturbances of the nerv-
ous mechanism of the heart or upon disturbances aris-
ing within the heart muscle. The neurogenic form
may be caused by strong emotions, tobacco, alcohol,
bacterial poisons, by meningitis or cerebral lesions
causing increased intracranial pressure, and by im-
pressions from stomach or intestines which act upon
the heart in a reflex manner. There are several types
of myogenic arrhythmia, of which auricular fibrilla-
tion and heart block are among the most important.
Auricular Fibrillation. — In this condition the uni-
form contractions of the auricle as a whole are re-
placed by a multitude of haphazard fibrillary contrac-
tions, and as a result the ventricular beats, and hence
97
MEDICAL RECORD.
the pulse beats, become grossly irregular, both as to
time and to force. The pulse rate is, as a rule, in-
creased (110-150), but it may be nearly normal, or if
heart-block coexists, even decreased. Auricular fibril-
lation is the result of inflammatory or degenerative
changes in the myocardium, and is especially common
in cases of mitral stenosis.
Heart-block. — This form of arhythmia is due to the
failure of the auricular contractions to reach the
ventricle, owing to defective conductivity in the bundle
of His. In complete heart-block the conducting func-
tion of the bundle is entirely lost and the ventricle de-
velops an independent rhythm of its own, the pulse
being usually regular and numbering about 30 per
minute. In partial heart-block the conductivity of the
bundle is merely impaired, the result being a prolonga-
tion of the interval between the auricular and the
ventricular contractions, or the dropping of one ventri-
cular beat in 6, 5, 4, etc. Heart-block may result from
organic lesions in the conducting bundles, such as
fibrosis, gumma, abscess, etc., from infectious toxemias
or from the action of certain drugs, especially digitalis.
In some cases of complete heart-block (occasionally
even in the absence of it) the Adams-Stokes syndrome
develops. This is characterized by a very infrequent
pulse (5 to 40 per minute) and recurring attacks of
a syncopal, epileptiform, or vertiginous character,
probably the result of cerebral anemia. In the aged
the Adams-Stokes syndrome is almost invariably an
expression of degenerative myocarditis; in young
adults it is usually indicative of syphilitic myocarditis,
although in rare instances it may be of nervous origin.
— (Stevens' Practice of Medicine.)
5. A parasyphilitic condition is one which is not of
syphilitic nature but is believed to be of syphilitic
origin; such as tabes dorsalis, and general paresis.
6. Many of the anomalous conditions of the male
genital tract are due to some error of development, and
it is only by a knowledge of their embryology that such
conditions are clearly understood. Among such anom-
alous conditions may be mentioned hypospadias, epis-
padias, undescended testicle, teratoid tumors, and
hermaphroditism (true and false).
7. Four diseases of protozoan origin: Malaria,
syphilis, amebic dysentery, and trypanosomiasis.
Malaria is caused by the Plasmodium malarias,
which is conveyed to man by the anopheles mosquito.
There are different varieties of Plasmodium; the
Hemameba malarise, or quartan parasite, is a unicel-
98
CALIFORNIA.
lular parasite which appears inside the red blood cells
as a small, unpigmented, irregular, hyaline body, cap-
able of ameboid movement; pigmented granules ap-
pear, and some fill up the center of the blood cor-
puscle, and later the parasite splits into from six to
twelve segments which, with the pigment, escape* into
the circulation. It requires three days for its develop-
ment. The Hemameba vivax, or tertian parasite, re-
quires only two days for its development. It is larger
than the quartan parasite, and the pigment particles
appear earlier and are actively motile; the parasite
splits into fifteen to twenty segments which are small
and round. It contains more granules than the quar-
tan parasite, but they are smaller. The Hemameba
falciparum, or aestivo-autumnal parasite, is smaller
than the other two, but is more active; when at rest
it assumes the signet-ring form; the pigment develops
within twenty-four hours in coarse granules located in
the center of the cell; the parasite becomes lobulated
and rosette-shaped, and splits into six to twelve seg-
ments.
Syphilis is due to infection by the Treponema pal-
lidum, also called the Spirochseta pallida. This is a
slender spirillum, with regular turns, the curves vary-
ing in number from three or four to twelve or even
twenty ; it is about 4 to 20 microns long, actively motile,
with a fine flagellum at each pole; it is flexible, hard
to stain, and has not been cultivated on artificial media.
How it divides is not known. It stains best with
Giemsa's eosin solution and azur.
Amebic dysentery is due to the Entamsebo. histolytica,
which is about 15 to 50 microns in diameter; it has
short, blunt pseudopods, vacuoles, a nucleus and re-
fractive granules. Trypanosomes have a long, spiral
body, 8 to 35 microns in length, to one side of which is
attached a membrane which is continued as a flagellum.
The flagellum arises in a small granule near the pos-
terior end, called the blepharoplast.
8. Serum sickness. — "About one-third of the persons
injected with horse serum for the first time are found
to be sensitive to it, an urticaria, more or less edema,
and sometimes arthritis,, appearing between the sixth
and twentieth days after injection. The only explana-
tion offered is that part of the serum used as an in-
jection remains unaltered in the subject, while the re-
mainder sensitizes the serum of the subject. In fact,
a sort of auto-anaphylaxis occurs." — (Aids to Bac-
teriology.)
9. Chromogenic bacilli. — "A large number of bac-
99
MEDICAL RECORD.
teria, when cultivated upon suitable media, give rise
to characteristic colors which are valuable as marks
of differentiation. For each species the color is usually
constant, depending to a certain extent upon the con-
ditions of cultivation. In only a few of the pigmented
bacteria is the pigment contained within the cell body,
and in only one variety, the sulphur bacteria, does the
pigment appear to hold any distinct relationship to
nutrition. In most cases, the coloring matter is found
to be deposited in small intercellular granules or
globules. The absence of any relationship of the pig-
ment to sunlight, as is the case with the chlorophyl
of the green plants, is indicated by the fact that most
of the ehromobacteria thrive and produce pigment
equally well in the dark as they do in the presence
of light. Among the most common of the pigment bac-
teria met with in bacteriological work are staphylococ-
cus pyogenes aureus, bacillus pyocyaneus, bacillus
prodigiosus, and some of the green fluorescent bacteria
frequently found in feces." — (Hiss and Zinsser's
Bacteriology.)
10. Antityphoid inoculation has been thoroughly
tested, especially in the American army, and is of the
greatest value. It is useful for those who have to live
in infected localities, and for those who attend typhoid
patients. By this means typhoid can be reduced to
a minimum. Leishman reports: "In 5473 soldiers
vaccinated against the disease, 21 took it and 2 died;
in 6610 soldiers practically under the same conditions,
who were not vaccinated, there were 187 cases and 26
deaths; that is, among the vaccinated soldiers there
were 3.8 cases per thousand, and among the un-
vaccinated 28.3 per thousand."
Vaccination against smallpox, if properly performed,
and made compulsory, would prevent, if not entirely
exterminate the disease. Osier says "the German army
since 1874, the date of the stringent laws (on com-
pulsory vaccination) has enjoyed practical immunity—
not a single death from smallpox (to the date of the
last report, 1902), except an isolated case under pecu-
liar circumstances in 1884-85."
11. The pneumococcus of Frankel is a diplococcus,
small, spherical, non-motile, non-flagellate, non-spor-
ogenous; it is aerobic and optionally anaerobic, and
does not produce pigment or liquefy gelatin. It is Gram
positive and stains by the ordinary methods. The
pneumobacillus of Friedlander is an encapsulated bacil-
lus, non-motile, non-flagellate, non-sporogenous ; it is
aerobic and optionally anaerobic, and does not produce
100
CALIFORNIA.
pigment or liquefy gelatin. It stains by ordinary meth-
ods, but is negative to Gram's stain.
12. The gonococcus is found within the pus cells, has
the characteristic coffee-bean form, and is decolorized
by Gram's stain. None of the other pus cocci have
these distinguishing characters.
GENERAL MEDICINE.
1. Causes of hemorrhoids: (1) Constipation, by in-
ducing hardened stools felt at the anal orifice; (2)
heavy printed paper used as a detergent may have the
same effect; (3) diarrhea or any other discharge from
rectum or vagina may act as an irritant; (4) force or
exertion, such as straining at stool, may cause the rup-
ture of the wall of a vein in the neighborhood of the
anus; (5) pressure, from liver, tight lacing, pregnant
uterus, or abdominal tumor, particularly when added
to inflammatory processes, may cause hemorrhoids;
(6) sedentary habits, by causing dilatation of the veins
and congestion of the parts.
2. Complications of gonorrheal urethritis: Balanitis,
chordee, protatitis, seminal vesiculitis, epididymitis,
orchitis, cystitis, nephritis, pyelitis, prostatic abscess,
retention of urine, paraphimosis, bubo, infection of
Cowper's glands, conjunctivitis. In the female, the in-
fection may spread to bladder, ureter, kidney, and also
to Bartholin's glands, vagina, uterus, Fallopian tubes,
ovaries, and peritoneum.
3. Empyema. Etiology: Wounds, injuries, pleuro-
pneumonia, direct extension of a suppurative process in
the lung, abdomen, or neck. The bacteria will vary
with the cause; Diplococcus pneumoniae is the common-
est; tubercle bacillus, staphylococcus, streptococcus, Co-
lon bacillus may also be present.
Pathology: The organisms causing it are pneumocci,
streptococci, staphylococci, tubercle bacilli, Bacillus coli,
and actinomycosis.
The physical signs are those of fluid in the pleural
cavity; that side does not move well, the percussion
note is dull, there is absence of breath sounds, vocal
fremitus and resonance are diminished. Left alone, an
empyema may burst through an intercostal space,
usually the fifth. The lung is collapsed in extent ac-
cording to the amount of pus. The pleura, at first
covered with lymph, soon becomes covered with layers
of granulation tissue, the deeper part of which is con-
verted into fibrocicatricial tissue, and the lung itself
also undergoes some fibroid change. If the pus is let
out early the lung and pleura soon expand, but if al-
101
MEDICAL RECORD.
lowed to go on the infiltration of the lung and the
density of the scar tissue covering it hinder expansion.
Nature attempts to remedy this in various ways: (1)
The other lung expands and pushes the heart over to
the opposite side; (2) the chest wall falls in, the inter-
costal spaces are obliterated, and the spine is curved,
with its concavity toward that side; (3) the abdominal
viscera are pushed up: and (4) exuberant granulations
form on the pleura. If a cavity still remains an opera-
tion is necessary.
Symptoms: Fever, sweats, chill, diminished breath
sounds and vocal fremitus, impaired mobility of chest,
dullness on affected side, heart displaced to opposite
side, leucocytosis.
Treatment: Aspiration, drainage, irrigation, resec-
tion of ribs (Estlander's operation), or resection of
chest wall (Schede's operation). Operation of some
sort is the only treatment.
4. Tumors of the cerebellum produce the following
symptoms: "Vomiting is quite frequent. Optic neuritis
with blindness occurs very early, and paralysis of the
external rectus muscle is very common and often bi-
lateral. There is also apt to be rigidity of the neck,
and involvement of the olfactory, oculomotor, and tri-
germinal nerves on the side of the tumor. One of the
most characteristic symptoms is a severe occipital head-
ache, most marked upon arising. Attacks of amyas-
thenia and general vertigo are also frequent. Another
characteristic symptom is the so-called cerebellar
ataxia. This latter is especially marked in children,
who have a tendency to fall to one side in walking,
usually toward that upon which the tumor is situated."
— (Eisendrath's Surgical Diagnosis.)
5. Tuberculosis of the spine: "There is usually a his-
tory of injury. The most common situation is at the
junction of the lumbar and dorsal regions, and the
bodies of the vertebrae are most often involved. De-
formity follows, and depends upon the location and
amount of destruction. In most cases the spine sinks
forward, the spinous processes project backward, and
compensatory curves in the opposite direction are de-
veloped above and below. The symptoms are pain, ten-
derness^ on pressure, rigidity of the back, and a sense of
weakness, which may usually be recognized by the
child's actions. When suppuration occurs, the pus may
enter the sheath of the psoas, destroying the muscle,
and presenting in the iliac fossa or groin as an iliac or
psoas abscess; or it may pass backward through or ex-
ternal to the quadratus lumborum, and point in the loin,
102
CALIFORNIA.
when it is known as lumbar abscess. In the cervical
region retropharyngeal abscess may occur. Spinal
paralysis may come on at any time and myelitis de-
velops in the later stages. The treatment in most cases
is that of tuberculosis in general. Rest in bed, using
sand bags as splints, is the first consideration. After
the acute symptoms have subsided, a Thomas splint,
Sayre's plaster case, or (Docking's felt jacket may be
applied to the back and the patient gradually allowed
to move about. To apply the plaster-of -Paris case, the
patient should be suspended so that the heels are just
off the ground. A skin-fitting vest is then appliedto
the trunk, under which a stomach-pad is inserted, which
should be removed after the plaster has become dry.
Plaster bandages should now be applied in the usual
manner, extending from the level of the axilla to just
below the crest of the ilium. When the case is dry, it
may be divided down the front and perforated, so that
it can be laced up or removed at any time. Abscesses
should be opened early and freely, and injections of
iodoform emulsion will be found very beneficial. Lamin-
ectomy is sometimes advisable." — (Pocket Cyclopedia.)
6. "Pneumonia is an acute specific disease, due to in-
fection with the diplococcus pneumonias (pneumococcus
of Fraenkel) and, less frequently, with other micro-
organisms, characterized by a fibrinous exudation into
the pulmonary air-cells and bronchioles, and following a
course that is more or less typical, the chief symptoms
being those of toxemia and of interference with the
respiratory and circulatory functions. It usually oc-
curs in early adult life during the winter months, and
affects women most often. It may result from surgical
operations, ether narcosis, previous attacks, infectious
fevers, nephritis, alcoholism, heart-disease, etc.
The affection is divided into 3 stages: Congestion,
consolidation, and resolution.
The first stage is characterized by sudden onset with
chill, a sharp pain in the side,, *ise of temperature, a
short and sharp cough, rusty-colored, viscid sputum, and
dyspnea. There may be headache, insomnia, scanty
urine with diminution of urea, chlorides, phosphates, and
sulphates, insomnia, and herpetic vesicles on- the face,
and there is always an increase in the number of
leukocytes in the blood. Physical examination will re-
veal diminished expansion, impairment of the normal
percussion note, feeble or suppressed respiratory mur-
mur, moist or dry rales, crepitation, and sometimes a
pleural friction sound.
In the second stage the dyspnea is more marked; the
103
MEDICAL RECORD.
face is more or less livid in color; the temperature is
high (104°-105° F.) ; and the pulse increases in rate
(110-120), its tension and fullness lessening with the
progress of the disease, and growing feeble and inter-
mittent. Headache, delirium, and various other nervous
symptoms may be present. Expansion is diminished
and vocal fremitus is exaggerated upon the affected
side. There is dullness with increased resistance over
the consolidated lung, and auscultation detects bron-
chophony or bronchial breathing over this same area.
The third stage is ushered in by a sudden drop of
temperature on or about the fifth or ninth day, followed
by a natural sleep, free sweating, and relief from suf-
fering. In this stage the subcrepitant rale (rale re-
dux) is heard in the midst of the bronchial breathing,
together with numerous moist rales. Dullness may per-
sist for some time, but usually by the twelfth or four-
teenth day the lung has returned to its normal state."—
{Pocket Cyclopedia.)
7. The secondary symptoms of syphilis are the cu-
taneous eruption (or syphilides) and the mucous
patches in the mouth, condylomata around the anus or
in the groins, ulceration of the throat, loss of hair,
anemia, nocturnal headaches, pains in the bones, iritis
and periostitis. The skin lesions are characterized by
being roughly symmetrical, of a raw ham or copper
color, of roughly circular outline, and not accompanied
by itching; macules, papules, pustules, and scales may
all be present at the same time in different parts of the
body.
8.
CHANCRE.
First lesion of a
constitutional
disease, v i z.,
syphilis.
Due to syphilitic
infection.
Generally a vene-
real infection.
May occur any-
where on the
body.
CHANCROID.
A local disease.
Due to contact
with secretion
from chancroid.
Always a vene-
real infection.
Nearly always on
genitals.
HERPES PROGENI-
TALIS.
A local neurosis.
Due to irritation.
May be non-vene-
real.
Occurs generally
on prepuce;
may occur any-
where on gen-
itals.
104
CALIFORNIA.
CHANCRE.
CHANCROID.
Period of incuba-
tion never so
short as ten
days.
Generally single.
Not autoinocula-'
ble.
Secretion slight.
Slightly or not at
all painful.
As a rule only oc- 1
curs once in
any patient.
Buboes are pain-
less and seldom
suppurate.
Period of incuba- i
tion always less
than ten days
(generally
about three.
Generally multi- 1
pie.
Autoinoculable.
Secretion profuse
and purulent.
Generally pain- '
ful.
May reoccur in ;
same patient.
Buboes are pain-
ful, and usually
suppurate.
HERPES PROGENI-
TALIS.
No incubation pe-
riod.
Multiple vesicles
occurring in
crops.
Not autoinocula-
ble.
Secretion little or
none.
Tingling and
itching rather
than painful.
Apt to reoccur.
Lymphatics sel-
dom involved.
Authorities differ as to when syphilis is cured. Periods
of 3, 4, and 5 years since the appearance of the chancre,
and during which time the patient has been under
active treatment, have been suggested. In addition,
the patient must have shown no symptoms for at least
a year, and for a year should have taken no treatment
and still show no symptoms. At the present time there
is a tendency to rely on the Wassermann reaction; this
should prove negative on repeated occasions, during a
period of a year or more when no treatment is being
followed.
9. The first thing is to find out the cause of the high
blood-pressure. This may be : Arteriosclerosis, nephritis,
cerebral disease, or toxins (generally found in patients
who indulge in high living, sedentary occupations,
tobacco, alcohol, or who suffer from intestinal putre-
faction). Then, if possible, the cause must be removed,
and the patient's mode of life must be modified ; alcohol
and tobacco should be forbidden, overwork and excite-
ment must be avoided, diseases must be properly
treated; proper hygiene, diet, and rest are indicated;
drugs (such as nitroglycerin, amyl nitrite, and vaso-
dilators in general) must only be used when there is a
distinct indication for them.
10. Acute anterior polionvjelitis. The early signs are
105
MEDICAL RFXORD.
fever, malaise, chilliness, tonsillitis, coryza, diarrhea,
convulsions, profuse sweating, rigidity of head, neck,
and limbs, pain in neck and back, or there may be no
early signs. "Except in epidemics the diagnosis is not
possible before the appearance of paralysis. In mul-
tiple neuritis the paralysis develops more gradually, is
more marked in the distal than in the proximal parts
of the limbs and is symmetrical, and the sensory dis-
turbances are more lasting. Myelitis may be distin-
guished by the presence of anesthesia, paralysis of the
bladder and rectum, and the tendency to bedsores. The
early occurrence of flaccid paralysis and the absence of
cocci in the cerebrospinal fluid will distinguish the
menmgitic type from epidemic cerebrospinal meningitis.
The cerebral paralyses of childhood are spastic, at-
tended by exaggerated reflexes, and not followed by
rapid wasting. Treatment: During the acute stage
the patient should be isolated and confined to bed.
Mild laxatives and febrifuges may be used with some
advantage. Hexamethylenamine (2 or 3 grains every
two hours during the acute stage) has been recom-
mended by Dana and others for the purpose of steriliz-
ing the cerebrospinal fluid. Aspirin or morphine may
be necessary for the relief of pain. Warm baths and
lumbar puncture are also worthy of trial. The affected
limbs should be wrapped in cotton wool. In the course
of two or three weeks, if the acute features have en-
tirely subsided, the use of massage and electricity
should be begun. The treatment of the latter stages
is chiefly surgical, and has for its object the prevention
or correction of deformities." — (Stevens' Practice of
Medicine.)
11. Grip is caused by the bacillus influenzae of
PfeifFer; contagion is conveyed by the moist secretions
of the nasal and bronchial mucous membranes. The
winter season predisposes to the disease. Treatment
consists of rest in bed; the pain may be relieved by
phenacetin or sodium salicylate; the fever may be re-
liquor ammonii acetatis or Dover's powder may be
duced by quinine or aconite; the diet must be regulated;
given ; tonics may be required, particularly if there are
indications of heart failure.
12. Tarry stools may denote: Gastric hemorrhage
(from ulcer or cancer), ulcer of the intestines, portal
obstruction, hepatic cirrhosis, cancer of liver, or pur-
pura hemorrhagica.
Clay-colored stools may denote: Obstruction to the
flow of bile, or deficient formation of bile; calculus in
the bile ducts, tumor or movable kidney pressing on the
106
CALIFORNIA.
bile ducts, cancer of the liver, chronic lead poisoning,
acute yellow atrophy of the liver.
Greenish, frothy stools may denote: Infantile diar-
rhea or enteritis.
Hard, lumpy stools may denote: Constipation, cancer
of the rectum, gastric dilatation, excessive use of opium.
OBSTETRICS AND GYNECOLOGY.
1. Syphilitic ulcer of the cervix is usually round and
smooth, with a glistening, dry floor, and bleeds easily
when touched; the edges are thick and sloping, and it
heals rapidly. As a rule there is very little secretion
and little or no inflammatory reaction in the surround-
ing tissues. — (From Thompson's 'Syphilis.)
2. Steyiosis of the cervix may be congenital or ac-
quired. The latter may be due to uterine displacements,
inflammations of the cervix, contraction after labor, or
to operations such as amputation or the frequent appli-
cation of strong caustics to the cervix. Treatment
consists in dilating the cervix and curing any local
condition that may be present (such as endometritis).
Incision is often advisable with the dilatation. For the
dilatation, the patient is placed in the lithotomy position
and anesthetized; the cervix is pulled down with a
volsella, and the canal enlarged with a series of Hegar's
dilators, or a Sims' dilator.
3. "Owing to the present low mortality of cesarean
section, the indications for its performance have been
considerably extended in recent years. It is now per-
formed under most of the conditions which were pre-
viously held to necessitate craniotomy upon the living
child, and it will probably in time almost replace symphy-
seotomy; while, owing to the uncertainty of the survival
of the child after induction of premature labor, it is
encroaching upon the field of this operation also. As
regards maternal risk, it compares unfavorably with
induction of premature labor, in which there is practi-
cally none; but the chances of the survival of the child
in the second degree of pelvic contraction are very much
greater by cesarean section than by induction. It
must, however, be understood that this operation is only
justifiable for moderate degrees of pelvic contraction,
when it can be performed with adequate preparation
and under favorable surgical conditions. In the case
of patients seen for the first time when in labor the
alternatives of craniotomy and symphyseotomy # will
sometimes have to be considered even when the child is
living. There is no doubt that it is better to perform
craniotomy than to attempt to deliver a child by
107
MEDICAL RECORD.
cesarean section hurriedly undertaken, with insufficient
antiseptic preparations, in insanitary surroundings, or
by an operator unaccustomed to the technique of aseptic
surgery. And further, it may be wiser to perform
craniotomy than cesarean section when repeated un-
successful attempts have been previously made to de-
liver through the natural passages ; for apart altogether
from the possible risk of infection having occurred, the
chances of the survival of the child, even if delivered
alive by cesarean section, have been necessarily preju-
diced by repeated and prolonged attempts to extract it
with forceps through a narrow pelvis. Cranial in-
juries may thus be caused from which the child will
almost inevitably die,* even if born alive. If there are
any positive signs of infection having occurred, such as
offensive smell of the liquor amnii, or fever associated
with 'signs of illness or exhaustion on the part of the
mother, the child's life should be unhesitatingly sacri-
ficed, cesarean section in such a case being an extremely
dangerous operation." — (Eden's Practical Obstetrics.)
4. Cesarean section: "Fluid extract of ergot, ir^xx, is
injected into the thigh muscles just as the anesthesia is
begun. The operator assures himself that there is no
loop of intestine between the uterus and abdominal wall,
beneath the field of incision. Should a coil of intestine
be found there, it is pushed above the fundus. An as-
sistant holds the uterus in central position. The skin
incision extends one-third above and two-thirds below
the level of the umbilicus. It is best made through the
right rectus muscle. The external layer of the rectus
sheath is divided, the muscular bundles separated with
handle of scalpel and the fingers, and the deep layer of
the sheath and the peritoneum divided after lifting
them with tissue forceps. Bleeding vessels are con-
trolled by gauze sponge, pressure, or held by catch-
forceps before opening the peritoneum. A short longi-
tudinal median incision is made in the uterine wall be-
ginning at the fundus, avoiding the membranes if still
unbroken. This is extended downward with fingers,
scissors, or scalpel to a total length of about six inches.
The hand is thrust through the membranes and the
child is extracted by the head or the feet, whichever is
most accessible. In case of anterior implantation of the
placenta, usually the hand may best be passed directly
through it. The cord is clamped at two points with
catch-forceps, cut between them, and the child is passed
to an assistant. The uterus slips out of the abdomen
as the child is extracted, and the intestines are kept
back with hot sterilized towels placed over the upper
108
CALIFORNIA.
part of the incision. The coverings help also to protect
the peritoneum from soiling. The uterus is wrapped
in hot moist cloths. As a rule, it is better not to wholly
eventrate the uterus. The placenta, if not spontane-
ously separated, may be peeled off by grasping it with
one hand like a sponge. If the cervix is not sufficiently
open for drainage, a large rubber tube or gauze strip is
passed down through it and withdrawn from below.
Irrigating or mopping the uterine cavity is unnecessary.
Asepsis is promoted by leaving it as nearly as possible
untouched. The peritoneum is sponged dry with the
least possible friction or handling. The uterine wound
is closed with deep No. 2 chromated catgut sutures at
intervals of about 1/3 inch. They are given a wide
sweep laterally through the muscular wall, falling short
of the decidua. The peritoneal coat of the uterus is
closed with a No. 1 continuous plain catgut suture,
forming a welt over the deep suture line. The hemor-
rhage is inconsiderable and usually ceases with the in-
troduction of the first sutures — a hypodermic of ergot
should be given before beginning the operation, and one
of ergotole and pituitrin on the delivery of the child.
Retraction of the uterus is ensured by manipulating it,
if necessary, through a hot towel, or by faradism.
When there has been much blood lost, a quart or two
of warm sterilized 0.9 per cent, salt solution may be
left in the peritoneum. The parietal peritoneum is
closed with a plain running No. catgut suture. In-
terrupted silkworm-gut sutures are then passed at in-
tervals of about % inch, through all but the peritoneum,
from within outward. The fascia is brought together
with interrupted No. 2 plain catgut sutures, or with a
continuous suture. The silkworm-gut sutures are now
tied. The abdomen is cleansed, and the wound covered
with a dressing of several thicknesses of dry sterile
cheesecloth; over this is placed a thick compress of
sterile absorbent cotton. The dressings are secured
with strips of zinc oxide adhesive plaster, and held in
place by a Scultetus binder." — (Polak's Obstetrics.)
5. Strictures divided in complete laceration of the
perineum: Skin, fascia, connective tissue, constrictor
vaginae, sphincter ani, transversus perinei, and levator
ani muscles, and the anterior wall of the rectum.
Operation for lacerated perineum: "The labia are
seized with Allis' forceps at the level of the lowest
carunculae myrtiformes. A guide stitch is placed in the
posterior vaginal wall directly under the external
urinary meatus. By pulling one Allis forceps and the
guide stitch in opposite directions outward and down-
109
MEDICAL RECORD.
ward, the posterior sulcus is exposed; denudation is
required, even in a recent tear, for a part of it is
always submucous. The other sulcus is exposed and de-
nuded. Then by holding the guide stitch upward in
the middle line and pulling the forceps apart the mucous
membrane between the sulci is denuded or freshly torn
surfaces covered with granulation-tissue are scraped
with the edge of a knife. The ruptured levator ani
muscle in the posterior sulci is united with a double
in the stitch as it turns upward after coming down
from the apex of the wound, in its deeper portion to
tier suture of chromic gut. two half hitches being taken
the base. One knot at the apex of the sulcal denuda-
tion secures the stitch. The retracted ends of the
transversus perinei and bulbocavernosus muscles are
brought together by silkworm sutures. Finally, a single
stitch at the top of the perineal wound unites the pos-
terior commissure of the vulva, restoring the fossa
navicularis. The perineal stitches are knotted ; they are
removed on the twelfth day." — (Hirst's Obstetrics.)
6. Relation of non-specific cystitis to gynecology :
Many of the causes of non-specific cystitis are closely
connected with the pelvic organs. Thus congestion of
the bladder may be related to diseases of the uterus,
ovaries or Fallopian tubes; or to pelvic and abdominal
tumors which obstruct the circulation ; or to pregnancy,
menstruation, and the puerperium. Another source of
cystitis is retention of urine, which may be due t©
cystocele and to uterine displacements.
Relation of constipation to gynecology: "Constipation
is an important factor in the causation of many dis-
eases and symptoms peculiar to women. An overloaded
bowel mechanically interferes with the pelvic circula-
tion and tends to produce congestion of the uterus and
its appendages. As a result, misplacements of the
uterus occur, followed by functional and organic dis-
orders, which give rise to dysmenorrhea, menorrhagia,
metrorrhagia, sterility, endometritis, etc. Slow toxemia
frequently results from the absorption of the fecal mat-
ters by the blood in obstinate cases of constipation."
(Ashton's Gynecology.)
7. The cause should be removed if possible; or failing
that, should receive appropriate treatment. If due to a
pessary, the latter should be removed. The vagina must
be kept as clean as possible, and antiseptic douches
should be taken two or three times a day. An as-
tringent such as nitrate of silver, or copper sulphate, or
protargol may be applied, and a tampon inserted for
from twelve to twenty-four hours.
8. The fetal circulation: "The arterial blood coming
from the placenta to the fetus travels along the um-
110
CALIFORNIA.
bilical vein to the liver. After giving off several
branches to the left lobe it divides into two streams, the
larger joining the portal vein and thus entering the
liver, the smaller passing directly into the inferior vena
cava through the ductus venosus. In the inferior vena
cava the blood carried by the hepatic veins and ductus
venosus mixes with the blood which has circulated
through the lower extremities. On entering the right
auricle the blood of the inferior vena cava is directed
by the Eustachian valve, through the foramen ovale
into the left auricle, and from thence into the left ven-
tricle. The left ventricle forces it into the aorta, and
it is then distributed to the head and upper extremities,
a small quantity only passing into the descending aorta.
The blood which has circulated through the head and
upper extremities returns to the heart along the supe-
rior vena cava, the blood then passing into the right
ventricle and pulmonary artery. A small part of the
blood in the pulmonary artery is conveyed to the lungs,
but the major part passes through the ductus arteriosus
into the aorta at the commencement of the descending
portion. This blood is distrbuted to the lower extremi-
ties, a certain portion of it entering the hypogastric
arteries and being conveyed to the placenta." — (Ashby's
Physiology.)
The changes occurring in the circulation at birth are:
The hypogastric arteries become obliterated, the um-
bilical vein becomes impervious, the foramen ovale
closes, the Eustachian valve atrophies, the ductus ar-
teriosus and ductus venosus become impervious and
shrivel up.
A blue-baby is one suffering from congenital cyanosis;
this is a form of asphyxia neonatorum in which there
is an accumulation of carbon dioxide in the blood, but
the circulation still continues and the reflexes are
preserved.
9. Mastitis: Prophylactic measures consist in not
touching the breasts (by doctor or nurse or patient)
without thoroughly clean hands; by washing and dry-
ing the nipple before and after nursing, and by proper
attention to hygienic conditions before labor, and the
nipple and breasts being preserved from pressure.
Ophthalmia neonatorum: Prophylaxis. Immediately
after birth the eyelids of the newborn child should be
washed with clean warm water and onto the cornea of
each eye should be dropped one or two drops of a 1 or 2
per cent, solution of nitrate of silver. This procedure
will prevent ophthalmia neonatorum in doubtful cases;
it will do no harm in innocent cases; and it is the first
stage in treatment if gonorrheal infection is present
111
MEDICAL RECORD.
Puerperal infection: Prophylaxis. The most careful
aseptic and antiseptic precautions on the part of all
concerned — physician, nurse, and patient; and making
no more examinations than are absolutely necessary.
Postpartum hemorrhage. Preventive treatment.
"This must be addressed to the uterine retraction. The
uterus should be watched, with the hand continuously
on the abdomen, from the birth of the child and for at
least a half hour after the placenta is delivered. Care
should be taken that no fragment of placenta is left in
the uterus. Friction may be used if required to provoke
normal contractions. Too early resort to Crede's
manipulation may cause imperfect separation of the
placenta, and produce hemorrhage from partial separa-
tion of the placenta. In persistent inertia, ergotole,
3ss, and pituitrin (1-3 decigrams) injected hypo-
dermically, and repeated, p. r. n., is a valuable prophy-
lactic. It is often indicated after chloroform anesthesia,
and in all conditions which predispose to hemorrhage.
It is a wise precaution to give ergot on birth of the head
when there is reason to fear postpartum hemorrhage.
It is the abuse, not the proper use, of ergot that has
brought it into disrepute in certain quarters." —
(Polak's Manual of Obstetrics.)
10. Differential diagnosis. — Pregnancy: The tumor
is hard and does not fluctuate, is situated in the median
line, and may give fetal heart sounds and movements;
the cervix is soft, and the other signs of pregnancy are
present. The rate of growth of the tumor, and the gen-
eral condition of the patient's health may also help in
arriving at a diagnosis.
Retained menses: Absence of other signs of preg-
nancy, cramp-like pains about once a month; the condi-
tion may be of longer duration than an early preg-
nancy, and the cause of the retained menses is gen- .
erally demonstrable.
11. The use of ergot: "The routine administration
of ergot after the birth of the child is not to be recom-
mended. No remedy should be administered in any con-
dition unless there is a direct indication for its use.
In primiparas and strong multiparas the uterine contrac-
tion should be strong enough to effectually empty the
cavity of the womb and obliterate the venous channels.
In such cases the ergot is useless or even dangerous m
that it may cause an irregular hour-glass contraction
of the uterus, with retention of clots, membranes, and
debris, and at the same time has a retarding influence
upon the development of the milk. Then again, if given
before the birth of the child, serious or even fatal
112
CALIFORNIA.
asphyxia may result from the tetanic contractions
induced by the drug. The danger of laceration of the
cervix, perineum, and vaginal wall as well as of rupture
of the uterus is increased by the use of ergot. There is,
however, a suitable class of cases in which the use of
ergot is indicated in appropriate doses. This includes
all forms of uterine exhaustion and inertia during the
late second and third stage and after delivery has been
completed." — (Dorland's Obstetrics.)
Pituitrin may be given, cautiously, in cases of uterine
inertia; the dose is 1 cc. by intramuscular injection.
As it may cause very severe uterine contractions it
should not be given unless the os is dilated and there is
no obstruction to delivery. And see above, Question 9,
Postpartum hemorrhage.
Quinine is used to promote uterine contractions, in
uterine inertia, also to alleviate after-pains.
Scopolamine has been used with morphine or narco-
phine, in the must advertised "twilight-sleep." It is
used by intramuscular injection, and is put up in
ampoules containing one cubic centimeter, = gr. 1/200
of scopolamine. In properly selected cases and with
proper environment, it is of service.
Lobelia is said to be of use in case of rigidity of the
os uteri when the latter is thick and unyielding.
Gelsemium has no recognized value in obstetrics.
12. In examining a primipara, the physician should
satisfy himself as to the existence of pregnancy, then
the duration of the pregnancy and the probable date of
labor should be determined, then the viability of the
fetus and the presentation should be ascertained, the
condition of the genital organs and the mammary glands
is then ascertained, and measurements of the pelvis are
to be made.
An examination should be made about six weeks
after delivery in order to ascertain: The condition of
the pelvic floor, and perineum, the position of the fun-
dus, the vaginal discharge, the degree of mobility of
the uterus, the condition of the breasts and nipples, and
the general condition of the patient.
SURGERY.
1. Treatment of recent scalp wounds. — -"To ensure
asepsis, the hair should be shaved from the area around
the wound, and the part then thoroughly purified.
Gross dirt ground into the edges of lacerated wounds is
best removed by paring with scissors. Undermined flaps
must be further opened up and drained by counter-open-
ings if necessary. When there is reason to suspect
their presence, foreign bodies should be carefully sought
113
MEDICAL RECORD.
for. Bleeding should be arrested by forcipressure or
by ligature; when the vessels cannot be caught with
forceps, the hemorrhage may be controlled by passing
a needle threaded with catgut through the tissues of
the scalp so as to include the bleeding vessels. The
wound is stitched with horse hair or sterilized silk and,
except in very small and superficial wounds, it is best
to allow for drainage. The most common complications
are those due to bacterial infection, which not only ag-
gravates the local condition, but is apt to lead to spread-
ing cellulitis, osteomyelitis, meningitis, or to inflamma-
tion of the intracranial venous sinuses. These danger-
ous sequelae are liable to follow infection of any scalp
wound, but more especially such as implicate the sub-
aponeurotic area or the pericranium. In the integu-
ment, a small localized abscess, attended with pain and
edema of surrounding parts, may form. Pus forming
under the aponeurosis is liable to spread widely, point-
ing above the eyebrows, in the occipital region, or in
the line of the zygoma. Suppuration under the peri-
cranium tends to be limited by the inter-sutural attach-
ments of the membrane. Necrosis of the outer table,
or even of the whole thickness of the skull, may follow,
although it is by no means uncommon for large denuded
areas of bone to retain their vitality." — (Thomson and
Miles' Surgery.)
2. The following factors have been suggested in the
etiology of post-operative thrombosis: (1) Disturbances
of the venous circulation which might exist before the
operation and would predispose to thrombosis, such as
heart lesions, varicose veins, exhaustion, prolonged de-
cubitus, and pressure of abdominal tumors. (2) Condi-
tions attending the operation, such as unavoidable
chilling and exposure of the contents of the abdominal
cavity and possibly traumatism to the vessel walls.
(3) The injurious effects upon the heart muscle of the
anesthetic. # (4) The topographic relations of the ves-
sels. (From Keen's Surgery.) Prevention of the con-
dition depends on avoidance of the etiological factors,
subjecting the patient to the minimum of trauma, and
carefully ligating the bloodvessels.
3. The treatment of ileus in acute cases consists in
the withholding of food, irrigation of the stomach and
colon, and the administration of cracked ice by the
mouth and opium hypodermically. Exploratory in-
cision may be performed. In chronic obstruction the
diet should be restricted and measures should be taken
to remove the obstruction. Impacted feces may require
the use of the scoop or similar instrument. Impacted
114
CALIFORNIA.
gallstones may require cholecystotomy. Internal stran-
gulation should be relieved by early operation. In vol-
vulus occasionally the intestine may be untwisted by in-
sufflations of air or hydrogen or a large enema. Intus-
susception is treated similarly, but operation may be
required in both conditions. Colotomy or enterotomy
is necessary in case of stricture and contractions.
CLASSIFICATION OF ILEUS.
INTUS-
TWISTS
STRANGULATION.
SUSCEPTION.
(VOLVULUS).
Subjective
Subjective
Subjective
Symptoms.
Symptoms.
Symptoms.
1.
Generally oc-
1.
Most frequent
1.
Most frequent
curs after
in childhood.
after age of
age of 20.
30.
2.
Pain localized,
rapid col-
lapse.
2.
Constant te-
nesmus.
2.
Pain diffuse.
3.
Pain intense,
3.
Pain develops
3.
Pain paroxys-
paroxys m a 1
suddenly and
mal ; recurs
in character.
is continuous.
less often
than in
s t ra n gula-
tion.
4.
Con stipation
4.
Frequent diar-
4.
Cons tipation
complete.
rhea, passage
of bloody
mucous.
complete.
Objective
Objective
Objective
Symptoms.
Symptoms.
Symptoms.
1.
Temp erature
1.
Temp erature
1.
Temp erature
often subnor-
normal or
slightly ele-
mal.
subnormal.
vated.
2.
Pulse very
2.
Same as in
2.
Same as in
weak.
stran gula-
tion.
stran gula-
tion.
3.
S t e rcoraceous
3.
Same as in
3.
Same as in
vomiting
stran gula-
stran gula-
comes on
tion.
tion.
early.
4.
L o c a t ion in
4.
Localization in
4.
Location, small
small intes-
small intes-
i n t e s tine;
tine.
tine; bowel
f r e q u ently
protrudes at
rectum.
abdomen of-
t e n pro-
trudes, in
certain areas,
giving dull-
ness on per-
cussion.
115
MEDICAL RECORD.
4. Delayed union in fracture is caused by: 111 health,
want of approximation of the end of the bone, want of
blood supply in the bone, defective innervation of the
bone, disease of the bone, lack of rest, and immobility.
Treatment is given by DaCosta as follows:
"When delayed union exists, seek for a cause and re-
move it, treating constitutionally if required, and thor-
oughly immobilizing the parts by plaster. Orthopedic
splints may be of value. Use of the limb while splinted,
percussion over the fracture, and rubbing the fragments
together, thus in each case producing irritation, have all
been recommended. Blistering the skin with iodine or
firing it has been employed. If the case be very long
delayed, forcibly separate the fragments and put up in
plaster as a fresh break. If these means fail, irritate
by subcutaneous drilling or scraping, or, better, by lay-
ing open the parts and then drilling and scraping at
many places."
5. Indications for paracentesis of the membrana tym-
pani: To evacuate pus in the tympanum (and so to re-
lieve pain, limit the infection, shorten the disease, and
prevent complications) ; for enlarging perforations
which are too small to allow adequate drainage ; it is em-
ployed also in certain catarrhal and inflammatory con-
ditions of the ear.
The parts are to be sterilized, an anesthetic (local or
general) given; and the incision is then made with a
slender, sharp-pointed knife. A speculum and adequate
illumination will be necessary. The particular quadrant
which should be incised depends upon the condition call-
ing for the operation. The incision should be made suf-
ficiently long; a mere puncture is not sufficient. If pos-
sible the incision should be so placed that the opening
will extend from near the floor of the canal upward
and through the bulging portion of the membrane. The
surgeon should avoid touching the auditory ossicles.
6. Backward dislocation of the thumb at the meta-
carpophalangeal joint "is usually produced by extreme
dorsiflexion of the thumb, whereby the palmar or glenoid
and the lateral ligaments are torn from their metacar-
pal attachments, the phalanx carrying with it the
glenoid ligament and sesamoid bones. The head of the
metacarpal passes forward between the two heads of
the flexor brevis pollicis, and the tendon of the long
flexor slips to the ulnar side. The phalanx passes on to
the dorsum of the metacarpal, where it is held erect
by the tension of the abductor and adductor muscles.
The attitude of the thumb is characteristic. The meta-
carpal is adducted, its head forming a marked promi-
116
CALIFORNIA.
nence on the front of the thenar eminence, and the
phalanges are displaced backwards, the proximal being
dcrsiflexed and the distal flexed toward the palm. Re-
duction is to be effected by flexing and abducting the
metacarpal while the phalanx is hyperextended and
pushed down towards the joint and levered over the
head of the metacarpal. When this manipulation
fails, the glenoid ligament should be divided longi-
tudinally through a puncture made with a tenotomy
knife on the dorsal aspect of the joint, so as to separate
the sesamoid bones and permit the passage of the head
between them." — (Thomson and Miles' Surgery.)
7. "After a perforating wound of the cornea the eye
should be thoroughly disinfected, the iris, if prolapsed,
replaced if possible, and eserine or atropine instilled,
according to the situation of the injury. If replacement
is not possible, the prolapsed portion should be seized
with iris forceps and excised. In either event the sub-
sequent treatment requires rest, disinfection of the con-
junctival cul-de-sac, and a carefully applied antiseptic
compressing bandage. Care must be taken to ascertain
whether a foreign body has lodged within the anterior
chamber or within the deeper portion of the globe.
X-ray examination may be necessary." — (De Schweinitz's
Diseases of the Eye.)
8. Hydronephrosis. — "The pelvis and calyces are dis-
tended with urine owing to some obstruction. Con-
genital stenosis at the junction of the ureter and pelvis
may cause unilateral hydronephrosis; a congenital im-
pervious condition of the urethra causes bilateral hy-
dronephrosis. Acquired forms are due to (1) blockage
of the urinary passages by stones, pasasites, stricture;
(2) kinking of the ureter due to a movable kidney; (3)
pressure of tumors or cicatrices on the ureter. A sud-
den and absolute block leads to suppression of urine.
Hydronephrosis results from intermittent or incomplete
obstruction, whether the urethra or the ureter is af-
fected. The pelvis and calyces become dilated, and later
the cortex and pyramids become thinned and expanded.
Interstitial inflammation accompanies this, and at first
the urine is abundant and of low specific gravity. In
the later stages the secreting substance is entirely
atrophied. At any stage septic processes may convert
the condition into pyonephrosis. The symptoms may be
entirely absent, only a painless enlargement of the kid-
ney being noticed. If both are affected, there is at first
an abundance of low specific gravity urine, which later
becomes scanty, uraemia following. If one^ kidney^ only
is affected, the urine remains normal. Pain, vomiting,
117
MEDICAL RECORD.
and increased frequency of micturition may be present.
The size of the tumors varies from time to time, diminu-
tion being accompanied by an increased flow of urine.
Sepsis may produce pyonephrosis at any time. Treat-
ment. — The cause should be removed, if possible. Uni-
lateral hydronephrosis usually needs an exploratory
incision, and if the block cannot be removed nephrec-
tomy is necessary." — (Aids to Surgery.)
9. Retropharyngeal abscess "may be acute or chronic,
and is most frequent in children. Acute abscess may be
caused by foreign bodies, or by infection of the lymph
glands in this region, which drain the nose and naso-
pharynx. The chronic form is usually the result of
caries of the spine or base of the skull, and is not asso-
ciated with the fever and inflammatory phenomena
characteristic of the former. In either case the posterior
wall of the pharynx bulges forward, exhibits fluctua-
tion, and may interfere with deglutition and respira-
tion. If unopened, the abscess will break into the
pharynx, point externally in the neck, or gravitate into
the posterior mediastinum. The treatment is evacuation
through the mouth in acute cases, and through the neck
in chronic cases, as in the latter secondary infection
should be prevented. When the abscess is to be opened
through the mouth, the head should hang over the edge
of the table, in order to prevent entrance of pus into
the air passages, and the abscess opened with a knife,
the edge of which is covered with adhesive plaster to
near the point. Anesthesia is dangerous. When the
abscess is opened through the neck, an incision is made
along the posterior border of the sternomastoid from
the apex of the mastoid downwards, unless the abscess
points in some other region. The finger or a pair of
forceps is passed along the anterior surface of the
bodies of the vertebras and a drainage tube inserted." —
(Stewart's Surgery.)
10. "The presence of a tumor, dimpling of the skin,
retraction of the nipple, with cachexia, enlarged lym-
phatic glands in axilla or above or below the clavicle,
and microscopical examination of an excised piece of
the tumor all aid in the diagnosis of malignant growth
of the breast. Treatment should be early and thor-
ough. However small the tumor may be, the entire
breast and its corresponding lymphatic area, as high as
the apex of the axilla, should be removed; for, once in-
fection of the lymphatic spaces has occurred, the whole
lymphatic area must be looked upon as infected. Suc-
cessful operations depend upon a knowledge of the
lymphatics and extent of the breast. The lymphatics
118
CALIFORNIA.
begin in plexuses around the acini, which converge to
vessels running along with the ducts and end in a sub-
areolar plexus. From this three or four main lym-
phatic trunks run to the axillary glands. In addition,
lymphatics run along the suspensory ligaments to the
skin all over the prominence of the breast from the in-
teracinous plexuses. Also vessels leave the deep part
of the breast to join lymphatic plexuses in the pectoral
fascia. The plexuses in the fascia run to the axilla, and
also communicate with those in the pectoralis major.
Lymphatic vessels pass into the mediastinum, and also
communicate with those of the opposite breast and
axilla. The extent of the breast is much greater than
the prominence would lead one to believe. It extends
almost to the clavicle, just to the edge of the sternum,
down to the seventh rib, and out to the mid-axillary
line. The points, then, in operating are that the whole
breast, the skin over the prominence, the pectoralis
major muscle (except the clavicular portion), the fat,
fascia, lymphatic vessels and glands of the axilla, must
be removed, and in one piece, for if cut across at any
part there is danger of strewing cancer cells on the
wound and so infecting it with growth. Removal or
division of the pectoralis minor facilitates the cleaning
of the axilla. " — {Aids to Surgery.)
11. "Fracture of the base of the skull, Causes:
Violence applied to the cranial convexity produces frac-
ture by irradiation or by bursting (in this latter form,
which is the more common, the vault is compressed, and
the base bulges beyond its limits of elasticity and gives
way) ; direct injury is an unusual cause; the impact of
the vertebral column against the occipital condyles pro-
duces fractures around the foramen magnum in some
cases of falls on the feet or nates. The signs are those
of (1) injury to the brain, (2) escape of cranial con-
tents, (3) injury of cranial nerves. (1) Injury to the
brain may be of the nature of concussion, compression,
or laceration. (2) Escape of cranial contents, which
may be blood, cerebrospinal fluid, or rarely brain itself.
1. Hemorrhage manifests itself in various situations,
according to the position of the fracture. In the ante-
rior fossa the bleeding may be from the nose or into
the orbit, or may pass back into the pharynx, be swal-
lowed, and subsequently vomited. The eye may be
pushed forward and pulsate if the cavernous sinus be
ruptured. In the middle fossa blood usually runs from
the ears ; but slight bleeding from the ear may be caused
by minor injuries, such as rupture of the membrana
tympani, tearing of the lining of the auditory canal,
119
MEDICAL RECORD.
and fracture of the tympanic bone. In the posterior
fossa a hematoma may form behind the mastoid process.
2. The escape of cerebrospinal fluid is a certain sign
that a fracture communicates with the subdural space.
It may appear in the same situations as hemorrhage,
but is usually found escaping from the ear, owing to
fracture of the petrous bone. The fluid is limpid, spe-
cific gravity 1005, with no albumin, but containing
pyrocatechin, which gives the same reaction as sugar
with Fehling's solution. The amount which escapes
may be small or very large, but as a rule it soon ceases.
(3) Injuries to the cranial nerves vary according to the
site of fracture. That most commonly involved is the
facial, in the aqueductus Fallopii, and the paralysis
may come on immediately from rupture, or after two or
three weeks from the pressure of callus." — (From Aids
to Surgery.)
12. Flat-foot "is most common in adolescents, and is
primarily due to giving way of the arch of the foot
from inability to support the weight of the body. It
affects those whose occupation entails prolonged stand-
ing, especially if there is any deterioration of the gen-
eral health. It is also met with in rickets, together
with genu valgum. Acute flatfoot is due to gonorrheal
inflammation affecting the inferior calcaneo-scaphoid
ligament. Pathological Changes. — The structures which
support the arch of the foot — viz., the inferior calcaneo-
scaphoid ligament, the tendon and insertions of the
tibialis posticus, the plantar ligaments and fascia — be-
come stretched, and allow the head of the astragalus to
be displaced downwards, obliterating the arch. In bad
cases the anterior part of the foot becomes abducted,
the scaphoid being partially dislocated outwards from
the head of the astragalus. The sole is flat, the inner
border of the foot is convex, severe pain is felt on walk-
ing, and the gait is shuffling. The pain is either in the
arch or about the heads of the metatarsal bones. Treat-
ment. — In the early stages, when pain with only slight
flattening of the arch is present, rest and massage of
the calf muscles, with tiptoe exercises twice a day.
Where there is deformity, but the natural arch can be
restored by manipulation, exercises should be practised,
and in the intervals a support, such as Whitman's steel
instep support, worn, or Golding Bird's webbing sling
for the arch. In worse cases, where there is secondary
shortening of the ligaments on the outer side of the foot
and of the peronei, the deformity must be forcibly recti-
fied during anesthesia, and the foot kept in plaster for
several weeks. In the w r orst cases, which cannot be
120
CALIFORNIA.
wrenched into position, a wedge must be removed, with
its base to the inner side of the foot, either from the
neck of the astragalus or from the tarsus, irrespective
of joints." — (Aids to Surgery.)
HYGIENE AND SANITATION.
1. "In selecting the sites for camps or homes of sol-
diers, consideration must be had as to whether these
are to be temporary or permanent, and as to whether
the men are to live in tents or barracks. In any case,
there should be sufficient space allotted to each com-
mand; there should be no interference w r ith the free
circulation of air, and the soil should be dry, porous,
and readily drained. The ground water especially
should not be too near the surface. Camps should not
I be located, except in event of grave military necessity,
on ground that has been recently occupied by other
troops; nor should they be on clay soils, in ravines or
valleys where they will receive the drainage from higher
ground or other camps, nor near marshes or the marshy
banks of rivers, nor where they will receive the winds
from malarial districts. Thought should also be given
to the source and abundance of the water supply and
its relation to the natural course of drainage from the
camp. If tents are to be used, these must be such as
to afford both thorough protection and good ventilation.
They should not be too crowded, either as regards the
number of occupants or the location of the tents one to
another. If the camp is of extended duration, the tents
should be floored, or, at least, the men should not sleep
on the ground. A trench should also be dug about each
tent to prevent flooding by rains, and from time to time
the tents should be moved about, as it is well known
that tents occupying the same ground for a length of
time become unhealthy. Camp kitchens, stables, sinks,
latrines, etc., should be as far from the sleeping tents
as reasonable convenience permits, and to the leeward
of prevailing winds. All camps should be regularly
and carefully policed, and the fact that a camp expects
to change its position does not justify neglect of proper
policing of the ground occupied. " — (Egbert's Hygiene
and Sanitation.)
2. Absolute humidity is the actual amount of moisture
in a given quantity of air. Relative humidity is the per-
centage of moisture present in the air, complete satura-
tion being taken as 100.
Respiratory diseases, with tuberculosis, influenza,
and rheumatic conditions are most prevalent in a humid
atmosphere.
121
MEDICAL RECORD.
3. To eradicate scurvy: Abundance of fresh air and
sunlight, with an ample supply of fresh vegetables and
fruit, milk, eggs, meat, and fish will go far to eradicate
the disease. The diet must not be monotonous ; canned
foods should be avoided. Orange juice or lime juice
may be beneficial.
4. Sewer gas is a mixture of a number of gases, such
as carbon dioxide, ammonia, hydrogen sulphide, and
certain organic matters the result of animal and vege-
table decomposition. When large quantities are in-
haled there may result vomiting, headache, prostration,
purging, loss of appetite, anemia, and general impair-
ment of health.
5. "Ptomaines are chiefly the cause of disease when
they are taken in with food in which they have been
produced by bacterial decomposition. Besides this food
poisoning, it is also possible that ptomaines may be
formed by putrefaction within the gastrointestinal
tract. Another possible source of ptomaines is fur-
nished by decomposing tissues in gangrene. It is doubt-
fnl if ptomaines are produced in sufficient quantities by
pathogenic bacteria infecting living tissue to be of any
importance. Food poisoning is by no means uncom-
mon, but it is not always due to ptomaines; it may be
the result of poisonous materials contained abnormally
in the food, that are not ptomaines, e.g. ergotism; or
it may be due to an infection of the animal from which
the meat came with pathogenic organisms, particularly
the bacillus enteritidis and other bacteria related to the
colon-typhoid group; or in other ways food ordinarily
wholesome may become poisonous. The commonest
sources of ptomaine poisoning are imperfectly pre-
served canned meats, sausages, decomposing fish, cheese,
ice cream, and milk." — (Wells' Chemical Pathology.)
6. Malaria is conveyed by the bite of an anopheles
mosquito which is itself infected with the Plasmodium
malariae.
Bubonic plague is conveyed by the bite of a flea from
a rodent (rat, etc.) which is infected with the disease.
Diphtheria is conveyed by direct contact, by carriers,
by dust, by droplets of saliva or mucous secretion from
mouth and nose, and by flies.
Syphilis is conveyed by direct contact with the chancre
and the secondary lesions.
Typhoid fever is conveyed by the medium of food,
fingers, flies, direct contact, carriers, water.
7. To prevent the spread of typhoid fever: Flies
should be kept out of the house as far as possible, by
means of screens or otherwise; all discharges from the
122
CALIFORNIA.
sick person must be disinfected; all utensils, dishes,
etc., used by the patient must be thoroughly cleansed
and boiled every day; soiled linen must be soaked in a
disinfectant solution before being washed; after each
attendance on a patient physicians, nurses, and others
should wash their hands in a disinfectant; thorough
sterilization of all bedding, etc., must be performed
after the disease is over. Further, each household
should boil all water that is to be used for drinking or
for washing dishes, etc.; milk should be boiled also;
and no ice should be put in water or other drink o*
food.
8. Immigrants are inspected for idiocy, imbecility,
feeblemindedness, epilepsy, insanity, tuberculosis,
loathsome and contagious diseases, including favus,
ringworm of scalp, sycosis barbae, actinomycosis, blasto-
mycosis, frambesia, mycetoma, leprosy, and venereal
diseases such as demonstrable syphilis in active com-
municable stage, gonorrhea, and soft chancre; trachoma
filariasis, uncinariasis, amebic infection; hernia, state
of permanently defective nutrition, chronic arthritis,
malignant new growths, cutaneous affections, eruptive
fevers, tuberculous affections. The inspection is con-
ducted by experienced men; the immigrants are drawn
up in line, and pass one by one before the inspector,
who examines them rapidly from the feet up ; the
facies, gait, attitude, etc., are also noted. There are
often three or four inspectors, and any one of them
who notices anything suspicious puts a chalk mark on
the clothes of the suspect, and later on those with such
marks are submitted to further and more searching ex-
amination.
9. "The original view that tuberculosis in a majority
of cases is hereditary and that children of tuberculous
ancestry were foredoomed to an early death from the
disease is untenable in light of the facts regarding the
Koch bacillus. A fair statement of the matter is as
follows : Tuberculosis cannot exist without the influence
of bacilli. For the bacillus to be transmitted by in-
heritance it must either pass to the embryo through the
spermatozoon, the ovum, or from the maternal blood
through the placental vessels. Tuberculosis of the
generative organs is not rare, but the chance of even a
single bacillus entering a spermatozoon or an ovum
and occupying so large a part of such cell as its sub-
stance would necessarily do without destruction of one
organism or the other seems incredible. As for blood
transmission of the bacillus through maternal vessels,
while its possibility must be admitted to account for
123
MEDICAL RECORD.
the few authentic cases of congenital tuberculosis re-
ported, the presence of bacilli in the blood of the most
advanced cases of tuberculosis is extremely rare ex-
cepting during the temporary accident of the perfora-
tion of a tuberculous mass into a bloodvessel as a fore-
runner of miliary tuberculosis. How, then, are the
early cases of socalled hereditary tuberculosis to be
explained? Of these not more than twenty have been
described as actually congenital (Hahn). The re-
mainder have ail appeared at a considerable interval
after birth. The nursing infant, weakened by the in-
heritance of poor vitality, is kept close beneath the bed-
clothing of a tuberculous mother, and cannot avoid in-
haling bacilli which have escaped with her expectora-
tion, transferred, perhaps, from handkerchief to sheet,
and soon dried in the warmth of the bed, or perhaps
the same handkerchief is used for the mother's sputum
and the child's nose. The older infant is kissed by a
tuberculous member of the family, bacilli from whose
sputum can easily be found upon the beard or face, or
it is allowed to crawl about upon a dusty, germ-impreg-
nated carpet. The disease thus acquired and developed
thus early in the ill-conditioned weakling makes rapid
strides, and is easily attributed in error to 'heredity.'
For 'heredity* in this sense should be substituted crim-
inal negligence ^ in matters hygienic." — (Thompson's
Practical Medicine.)
10. To eradicate hookworm: All drinking water
should be boiled; the hands should be washed before
eating; shoes should be worn and none should go bare-
footed; proper toilet facilities should be provided, and
people should not be allowed to scatter fecal matter
around; mines should be disinfected with chloride of
lime.
11. Prophylaxis of filth diseases: This includes gen-
eral cleanliness of person, clothes, food, habitation, and
habits; pure air, proper ventilation, sufficient sunlight,
adequate warmth; preventive inoculation where pos-
sible; avoidance of those suffering from disease; disin-
fection and isolation to be practised where necessary.
12. All receptacles should be scalded with boiling
water. Milkers should wipe the teats and also wash
their own hands before milking. Stables should be kept
scrupulously clean and freely ventilated. All accidental
contamination should cause the rejection of that par-
ticular pail of milk. The milk should at once be
strained and cooled to about 40° F., and kept at not
above that temperature until delivery to the customer.
Delivery should be as prompt as possible. Sale of
"loose" milk should be prohibited, and adulteration of
milk should be penalized.
124
COLORADO.
STATE BOARD EXAMINATION QUESTIONS.
Board of Medical Examiners, State of Colorado.
ANATOMY.
1. Describe the bony points in connection with the
elbow joint.
2. Give the muscular attachments around the
shoulder.
3. Describe the anterior and posterior fontanelles in
the new born child.
4. Describe the sternomastoid muscle, in what way
is it important?
5. Describe the clavicle.
6. Draw a diagram illustrating the area of hepatic
dullness.
7. Describe the acetabulum.
8. Explain the formation and location of the super-
ficial and deep palmar arches.
9. Draw a diagram illustrating the areas into which
the abdomen is divided, naming the regions.
10. Describe the inguinal canal.
11. What do you understand by the saphenous open-
ing, discuss its importance.
12. Give gross anatomy of the kidney.
Answer any ten questions.
PHYSIOLOGY.
1. Follow a molecule of fat through the process of
its digestion and assimilation, and tell what becomes of
it in the body.
2. Name and describe the function of the several com-
ponent parts of the blood.
3. Tell how urine is secreted, and mention its physio-
logical constituents.
4. What do you understand by association areas in
the brain?
5. Describe the physiology of menstruation.
6. Give a detailed description of how we hear.
7. What are the physiological functions of spleen, the
pancreas, and the thyroid gland?
8. What physiological factors are concerned in the
regulation of blood pressure.
9. Name five enzymes and give action of each.
10. What elements are essential to impregnation?
CHEMISTRY.
1. Define (a) Inorganic chemistry; (6) Organic
chemistry.
2. Define qualitative and quantitative analysis.
125
MEDICAL RECORD.
3. Define valence and give examples.
4. What is an alcohol? Its chief forms and their
sources?
5. What are carbohydrates, and into what three
groups are these compounds usually divided?
6. Give chemical constituents of normal urine.
7. Give qualitative and quantitative tests for al-
buminuria, with its chemical significance.
8. Give qualitative and quantitative tests for sugar
in the urine with its chemical significance.
9. To what is the color of the blood due, and in what
form?
10. Define with some detail the chemistry of respira-
tion.
PATHOLOGY.
1. Discuss aneurysm.
2. Give the pathology of gastric ulcer.
3. Describe the tubercle bacillus.
4. Give the pathology associated with jaundice.
5. Define anaphylaxis.
6. Describe leucocytosis and its significance.
7. What is pellagra?
8. Name the varieties of vesical calculi.
9. Give the technique of the Gram stain.
10. What conditions are accompanied by eosinophilia?
SYMPTOMATOLOGY.
1. Give the causes and symptoms (including the
character of the urine) of acute nephritis.
2. What are the symptoms of rheumatic fever?
3. Describe a case of erysipelas.
4. What are the symptoms and commonest complica-
tions of diphtheria?
5. Give the symptoms and signs in a case of incipient
pulmonary tuberculosis.
6. Describe a case of croupous pneumonia.
7. If an embolus arises from the saphenous vein
where will it lodge, and what symptoms will it cause?
8. If an embolus arises from the mitral valve where
may it lodge, and what symptoms will it cause?
9. Describe a case of acute poliomyelitis.
10. Discuss the anomalies of rate and rhythm of the
heart beat.
OBSTETRICS.
1. Give the successive changes that take place in the
ovum after fecundation and during its passage to the
uterus.
2. Name and describe the five movements in the
mechanism of an L. O. A.
126
COLORADO.
3. Give the differential diagnosis between placenta
praevia and abruptio placentae.
4. Give the causes, diagnosis, and treatment of uter-
ine inertia.
5. Give the indications and conditions requiring
cesarean section and describe Sanger's modification.
6. Name indications, conditions and give technique
in the use of low forceps.
7. Mention the varieties of hemorrhage that may
affect the pregnant woman, the parturient woman and
the puerperal woman.
8. What is placenta previa, give its causes, varieties,
symptoms, and treatment.
9. Give in outline form the manner in which you
would go about to make a diagnosis of the position of
the child.
TOXICOLOGY.
1. What is a poison? How are they classified?
2. What are the symptoms of opium poisoning?
3. How may carbolic acid poisoning be produced?
Give symptoms.
4. Describe bromism and state how it is produced.
5. What symptoms are produced by toxic doses of
tartar emetic?
6. Describe forms of poisoning by ergot.
7. Name five common vegetable poisons; give anti-
dotes for one.
8. Describe the symptoms of hydrargyrism.
9. Describe the case of strychnine poisoning.
10. Give symptoms arising from a toxic dose of digi-
talis.
SURGERY.
1. Discuss disease of the thyroid gland.
2. Discuss disease of the mammary gland.
3. Varieties of intestinal obstruction. Give differen-
tial diagnosis.
4. Describe Pott's fracture of the leg.
5. Differential diagnosis of injuries of the shoulder.
6. Name the hernias of the abdomen. Describe fully
three varieties (anatomy).
7. Describe a case of sapremia, giving differential
diagnosis.
8. Discuss gastrointestinal hemorrhage.
9. Discuss cerebral hemorrhage.
10. Discuss the following case: A man 30 years of
age. On Sunday night at 11 o'clock was taken with
severe abdominal pains. He vomits once or twice, and
describes the pain as being mostly below the navel.
127
MEDICAL RECORD.
On examination the abdomen is generally tender. Tem-
perature 100°; pulse 90; respiration 20. Monday noon
his temperature is 101.5° ; pulse 100. The pain is very
severe, and palpation elicits an area of exquisite ten-
derness to the right of the abdomen above the crest of
ilium. A leucocyte count gives 12,500. Discuss the
case.
ANSWERS TO STATE BOARD EXAMINATION
QUESTIONS.
Board of Medical Examiners, State of Colorado.
ANATOMY.
1. There are three bony points at the elbow: The
external condyle of the humerus, the internal condyle
of the humerus, and the olecranon process of the ulna.
When the forearm is extended these three points are in
a straight line; when the forearm is flexed, the ole-
cranon is a little below the line joining the two con-
dyles. The head of the radius can be felt from behind,
nearly one inch below the external condyle. The in-
ternal condyle is more prominent than the external
condyle; the olecranon is nearer to the inner than to
the outer condyle.
2. Muscular attachments around the shoulder: To
the outer end of the clavicle are attached the trapezius
and deltoid; to the coracoid process of the scapula, the
coracobrachialis and the short head of the biceps; to
the acronical process and spine of the scapula, the
deltoid and trapezius; to the posterior surface of the
scapula, the supraspinatus and infraspinatus; to the
supraglenoid tubercle, the long head of the biceps; to
the great tuberosity of the humerus, the supraspinatus,
infraspinatus and teres minor; to the lesser tuberosity,
the subscapularis ; to the upper and anterior part of
the shaft of the humerus, the latissimus dorsi and
teres major.
3. The anterior fontanelle is a lozenge-shaped space,
formed by lack of ossification in the posterior superior
angles of the two halves of the frontal bone and in the
anterior superior angles of the parietal bones. It is
situated where the coronal suture crosses the sagittal
suture.
b The posterior fontanelle is a triangular depression
situated at the point where the sagittal and lambdoidal
sutures meet; it is much smaller than the anterior
fontanelle.
128
COLORADO.
f 4. The stemo mastoid muscle arises by two heads,
one from the upper and inner end of the clavicle, the
other from the upper border of the sternum; there is a
triangular space between these two heads; the fibres
from each head pass upwards and backwards and
unite, and are inserted into the mastoid process of the
temporal bone and the outer part of the superior curved
line of the occipital bone. The nerve supply is from
the spinal accessory and branches of the cervical plexus.
The muscle divides the side of the neck into two tri-
angles, the anterior and posterior; it is an important
landmark, especially of the carotid region, since the
great vessels of the neck lie beneath its anterior border ;
it marks the line of incision for several operations.
5. The clavicle forms the anterior part of the
shoulder girdle; it articulates internally with the first
part of the sternum, and externally with the acromion
process of the scapula. It is broad and flattened at its
outer end, and thick and rounded at the inner end. It
consists of a double curve, the outer part is concave
forward, the inner part convex forward. The bone
has two surfaces, superior and inferior, and two bor-
ders, anterior and posterior. On the under surface
are the conoid tubercle, a groove for the subclavius, a
rough impression for the rhomboid ligament, Muscles
attached to it are: Deltoid, trapezius, pectoralis major,
subclavius, sternomastoid, and sternohyoid. Ligaments
attached to it are: Interclavicular, rhomboid, conoid,
trapezoid, and capsular (of sternoclavicular and
acromioclavicular articulations) .
6. The upper border of hepatic dullness is found in
the mamillary line at the level of the sixth rib, in the
midaxillary line at the eighth rib, and in the scapular
line at the tenth rib. The lower margin of dullness is
situated in the middle line in front, about a hand's
breadth below the junction of the gladiolus and ensi-
form; in the right mamillary line it reaches the costal
margin ; in the midaxillary it is in the tenth intercostal
space; and behind, in the scapular line it blends with
the dullness over the right kidney.
7. The acetabulum is a deep, hemispherical depres-
sion in the os innominatum. It is made up of all three
bones comprising the os innominatum, viz.: the ilium,
ischium, and pubis. It looks downward, outward, and
forward. It is made deeper by a marginal rim, which
does not go completely around it. At the bottom of
the cavity is a circular depression, called the fossa of
the acetabulum, which lodges a mass of fat, and to
129
MEDICAL RECORD.
the margins of which are attached the ligamentum
teres. There is a deep notch on the lower border,
called the cotyloid notch, which is converted into a
foramen by a tough ligamentous band which passes
across it ; through this f ormen the nutrient vessels and
nerves enter the hip joint.
8. The superficial palmar arch is formed by the
ulnar artery, and is completed by the ulnar artery
anastomosing with a branch of the radial (superficial
volar or princeps pollicis). It gives off the four digital
branches.
The surface marking is a line drawn transversely
across the palm from a point where the web of the
thumb joins the palm. •
The deep palmar arch is formed by the radial artery,
and is completed by the radial artery anastomosing
with a deep branch of the ulnar. Its branches are the
palmar interosseous, perforating, and palmar recurrent
arteries.
The suface marking is a line drawn transversely
across the palm, one-half inch nearer the wrist than
the superficial arch.
9. The abdomen may be divided into nine regions by
four lines, two of which are vertical and two hori-
zontal. There is no uniformity in the location of these
lines. One method consists in drawing the vertical
lines through the middle of Poupart's ligament, the
upper horizontal line through the lowest point of the
costal border, and the lower horizontal line through the
anterior superior iliac spines. The regions in the upper
row are the right hypochondriac, epigastric, and left
hypochondriac; in the middle row, the right lumbar,
umbilical, and left lumbar ; in the lowest row, the right
inguinal, hypogastric, and left inguinal.
10. The inguinal canal is an oblique canal situated a
little above and running parallel with Poupart's liga-
ment. It is from an inch and a half to two inches in
length, runs downward and inward, and extends from
the internal abdominal ring to the external abdominal
ring.
Its boundaries are: In front: the skin, superficial
fascia, aponeurosis of the external oblique, and (for its
outer third) the internal oblique. Behind: the con-
joined tendon, the triangular fascia, the transversalis
fascia, subperitoneal fat, and peritoneum. Above: the
fibers of the internal oblique and transversalis. Below:
Poupart's ligament and the transversalis fascia.
130
COLORADO.
Contents : the spermatic cord in the male, and the
round ligament in the female.
11. The saphenous opening is an oval aperture in the
deep fascia of the upper and front part of the thigh.
It is about an inch and a half long and half an inch
wide, and the saphenous vein passes through it in order
to reach the femoral vein. It is covered by the cribri-
form fascia, and is of importance because through it
a femoral hernia makes its way towards the surface.
12. The kidneys are situated in the back of the ab-
dominal cavity, one on each side of the vertebral col-
umn, behind the peritoneum, and extending from the
eleventh rib to the second or third lumbar vertebra.
The right kidney is about half an inch lower than the
left one. Each kidney is about four inches long, two
inches broad, and one inch thick, and weighs about four
and a half ounces. The kidneys are kept in place by
their vessels, fatty tissue, and the peritoneum. The
shape is characteristic. Each kidney is surmounted by
the suprarenal gland, is surrounded by a capsule, and
consists of a cortical and medullary portion. In the
cortical portion are found the Malpighian corpuscles,
which are tufts of capillaries, and are surrounded by a
capsule which is continuous with the uriniferous tubule
which ends in the renal papilla.
PHYSIOLOGY
1. Digestion of fats. In the stomach, the gastric
juice dissolves the connective tissue binding the fat
cells together, and sets free the fat, which passes into
the duodenum. Here the steapsin of the pancreatic
juice splits up the fats into glycerin and fatty acids.
Absorption of fat. "Fat is not absorbed as fat, but
as glycerin and fatty acid or soap. It is generally
accepted that the fatty acid set free in the intestine is
dissolved by the bile salts, and in this way, together
with the glycerin, is absorbed by the columnar cells,
but that during absorption a lipase which is contained
in the columnar cells re-synthesizes, by reverse action,
the glycerin and fatty acid. In this way minute fat
particles are found near the bases of the columnar cells,
and these may be demonstrated by staining with a
1 per cent, solution of osmic acid. The fat globules
are further taken up from the columnar cells by some
of the lymphocytes, which are capable of exhibiting
ameboid movements, and which are found in the lym-
phoid tissue between the columnar cells and the cen-
tral lacteal. The fat is then deposited in the central
lacteal by these ameboid cells, and in this way it gets
131
MEDICAL RECORD.
into the general lacteal stream, and thence into the
thoracic duct. The bile salts, which have been absorbed
by the columnar cells, in all probability get into the
portal vein radical, and in this way are taken back
to the liver to be excreted again in the bile. After
a fatty meal minute globules of fat may be demon-
strated in the blood plasma of an animal ; but they
disappear rapidly, possibly existing in a soluble and
invisible form absorbed to the blood proteins before
they are deposited in the fat depots of the body."
2. Functions of the blood: The red blood cells carry
oxygen from the lungs to the tissues. The white blood
cells: (1) Serve as a protection to the body from the
incursions of pathogenic microorganisms; (2) take
some part in the process of the coagulation of the blood;
(3) aid in the absorption of fats and peptones from the
intestine, and (4) help to maintain the proper proteid
content of the blood plasma. The function of the
platelets is not determined ; it is possible that they take
some part in the coagulation of the blood. The plasma
conveys nutriment to the tissues; it holds in solution
the carbon dioxide and water which it receives from the
tissues, and takes them to be eliminated by the lungs,
kidneys, and skin; it also holds in solution urea and
other nitrogenous substances that are taken to and ex-
creted by the liver or kidneys.
3. Hoiv the urine is secreted is not settled. Bow-
man's theory was that the water of the urine, together
with the soluble inorganic salts, are taken from the
capillaries of the glomeruli through the epithelial cells
-of Bowman's capsule; and that the nitrogenous sub-
stances (urea, uric acid, creatinin, etc.) are excreted
by the cubical cells which line the convoluted tubules.
Ludwig's theory was that the glomeruli are little
more than filters, and that the urine in a dilute form
is taken out of the blood by the glomeruli (by filtration) ,
and that in its passage through the tubules these latter
absorb some of the water.
Many also believe that urinary excretion is partly
due to mechanical filtration and partly to secretory or
selective action of the glomerulus; at the same time
the epithelium of the tubules is believed to contribute
substances to the urine.
Bowman's theory was based on the general structure
of the kidneys, the high blood pressure in the renal
arteries, and the low. blood pressure in the renal veins.
According to Ludwig's theory, the function of Bow-
man's capsule is purely physical (filtration), and the
132
COLORADO.
function of the convoluted tubules is physiological (re-
absorption).
The normal constituents of urine are: Water, urea,
uric acid, urates, hippuric acid, creatin, creatinin,
xanthin, hypoxanthin; sulphates, chlorides, and phos-
phates of sodium and potassium; phosphates of mag-
nesium and calcium; nitrogen, and carbon dioxide.
4. Association areas of tlte brain. "When all the
motor and sensory areas have been marked off, a con-
siderable portion of the cortex still remains. This re-
mainder consists of areas called association areas in
which, it is supposed, elaborated impressions arrive
from all the sensory areas and are combined into percep-
tions and conceptions. Four association areas are
usually described: (1) frontal, immediatedly anterior
to the motor area; the part of this region which forms
the frontal pole is delimited as a special area, the pre-
frontal; (2) parietal, between the general sense area
and the visual area; (3) temporal, occupying the
greater part of the temporal lobe; (4) insular, the
island of Reii." — (Lickley's Nervous System.)
5. Menstruation is a periodic disturbance in the
female characterized by a bloody discharge from the
uterine cavity; it occurs periodically during the time
of the woman's sexual activity, but is temporarily sus-
pended during pregnancy and early lactation. The re-
lation existing between ovulation and menstruation is
not known. The two processes are usually coexistent,
but they may be independent of each other. The fol-
lowing theories have been held: (1) Menstruation is
dependent upon ovulation; (2) ovulation is dependent
upon menstruation; (3) they are independent of each
other; (4) they both depend upon some other (at pres-
ent unknown) cause. Each month the mucous mem-
brane of the uterus becomes thickened and congested,
and some of the small bloodvessels rupture; the blood,
with superficial epithelium of the uterus and the secre-
tion of the uterine glands, forms the menstrual flow.
When the flow ceases, the mucous membrane of the
uterus is gradually regenerated and returns to its origi-
nal condition.
6. "The waves of sound are gathered together by the
pinna and external auditory meatus, and conveyed to
the membrana tympani. This membrane, made tense
or lax by the action of the tensor tympani and laxator
tympani muscles, is enabled to receive sound waves of
either high or low pitch. The vibrations are conducted
across the middle ear by a chain of bones to the fora-
men ovale, and by the column of air of the tympanum
133
MEDICAL RECORD.
to the foramen rotundum, which is closed by the second
membrana tympani, the pressure of the air in the tym-
panum being regulated by the Eustachian tube. The
internal ear finally receives the vibrations, which ex-
cite vibrations successively in the perilymph, the walls
of the membranous labyrinth, the endolymph, and,
lastly, the terminal filaments of the auditory nerve, by
which they are conveyed to the brain." — (Brubaker's
Physiology.)
7. The function of the spleen: The following theories
have been held: (1) It is a source of production of the
white blood corpuscles; (2) it is a source of production
of the red blood corpuscles during fetal life; (3) it is a
place where the red blood corpuscles are destroyed;
(4) uric acid is produced in the spleen; (5) an enzyme
is produced in the spleen and is carried by the blood to
the pancreas, where it converts the trypsinogen into
trypsin.
The function of the thyroid is not definitely settled:
(1) it has some trophic function, regulating oxidation
in the body, and it is supposed to have also a special
influence on the vasomotor nerves, the skin, the bones,
and on the sexual functions; (2) it is supposed to an-
tagonize toxic substances, and (3) it produces an in-
ternal secretion.
The functions of the pancreas are: (a) The secre-
tion of the pancreatic juice, which (1) changes proteids
into proteoses and peptones, and afterward decomposes
them into leucin and tyrosin; (2) converts startch into
maltose; (3) emulsifies and saponifies fats, and (4)
causes milk to curdle, (b) The manufacture of an in-
ternal secretion.
8. Blood pressure is the force exercised by the blood
against the walls of the blood vessels. It is regulated
by the force and frequency of the ventricular systole,
the quantity of blood contained in the vessels, the elas-
ticity of the walls of the arteries, and the resistance in
the capillaries.
9. Five enzymes:
ENZYMES.
ORIGIN.
FUNCTIONS.
Ptyalin.
Saliva
Changes starches
into dextrin
and sugar.
Pepsin.
Gastric juice.
Changes proteids
i n't o proteoses
and peptones in
an acid me-
dium.
134
COLORADO.
ENZYMES.
ORIGIN.
FUNCTIONS.
Trypsin.
Pancreatic juice.
Changes proteids
into proteoses
and peptones,
and afterward
decomposes
them into leu-
cm and tyrosin
in an alkaline
medium.
Amylopsin.
Pancreatic juice.
Converts starches
into maltose.
Steapsin.
Pancreatic juice.
Emulsifies and
saponifies fats.
10. Impregnation is the result of the meeting of a
live and healthy spermatozoon, with a live and healthy
ovum, in a suitable medium (generally the Fallopian
tube). During coitus the seminal fluid is ejected into
the upper part of the vagina and against the cervix
of the uterus ; the spermatozoa enter the uterine cavity
(either by the suction of the uterus or by their own
vibratile motion) and so pass on to the Fallopian tube.
Several spermatozoa may surround an ovum, or even
pierce the perivitelline space ; but only one spermatozoon
enters the vitellus. This spermatozoon loses its tail;
and its head becomes the male pronucleus. The male
pronucleus and the female pronucleus now fuse to-
gether and fecundation is completed.
CHEMISTRY.
1. Organic chemistry is the chemistry of the carbon
compounds.
Inorganic chemistry is the chemistry of such sub-
stances as do not contain carbon.
2. Qualitative analysis is the determination of the
nature of the elements which enter into the composition
of a substance. Quantitative analysis is the determina-
tion of the amount as well the nature of the elements
which enter into the composition of a substance.
3. Valence is the combining power of an atom of an
element as compared with that of an atom of hydrogen.
Thus oxygen has a valence of two, because one atom of
oxygen combines with two of hydrogen ; similarly nitro-
gen has a valence of three, and carbon has a valence of
four.
4. An alcohol is the hydroxide of a hydrocarbon
radical, and is capable of reacting with an acid to form
an ester. Alcohols are termed monoatomic, diatomic,
135
MEDICAL RECORD.
and triatomic, according to the number of hydroxyl
groups which they contain. Alcohols which contain the
characterizing group CH 2 OH are called primary alco-
hols; those which contain the characterizing group
CHOH are called secondary alcohols; and those which
contain the characterizing group COH are called ter-
tiary alcohols.
The chief forms are methyl, ethyl, propyl, butyl and
amyl alcohols; also glycerol or glycerin, which is a
triatomic alcohol.
Alcohols may be produced by the saponification of
their esters by caustic potash; primary alcohols may
also be produced by the reduction of aldehydes or
anhydrides; and secondary alcohols may be produced
by the reduction of ketones.
5. Carbohydrates. — The name carbohydrate was origi-
nally given to the group of compounds found chiefly in
vegetables, and containing the elements carbon, hydro-
gen and oxygen; the molecule contained six or some
multiple of six times the atom of carbon, and hydrogen
and oxygen in the proportion to form water. The name
is not a good one, and the definition is not accurate;
but the term is still used to denote a group of substances
which includes the various starches, sugars, and gums,
etc. They are generally divided into three groups:
monosaccharids, disaccharids, and polysaccharids.
6. Composition of urine:
(PARTS in
1000)
Water A 950.001
Urea 28.00
Uric acid 0.60
Hippuric acid 0.35
Creatinin 0.65
Extractives 8.00^
>. Organic
Sodium chloride 8.00
Phosphoric acid 2.00
Sulphuric acid 1.25
Lime (CaO) 0.25
Magnesia (MgO) 0.30
Potash (K 2 0) and soda (Na 2 0) 0.60
Inorganic.
Total 1000.00
7. Test for albumin in the urine : "The urine must be
perfectly clear. If not so, it is to be filtered, and if this
does not render it transparent it is to be treated with a
136
COLORADO.
lew drops of magnesia mixture and again filtered. The
reaction is first observed. If it be acid, the urine is
simply heated to near the boiling point. If the urine be
neutral or alkaline, it is rendered faintly acid by the
addition of dilute acetic acid and heated. If albumin be
present a coagulum is formed, varying in quantity from
a faint cloudiness to entire solidification, according to
the quantity of albumin present. The coagulum is not
redissolved upon the addition of HNOs."
Quantitative test for albumin in urine: "Place 100
c.c. of the clear urine in a beaker of 200 c.c. capacity;
if alkaline, acidulate faintly with acetic acid. Heat the
beaker over the water-bath, add one or two drops of
acetic acid, largely diluted with water, when nearly
boiling; continue boiling gently until the diffuse pre-
cipitate has collected in lumps. Have ready a small
filter whose weight, with that of watch-glasses and
clamp has been determined. Collect the coagulated
albumin upon the filter, wash with H 2 containing a
little HN0 3 , then with boiling H 2 until the filtrate
no longer forms a precipitate with AgN0 3 , then with
alcohol, and finally with ether. Dry the filter and con-
tents in the air-oven, and weigh between the watch-
glasses. The difference between this last weight and
the one first determined is the weight of dry albumin
in 100 c.c. urine, which, multiplied by 1/100 the quan-
tity in twenty-four hours, gives the elimination of
albumin in twenty-four hours. " — (Witthaus' Urin-
alysis.)
Albuminuria is found: "(1) In fevers, as typhoid
and pneumonia. (2) In valvular heart lesions, de-
generation of the heart muscles, diseases of the coronary
arteries, impeded pulmonary circulation, in pregnancy
by pressure upon the renal veins, in intestinal catarrh,
and in Asiatic cholera. (3) In purpura, scurvy, leu-
kemia, pernicious anemia, jaundice, diabetes, and syph-
ilis. (4) After taking lead, mercury, iodine, phos-
phorus, arsenic, antimony, chloroform, cantharides,
oxalic, carbolic, salicylic, or the mineral acids, turpen-
tine and nitrates. (5) In large amounts in acute
nephritis and chronic parenchymatous nephritis; in
small amounts in chronic interstitial nephritis, and
amyloid kidney." — (Witthaus' Essentials of Chemis-
try.)
8. "(a) Qualitative test for sugar in the urine: Ren-
der the urine strongly alkaline by addition of Na 2 C0 3 .
Divide about 6 c.c. of the alkaline liquid in two test
tubes. To one test tube add a very minute quantity of
137
MEDICAL RECORD.
powdered subnitrate of bismuth, to the other as much
powdered litharge. Boil the contents of both tubes.
The presence of glucose is indicated by a dark or black
color of the bismuth powder, the litharge retaining its
natural color." — (Witthaus' Essentials of Chemistry.)
(b) Method for the quantitative estimation of sugar
in urine: Fehling's method: The solution is made as
follows :
I. Dissolve cupric sulphate 51.98 gm.
in water to 500.00 c.c.
II. Dissolve Rochelle salt 259.9 gm.
in sodium hydroxide solution sp. gr. 1.12 to
1,000 c.c. (Piffard)
When required for use, one volume of I is to be
mixed with two volumes of II. The copper contained
in 10 c.c. of this mixture is precipitated completely, as
cuprous oxide, by 0.05 gm. of glucose.
"To determine the quantity of sugar, place 10 c.c.
of the mixed soln. in a flask of about 250 c.c. capacity,
dilute with H 2 to about 30 c.c, and heat to boiling.
On the other hand, the urine to be tested is diluted and
thoroughly mixed with four volumes of H 2 if it be
poor in sugar, or with nine volumes of H 2 if highly
saccharine, and a burette filled with the mixture.
When the Fehling soln. boils, add a few gtt. NH 4 HO
and then 5 c.c. of the urine from the burette, boil
again, and continue the alternate addition of diluted
urine and boiling of the mixture until the blue color
is quite faint. Now add the diluted urine in quantities
of 1 c.c. at a time, boiling after each addition until
the blue color just disappears. Have ready a small
filter, and, having filtered through it a few gtt. of
the hot mixture, acidulate the filtrate with acetic acid,
and add to it 1 gtt. soln. of potassium ferrocyanide.
If a brownish tinge be produced, add another V 2 c.c.
of dil. urine to the flask, boil, and test with ferro-
cyanide as before. Continue this proceeding until no
brown tinge is produced. The burette reading, taken
at this point, gives the number of c.c. of dilute urine
containing 0.05 gm. glucose, and this divided by 5 or
10, according as the urine was diluted with 4 or 9
volumes of H 2 0, gives the number of c.c. urine contain-
ing 0.05 gm. sugar. The number of c.c. urine passed
in twenty-four hours divided by 20 times the number
of c.c. containing 0.05 gm. glucose, gives the elimina-
tion of glucose in twenty-four hours in grams.
138
COLORADO.
Example : Urine in 24 hours = 2,436 c.c.
Fehling's soln. used =: 10 c.c.
Urine diluted with 4 vols. H 2
Burette reading = 18.5 c.c.
18.5
= 3.7 == c.c. urine containing 0.05 gm. glucose.
5
2,436
: 32.92 = grams glucose eliminated in 24
3.7X20 hours." — ( Witthaus' Urinalysis. )
Significance of sugar in the urine : Diabetes mellitus ;
brain lesions involving the floor of the fourth ventricle ;
cerebral tumors and hemorrhages; some nervous dis-
eases, sciatica, tetanus; certain hepatic disorders;
pneumonia, typhoid, or some febrile disease, par-
ticularly during convalescence; after ingestion of
chloral, morphine, and some other poisons.
9. The color of the blood is due to the presence of
hemoglobin in the red corpuscles; in arterial blood it
is loosely combined with oxygen, and is called oxy-
hemoglobin.
10. Respiratory changes in the lungs. "Oxygen:
During a normal inspiration atmospheric air is drawn
into the larger bronchi ; here the tension of the oxygen
is greater than the tension of that oxygen which is in
the infundibula, where the oxygen tension in man has
been calculated to be 13 per cent, of an atmosphere of
oxygen. The gases in the infundibula, and conse-
quently in the alveoli, are separated from the blood
plasma in the lung capillaries by the flattened cubical
epithelium of the alveoli and the endothelium lining the
capillaries; it is believed that oxygen diffuses from the
alveoli through the two kinds of epithelium into the
plasma of the venous blood which has just arrived in
the lung, and which is collected in the distended capil-
laries. Now, oxygen accumulates in the blood, which is
consequently becoming rapidly arterial, until its tension
rises to 38.5. It is obvious, therefore, that there must
be another factor at work besides diffusion to account
for this difference of oxygen tension. The epithelium
which lines the alveoli is cuboidal in shape, and was
originally derived from the epithelium lining the ali-
mentary canal, and in function it is probably secretory.
The inference to be drawn, therefore, is that some oxy-
gen diffuses from the alveoli into the plasma of the
lung capillaries so long as the oxygen in the alveoli is
at a higher tension than that in the plasma ; when, how-
ever, a state of equilibrium is reached, the cubical cells,
139
MEDICAL. RECORD.
possibly controlled by the vagi, begin to secrete oxygen
from the alveoli into the blood plasma.
"Carbon-dioxide leaves the venous blood in the pul-
monary capillaries and gets into the alveolar air, where
its tension is usually 5 per cent, in males and 4.7 per
cent, in women and children. The tension of carbon-
dioxide in venous blood is higher than 5 per cent.; so
that it is, by diffusion that the C0 2 leaves the venous
blood and enters the air in the alveoli, and it is by a
continuation of the process of diffusion that the CO,
leaves the air in the alveoli and enters the bronchioles/'
— (Lyle's Physiology.)
PATHOLOGY.
1. An aneurysm is a pulsating sac containing blood,
and communicating with the lumen of an artery.
A true aneurysm is one in which the sac is composed
of one or more of the coats of the artery.
A false aneurysm, is one whose sac contains no
arterial coat, but is formed of condensed perivascular
tissue.
Causes of true aneurysm: Some preceding disease is
always present, usually atheroma; and dilatation oc-
curs only after the middle coat has been weakened.
Contusions or strains may rupture the middle coat, and
so produce weakness, which subsequently allows dilata-
tion to occur. Increase in the blood pressure by sudden
and violent exertions tends to the production of
aneurysm.
Varieties: There are three forms: (1) Sacculated
aneurysm is one in which the dilatation springs from
one side of the artery only, and in which the sac com-
municates with the artery by a comparatively narrow
opening. (2) Fusiform aneurysm is due to a general
dilatation of the whole circumference of an artery. Its
progress is slower than that of the sacculated variety,
and there is little or no laminated clot at first. It
usually ends in the formation of a sacculation at one
part. (3) Dissecting aneurysm is due to blood getting
into the middle coat and stripping it up. It cannot be
recognized during life.
Usual locations: Thoracic aorta, abdominal aorta,
popliteal, femoral, carotid, subclavian, innominate,
axillary, and iliac arteries.
Symptoms: A soft, elastic, pulsatile tumor in the line
of an artery; pulsation ceases if pressure is made on
the artery above the tumor, and reappears on relaxing
the pressure; similar pressure on the artery below the
tumor causes it to enlarge; a systolic bruit can often
140
COLORADO.
he heard over the tumor; the pulse below an aneurysm
: s weaker than the corresponding pulse in the opposite
limb; there may be pain, and weakness of the part
affected.
Treatment : Rest in bed; restricted diet (both solid
and liquid) ; iodide of potassium in doses of gr. xv to
xx ; hypodermic injection of gelatin; pressure; ligature,
various methods (Antyllus, Anel, Hunter, Wardrop,
Brasdor) ; extirpation of the sac; and aneurysmor-
rhaphy.
2. Peptic ulcer "is a peculiar form of ulceration gen-
erally found in the posterior wall in the lesser curva-
ture at the pyloric end of the stomach, and probably
due to the action of the gastric juice upon diseased
tissue. It is thought to be due to a thrombosis in a
vessel giving rise to a local area of necrosis, which,
being no longer able to resist the action of the gastric
juices, undergoes digestion. Infection, embolism, in-
farction, spasmodic contractions of the bloodvessels,
are all thought to have some bearing upon the forma-
tion of these ulcers. They are found most frequently
in chlorotic girls in whom there is an associated in-
crease in the acidity of the gastric juice. The peptic
ulcer is usually single and small, but is sometimes
multiple and large. It is generally round or slightly
oval, 2 to 4 cm., wider at the top than at the bottom,
and is accompanied by very little inflammation. The
mucous layer alone may be involved, or the destruction
may extend to the submucosa, the muscularis, or even
to the serous covering. In healing there is cicatricial
tissue formed which on contracting gives rise to a
peculiar white stellate scar. If the ulcer was in the
region of the pylorus, stenosis of that outlet may result.
From the floor of the healed ulcer carcinoma sometimes
develops. The two dangerous results are perforation
or hemorrhage. The perforation is usually smooth and
round and looks as if it had been punched out. Some-
times there have been adhesions to neighboring organs,
so that damage is prevented, but more frequently the
gastric contents will escape into the abdominal cavity
and give rise to peritonitis. ' Hemorrhage is the result
of ulceration of a large arterial branch. This is more
common than perforation. The amount of blood lost
may cause death or there may be merely a constant
oozing. Peptic ulcers sometimes occur in the upper end
of the duodenum close to the pyloric orifice and also in
the lower portion of the esophagus." — (McConnelPs
Pathology.)
3. The tubercle bacillus is a rod-shaped organism,
141
MEDICAL RECORD.
straight or slightly curved, with rounded ends, about
2 to 4 microns long by 0.1 to 0.5 micron broad, it often
has a beaded appearance, is non-motile, has neither
flagella nor spores, is aerobic, is acid-fast, and stains
well by Ehrlich's or Ziehl-Nielsen's or Gabbett's
method, also by Gram's method.
4. Jaundice "is a staining of the tissues by biliary
pigments that have been conveyed by the blood stream.
It is a symptom common to most diseases of the liver.
There were formerly thought to be two forms of
jaundice, the obstructive or hepatogenous and the non-
obstructive or hematogenous. The latter variety prob-
ably does not really exist, all icterus being due to
biliary coloring matter. There are, however, cases in
which no mechanical obstruction can be observed,
either by absence of bile in the feces or by lesions in
the liver. This discoloration is seen in some infectious
diseases and after experiments in which various sub-
stances have been injected into the blood. By the de-
struction of red cells, hemoglobin is set free and this
material, from which the bile pigments are formed, is
provided in excess. Catarrhal jaundice resulting from
obstruction to the duct by an inflammation of its mu-
cous membrane is the commonest form. Any obstruc- /
tion from within or without will, however, cause it. y
Microscopically, it is seen that the biliary capillaries
are distended and the liver cells contain more or less
pigment. The bile escapes from its normal channels,
is taken up by the lymphatics, from which it passes
into the circulation and thence to the tissues through-
out the body. The secretion and exudations of the
body may be distinctly tinged. The tissue first stained
is the intima of the blood vessels; finally the skin and
the sclera, where it is seen most characteristically.
According to the duration, the color will vary from a
light yellow to a dark bronze-green; the longer con-
tinued, the darker the color. If little or no bile es-
capes, the feces will usually be very light in color, clay-
like. The retention of bile within the body is generally
accompanied by quite marked disturbances, particularly
of the nervous system. As the flow of bile is re-
established the discoloration gradually disappears." —
(McConnell's Pathology.)
5. Anaphylaxis is a condition of hypersusceptibility
or supersensitiveness of an organism to foreign pro-
teins; it may be induced when a second injection of
toxin or of serum is given within ten or twelve days
after the first. It is the opposite of immunity.
142
COLORADO.
6. Leucocytosis is an increase in the number of white
corpuscles in the blood; it is an essential feature of
leukemia, but it is also found in other conditions. Leu-
cocytosis may be physiological or pathological.
A physiological leucocytosis is a leucocytosis which
is found in certain physiological conditions; it is gen-
erally moderate and of brief duration. It is found in
the newborn, after parturition, after exertion, after
a cold bath or massage, during pregnancy, and during
digestion.
A pathological leucocytosis is a leucocytosis which is
found in certain pathological conditions; it is generally
found in inflammatory, toxic, and infectious conditions.
As a rule, the polynuclears are increased.
7. Pellagra is a disease of unknown origin, endemic
or epidemic in some temperate and subtropical coun-
tries, and characterized by nervous, gastric and cu-
taneous symptoms. It is said to be due to maize ; it
has also been attributed to a parasite transmitted by
the Simulium reptans.
8. The varieties of vesical calculi are: Uric acid,
ammonium urate, calcium oxalate, phosphatic, cystin,
and xanthin.
9. Technique of the Gram stain: After the cover
glass has been smeared and fixed it is stained and
washed and then put in Gram's solution for thirty
seconds; this solution consists of iodine, 1 gm., potas*
sium iodide, 2 gm., and water, 300 c.c. ; it is then washed
in 95 per cent, alcohol until the color ceases to come
out of the preparation, and is then dried and mounted
in balsam. Its value lies in the fact that certain bac-
teria retain this stain, while others give it up. Hence,
it is made use of to differentiate certain organisms that
may resemble each other in size and shape.
10. Eosinophilia may be found in : Bronchial asthma,
scarlet fever, myelogenous leukemia, trichinosis, un-
cinariasis, filariasis, echinococcus disease, urticaria,
pemphigus, prurigo, psoriasis.
SYMPTOMATOLOGY.
1. Acute nephritis. Causes: Cold, exposure, scarlet
fever, diphtheria, other infectious diseases, traumatism,
pregnancy, certain irritant drugs, skin diseases and ex-
tensive burns. Symptoms: "In mild cases, slowly de-
veloping dropsy with anemia, shortness of breath or
dyspnea, and weakness are the only symptoms, the
diagnosis being confirmed by the results of urinary
examination. Usually, however, it begins suddenly
143
MEDICAL RECORD.
with nausea, violent and persistent vomiting, fever, and
dull pain over the kidneys, following the course of the
ureters. There is a frequent desire to urinate, and
diarrhea, harsh and dry skin, and a quick, tense, and
full pulse are present. Dropsy soon appears, beginning
first in the eyelids and face, but later becoming gen-
eralized. Anemia and weakness are marked, particu-
larly in post-scarlatinal cases. Uremic symptoms may
develop at any time during the attack. The affection
lasts from one to four weeks. The urine is of high
specific gravity, 1025 to 1030, scanty, smoky (like beef
washings) in color, due to the presence of blood. Al-
bumin is present in large quantities, and the microscope
reveals hyaline, blood, granular and epithelial casts
of the uriniferous tubules, blood corpuscles, uric acid,
urates, oxalate crystals, and epithelium. The total
amount of urea eliminated during the twenty-four
hours is lessened from one-fourth to one-half. The
amount of phosphates and chlorides is also lessened." —
(Hughes' Practice of Medicine.)
2. Symptoms of rheumatic fever: The affected joints
are generally the larger ones, and these are tender,
swollen, hot, and painful; the trouble seems to flit from
one joint to another; the fever is irregular, and may
reach 103° F.; the perspiration is acid and may be
copious; the urine is scanty and high colored; the
tongue is coated, the appetite is lost, and the bowels
are apt to be constipated; moderate leucocytosis and
secondary anemia may be observed.
3. Erysipelas. "Etiology: Predisposing causes: (1)
A wound or abrasion; (2) constitutional debility; (3)
bad hygiene. Exciting causes: Streptococcus erysipe-
latis, which is indistinguishable from the Streptococcus
pyogenes.
Symptoms: Malaise with rigor and headache. Rash
appears within twenty-four hours; it appears first
round the wound, which breaks open ; it is of a vivid red
color, which fades on pressure. Pain and swelling are
not much marked. The eyelids and scrotum when af-
fected become very edematous. Vesicles and bullae form
superficially, and a fine desquamation occurs, with some
staining of the skin as the rash fades away. The
margin is well marked, rather gyrate, slightly swollen,
rapidly advancing. Sloughing of the skin rarely oc-
curs, and then usually in cases of scrotal affection.
Lymphatic glands in the neighborhood are enlarged and
tender. Extension may occur by the lymphatics or veins
to the deep structures, or pyemia may be set up. Con-
144
COLORADO.
stitutionally, the patient is very ill, with high temper-
ature — 102°-104° F. Delirium is frequent, especially
when the scalp is affected. Vomiting is common.
Varieties: Facial erysipelas is often apparently idio-
pathic and recurrent. It is accompanied by great
edema; it is liable to be complicated by meningitis.
Faucial erysipelas spreads from the exterior to the
pharynx; causes great swelling of the parts, with a
tendency to edema glottidis. Sloughing or ulceration
may follow. Massive enlargement of the glands at the
angle of the jaw. Scrotal erysipelas causes great
edema, and in children a tendency to sloughing. Cel-
lulo- cutaneous erysipelas partakes of the character of
both cellulitis and erysipelas, affecting the skin and
subcutaneous tissue. The margin is less sharply de-
fined; the tendency to general septic infection and
sloughing of the skin is greater than in either of the
simpler diseases." — (Grove's Synopsis of Surgery.)
4. Symjitoms of diphtheria: — General malaise, slight
fever, headache, backache, stiffness of the neck and
swelling at the angles of the jaws; the tonsils are red
and swollen, the soft palate is congested, and whitish
patches of necrosed tissue appear, first on the fauces,
these patches are surrounded by a deep scarlet in-
flamed area of mucous membrane, and spread to tonsils
and uvula; this membrane strips off with difficulty,
leaves a bleeding surface, and reforms; the lymphatic
glands of the neck usually enlarge, but do not suppurate
as a rule; the temperature varies from 100° F. to about
102° F., but it may be subnormal; albumin is generally
present in the urine. Complications: — Pneumonia,
pleurisy, adenitis, otitis media, paralysis, endocarditis,
nephritis.
5. The early manifestations of pulmonary tuber-
culosis are: (1) Physical signs: Deficient chest expan-
sion, the phthisical chest, slight dullness or impaired
resonance over one apex, fine moist rales at end of in-
spiration, expiration prolonged or high pitched, breath-
ing interrupted. (2) Symptoms: General weakness,
lassitude, dyspnea on exertion, pallor, anorexia, loss of
weight, slight fever, and night sweats, hemoptysis.
6. In a typical case of croupous pneumonia, "there
may be slight catarrhal symptoms for a day or two;
but as a rule the disease sets in abruptly with a severe
chill, which lasts from fifteen to thirty minutes or
longer. In no acute disease is the initial chill so con-
stant or so severe. The patient may be taken abruptly
in the midst of his work, or may awaken out of a sound
sleep in a rigor. The temperature taken during the
145
MEDICAL RECORD.
chill shows that the fever has already begun. If seen
shortly after the onset, the patient has usually features
of an acute fever, and complains of headache and gen-
eral pains. Within a few hours there is pain in the
side, often of an agonizing character ; a short, dry, pain-
ful cough begins, and the respirations are increased in
frequency. "When seen on the second or third day, the
picture in typical pneumonia is more distinctive than
that presented by any other acute disease. The patient
lies flat in bed, often on the affected side; the face is
flushed, particularly one or both cheeks; the breathing
is hurried, accompanied often with a short expiratory
grunt ; the alse nasi dilate with each inspiration ; herpes
is usually present on the lips or nose; the eyes are
bright, the expression is anxious, and there is a fre-
quent short cough which makes the patient wince and
hold his side. The expectoration is blood-tinged and
extremely tenacious. The temperature may be 104° or
105° F. The pulse is full and bounding and the pulse-
respiration ratio much disturbed. Examination of the
lungs shows the physical signs of consolidation — blow-
ing breathing and fine rales. After persisting for from
seven to ten days the crisis occurs, and with a fall in
the temperature the patient passes from the condition
of extreme distress and anxiety to one of comparative
comfort." (From Osier's Practice).
7. An embolus arising from the saphenous vein will
most likely lodge in a branch of the pulmonary artery.
It may cause sudden death; or syncope, and precordial
distress, followed by suffocation. Or there may be
sense of oppression in the chest, rapid respiration, dys-
pnea, pallor followed by cyanosis, exophthalmos, cold
sweat, chills, convulsions.
8. An embolus arising from the mitral valve may lodge
in any of the systemic arteries. It may cause necrosis,
infarction, degeneration or death of the part supplied
by the affected artery, unless adequate collateral cir-
culation is established. The symptoms are those of
local anemia and (possibly) of infection. Pain, chill,
fever, and annihilation of function may be observed.
9. Acute poliomyelitis occurs most often in child-
hood, and is characterized by sudden paralysis of one or
more limbs or of individual muscle-groups, and fol-
lowed by rapid wasting of the affected parts, with
reaction of degeneration and deformity. The onset is
sudden and marked by fever, vomiting, convulsions,
or even coma. Paralysis and atrophy of the muscles,
with reactions of degeneration, then present them-
selves. It occurs usually during the first three years
146
COLORADO.
of life and most often during the summer months. It
sometimes occurs in epidemics.
The treatment during the initial stage consists in
rest in bed, restricted diet, fractional doses of calomel,
and sponging, or small doses of phenacetin if the fever
and nervous symptoms are marked. An ice-bag should
be placed along the spine, or mild counterirritation to
the spine by mustard plasters may be practised. After
the acute symptoms have subsided, electricity and pass-
ive movements may be employed. Deformities may re-
sult and will require the application of mechanical ap-
paratus or the performance of surgical operations for
their correction. (Pocket Cyclopedia.)
10. The chief anomalies of the rate and rhythm of
the heart are tachycardia, bradycardia, palpitation, and
arrhythmia. The chief forms of arrhythmia are sinus
irregularities, extra-systole, nodal rhythm, auricular
fibrillation, irregularities due to failure of the conduct-
ing power of the primitive bundle, failure of contrac-
tility of the ventricle, and pulsus alternans.
OBSTETRICS
1. Development of the fertilized ovum. " (1) When
the ovum is mature, two small cells are detached from
the main body of cells; these are called polar globules.
It was formerly supposed that these were associated
with the disappearance of the germinal vesicle, but
recent experiments have demonstrated that the germ-
inal vesicle plays an active part in their formation.
This can take place independently of fecundation. (2)
The portion of the ovum remaining after the throw-
ing off of the polar globules is called the 'female
pronucleus. ' (3) Fecundation is effected by the pene-
tration of the head of one spermatozoon. This is
called the 'male pronucleus.' (4) The male and female
pronucleus coalesce. The ovum is now called the
oosperm, or blastosphere. (5) The segmentation of
the nucleus and vitellus, i.e. they both split into two
masses, these into four, and so on until a large num-
ber of segments are formed. This is known as the
morula, moriform body, or mulberry mass. (6) A
clear fluid is secreted within the ovum, which presses
these segments to the surface of the ovum, where they
form a double layer of cells, differing somewhat in
size. The outer and larger is termed the epiblast or
ectoderm, and the inner and smaller the hypoblast or
endoderm. Together they are known as the blasto-
dermic vesicle. (7) There then appears upon the out-
side of the vitellus a small oval elevation, surrounded
147
MEDICAL RECORD.
by a depression, which is called the area germinativa.
(8) There appears in the area germinativa a small,
dark line called the primitive trace. About this line
will be grouped the various parts of the embryo, the
rest of the ovum serving only as a covering and for
nutriment. (9) A covering for this trace or embryo
is now formed. Thus far the vitelline membrane has
been sufficient. The embryonic line sinks into the
center of the ovum, while the edges of the external
blastodermic layer about the area close around it, in-
closing it in a sac called the amnion. Between the
amnion and the embryo, fluid at a later period is de-
posited; this constitutes the liquor amnii. The vitel-
line membrane then disappears." — (Landis's Ob-
stetrics.)
2. The movements in the mechanism of L.O.A.:
Flexion, by 'which the chin tilts up and the occiput
down, so as to get the long diameter of the head more
or less endwise to the pelvic brim. Descent, by which
the head descends, occiput first, through the brim into
the cavity, down to the inclined planes of the pelvic
floor. Rotation, by which the occiput glides along the
left anterior inclined plane, downward, forward and
inward to the symphysis pubis; and the forehead
glides along the right posterior' inclined plane to mid-
dle of sacrum. Extension, by which occiput escapes
under pubic arch and rises up outside, towards mons
veneris, while forehead, nose, mouth, and chin success-
ively escape at perineum. Restitution, by which oc-
ciput turns towards mother's left thigh, in consequence
of shoulders rotating upon inclined planes — the right
shoulder to the pubes, the left to the coccyx. — (From
King's Obstetrics.)
PLACENTA PREVIA. ABRUPTIO PLACENTAE
Most commonly man- , Most commonly occurs
ifests itself after t h e | during the first stage of
sixth month of gestation,
but may occur as early as
the second month.
The hemorrhage is ab-
rupt, but painless.
There are generally re-
peated hemorrhages of in-
creasing severity.
labor, but may occur at
any time during the last
three months of preg-
nancy.
The hemorrhage is sud-
den, and generally is at-
tended with sharp pain.
Hemorrhage persists
until the uterine contents
are evacuated or the pa-
tient perishes.
148
COLORADO.
PLACENTA PREVIA. [ ABRUPTIO PLACENTAE.
There is an edematous Vaginal examination re-
condition of the cervix i veals no deviation from
and lower uterine seg- the condition normal to
ment, with marked pulsa- pregnancy,
tion. |
Cervix is generally The cervix is perhaps
quite patulous, and with- (if labor be initiated)
in may be detected the slightly patulous,
placenta.
The placental bruit is The placental bruit is
situated low down. in normal position.
— (Dorland's Obstetrics.)
4. Uterine inertia may be caused by: Debilitated
constitution, exhausting disease; uterus weakened be-
cause of congenital malformation, inflammation, or too
frequent child-bearing; adhesions to neighboring struc-
tures; tumors of the uterus or neighboring tissues;
distention of the bladder or intestine; displacement of
the uterus; premature escape of the liquor amnii;
pregnancy in an old primipara; hydramnios; twin
pregnancy; fright or mental emotion.
The cervix dilates slowly or not at all; if the mem-
branes are ruptured the fetus makes little or no ad-
vance; the woman shows evidences of fatigue and may
be anxious or restless; the skin gets dry, the pulse
small and rapid, the temperature elevated, the tongue
dry and furred, nausea and vomiting may supervene,
and delirium and coma may follow. — (From Web-
ster's Obstetrics.)
Treatment consists in removing the cause if possible ;
the bladder and bowel should be emptied; opium, mor-
phine and chloral may be given so that the patient may
get a little sleep, at the same time food may be admin-
istered; the uterus may be massaged through the ab-
dominal walls; hot vaginal douches are sometimes help-
ful; the vagina may be distended with a rubber bag;
if the membranes are ruptured, a Champetier de Ribes
bag may be placed in the lower part of the uterus ; an
anesthetic may be necessary; quinine, strychnine, and
ergot have been recommended by some, and condemned
by others; the newest remedy is pituitrin, which may
be injected into the muscles in doses of from one to
one and a half cubic centimeters, provided that the
cervix is dilated and that there is no obstruction to
delivery.
5. Cesarean section. — "Indications : The cases in
149
MEDICAL RECORD.
which it is performed are: (1) Extreme deformity of
the pelvis, in which delivery by forceps and version is
excluded, and in which craniotomy is either impossible
or would be more dangerous to the mother than cutting
into the abdomen and uterus; and in which there is
not room for a successful symphyseotomy. Such cases
present the 'positive' indication for cesarean section;
there is nothing else to be done. Flat pelves having a
conjugata vera of 2% inches or less, and justo-minor
pelves with a conjugata vera of 2% inches or less,
present this positive indication; (2) cases of more
moderate pelvic contraction in which craniotomy is
possible, but cesarean section is agreed upon to save
the life of the child; (3) mechanical obstruction in the
pelvis from fibroid, cancerous, bony, or other tumors
which cannot be pushed up out of the way or be safely
removed; (4) irreducible impaction of a living child in
transverse presentations; (5) in women dying near
the end of pregnancy the child, if alive, is rapidly de-
livered by post-mortem cesarean section; (6) various
other obstructions from inflammatory adhesions, atre-
sia, constrictions, etc., of the vagina, and uterine dis-
placements, may rarely require the operation; (7)
recently the operation has been done in eclampsia cases,
where more conservative methods of rapid delivery
were impracticable; and (8) in placenta praevia, chiefly
with a view to lessen the infant mortality attending
the usual treatment of this complication. ,, — (King's
Obstetrics.)
Cesarean section. — "Fluidextract of ergot, n^xx, is
injected into the thigh muscles just as the anesthesia is
begun. The operator assures himself that there is no
loop of intestine between the uterus and abdominal
wall, beneath the field of incision. Should a coil of in-
testine be found there, it is pushed above the fundus.
An assistant holds the uterus in central position. The
skin incision extends one-third above and two-thirds
below the level of the umbilicus. It is best made
through the right rectus muscle. The external layer
of the rectus sheath is divided, the muscular bundles
separated with handle of scalpel and the fingers, and
the deep layer of the sheath and the peritoneum divided
after lifting them with tissue forceps. Bleeding vessels
are controlled by gauze sponge pressure or held by
catch-forceps before opening the peritoneum. A short
longitudinal median incision is made in the uterine wall
beginning at the fundus, avoiding the membranes if still
unbroken. This is extended downward with fingers,
scissors, or scalpel to a total length of about 6 inches.
150
COLORADO.
The hand is thrust through the membranes and the
child is extracted by the head or the feet, whichever
is most accessible. In case of anterior implanation of
the placenta, usually the hand may best be passed
directly through it. The cord is clamped at two points
with catch-forceps, cut between them, and the child
is passed to an assistant. The uterus slips out of the
abdomen as the child is extracted, and the intestines
are kept back with hot sterilized towels placed over
the upper part of the incision. The coverings help
also to protect the peritoneum from soiling. The
uterus is wrapped in hot moist cloths. As a rule, it is
better not to wholly eventrate the uterus. The placenta,
if not spontaneously separated, may be peeled off by
grasping it with one hand like a sponge. If the cervix
is not sufficiently open for drainage, a large rubber
tube or gauze strip is passed down through it and
withdrawn from below. Irrigating or mopping the
uterine cavity is unnecessary. Asepsis is promoted by
leaving it as nearly as possible untouched. The peri-
toneum is sponged dry with the least possible friction
or handling. The uterine wound is closed with deep
No. 2 chromated catgut sutures at intervals of about
1/3 inch. They are given a wide sweep laterally
through the muscular wall, falling short of the decidua.
The peritoneal coat of the uterus is closed with a
No. 1 continuous plain catgut suture, forming a welt
over the deep suture line. The hemorrhage is incon-
siderable and usually ceases with the introduction of
the first sutures — a hypodermic of ergotole should be
given before beginning the operation, and one of ergo-
tole and pituitrin on the delivery of the child. Retrac-
tion of the uterus is ensured by manipulating it, if
necessary, through a hot towel, or by faradism. When
there has been much blood lost, a quart or two of warm
sterilized 0.9 per cent, salt solution may be left in the
peritoneum. The parietal peritoneum is closed with a
plain running No. catgut suture. Interrupted silk-
worm-gut sutures are then passed at intervals of about
% inch: through all but the peritoneum, from within
outward. The fascia is brought together with inter-
rupted No. 2 plain catgut sutures, or with a continuous
suture. The silkworm-gut sutures are now tied. The
abdomen is cleansed, and the wound covered with a
dressing of several thicknesses of dry sterile cheese-
cloth; over this is placed a thick compress of sterile
absorbent cotton. The dressings are secured with
strips of zinc oxide adhesive plaster, and held in place
by a Scultetus binder." — (Polak's Obstetrics.)
151
MEDICAL RECORD.
6. Indications for the use of forceps are: (1) Forces
at fatdt: Inertia uteri in the presence of conditions
likely to jeopardize the interests of mother or child,
(a) Impending exhaustion; (b) arrest of head, from
feeble pains. (2) Passages at fault: Moderate narrow-
ing, S X A to 3% inches, true conjugate; moderate ob-
struction in the soft parts. (3) Passenger at fault:
A. Dystocia due to (a) occipito-posterior, (b) mento-
anterior face, (c) breech arrested in cavity. B. Evi-
dence of fetal exhaustion (pulse above 160 or below
100 per minute). (4) Accidental complications: Hemor-
rhage ; prolapsed funis ; eclampsia, All acute or chronic
diseases or complications in which immediate delivery
is required in the interest of mother or child, or both
(Jewett). Conditions necessary for the use of forceps
are: (1) The rectum and bladder must be empty;
(2) the os, uteri must be fully dilated; (3) the mem-
branes must be ruptured; (4) the pelvis must be of
sufficient size.
Contraindications: Mechanical obstruction in the
parturient canal; incomplete dilatation of the os; non-
rupture of membranes; non-engagement of the present-
ing part; the fetal head being too large or too small;
distended bladder or rectum.
Manner of using^ forceps: "They should not be used
when the os is undilated, when the head is not engaged,
except in placenta prsevia, when the membranes are
unruptured, when the disproportion between the child's
head and the parturient canal is too great, or in
impossible positions and presentations. Before apply-
ing the instruments they should be sterilized, preferably
by boiling; and the patient anesthetized and placed
in the lithotomy position. Two fingers of the right
hand are introduced into the vagina; the left blade
of the forceps is then held almost perpendicularly by
the left hand, with the tip of the blade opposite the
vulva ; the tip is introduced into the vagina, and passed
along the floor toward the sacrum. The blade is
rotated outward in its long axis in order to escape the
promontory of the sacrum. The right blade is intro-
duced in a similar manner. To facilitate locking, one
of the blades must be rotated forward. If the head
occupies the right oblique diameter, as in L. O. A. and
R. O. P. positions, the right blade must be rotated; if
it occupies the left oblique diameter, the left blade must
be rotated. Traction is made in the direction of the
pelvic axis until the perineum is well distended. The
perineum is then protected by one hand, while the face
is swept over it by an upward movement of the forceps.
152
COLORADO.
In posterior positions it is necessary to remove the
instruments after the head is drawn down to the
pelvic floor; after anterior rotation is secured they
may be reapplied. If the occiput rotates into the hol-
low, of the sacrum the hands should be depressed as the
face is swept out under the symphysis pubis." —
(Pocket Cyclopedia.)
7. Hemorrhages of pregnancy: Caused by (1)
placenta prsevia; (2) premature separation of a nor-
mally situated placenta; (3) apoplexy of the decidua
or placenta.
Hemorrhages of labor: Caused by (1) placenta
prsevia; (2) premature separation of a normally sit-
uated placenta; (3) relaxation of the uterus; (4)
laceration of cervix; (5) rupture or inversion of the
uterus.
Hemorrhages of the puerperium: Caused by (1)
retained secundines; (2) displaced uterus; (3) dis-
placed thrombi; (4) fibroid tumors; (5) hypertrophied
decidua; (6) carcinoma.
8. Placenta prsevia is the condition in which the
placenta is attached in the lower uterine segment and
may be near or over (partially or completely) the in-
ternal os. The causes are unknown; multiparity, fre-
quent pregnancies with subinvolution, and abnormalities
of uterus, placenta or cord are said to predispose to this
condition. Varieties: (1) Central, when the placenta
completely covers the os. (2) Partial, when the pla-
centa overlaps the os. (3) Marginal or lateral, when
the placenta reaches the margin of the os but does not
overlap it. Symptoms: Sudden hemorrhage, accom-
panied by syncope, vertigo, restlessness, and feeble
pulse. Dangers: Hemorrhage, sepsis, death of the
mother, death of the fetus.
Treatment before term: Rest in bed, with or without
a tampon, will arrest hemorrhage for the time; the
sinuses are closed by thrombi, and the case may go on
to term or another hemorrhage. The patient should
be allowed cold drinks; opium may be used where pain
is present. If the hemorrhage is great, it is safer to
induce labor at once than to wait. Occasionally no hem-
orrhage occurs during pregnancy, not even in labor.
Treatment at term: (1) Introduce one or two fingers
within the os (the hand being in the vagina) and
dissect the placenta from the uterine wall for about
three inches from the os uteri in all directions, pushing
it to one side if necessary. (2) Rupture the mem-
branes, and if there is an unfavorable presentation,
turn the child and make the breech engage in the os;
153
MEDICAL RECORD.
or, if the head presents, the forceps may be used, if
speedy delivery is necessary. Stop the hemorrhage by
a tampon; this must be tight and thorough. Accouche-
ment force is indicated; this consists of dilatation of
cervix, version and immediate extraction of the child.
^ 9. Diagnosis of position: "The examiner stands along-
side the patient, facing her head; the tips of the fingers
of both hands, moving together and at equal distances
from the middle line, are carried up the sides of the
abdomen by a series of tapping movements; and upon
one side (for example, the left, in the L. O. A. position)
is noticed a firm, broad, even sense of resistance, con-
tracting with the cystic, tumor-like sensation of the
other side, with the occasional encounter of firm, irregu-
lar bodies — the fetal extremities. This firm, broad,
even resistance is produced by the fetal back, and to
confirm this fact the extremities are felt for by a
rubbing motion with one outstretched hand on the
opposite side. They are felt as cylindrical, irregular
bodies, slipping away from the hand, and changing
their position from time to time. Having located the
back and the extremities, the portion of the fetal ellipse
presenting at the superior strait is next ascertained.
The examiner now faces the woman's feet and, with the
outstretched hands, the fingers parallel with and the
middle finger over the center of Poupart's ligament into
the pelvic cavity. If the head is presenting, it is felt
as hard, regular, round body, the greater mass of the
occiput, the sharp point of the chin, and the groove
between occiput and back being often distinguishable.
At the same time, the density of the head, its com-
pressibility, its approximate size, and its relative size
to the pelvis may be learned." — (Hirst, Obstetrics.)
TOXICOLOGY.
1. A poison is a substance which, on being in solution
in or acting chemically upon the blood, causes death or
serious bodily harm. Classification: There are many
classifications given, but not one of them is entirely
satisfactory. That of Witthaus is into corrosives and
poisons proper, the latter being subdivided into mineral
poisons, vegetable poisons, animal poisons, and syn-
thetic poisons.
2. The symptoms of poisoning by opium: At first
there is usually a period of excitation, marked by rest-
lessness, great physical activity, loquacity, and halluci-
nations. The patient then becomes weary, dull, and
drowsy; he yields to the desire for sleep, from which
at first he may be roused. The lips are livid, the face
154
COLORADO.
pale, the pupils contracted, and the surface bathed in
perspiration. The condition of somnolence rapidly
passes into narcosis. The patient cannot be roused,
and lies motionless and senseless, with completely re-
laxed muscles. The pulse, at first full and strong, be-
comes feeble, slow, irregular, and easily compressible;
the respiration slow, shallow, stertorous, and accom-
panied by mucous rales. The patient rapidly becomes
comatose, and, in fatal cases, dies in from 45 minutes
to 56 hours, usually in from 12 to 18 hours. In cases
of recovery after the stage of narcosis, the pulse and
respiration gradually return to the normal, and the
condition of coma passes into one of deep sleep, lasting
24 to 36 hours.
3. Carbolic add poisoning may be produced by in-
gestion of phenol or its derivatives, by the application
of phenol dressings, by intrauterine douche of phenol,
by vaginal douche of phenol, by using lotions containing
phenol. Symptoms of carbolic acid poisoning: Buccal
mucous membrane is whitened and hardened; vomiting;
burning pain in mouth, esophagus, and stomach; pulse
and body temperature are lowered; the pupils are con-
tracted; collapse, and finally death. The urine may be-
come dark.
4. Bromism is the name given to certain peculiar
phenomena produced by the excessive administration of
the bromides. The most marked symptoms are head-
ache, coldness of the extremities, feebleness of the
heart's action, somnolence, apathy, anesthesia of the
soft palate and pharynx, pallor of the skin, and a
peculiar eruption of acne that, with lowered faucial
sensibility, is one of the earliest and most constant
symptoms. There is also anrexia, with loss of sexual
power and atrophy of the testes or mammae. The
patient may become almost imbecile.
5. Symptoms of poisoning by tartar emetic: "These
are seldom delayed more than half an hour. Nausea,
violent and continual vomiting, burning pain in
stomach and bowels, with an acrid, burning sensation
in the throat, are usually the first symptoms. Then
purging, intense thirst, feeble, rapid pulse, cramps in
legs, and general lowering of the temperature, with
great prostration, follow. The coldness extends even
to the internal organs. The bowels become tympanitic.
The spinal centers are greatly depressed. The urine
is generally increased, but sometimes diminished or
suppressed, and may be bloody and passed with diffi-
culty and pain. Delirium and convulsions may precede
death, or the patient may sink into coma, or die from
155
MEDICAL RECORD.
exhaustion. The progress of the case often resembles
arsenical poisoning so closely that it is difficult to
decide which it is without chemical analysis. Generally,
however, the persistent nausea and vomiting will dis-
tinguish between them. Sometimes neither vomiting
nor purging is seen. In such cases the patient is apt to
collapse, with cold sweat, feeble respiration, cyanosis,
delirium, irregular pulse, and lapse into unconsciousness
and die in convulsions. — (Riley's Toxicology.)
6. Acute ergotism: "In a large dose ergot acts as a
gastrointestinal irritant, causing nausea and vomiting,
gastralgia, colic, thirst, and purging. It slows the
heart, raises the arterial tension greatly, dilates the
pupils and produces pallor, vertigo and frontal head-
ache. It stimulates the contraction of unstriped mus-
cular fiber, especially affecting the sphincters and
causing contraction of the sphincter of the bladder,
making micturition difficult if not impossible. It
produces cerebral and spinal anemia, a great fall of
the body temperature, coldness of the surface, tetanic
spasms, and violent convulsions/' Chronic ergotism
"occurs in two forms, the convulsive and the gangrenous
— either usually excluding the other. The convulsions
are tetanoid spasms of the flexor muscles, the uterus,
the intestinal fibers, and the muscles of respiration,
ending in coma and death by asphyxia. The gangrenous
form begins with coldness and numbness of the limbs,
formication of the skin all over the body, loss of sensi-
bility and abolishment of the special senses, bullae of
blood and ichor, followed by dry or moist gangrene of
the lower extremities, buttocks, and other parts, epi-
leptiform, convulsions, coma, and death. Autopsies
show changes in the posterior columns of the cord,
resulting probably from spinal anemia."— (Potter's
Materia Medica, etc.)
7. Five common vegetable poisons: Aconite, bella-
donna, strychnine, cocaine, and opium. Chloral hydrate
is antidotal to the spasms caused by strychnine.
8. Hydrargyrism. The first symptoms of salivation
are fetid breath, swollen and spongy gums, having a
bluish line along their margins, stomatitis, sore and
loosened teeth, inflamed and tender salivary glands
pouring out a peculiar, thin saliva of foul odor in large
quantity, and a metallic taste in the mouth. Emacia-
tion, pallor, edema, ulcerated skin, erythematous, vesic-
ular, or pustular eruptions, headache, insomnia, neu-
ralgia, tremor through paresis of the muscles of the
head and extremities, epilepsy, coma, and convulsions
may ensue. An influenzal condition is not uncommon.
156
COLORADO.
9. Strychnine produces a sense of suffocation, thirst,
tetanic spasms, usually opisthotonos, sometimes em-
prosthotonos, occasionally vomiting, contraction of the
pupils during the spasms, and death, eitherby asphyxia
during a paroxysm, or by exhaustion during a remis-
sion. The symptoms appear in from a few minutes to
an hour after taking the poison, usually in less than
twenty minutes; and death in from five minutes to six
hours, usually within two hours.
10. Symptoms of digitalis poisoning: Nausea and
occasionally vomiting. Sometimes colic and diarrhea.
After two or three hours marked diminution in the fre-
quency of the pulse, which may fall to 40 or even 25.
Dyspnea, attended by a sense of oppression in the chest
and coldness of the extremities. Headache, vertigo, and
tendency to sleep. Usually attacks of syncope occur,
provoked sometimes by the slightest movement of the
patient.
SURGERY.
1. The thyroid gland is subject to atrophy, hyper-
trophy, inflammation, goitre (which may be benign,
cystic, exophthalmic, parenchymatous, adenomatous,
fibrous, and malignant) ; myxedema and cretinism are
also conditions in which the thyroid gland is affected.
In goitre, the gland is swollen, and moves on degluti-
tion; there may be dyspnea from pressure on the sur-
rounding parts or from pressure on the recurrent
laryngeal nerve. Exophthalmic goitre is believed to be
due to excessive absorption of the thyroid secretion,
or to some nervous derangement; it is characterized by
exophthalmos, goitre, rapid heart beat, and fine tremors.
Removal of the thyroid without the parathyroids is
usually not fatal, but myxedema may result.
2. Benign tumors of the breast are fibroma, adenoma,
cvstadenoma, lipoma, myxoma, and enchondroma. It is
generally believed that benign tumors may become
malignant. The malignant tumors are sarcoma, and
carcinoma. It is of the utmost importance that the
uresence of a tumor be recognized at an early date, and
in case of doubt as to the character of a tumor it should
be considered malignant until it is proved to be other-
wise. "If the mistake is made of regarding an innocent
tumor as malignant the woman loses her breast. If a
malignant tumor is regarded as innocent, the woman
loses her life." Benign tumors should be removed;
malignant, if operable, require entire removal of the
breast and neighboring lymphatics. Besides tumors,
the breast may be the seat of inflammation, abscess,
cysts and hypertrophy. In chronic inflammatory think-
157
MEDICAL RECORD.
ening the skin may be pitted, and the tumor fixed in
the breast, and ill-defined ; but the whole gland is often
uniformly enlarged, scars of old abscesses may be
visible, and the glands are swollen at an earlier stage,
and to greater size than in cancerous conditions.
Adenomata are generally clearly limited and freely
movable; there is no dimpling of the skin, and the lym-
phatic glands are not enlarged. Tense cysts, when
fluctuation cannot be elicited, are similar in most of
their symptoms to adenomata; and differ from "malig-
nant cysts" by the absence of adhesions or extension
of the disease to lymphatics. Sarcomata are more
rapid in growth and soon involve the skin, and do not
affect the glands in the early stages. Duct cancers
are apt to be multiple, are more circumscribed, and are
specially distinguished from scirrhus by the bloody
discharge from the nipple; they differ also from simple
papuliferous cysts of the ducts by the tumor invading
the breast. Epithelioma of the areola or nipple differs
from eczema in its intractability to soothing treatment;
and from scirrhus in its superficial and more localized
situation, at all events in the early stages. In cases of
doubtful diagnosis it is advisable to prepare for a
radical extirpation of the disease; but first to incise
the tumor and remove a piece from the growing edge
for immediate examination.
3. Varieties of intestinal obstruction are: (1) Acute,
including strangulation, Volvulus, and Intussusception;
and (2) Chronic. (See table on page 159.)
4. Pott's fracture is very common, and is due to in-
direct violence, such as turning over on the inside of
the foot. The strain tears through the internal lateral
ligament of the ankle or tears off the tip of the mal-
leolus; then the astragalus is pressed against the inner
side of the external malleolus by the continuation of
the violence. The fibula is overbent, and breaks about
3 inches above the tip of the malleolus. At the same
time the foot is displaced outwards or outwards and
backwards. Treatment : An anesthetic should always
be given, and the fracture reduced by relaxing the calf
muscles and applying traction to the foot. The limb
must then be fixed on a back-splint, with side-splints in
addition. The foot must be at right angles to the leg,
the bony points in line, and the posterior displacement
corrected. The surest way of maintaining the foot in
good position is to at once apply plaster of Paris. Other
splints used are Dupuytren's and Syme's horseshoe
splint. Massage and passive movement at the end of
ten days are advisable, the fragments being firmly
158
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MEDICAL RECORD.
press the elbow to the side, rotate the arm outward.
Bring the arm forward and upward to a right angle
with the body, then rotate inward, while the elbow is
brought down over the body so that the fingers sweep
the opposite shoulder.
3. Amputation in contiguity is amputation at a joint.
Amputation in continuity is amputation elsewhere than
at a joint.
Conditions which justify amputation of a limb are:
"Any injury, disease, or malformation rendering reten-
tion of the limb incompatible with life or comfort; avul-
sion of limb ; compound fracture ; compound dislocation ;
fracture with great comminution of bone; laceration of
important vessels; extensive contusion; extensive lacer-
ation; gunshot injuries; aneurysm; effects of heat and
cold; gangrene; extensive bone disease; tumors; ele-
phantiasis; tetanus; snake bite; deformities." — Bick-
ham's Operative Surgery.)
4. Degrees of Burns. — Dupuytren's classification:
First degree, reddening of the skin. Second degree,
blistering. Third degree, destruction of the epidermis,
Malpighian layer, and papillae of the derma. The sensi-
tive nerve terminals are exposed; consequently this is
the most painful degree. The sweat and sebaceous
glands and hair follicles are not destroyed, and from
these epithelium spreads in healing, so that repair is
rapid, and the scar is not a contracting one. Fourth
degree: the whole thickness of skin and part of the
subcutaneous tissues are destroyed. Fifth degree: the
muscles are injured. Sixth degree: the whole limb is
charred.
Treatment. — General: If carbonic-oxide-poisoning is
present, artificial respiration and administration of
oxygen. For the relief of shock, opium and stimulants
are called for.
Local: For burns of the first degree, powder with
boracic acid. Puncture blisters, and cover the part
with an antiseptic dressing.
Burns of deeper degrees than the second must
be made aseptic with 1 in 1,000 perchloride of mercury.
Carbolic acid is absorbed readily, and must not be used.
Antiseptic gauze dressings should then be used. Picric
acid (20 grains to 1 ounce of water) is used as a dress-
ing. It lessen the pain, and can be left on two or three
days. The continuous bath may be used. If the burn be
of any size, it should be skin-grafted, as the scars of
burns contract very much, and may produce deformities.
— (Aids to Surgery.)
Opium is not contraindicated.
226
GEORGIA.
REDUCIBLE SCRO-
TAL HERNIA.
Impulse on cough-
ing.
Percussion clear
if i n t e s tinal,
dull if omental.
Ring and inguinal
canal occupied,
spermatic cord
obscured.
Intestine to be
felt, and re-
turned with slip
and gurgle, and
remains up till
effort is made,
when it returns
from above.
Opaque.
Testicle below tu-
mor.
Any age.
CONGENITAL HY-
DROCELE.
No impulse, un-
less combined
with hernia.
Percussion dull.^
HYDROCELE OF
CORD.
No impulse, un-
less actually in
abdominal ring.
Percussion dull.
Ring and canal | Ring and canal
clear. usually clear.
Fluid to be felt,
and readily re-
turned when pa-
tient lies down,
and reappears
slowly when he
stands up, fill-
ing from below.
Translucent.
Testicle behind
tumor.
Childhood.
Small, ovoid, elas-
tic tumor, con-
nected with but
movable upon
spermatic cord.
Translucent.
Testicle below tu-
mor.
Childhood.
— (Heath's Surgical Diagnosis.)
IRREDUCIBLE SCROTAL
HERNIA.
HYDROCELE.
Sausage-shape.
Intestine clear, omentum
dull on percussion.
Intestinal or knotty in
feel, according to con-
tents.
Testicle below tumor.
Opaque.
Sudden.
Pyriform.
Dull on percussion.
Elastic or fluctuating.
Testicle behind tumor*
Translucent.
Chronic.
— (Heath's Surgical Diagnosis.)
Hernia is a protrusion of an internal viscus through
an abnormal opening in the parietes.
Bassini's operation: "An incision 2^ inches long is
made over the inguinal canal, exposing the structures of
the cord and the external oblique. The external oblique
fibers are split from the apex of the external ring to ex-
227
MEDICAL RECORD.
pose the canal. The sac is found, opened, emptied of its
contents, and isolated from the structures of the cord up
to the internal ring. If the hernia is irreducible, the in-
testine is freed and returned to the abdomen, omentum
being ligatured and removed. The neck of the sac Is
then transfixed and tied with silk, and the fundus re-
moved. The stump returns to the abdomen, three or
four stitches are then passed through the conjoined
tendon and arched fibers of the internal oblique and
transversalis muscles above, and the deep part of Pou-
part's ligament below. These are tied behind the cord.
The external oblique is then sutured in front of the
cord, leaving just sufficient opening for it to pass
through without pressure. The skin is then closed by
a continuous stitch. The patient should be kept in bed
for three weeks, and should not exert himself for at
least six weeks. If the wound has suppurated, or if the
case is one in which the abdominal muscles are weak,
it is advisable that a light truss should be worn after-
wards for six months." — (From Aids to Surgery.)
6. Fistula in Ano. — Classification: There are four
varieties: (1) The complete, which opens into the rec-
tum internally and on the perineum externally; (2)
the external incomplete or blind external, which opens
on the perineum but not into the rectum; (3) the inter-
nal incomplete or blind internal, which opens into the
rectum but not on the perineum; (4) the horseshoe fis-
tula, which extends around the rectum and opens on
each side. The internal opening is generally between
the two sphincters, but may be above the internal
sphincter and below the external sphincter. There may
be several pockets or side tracts extending in different
directions.
Treatment: This consists in "the conversion of the
fistula into an open wound so that it may heal from
the bottom. A grooved director is passed through the
fistula into the rectum, and the overlying tissues severed
with a bistoury. The sphincter should never be cut
more than once, because of the danger of incontinence.
AH branching sinuses likewise should be opened, and
all fibrous tissue, with undermined skin, cut away with
scissors. The bleeding is then checked, and the wound
packed with iodoform gauze. If the fistula is lined with
mucous membrane it must be completely excised. A
blind external fistula may be excised and the wound
sutured. A blind internal fistula may be converted into
a complete one and treated as above. The bowels are
confined for the first three or four days and the wound
dressed after each defecation, being irrigated with ere-
228
GEORGIA.
olin and repacked with iodoform gauze." — (Stewart's
Surgery.)
7. Congestion is excess of blood in the more or less
dilated blood vessels of a part.
Inflammation is the name given to the series of
changes occurring in a part as the result of injury, pro-
vided that the injury is not sufficient to kill the part.
An aneurysm is characterized by a pulsation, which is
expansive; if firm pressure is made on the artery above
the aneurysm the pulsation ceases and the swelling dis-
appears; on relaxing this pressure the pulsating en-
largement promptly reappears. Pressure on the artery
below the aneurysm causes the enlargement to increase
in size; by placing a stethoscope over the aneurysm, a
bruit may be heard. In the case of an abscess over a
vessel, there may be a transmitted pulsation, but it is
not expansive; the pulsation ceases when the abscess is
lifted away from the vessel; pressure on the proximal
side does not cause the growth to disappear; there is
never a true bruit.
Abscess should be opened as soon as possible.
Aneurysm is treated medically, by lowering the diet,
especially the quantity of fluid; iodide of potassium or
calcium chloride may be given. Surgically, complete
extirpation of the sac is advised; or ligature of the
artery, or compression of the artery may be tried.
8. "Treatment of empyema should be undertaken
without delay. Aspiration seldom cures, but may be
undertaken where the dyspnea is great, and an anes-
thetic given afterwards for the excision of a piece of
rib. Drainage is always necessary, and is best done by
excising a portion of the fifth or sixth rib in the mid-
axillary line. The patient should be allowed to come
round quickly from the anesthetic, so that the coughing
which occurs will expel the masses of coagulated lymph
and help to expand the lung. A big drainage-tube is
then inserted. Daily dressings are necessary, but ir-
rigation of the cavity is seldom needed. If, because of
delay in treatment the cavity does not soon close, Est-
lander's operation, or some modification, must be per-
formed. The wound must be enlarged and a number
of ribs exposed, and sufficient of them removed to con-
vert the cavity into a pyramidal one, the base of which
is the open wound. This is packed with gauze and al-
lowed to heal from the bottom. If the operation has to
be extensive, the flaps are allowed to fall back upon
the granulating surface of the lung, and in these cases
marked scoliosis and weakness of that side of the chest
follows." — (Aids to Surgery.)
229
MEDICAL RECORD.
HYGIENE.
1. Temperament is the character of a person's physi-
cal constitution as affected by his mental disposition.
Idiosyncrasy is a special peculiarity of temperament
or constitution which makes a person different from
other persons.
Diathesis is a bodily condition by virtue of which a
person is specially liable to certain diseases.
2. A virus is the specific poison of an infectious dis-
ease. Vaccine lymph is also called a virus.
3. Parasitic diseases that may be caused by eating
insufficiently cooked meats: Infection by tapeworm, by
trichina, anol by echinococcus.
4. In the management of lobar pneumonia "ordinary
ventilation is not enough. It is often better to place
the bed directly at an open window, day and night, the
Eatient being allowed to breathe the pure cold air; but
is body should be protected from the cold by warm,
light coverings. It is often better, when possible, to
have the patient out of doors, in a tent, on a veranda
or roof, and when this cannot be done, he should be
given the benefit of the open air for a few hours each
day. The relief experienced by the patient in a severe
condition from removal to the open air is remarkable,
and it undoubtedly makes recovery possible in many
cases that are hopeless without it." — (French's Prac-
tice of Medicine.)
5. Period of infectivity of diphtheria. "The length
of time during which a patient who has suffered from
diphtheria may remain infectious is very variable. The
bacillus has been found to be absent from the throat as
early as the end of the second week. In view of the
uncertainty which attends the recovery of the bacillus
from the throat it is well to consider that all patients
are infectious for at least six weeks, and no child should
be allowed to return to school until eight weeks have
elapsed from the beginning of treatment."— (McClure's
Handbook of Fevers.)
6. The patient must be isolated ; no one but the physi-
cian and nurse must enter the room; the physician
should put on a large washable gown when he goes in,
and remove it on leaving, at the same time washing his
hands in a disinfectant; the nurse, when she leaves the
sick room should also remove her clothes and put on
others, at the same time disinfecting herself. At the
termination of the disease everything should be disin-
fected; toys and books, etc., are better burned.
7. A disinfectant is an agent which restrains infec-
230
GEORGIA.
tious diseases by destroying or removing the micro-
organisms which cause them.
8. Formaldehyde is a good surface disinfectant, has
poor penetrating qualities, does not destroy fabrics and
injure objects, and is non-toxic. Sulphur dioxide dam-
ages textile fabrics, tarnishes metal objects, and is very
poisonous.
To disinfect a room by formaldehyde: (1) By Tril-
lat's apparatus, which "allows the solution of formalin
to flow in a fine stream through a copper coil heated to
redness by a flame beneath, and the gas and vapor
passing directly into the room. The apparatus may be
operated outside of a room, and the amount of gas
liberated depends directly upon the strength and quan-
tity of the solution evaporated. (2) In Schering's
method the solid paraform is heated in a receptacle over
an alcohol lamp, and is especially valuable in disinfect-
ing small rooms, closets, etc. (3) The cheapest and
most common form develops the gas directly by the
oxidation of methyl alcohol, the vapors of the latter
passing over and through tubes or coils of heated
metal. The amount is uncertain and results indefinite."
— (Cyclopedia of Medicine and Surgery.)
To fumigate by sulphur dioxide: For each 1,000 cubic
feet of space, three pounds of sulphur are burned, care
being taken to prevent accidents. In all cases all aper-
tures and crevices of the room should be closed, all
closets, drawers, or other receptacles opened; and after
the fumigation the room should be well ventilated and
thoroughly cleansed with a solution of corrosive sub-
limate.
9. Diseases , the prevention of which would lengthen
the average of human life: Tuberculosis, typhoid, pneu-
monia, syphilis, gonorrhea, malaria, yellow fever, diph-
theria, influenza, cerebrospinal meningitis, septicemia,
pyemia, dysentery, cholera, plague, smallpox, measles,
scarlet fever, hydrophobia, leukemia, endocarditis, hy-
pertrophy of the heart, angina pectoris, heart-block,
arteriosclerosis, aneurysm, asthma, pneumokoniosis,
emphysema, pleurisy, empyema, gastric ulcer, gastric
cancer, appendicitis, constipation, cirrhosis of liver, ab-
scess of liver, cholecystitis, gallstones, tumors of pan-
creas, peritonitis, nephritis, pyelitis, diabetes mellitus,
alcoholism and addiction to drugs, various poisonings,
sunstroke, and industrial diseases.
10. Bubonic plague is an acute infectious disease as-
sociated with glandular enlargement, and due to the
Bacillus pestis which is conveyed by fleas on rats.
To prevent the spread of the disease, the following
231
MEDICAL RECORD.
routine was followed in Glasgow, during the epidemic
of 1900: "(1) Within the infected area, ashpits were
emptied thrice weekly and washed once a week with
chloride of lime solution. (2) Back courts were hosed
every night with chloride of lime solution. (3) A spe-
cial inspection of the district was undertaken for the
detection of dirty houses, entries, etc., and for the over-
crowding of houses. (4) Medical inspection of the dis-
trict was carried out and the inhabitants of infected
buildings and all 'contacts' were offered injection with
Yersin's serum or Haffkine's vaccine, while all sus-
pected cases were visited with their own medical at-
tendants. (5) Handbills were distributed offering the
service of the medical staff at any time. (6) the crews
of all ship's were inspected on arrival in port. (7)
Fumigation of infected houses was carried out by
liquefied S0 2 for twelve or twenty-four hours, after
which the house was entered and all articles of bed-
ding, clothing, etc., were wetted with a 2 per cent, solu-
tion of formalin (1 gallon of a 40 per cent, solution of
formaldehyde to 50 gallons of water), removed to the
sanitary wash-house, and then boiled or steamed. All
articles which could not be boiled or steamed were
burned. (8) All houses where cases had occurred or
from which contacts were removed were sprayed with
the formalin solution, as were also the lobbies and en-
tries. (9) Clinical demonstrations were given daily to
medical practitioners at the hospital. (10) A pam-
phlet descriptive of the varieties of the disease was dis-
tributed among the medical practitioners of the city.
(11) Physicians to out-patients at the various hospi-
tals were specially circularized. (12) A campaign
against rats was entered upon; rat-catchers were en-
gaged and the bodies of rats were investigated for the
signs of plague. The sewers of the hospital were
treated with liquefied S0 2 , and the rats driven from the
hospital by this method. (13) The bodies of those who
died from plague were drenched with formalin and en-
closed in an airtight leaden shell before burial. (13)
The holding of wakes over any dead bodies was pro-
hibited." — (McClure's Handbook of Fevers.)
STATE BOARD EXAMINATION QUESTIONS.
Illinois State Board of Health,
anatomy.
1. Name the classes into which the vascular system
is divided. Give the anatomical structures of each
class.
232
ILLINOIS.
2. Give the three forms of articulations, with one
example of each.
3. Name the ligaments of the temporo-maxillary
articulations.
4. Name the muscles of the arm, giving the origin
of each.
5. What is the longest muscle in the body? Give its
origin and insertion.
6. Name the coronary arteries. Where do they arise
and terminate?
7. Name the branches of the axillary artery.
8. What does the foramen magnum transmit?
9. Name the lobes, fissures, and arteries of the liver.
10. Where and into what does the great sciatic
nerve divide?
MATERIA MEDICA AND THERAPEUTICS.
1. Give the dose, mode of administration, uses, and
dangers of apomorphine hydrochloride.
4 2. Define local anodyne. Name one and describe
its use.
3. Name three antacids, give dose and therapeutic
indications.
s 4. Define diuretic, name three and explain use and
mode of action of one of them.
5. Classify each of the following according to its
therapeutic use: Camphor, morphine, nitrite of sodium,
veronal, ergot.
j 6. Name two drugs which increase the hemoglobin of
the blood. Give dose and use.
7. Name two drugs which are alleged to increase the
coagulability of the blood. Give uses.
8. Name two drugs which lower blood pressure, giv-
ing dose, mode of administration, and uses.
9. Name two diaphoretics and. give physiological ac-
tion of one of them.
10. Name five drugs used for reducing or lowering
the temperature in fever, giving dose of each.
CHEMISTRY.
1. Define briefly the following terms: Matter, force,
energy, and law of Avogadro.
2. Explain the terms radicle and residue, also re-
action and reagent.
3. Name some uses of phosphorus. Give one test for
phosphorus in case of poisoning. How many oxides of
phosphorus?
4. State chemical action of nitric acid. Complete the
following formula : Ca H fi + HNCh =
5. (a) Name some of the characteristic properties
233
MEDICAL RECORD.
of hydrocarbons, (b) Give formula for marsh gas.
(c) Complete the formula 6Cu + CS 2 + 2H 2 =z
ETIOLOGY AND HYGIENE.
1. Give the etiology of Hodgkin's disease.
2. Give the etiology of cirrhosis of the liver.
3. Give the etiology of rheumatic fever.
4. Briefly discuss the prophylaxis of trachoma.
5. What hygienic conditions should exist in a manu-
facturing plant employing 3,000 men and 800 women,
to protect and maintain the health of the employees?
PATHOLOGY.
1. Describe the pathology of arthritis deformans.
2. Give the gross pathology of acute lobar pneu-
monia.
3. Name six pus-producing cocci in the order of
their virulence.
4. Describe the pathology of pyonephrosis.
5. Describe the pathology of chronic parenchymatous
nephritis.
BACTERIOLOGY.
1. Name some of the important pathogenic diplococci.
2. What are the important pathogenic bacteria found
in sputum.
3. Give the bacteriology of syphilis.
4. Give the technique of the Widal test.
5. Describe the blood findings (microscopic) in a
case of pernicious anemia.
PHYSIOLOGY.
1. How is heat produced in the body, and how is it
given off from the body?
2. Explain dangers of transfusing blood from lower
animals into man.
3. What is meant by "physiological leucocytosis"
and under what conditions found?
4. Discuss functions of (a) proteins, (b) carbohy-
drates, (c) fats, (d) salts, (e) water, all of which
constitute foo'd.
5. What physical and chemical changes take place
in a muscle during contraction?
6. Give o' igin and function of the bile.
7. Name parts of (a) small intestine, (6) large in-
testine.
NEUROLOGY.
1. Define and give etiology of acute ascending
paralysis.
234
ILLINOIS.
2. By which nerves is the heart controlled?
3. Where are the speech areas situated?
PHYSICAL DIAGNOSIS.
1. Describe herpes zoster.
2. Give differential diagnosis between acute bron-
chitis and lobar pneumonia.
3. How would you determine high blood-pressure?
What is its significance?
4. Give physical signs of aortic regurgitation.
5. Give distinctions between organic and functional
heart murmurs.
OPHTHALMOLOGY AND OTOLOGY.
1. Differentiate between trachoma and conjunctivitis.
2. Describe, in detail, how you would treat a chemi-
cal burn of the eyeball.
3. Give symptoms, etiology, and probable serious re-
sults of mastoiditis.
PEDIATRICS.
1. Give differential diagnosis between measles and
scarlet fever.
2. Give cause and treatment of "summer diarrhea."
PRACTICE.
1. Give the diagnosis and treatment of lobar pneu-
monia.
2. Outline the modern treatment of syphilis in the
acute stage.
3. Give the differential diagnosis of cirrhosis of the
liver.
4. Give the treatment of la grippe and its compli-
cations.
5. Give the treatment of tapeworm.
6. Give the treatment of the conditions in which head-
ache is a prominent symptom.
7. Give the treatment of constipation.
8. Give the diagnosis, cause and treatment and prog-
nosis in locomotor ataxia.
9. Differentiate endocarditis from pericarditis and
give the cause and treatment of the former.
10. Give the cause and treatment of chronic rheu-
matism.
SURGERY.
1. Outline briefly the surgical diseases of the third
nerve.
2. Outline the technique of tendon transplantation.
3. Name the structure in which rodent ulcers most
commonly develop, and give surgical treatment.
235
MEDICAL RECORD.
4. Give etiology of delayed fracture union.
5. Outline the best method for male sterilization.
6. Describe the bloodless operation for amputation at
the hip.
7. Give etiology and treatment of tenosynovitis.
8. Name five forms of talipes and give attitude of
foot in each.
9. Name the principal blood-vessels and nerves,
severed in wrist amputation.
10. Under what conditions may a wound be closed
without drainage?
OBSTETRICS.
1. Name and give location of female organs of gen-
eration.
2. Describe and give function of ovaries.
3. What is the composition of liquor amnii, and
what is its function?
4. From what structure does hydatidiform mole de-
velop?
5. What are the anomalies of the placenta?
6. Describe congenital umbilical hernia, and outline
treatment.
7. Name the objective signs of pregnancy at the fifth
month.
8. Give treatment for edema of the vulva during
pregnancy.
9. Name the positions and presentations in order of
their occurrence.
10. Give etiology and treatment of mastitis.
GYNECOLOGY.
1. Give the etiology of metrorrhagia.
2. Give the differential diagnosis between appendi-
citis and ovaritis.
3. How would you diagnose extrauterine pregnancy,
and what are the indications for operation?
4. What are the principal causes of incontinence of
urine in women, and the indications for treatment in
each case?
5. What are the causes of procidentia uteri?
6. Give the differential diagnosis of uterine fibroids.
LARYNGOLOGY AND RHINOLOGY.
1. Give the diagnosis and treatment of abscess of
antrum of Highmore.
2. Give the indications for laryngotracheotomy and
describe operation.
236
ILLINOIS.
MEDICAL JURISPRUDENCE.
1. At post-mortem, how would you determine a child
was born alive?
2. Give the symptoms of poisoning by mercuric
chloride, and state how it can be demonstrated in a
fatal case.
ANSWERS TO STATE BOARD EXAMINATION
QUESTIONS.
Illinois State Board of Health.
anatomy.
1. The vascular system is divided into two classes:
(1) The blood-vascular system, which consists of the
heart, arteries, capillaries, and veins, and (2) the
lymph-vascular system, which consists of the lymph
glands and lymph vessels.
2. The three forms of articulations are: (1) Syn-
arthrosis, or immovable articulation, such as that be-
tween the two parietal bones. (2) Amphiarthrosis, or
mixed articulation, such as that between the two pubic
bones. (3) Diarthrosis, or freely movable articulation,
such as that between the humerus and the ulna.
3. Ligaments of the temporomaxillary articulation
are: External lateral, internal lateral, stylomaxillary,
and capsular; with an interarticular disc of cartilage.
4. The muscles of the arm are: Coracobrachial (ori-
gin from coracoid process of scapula), Biceps (origin
from coaracoid process of scapula, and upper margin
of glenoid cavity of scapula), Brachialis anticus (ori-
gin from outer and inner surfaces of shaft of humerus,
beginning at about the level of the insertion of the
deltoid), Triceps (origin from below the glenoid cavity
of the scapula, from posterior surface of shaft of
humerus and external border of humerus above the
musculospiral groove, also from posterior surface of
shaft of humerus and internal border of humerus,
below the musculospiral groove), and Subanconeus,
which is really the name of some of the fibers of the
lower part and under surface of the triceps.
5. The longest muscle in the body is the Sartorius.
It arises from the anterior superior spine of the ilium,
and is inserted into the upper part of the inner surface
of the shaft of the tibia.
6. The right and left coronary arteries of the heart,
arise near the commencement of the aorta; the right,
from the anterior sinus of Valsalva; and the left, from
237
MEDICAL RECORD.
the left posterior sinus of Valsalva; these two arteries
anastomose in the substance of the heart. The supe-
rior and inferior coronary arteries of the face are
branches of the facial artery, and run along the upper
and lower lips respectively; each one anastomoses with
its fellow of the opposite side. The coronary artery
is also a name for the gastric artery, a branch of the
celiac axis, which supplies the stomach.
7. Branches of the axillary artery: Superior
thoracic, acromiothoracic, long thoracic, alar thoracic,
subscapular, posterior circumflex, and anterior circum-
flex.
8. The foramen magnum transmits: The lower part
of the medulla oblongata and its membranes, the spinal
portion of the spinal accessory nerves, the vertebral
arteries, the anterior and posterior spinal arteries, and
the occipitoaxial ligaments.
9. The lobes of the liver are: Right lobe, left lobe,
lobus quadratus, lobus caudatus, and Spigelian lobe
(the last three are subdivisions of the right lobe) . The
fissures of the liver are: Umbilical fissure, fissure for
the ductus venosus, transverse fissure, fissure for the
gall-bladder, and fissure for the inferior vena cava.
The arteries of the liver are: The hepatic artery, with
the two branches into which it subdivides, the right
and left hepatic arteries.
10. The great sciatic nerve generally divides at about
the lower third of the back of the thigh into the inter-
nal popliteal and external popliteal nerves.
MATERIA MEDICA AND THERAPEUTICS.
1. Apomorphine hydrochloride. Dose 1/30 grain
(expectorant); 1/10 grain (emetic). It is usually ad-
ministered by hypodermic injection. Uses: To produce
vomiting, as an expectorant (in bronchitis). Danger:
Collapse.
2. A local anodyne is an agent which, when applied
to a part, is capable of relieving pain in that part.
Heat is a local anodyne; it may be applied in the form
of hot water, by compresses, hot packs, or by immers-
ing the part in hot water; dry heat and steam are also
used.
3. Three antacids: Sodium bicarbonate, potassium
bicarbonate, and magnesia.
Sodium bicarbonate, dose gr. xv, is sedative to the
gastric nerves, and is used in dyspepsia, hyperacidity,
and acid diarrhea (of infants) ; it is applied locally in
burns, ivy poisoning, and to allay itching.
Potassium bicarbonate^ dose gr. xxx, is used in dys-
pepsia, hyperacidity, gout, and rheumatism.
238
ILLINOIS.
Magnesia, dose gr. xxx, is used for acidity, sick head-
ache, and mild digestive disturbances.
4. Diuretics are agents which promote the secretion
of urine. Three diuretics: Water, digitalis, potassium
acetate. Potassium acetate acts as a diuretic by stimu-
lating the renal epithelium, and causing hyperemia of
the kidneys, thus increasing the water in the urine.
It is used in gouty and rheumatic conditions.
5. Camphor is a cardiac stimulant; morphine is a
hypnotic anodyne and antispasmodic; nitrite of sodium
is a vascular dilator; veronal is a hypnotic; ergot is
used to cause contraction of the pregnant uterus, also
of the muscle fibers in arteries (in case of hemor-
rhage).
6. Two drugs which increase the hemoglobin of the
blood: Iron and perhaps arsenic.
Iron. Mass of ferrous carbonate, dose gr. iv; used
in chlorosis.
Arsenic, Dose of liquor potassii arsenitis, TO? iij, to
be increased; used in anemic conditions.
7. Two drugs which are alleged to increase the
coagulability of the blood: Calcium chloride and gela-
tine. Said to be useful in cases of internal hemorrhage
and in hemophilia.
8. Two drugs which lower blood pressure: Nitro-
glycerin and amyl nitrite. Nitroglycerin is given by
mouth or hypodermically in doses of rrp 1 : amyl nitrite
is inhaled, dose rrg 3 Nitroglycerin is used in ca^o« of
chronic nephritis with high blood pressure, also in
anticipated attacks of angina pectoris. Amyl nitrite
is used in angina pectoris, epilepsy, and cardiac dv^pnea,
9. Two diaphoretics: Pilocarpine and Dover's pow-
der.
Action of pilocarpine: "Especially stimulates the
terminations of the secretory nerves, the first effect
being a marked increase of the saliva; a^o stimulates
unstriped muscle grenerally (with the exception of that
of the b 7 ood vessels), and particularly in the intestine,
causing violent peristalsis. The heart is at first ac-
celerated and then slowed, and the blood-pressure first
rises and then falls. The pupil is contracted, and
spasm of accommodation occurs. The effects on the
central nervous system are mainly depressing: they
appear late and are quite overshadowed by the
peripheral effects. This drug is the most efficient
sudorific known, and with the exception of the
diaphoresis its most important effects are the salivation
and the myosis. In consequence of the hyperemia of
the skin caused by it, the temperature may be tern-
239
MEDICAL RECORD.
porarily elevated, but the evaporation of the sweat soon
produces a decided fall." — (Wilcox's Materia Medica.)
10. Five drugs used for reducing or lowering the tent-
perature in fever: Acetanilide, gr. iv; antipyrine, gr.
iv ; acetphenetidine, gr. vij; quinine sulphate, gr. iv;
and salicylic acid, gr. vij.
CHEMISTRY.
1. Matter is that which occupies space.
Force is that which produces, or tends to produce,
motion or change of motion of matter.
Energy is the capacity to do work and also the exer-
tion of doing work.
Law of Avogadro: Equal volumes of all gases, under
like conditions of temperature and pressure, contain
equal numbers of molecules.
2. Radical is a group of atoms which can enter or
leave a chemical reaction, and behave in general as a
single atom.
Radical of an acid is obtained by the subtraction
from the acid of a number of hydroxyls equal to the
basicity of the acid.
Residue of an acid is that which remains after re-
moving the replaceable hydrogen.
Reaction is the interaction of two or more substances
with chemical union or decomposition; also, the evi-
dences of chemical decomposition afforded by changes
in color, solubility, state or shape.
Reagent is a substance used to bring about a reaction.
3. Uses of phosphorus: In making matches, rat
paste, and phosphor bronze.
Mitscherlich y s process for detecting phosphorus:
"This process is based upon the property of unoxidized
phosphorus of becoming luminous in the dark. The
matters supposed to contain the poison are rendered
fluid by dilution with water, and acidulated with sul-
phuric acid. They are placed in a flask upon a sand
bath, and the flask connected with a Liebig's condenser,
which is placed in absolute darkness. Upon heating the
flask any phosphorus present is volatilized, and, con-
densing in the tube, forms a luminous ring. This re-
action is very delicate, and the appearance of the ring
is proof positive of the presence of unoxidized phos-
phorus." — (Witthaus* Essentials of Chemistry and
Toxicology.)
There are two oxides of phosphorus, the trioxide,
P 2 3 , and the pentoxide, P 2 Or,.
4. Nitric acid is decomposed on exposure to air and
240
ILLINOIS.
light or to strong heat; it is an oxidizing agent; it dis-
solves many metals, forming nitrates.
C 6 H 6 + HNOs = C«H 5 NO* + H 2 0.
5. Hydrocarbons are gaseous (the first four members
of the methane series), liquid (the next ten or eleven),
and the remainder are solid; they are lighter than
water and are insoluble in water, but soluble in alcohol,
ether, and liquid hydrocarbons.
Formula for marsh gas is CH 4 .
6 Cu + CS 2 + 2 H 2 = 2 Cu 2 S + 2 CuO + CH 4 .
ETIOLOGY AND HYGIENE.
1. The etiology of Hodgkin's disease is unknown.
2. Etiology of cirrhosis of the liver: Irritants taken
to the liver by the blood; alcohol, and certain infectious
diseases.
3. Etiology of rheumatic fever is unknown; probably
some diplococcus, staphylococcus, or streptococcus.
4. Prophylaxis of trachoma: "The patient and his
family must be warned of the contagiousness of the
secretion, and impressed with the necessity for keeping
the patient's handkerchiefs, towels, wash basin, etc.,
apart from those of other persons. In schools, asylums,
institutions, and barracks, the prevention of epidemics
of trachoma is a very serious matter, requiring con-
stant vigilance, careful inspection of every new addi-
tion or inmate, and the isolation of trachoma cases so
long as the latter are capable of conveying the disease."
— (May's Diseases of the Eye.)
5. "In addition to the ordinary hygiene of factories
and workshops, such as proper space, air, ventilation,
water supply, lighting, heating, drainage and plumb-
ing, ordinary cleanliness, and absence of dust, care
should be taken that women and children do not work
too long at a time or at occupations involving the use
of poisonous or deleterious materials; that there are
ample toilet and lavatory accommodations, and that
these are separate and away from those used by men;
there should also be opportunity to sit, and women
should not be expected to remain standing for long
periods of time."— (Scott's State Board of Physiology
and Hygiene.)
PATHOLOGY.
1. Pathology of arthritis deformans: "The cartilage
cells proliferate and burst into the joint, leaving the
matrix, which has become fibrillated, looking like coarse
velvet or plush. The softened cartilage is worn away
at the points of pressure, and the underlying bone be-
241
MEDICAL RECORD.
comes hard and polished (eburnated). In spite of this
hardness, the bone becomes worn away and perhaps
grooved. At the same time there is overgrowth of the
cartilage at their margins, which produces 'lipping,'
while new bone is formed underneath. These osteo-
phytes may lead to impairment of mobility, or may be-
come broken off and form loose bodies in the joint.
The synovial membrane is thickened and its villi hyper-
trophied. Cartilage may develop in the synovial
fringes, and then, if detached, another type of loose
body in the joint is formed. Effusion may or may not
be present." — (Aids to Surgery.)
2. Lobar pneumonia. (1) Stage of engorgement. —
This is the stage of inflammatory hyperemia and
edema, and it is characterized microscopically by over-
fullness and slight tortuosity of the pulmonary capil-
laries, and by swelling of the alveolar epithelium. The
lung is of a dark red color ; it is heavier and less crepi-
tant than natural ; it pits on pressure ; and its cut sur-
face yields a reddish, frothy, tenacious liquid.
(2) Red hepatization. — Here there is an exudation of
liquor sanguinis and blood-corpuscles. The exuded
liquids coagulate within the alveoli and terminal bron-
chioles, the coagulum enclosing numerous white and a
few red blood-corpuscles. The alveolar epithelium ^ is
swollen and granular. The lung is now much heavier
than in the preceding stage, and is increased in size, so
as to be often marked by the ribs. It is quite solid;
sinks in water, and cannot be artificially inflated. It is
remarkably friable, breaking down with a soft granular
fracture. The cut surface has a markedly granular
appearance, seen especially when the tissue is torn, and
due to the plugs of coagulated exudation-matter which
fill the alveoli. The color is of a dark reddish-brown,
often here and there passing into gray. This admix-
ture with gray sometimes gives a marbled appearance.
The pleura covering the solid lung always participates
more or less in the inflammatory process. It is opaque,
hyperemic, and coated with lymph.
(3) Gray hepatization. — This stage is characterized
by a continuance of the process of inflammatory cell-
emigration, and by more marked changes in the epi-
thelium. The white blood corpuscles continue to es-
cape from the vessels, and the alveolar epithelium be-
comes more swollen and granular. The alveoli thus
become more completely filled with young cell-forms, so
that the fibrinous exudation is no longer visible as an
independent material. The fibrinous exudation now
disintegrates, and the young cells rapidly undergo fatty
242
ILLINOIS.
metamorphosis. The alveolar walls themselves, with
few exceptions, remain throughout the process un-
altered, although very occasionally, when this stage is
unusually advanced, they may be found here and there
partially destroyed. Owing to these changes, the red-
dish-brown color of the lung becomes altered to a gray-
ish or yellowish white. The granular appearance is
much less marked; the solid tissue is much softer and
more pulpy in consistence, and a puriform liquid
exudes from the cut surface of the organ. This stage,
when advanced, has been termed 'suppuration or puru-
lent infiltration' of the lung." — (Quain's Dictionary of
Medicine.)
3. Six pus-producing cocci: Streptococcus pyogenes,
Staphylococcus pyogenes aureus, Staphylococcus py-
ogenes albus, Staphylococcus pyogenes citreus Gono-
coccusy Streptococcus erysipelatis.
4. Pathology of pyonephrosis : "The kidney presents
a number of abscess cavities, the intervening paren-
chyma being pale and tough as a result of chronic in-
terstitial nephritis. Unless there has been antecedent
hydronephrosis the pelvis is usually small in propor-
tion to the greatly enlarged and flask-shaped calyces,
which constitute the abscess cavities and form the chief
bulk of the kidney. Their communications with the
pelvis and with each other are narrowed or obliterated,
so that they, may be regarded as separate cavities. The
purulent contents are often mixed with crumbly masses
of phosphates. The mucous membrane of the pelvis
and calyces is converted into granulation tissue, and,
in advanced cases, becomes the seat of ulceration which
eats into the parenchyma. The renal blood-vessels are
thickened and narrowed by endarteritis, so that there
may be very little hemorrhage when the pedicle is
divided. The perinephric cellular tissue is converted
into granulation and scar tissue, and is frequently the
seat of scattered foci of suppuration, and sometimes a
large perinephric abscess is found to communicate di-
rectly with one of the dilated calyces. The perinephric
suppuration may extend into the psoas and quadratus
muscles, or into the cellular planes of the abdominal
wall." — (Thomson and Miles' Manual of Surgery.)
5. In chronic parenchymatous nephritis both degen-
erative and proliferative changes are seen. The tubular
epithelium is always more or less affected, showing
signs of cloudy swelling, fatty degeneration, desquama-
tion, and disintegration, most marked in the convoluted
tubules, but also present in the loops and collecting
tubules. The distribution of these changes is usually
243
MEDICAL RECORD.
patchy, giving rise to mottling of the cortex. The
lumina of the tubes may be dilated, and contain granu-
lar and fatty matters, and hyaline casts, the latter
formed by coagulation of exudation in the tubules. The
glomeruli may occasionally appear normal, but there is
almost always some swelling and hyaline degeneration,
together with some proliferation and desquamation of
the epithelium, so that they become highly cellular.
Occasionally the glomerular changes may be more
marked than the tubular; fatty degeneration of the
glomerular and capsular epithelium may be prominent,
or there may be swelling, proliferation, and desquama-
tion of the epithelium, or both these changes may be
combined. The glomerular vessels may be compressed,
their endothelium degenerate, and they may be ob-
structed by leucocytes or by hyaline thrombi, and
finally obliterated. Interstitial changes, though pres-
ent, are not conspicuous, and consist of edema, and
scattered foci of round-celled infiltration about the
glomeruli and veins. Sometimes hemorrhages are evi-
dent in some of the glomeruli and the corresponding
tubules. Lardaceous infiltration frequently accom-
panies parenchymatous nephritis.
BACTERIOLOGY.
1. Pathogenic diplococci: Diplococcus meningitidis,
Diplococcus gonorrhoea, Diplococcus pneumoniae, Diplo-
coccus catarrhalis.
2. Pathogenic bacteria found in sputum: Tubercle
bacilli, streptococci, staphylococci, pneumococci, Fried-
lander's bacilli, influenza bacilli, and Micrococcus
catarrhalis.
3. Syphilis is due to infection by the Treponema
pallidum. This is a slender spirillum, with regular
turns, the curves varying in number from three or four
to twelve or even twenty; it is about 4 to 20 mikrons
long, actively motile, with a fine flagellum at each pole ;
it is flexible, hard to stain, and has not been cultivated
on artificial media. How it divides is not known. It
stains best with Giemsa's eosin solution and azur.
4. WidaPs test in typhoid fevSr "depends upon the
fact that serum from the blood of one ill with typhoid
fever, mixed with a recent culture, will cause the
typhoid bacilli to lose their motility and gather in
groups, the whole called 'clumping. ' Three drops of
blood are taken from the well-washed aseptic finger
tip or lobe of the ear, and each lies by itself on a sterile
slide, passed through a flame and cooled just before
use; this slide may be wrapped in cotton and trans-
244
ILLINOIS.
ported for examination at the laboratory. Here one
drop is mixed with a large drop of sterile water, to re-
dissolve it. A drop from the summit of this is then
mixed with six drops of fresh broth culture of the ba-
cillus (not over twenty-four hours old) on a sterile
slide. From this a small drop of mingled culture and
blood is placed in the middle of a sterile cover-glass,
and this is inverted over a sterile hollow-ground slide
and examined. * * * A positive reaction is ob-
tained when all the bacilli present gather in one or two
masses or clumps and cease their rapid movement in-
side of twenty minutes." — (From Thayer's Pathology.)
5. In progressive pernicious anemia: The marked
feature of the disease is pronounced oligocythemia.
This progresses rapidly, and in ordinary cases the num-
ber of red corpuscles sinks to 1,000,000 or less per
cu. mm.; at the same time, changes in size (microcytes
and megalocytes) and in shape (poikilocytes) make
their appearance and reach grades rarely attained in
other diseases. Nucleated red corpuscles are always
present in some number, and are usually abundant.
The largest forms (megaloblasts) as a rule predomi-
nate, but in some cases the smaller forms are more
abundant. Karyokinetic figures may be found in the
nuclei. Polychromatophilia is generally present. The
leucocytes may be decreased or normal in number; in
the late stages leucocytosis is not uncommon, and it
may become extreme. The larger mononuclear leuco-
cytes are usually more abundant than in health, and
myelocytes often occur in considerable numbers. In
the terminal leucocytosis of pernicious anemia the
lymphocytes often predominate.
PHYSIOLOGY.
1. Heat is produced in the body by: (1) Muscular
action; (2) the action of the glands, chiefly of the
liver; (3) the food and drink ingested; (4) the brain;
(5) the heart; and (6) the thermogenetic centers in
the brain, pons, medulla, and spinal cord. Heat is
given off from the body by: (1) the skin, through
evaporation, radiation, and conduction; (2) the ex-
pired air; (3) the excretions— urine and feces.
2. Danger 8 of transfusing blood from lower animals
to man: "The serum of certain animals possesses the
property of dissolving the red corpuscles of another
species of animals. The serum of a dog destroys the
red corpuscles of a man; the hemoglobin is dissolved
out. The serum, besides its action on the red cor-
puscles, is also active against the white corpuscles of
245
MEDICAL RECORD.
the same animal, stopping their ameboid movements.
The globulicidal action of the serum is related to its
poisonous action on microbes. The normal serum of
certain animals kills microbes, as the serum of the dog
kills the typhoid bacilli. The power to kill red cor-
puscles and microbes is due to the presence ^ in the
serum of a substance, an alexin. In transfusion this
plays an important part. ,, ~(Ott , s Pathology.)
3. Physiological leucocytosis is an increase in the
number of the white blood corpuscles occurring under
normal or physiological conditions, such as: Digestion,
exercise, after a cold bath, or during pregnancy.
4. Function of proteids: Formation and repair of
tissues and fluids of the body, regulation of the absorp-
tion and utilization of oxygen, formation of fats and
carbohydrates, production of energy. Function of car-
bohydrates: Production of heat and energy and forma-
tion of fats. Function of fats : Supply of heat and en-
ergy, supply of fatty tissues, nutrition of nervous sys-
tem. Function of salts: Support of bony skeleton, sup-
ply of HC1 for digestion, regulation of nutrition and
energy. Function of water: It enters into the composi-
tion of all the tissues and fluids of the body, it moistens
the surfaces and membranes of the body, it keeps the
fluids of the body at their proper degree of dilution,
it removes waste matters, distributes and regulates
body heat.
5. When a muscle is in a state of activity: (1) It
becomes shorter and thicker, but (2) there is no change
in volume; (3) there is an increased consumption of
oxygen; (4) more carbon dioxide is set free; (5)
sarcolactic acid is produced; and hence (6) the muscle
becomes acid in reaction; (7) it becomes more extensi-
ble, and (8) less elastic; (9) there is an increase in
heat production and consequently a rise of tempera-
ture; (10) the electrical reaction becomes relatively
negative; and (11) a sound is produced.
6. Bile is secreted by the liver. The functions of the
bile are: (1) To assist in the emulsification and saponi-
fication of fats; (2) to aid in the absorption of fats;
(3) to stimulate the cells of the intestine to increased
secretory activity, and so promote peristalsis, and at
the same time tend to keep the feces moist; (4) to
eliminate waste products of metabolism, such as
lecithin and cholesterin; (5) it has a slight action in
converting starch into sugar; (6) it neutralizes the
acid chyme from the stomach and thus inhibits peptic
digestion; (7) it has very feeble antiseptic action.
7. Parts of the small intestine: Duodenum, jejunum,
246
ILLINOIS.
ileum. Parts of the large intestine: Cecum, ascending
colon, hepatic flexure, transverse colon, splenic flexure*
descending colon, sigmoid flexure, rectum.
NEUROLOGY.
1. Acute ascending paralysis is an ascending paral-
ysis beginning in the legs, rapidly involving the trunk,
diaphragm, arms, and the muscles innervated by the
bulb (particularly the muscles of respiration), and so
causes death. Its etiology is not settled; it is probably
an acute infection of the spinal cord (sometimes in-
cluding peripheral nerves and the bulb).
2. The heart is controlled by: Sympathetic nerves,
which accelerate it; by the pneumogastrics, which have
an inhibitory influence; probably by a depressor nerve;
also by certain intrinsic cardiac ganglia.
3. "The speech areas, four in number and in kind,
are in the left hemisphere in righthanded persons and
in the right in lefthanded persons. * * * * The
motor speech center lies in the posterior part of the
third frontal convolution (Broca's convolution), just
in front of the center of the muscles of speech (hypo-
glossal and facial nerve centers). * * * * The
power of writing is usually lost with motor speech.
The probable location of its cortical center is in the
posterior two-thirds of the first, and perhaps in the
second, temporal convolution. * * * * The visual
speech center lies in the posterior part of the angular
gyrus in the outskirts of the higher visual or the visuo-
psychic field." — (From Woolsey's Applied Surgical
Anatomy.)
PHYSICAL DIAGNOSIS.
1. Herpes zoster is "an acute inflammatory disease,
characterized by the development of groups of firm
and distended vesicles situated upon inflamed bases
corresponding to a definite cutaneous nerve, and accom-
panied by more or less severe neuralgic pains. The
affection begins with neuralgic pains, either of a burn-
ing or lightning-like character, with slight febrile
phenomena, followed by the appearance of papulo-
vesicles along the tract of pain; these soon become
vesicles situated on bright red, highly inflamed bases.
The vesicles are about the size of pin-heads, or, per-
haps, a little larger; usually discrete, although they
frequently coalesce, forming irregular patches, appear-
ing in groups until the third to the fifth or even tenth
day, when they gradually desiccate, and at the end of
the second week nothing remains except occasionally a
247
MEDICAL RECORD.
slight scar, which may disappear or become permanent.
When the eruption is at its height it is perfect in its
anatomic formation, each vesicle being well shaped
and seated on a bright red, inflamed patch of skin, and
distended with a translucent, yellowish fluid. The
vesicles show no tendency to rupture spontaneously. In
rare instances they may become purulent, hemorrhagic,
or gangrenous. The eruption is almost invariably con-
fined to one side of the body, although in rare instances
it is seen upon both sides. It is usually found upon
well-known nerve-tracts. Recurrence is rare." —
(Hughes' Practice of Medicine.)
2. Acute bronchitis begins with coryza; soreness and
tenderness may be behind the sternum; pain may be
caused by coughing; expectoration is abundant;
dyspnea is in proportion to the extent of the disease;
the pulse-respiration ratio is not altered; fever is slight
or absent; various rales may be present; the condi-
tion is generally bilateral; ends by lysis.
Lobar pneumonia begins with rigors, sometimes also
with vomiting; pain on affected side; expectoration is
rusty and tenacious ; breathing is very rapid ; the pulse-
respiration ratio is much disturbed; there is consider-
able fever; crepitant rales are heard in first stage,
also in third stage (rale redux) ; usually only one side
is affected; ends by crisis.
3. High blood pressure can be determined by the use
of a sphygmomanometer; it is found in: Arterio-
sclerosis, chronic interstitial nephritis, cerebral hemor-
rhage, uremia, gout, aortic regurgitation, angina pec-
toris, puerperal eclampsia.
4. Physical signs of aortic regurgitation: "Inspection
shows that the cardiac impulse is forcible and displaced
downward and to the left. The pulsation is visible far
beyond the normal apex. Palpation confirms inspec-
tion. It may at times serve to detect a diastolic thrill
over the base of the heart and the adjacent large ves-
sels. The Corrigan pulse and the capillary pulse are
recognized by palpation. Percussion serves to demon-
strate an increase in the area of cardiac dullness down-
ward and to the left. Occasionally it is increased
upward and to the left of the sternum as the result
of hypertrophy of the left auricle. Auscultation re-
veals characteristic alterations in the heart sounds. The
first sound is forcible; the second sound is replaced or
associated with a churning, rushing, or blowing mur-
mur of low pitch, well heard at the second right costal
cartilage (aortic area), but most distinct at the junc-
tion of the sternum and the fourth left costal car-
248
ILLINOIS.
tilage. It is diastolic in time, and is transmitted down-
ward and toward the apex. A presystolic rumbling
murmur (Flint murmur) may occasionally be heard
over a limited area at the apex." — Hughes' Practice of
Medicine.)
5. Organic murmurs are due to stenosis or incom-
petency of one or more of the valves of the heart,
Functional murmurs are not due to valvular disease.
Organic murmurs may be systolic or diastolic; may
be accompanied by marked dilatation or hypertrophy,
and there will probably be a history of rheumatism or
of some other disease capable of producing endocar-
ditis. Whereas a murmur, usually systolic, soft, and
blowing, heard best over the pulmonic area, associated
with evidences of chlorosis or anemia, and affected by
the position of the patient, is a hemic or functional
murmur, and denotes as a rule an impoverished condi-
tion of the blood.
OPHTHALMOLOGY AND OTOLOGY.
1. Trachoma is an inflammatory condition of the
conjunctiva, accompanied by hypertrophy, granule
formation, and subsequent cicatricial changes.
In conjunctivitis there are no granules with subse-
quent cicatricial changes.
2. For chemical burns of the eyeball: The treatment
consists in the complete removal of the caustic sub-
stance as soon as possible. Solid particles are re-
moved with cotton or forceps. Then the conjunctival
sac is washed out with solutions which tend to neu-
tralize the corrosive substance or render it insoluble.
In the case of lime, mortar, or caustic alkalies, we
flush out with a solution of boric acid; or we may wash-
out the eye with oil. If the corrosive agent consisted
of an acid, the eye is irrigated with a weak solution
of sodium bicarbonate. Subsequently we use cold com-
presses, atropine, and sometimes a bandage. After
the loosening of the eschars, we must separate the
adhesions frequently. Symblepharon often occurs not-
withstanding the greatest care. — (May's Diseases of
the Eye.)
3. Mastoiditis. "Inflammation of the mastoid cells
may be produced by the extension of the disease from
the tympanum. Rarely it is due to extension of exter-
nal inflammation. The symptoms are deep-seated pain
(increasing on deep pressure), swelling and tender-
ness over the mastoid process, accompanied by more
or less fever and rapid pulse, coated tongue, anorexia,
and malaise. When the periosteum is affected the
249
MEDICAL RECORD.
tissues behind the ear are swollen and the auricle
stands out from the head, the canal is smaller and the
posterior superior, inner bony wall of the canal droops.
If pus has formed, fluctuation may be detected." —
(Cyclopedia of Medicine and Surgery.) Other causes
are: Long exposure to wet or cold, and some of the
acute exanthematous diseases. Possible serious results
are: Thrombus formation in the sigmoid or other
sinus, abscess formation in the brain, meningitis,
septicemia, pyemia.
PEDIATRICS.
1. Scarlet fever. Period of incubation, from a few
hours to seven days. Stage of invasion, twenty-four
hours. Character of eruption, a scarlet punctate rash,
beginning on neck and chest, then covering face and
body; desquamation is scaly or in flakes. The erup-
tion is brighter, is on a red background, punctiform,
and is more uniform; the temperature is higher, the
pulse quicker; the tongue is of the "strawberry" type,
the lymphatics in the neck may be swollen, and there
is sore throat; Koplik's spots are absent.
Measles. Period of incubation, ten to twelve days.
Stage of invasion, four days. Character of eruption,
small dark red papules with crescentic borders, begin-
ning on face and rapidly spreading over entire body;
desquamation is branny. The eruption is darker, less
uniform, more shotty; the temperature is lower, pulse
slower, the tongue is not of the "strawberry" type;
coryza, coughing, and sneezing may be present; Kop-
lik's spots are present.
2. Summer diarrhea, or cholera infantum, is due to
the toxins produced by bacteria in milk. Treatment:
Ordinary diarrhea snould be prevented from terminat-
ing in cholera infantum. The stomach and colon
should be irrigated. From 32-4 of water at 100° F.
should be allowed to flow into the stomach through a
soft-rubber catheter and be siphoned out. This should
be done only once. For the colon, sodium bicarbonate,
51, should be added to the pint, and the irrigation per-
formed twice daily. If the rectal temperature is very
high ice-cold water should be used; otherwise warm
water. When symptoms of collapse appear hot pack
is used. Ice-water quenches the thirst, even if it is
vomited. Champagne and drop-doses of brandy may
be given if the stomach is tolerant. Strychnine, gr.
1/100 hypodermically, to a child one year old, is a
valuable stimulant. Morphine, gr. 1/100, and atropine,
gr. 1/800, may be given in the same way and repeated
every hour until the child is quieted— (Pocket Cyclo-
pedia.)
250
ILLINOIS.
PRACTICE.
1. Lobar Pneumonia. Diagnosis: (1) From acute
phthisis: .The symptoms and physical signs of lobar
pneumonia and acute pneumonic phthisis may be the
same for the first eight or ten days; at this period
the fever in pneumonia drops by crisis; whereas in
phthisis the fever continues for some time longer and
the patient gets worse; the sputum contains tubercle
bacilli and elastic fibers, and instead of retaining the
rusty color it becomes purulent and greenish.
In pneumonia, the breathing is very rapid, the pulse-
respiration rate is disturbed, the fever is usually high,
and runs a regular course, crepitant rales are heard
at first, then signs of consolidation follow, and crepi-
tant rales again succeed.
In phthisis, the breathing is hurried and there is
dyspnea, the fever is often high, but does not run a
regular course, at first the signs are those of bron-
chitis, followed by consolidation, a softening, or exca-
vation in different parts of the lungs; sometimes there
is nothing to be heard but scattered rales.
(2) From bronchopneumonia:
LOBAR PNEUMONIA
Generally a primary dis-
ease.
Age has little influence.
Sudden onset.
Fever is high and regular.
Ends by crisis between
sixth and tenth day.
Generally only one lung
affected.
The physical signs are dis-
tinct, and there is a
large area of consolida-
tion.
Sputum is rusty.
BRONCHOPNEUMONIA
Generally secondary (to
bronchitis or an infec-
tious disease).
Generally found in very
young or very old.
Gradual onset.
Fever is not so high, and
is irregular.
Ends by lysis, at no par-
ticular date.
Generally both lungs af-
fected.
Physical signs indistinct,
and the evidences of con-
solidation are indefinite.
Sputum is rather streaked
with blood.
(3) From acute bronchitis, see Physical Diagnosis,
question 2.
Treatment: "Consists in rest in bed, milk diet, and
the administration of fractional doses of calomel fol-
lowed by a saline in the early stage. The nervous
symptoms and temperature may be controlled by apply-
251
MEDICAL RECORD.
ing ice-bags or compresses wrung out of cold water
(60°-70° F.) to the chest or by the use of the warm
or cold wet-pack. The heart and pulse should be sus-
tained by the administration of alcohol, strychnine (gr.
1/60-1/20), atropine, caffeine, strophanthus, and nitro-
glycerin. Digitalis may also be employed. Inhala-
tions of oxygen afford temporary relief when the
dyspnea and cyanosis are extreme. In young, vigor-
ous, and plethoric adults, with hyperpyrexia and a
high-tension pulse, bleeding may be beneficial in the
first 48 hours. Convalescence should be guarded, and
tonics, stimulants, etc., will be found very useful in
this period of the disease."' — (Pocket Cyclopedia.)
2. The chancre requires local cleanliness. Some
preparation of mercury must be given for a long period
of time, either by mouth, by inunction, or by hypo-
dermic injection. Salvarsan given either subcutan-
eously, intravenously, or intramuscularly is the most
modern form of treatment.
HYPERTROPHIC CIRRHOSIS.
Jaundice. Early and
marked, bile often ab-
sent from feces.
Ascites. Late and unim-
portant.
Spleen. Enlarged early
and markedly.
Alimentary hemorrhage,
piles. Not common.
Liver. Large, smooth,
mottled, green.
New fibrous tissue. In fine
lines and strands be-
tween acini and cells,
involving all parts
equally.
ATROPHIC CIRRHOSIS.
Late and slight, bile usual-
ly present.
May be early; often enor-
mous.
Late and less.
Common.
Small, rough, pale or yel-
low.
In broad bands, making
prominent islands in
which the single acinus
may appear nearly nor-
mal; distributed irregu-
larly.
3. Diagnosis of cirrhosis of the liver. "The char-
acteristics of hepatic cirrhosis are the history, area of
liver dullness, symptoms of portal obstruction, jaun-
dice, and the course and termination. The distinction
between the two varieties is well given by Thayer in
the preceding table:
Atrophy of the liver, or the nutmeg liver, is almost
always confounded with cirrhosis; the former occurs
most commonly with obstructive diseases of the heart
252
ILLINOIS.
and lungs, and the surface of the organ is not nodu-
lated, nor is there a history of alcoholism.
Cancer and tubercle of the peritoneum have many
symptoms akin to cirrhosis. The points of differentia-
tion are great tenderness over abdomen, rapidly-de-
veloped ascites, rapid decline in strength and flesh,
absence of jaundice, absence of long-continued dys-
pepsia, absence of hepatic changes on percussion, and
the presence of tubercle or cancer deposits in other
organs."— (Hughes' Practice of Medicine.)
4. Treatment of la grippe : "Absolute rest in bed and
liquid diet should be prescribed. The administration
of fractional doses of calomel (gr. 1/6 every hour for
6 doses) should begin the treatment. Phenacetin, gr.
5 every 3 or 4 hours, may be given for the fever and
the pains. Quinine (gr. 4), sodium salicylate (gr. 7),
or whiskey (34) may be administered every 3 or 4
hours. The local application of menthol (gr. l 1 /^) in
liquid vaselin (31) to the nasal mucous membrane is
beneficial. Sulphonal (gr. 10) or trional (gr. 15) will
relieve insomnia. Iron, quinine, and strychnine are
indicated in the convalescence." — (Pocket Cyclopedia.)
5. Treatment of tapeworm: The patient should be
limited to a liquid diet for two days; salines should
then be administered; then the oleoresin of aspidium
in a dose of one to two drams, followed in a few hours
by another saline. The treatment can only be con-
sidered successful when the head of the worm is found
in the dejecta.
6. Headache "may be due to organic cerebral disease,
congestion and anemia of the brain, functional ner-
vous disorders, toxemic conditions, derangements of the
stomach and liver, and reflex causes, such as eye-
strain, nasal disease, etc. The treatment should be
directed to the cause. Eye-strain should be sought
for and corrected, as well as any existing nasal dis-
ease. Toxemic states should be remedied by dietary
and medicinal prescriptions. Anemia calls for prepara-
tions of iron. Uterine disease should be corrected.
Cerebral syphilis demands mercurials and iodides.
Preparations containing citrated caffeine, monobro-
mated camphor, acetanilid, phenacetin, etc., may be
given during the attack. For nervous headaches, a pill
containing zinc phosphide (gr. 1/10) and extract of
nux vomica (gr. 1/3) may be administered. Pallia-
tive treatment consists in local applications of cold,
evaporating lotions, menthol, thymol. Various pungent
and aromatic spirits are useful for inhalation."—
(Pocket Cyclopedia.)
253
MEDICAL RECORD.
7. Treatment of constipation: The cultivation of a
regular habit is essential; fruit, vegetables, and sub-
stances which leave a residue should form part of the
diet; castor oil, or cascara, or calomel or a saline or
an injection of water or oil may be tried, but drugs
should be dispensed with as long as possible; exercise
or massage may be beneficial; fats or olive oil may be
taken ; the pill of aloin, belladonna and strychnine may
be tried.
8. Locomotor Ataxia. Etiology: It is a disease of
adult life; is more common in men than in women; is
more common in cities than in the country; syphilis
is believed to be the most frequent direct cause; alco-
holism, injury, exposure to cold and wet, have all been
urged as causes, but they are not now assigned so im-
portant a place as etiological factors as was formerly
the case.
Symptom: Loss of coordination; characteristic and
unsteady gait; tendency to stagger when standing up
with feet together and eyes closed; sharp and paroxys-
mal pain, called crises; girdle sensation; loss of knee-
jerk and other reflexes; Argyll-Robertson pupil.
Prognosis is unfavorable; the disease is chronic, but
may remit for a period; death by some intercurrent
affection may occur.
Treatment consists of rest in bed for long periods,
absence of excitement, nutritious food, cod liver oil,
tonics, silver nitrate, massage, systematic exercises,
counterirritation, and analgesics.
9. In endocarditis: The murmur is soft, not harsh;
it is systolic or diastolic; it may be transmitted; it is
heard loudest at definite points; it is not followed by
signs of effusion ; the apex beat may be strong.
In pericarditis: The murmur is harsh; is not in con-
nection with the heart sounds; is heard loudest at the
base of the heart and over the precordium; is followed
by (or accompanied with) signs of effusion; the apex
beat is generally feeble.
Some of the causes of endocarditis are: Acute articu-
lar rheumatism, chorea, tonsillitis, scarlet fever, pneu-
monia, cancer, gout, diabetes meilitus, Bright's disease,
septicemia, gonorrhea.
Treatment of endocarditis : "All forms of endocar-
ditis require absolute rest, which should be prolonged
for weeks or even months. The primary disease should
be treated. Overstimulation of the heart must be
avoided, and it is in acute endocarditis that most harm
is likely to be done by the indiscriminate use of digi-
talis, though it may be called for if the heart is fail-
254
ILLINOIS.
ing. Rest, light diet, milk while fever is present, at-
tention to the bowels and to sleep, form the best treat-
ment of simple endocarditis. The malignant form
should be treated like septicemia. If the organism can
be isolated from the blood, antistreptococcic serum or a
vaccine may be tried, but under any treatment most
cases have a fatal ending." — (Wheeler and Jack's
Handbook of Medicine,)
10. Chronic rheumatism. Cause: "The disease is
most common among the middle-aged poor, particu-
larly those who are exposed to cold and wet. Very
rarely it follows acute rheumatism." Treatment. — "In-
ternal medication is unsatisfactory. Guaiacum, iodide
of potassium, and arsenic are recommended, but the
salicylates are ineffectual. Local measures, such as
counterirritation, massage, passive movement, and
hydrotherapy are much more useful. Obstinately pain-
ful nodules may be excised. A course of baths, and a
warm winter climate may be of great service in cases
where such measures are possible." — (Wheeler and
Jack's Handbook of Medicine.)
SURGERY.
1. Surgical diseases of the third nerve: "One or more
of the branches of this nerve may be compressed by
extravasated blood, or be contused and lacerated in
fractures implicating the region of the sphenoidal
fissure. Tumors and aneurysms growing in this region
also may press upon the nerve. Sometimes both nerves
are involved; for example, in fractures involving both
sides of the anterior fossa, and in tumors, particularly
gummata, growing in the region of the floor of the
third ventricle. In lesions of the cerebral hemispheres
the third nerve is very frequently paralyzed. Its cor-
tical center lies in close proximity to the center for
the face. The most prominent symptoms of complete
paralysis are ptosis or drooping of the upper eyelid,
external strabismus, and slight downward rotation
of the eye. There is also dilatation of the pupil from
paralysis of the circular fibers of the iris, and loss of
accommodation from paralysis of the ciliary muscle.
Paralysis of the muscles supplied by the third nerve
is frequently associated with paralysis of other ocular
muscles. When all the muscles of the eye are para-
lyzed, the condition is known as "ophthalmoplegia ex-
terna"; it is usually due to syphilitic disease in the
floor of the third ventricle."— (Thomson and Miles'
Manual of Surgery.)
2. Tendon transplantation: "This operation consists
255
MEDICAL RECORD.
in altering the attachments of the tendons of healthy
muscles so as to have them fulfil the functions of those
which are paralyzed. Four methods of transplantation
are practised: first, the tendon of the healthy muscle
may be completely divided and the upper end sutured
to the paralyzed tendon; second, the tendon of the
paralyzed muscle may be divided and the lower end
sutured to the healthy one; third, the tendon of the
sound muscle may be split, one end remaining attached
to its normal insertion, and the other sutured to the
paralyzed tendon ; fourth, a portion or the whole of
the healthy tendon may be implanted subperiosteal^
at the desired point, instead of stitching it to the
paralyzed tendon."' — (Wharton's Minor Surgery.)
3. The structure in which rodent ulcer most com-
monly develops is the sebaceous glands of the skin.
Surgical treatment consists of free removal with a good
margin all around the ulcer; if this is not practicable
the Roentgen rays may be tried.
4. Delayed union in fracture is caused by : 111 health,
want of approximation of the end of the bone, want of
blood supply in the bone, defective innervation of the
bone, disease of the bone, lack of rest, and immobility.
5. To accomplish male sterilization a partial vasec-
tomy may be performed. The skin and fascia are in-
cised, the spermatic cord is exposed just below the ex-
ternal abdominal ring, the vas is separated, and two
ligatures are placed around it about % inch apart;
half an inch of this part is excised, and the wound is
closed with ligatures.
6. Bloodless operation for amputation at the hip:
"The most satisfactory method in the great majority
of cases is Wyeth's, in which a constrictor is held in
place by the preliminary passage of two steel pins.
The outer pin is inserted an inch and a half below and
a little internal to the anterior superior spine of the
ilium, and is brought out just back of the great
trochanter. The inner pin is entered one inch below
the level of the crotch and internal to the saphenous
opening, and it emerges an inch and a half in front of
the tuberosity of the ischium. A sterile cork is pushed
on the end of each pin, to save the surgeon from wound-
ing himself from the sharp points. After the limb has
been emptied of blood by holding it in a vertical posi-
tion for five minutes and stroking it from the periphery
toward the body, the constricting band is fastened
about the limb above the pins. After the passage of
the pins and the application of the band of the Es-
march apparatus, the amputation is proceeded with.
256
ILLINOIS.
The hip is brought well over the edge of the table, a
circular incision is made down to the deep fascia, six
inches below the constricting band, and is joined by a
longitudinal skin-cut reaching from the band to the
level of the circular incision, and the cuff is reflected
to the level of the lesser trochanter. The muscles are
cut by a circular sweep at the level of the retracted
cuff, the capsule of the hip- joint is opened freely, the
cotyloid ligament is cut posteriorly, the thigh is bent
upward, forward, and inward to dislocate the head of
the bone, and, using the thigh as a handle, the round
ligament is incised and the limb removed. After
ligating the vessels and introducing drainage tubes the
flaps are sewn together vertically." — (Da Costa's Mod-
ern Surgery.)
7. Tenosynovitis. Etiology: Strain, sprain, over-
use, wounds, infection, tuberculosis, inflammation.
Treatment: Rest, hot fomentations, massage, counter-
irritation, rupture by pressure, incision, excision.
8. (1) Talipes varus, in which the inner edge of the
foot is drawn up, the anterior two-thirds is twisted in-
ward, and the outer edge rests on the ground.
(2) Talipes valgus, in which the outer edge of the
foot is drawn upward, and the inner side of the foot
and ankle rest on the ground. This condition is the
reverse of talipes varus.
(3) Talipes equinus, in which the heel is raised and
cannot be brought to the ground, and the patient walks
on the toes and on the distal ends of the metatarsal
bones.
(4) Talipes calcaneus, in which the toes are raised
and the heel depressed, so that the patient walks on
the latter. This condition is the reverse of talipes
equinus.
(5) Talipes equinovarus, in which the heel cannot
be brought to the ground, and the patient walks on the
outer margin of the sole.
9. In wrist-amputation the following blood vessek
and nerves are severed: Radial, ulnar, superficial volar,
dorsalis indicis, and radialis indicis arteries; and
median, radial, and ulnar nerves.
10. A wound may be closed when there is no severe
hemorrhage, no foreign bodies present, and when the
wound is not infected.
OBSTETRICS.
1 and 2. Female organs of generation: Uterus.
The rectum lies behind and the bladder in front; it is
below the abdominal cavity and above the vagina. Its
position is one of slight anteflexion, with its long axis
257
MEDICAL RECORD.
at right angles to the long axis of the vagina. The
anterior surface of its body rests on the bladder, and
the cervix points backward toward the coccyx.
The Fallopian tubes are about 4% inches long, situ-
ated in the broad ligament, and extending from the
upper corner of the fundus of the uterus outward to
the pelvic wall. Their caliber is larger at the outer
fimbriated end than at the inner end.
The ovaries are almond-shaped bodies situated below
the outer end of the Fallopian tube, and between the
layers of the broad ligaments.
The vagina is a muscular tube extending from the
uterus to the external surface. The anterior and pos-
terior surfaces are in apposition. The anterior wall is
about 3% inches long, the posterior about 4% inches.
Function of ovaries: To develop ova, and an internal
secretion.
3. Liquor amnii. Functions: (a) During preg-
nancy: (1) As a protection to the fetus against
pressure and shocks from without. (2) As a protec-
tion to the uterus from excessive fetal movements. (3)
It distends the uterus and thus allows for the growth
and movements of the fetus. (4) It receives the excre-
tions of the fetus. (5) It surrounds the fetus with a
medium of equable temperature, and serves to prevent
loss of heat. (6) It prevents the formation of adhe-
sions between the fetus and the walls of the amniotic
sac. (7) It has been supposed, by some, to afford some
slight nutrition to the fetus, (b) During labor: It acts
as a fluid wedge, and dilates the os uteri and the cervix ;
it also slightly lubricates the parts.
Composition : Chiefly water, but it contains also small
amounts of albumin, epithelial cells, urea, phosphates,
chlorides, etc.
4. Hydatidiform mole is derived from the chorionic
villi.
5. Anomalies of placenta: Low insertion, placenta
praavia, hypertrophy, abnormally thick, abnormally
small, horseshoe or crescentic shaped, lobed; degenera-
tion, edema, infarction, calcification, or disease of the
placenta.
6. Umbilical herniaj — "There are two varieties of this
deformity. In one, a knuckle of intestine covered by
skin projects from the navel. This degree of de-
formity is common, occurring in two per cent, of in-
fants. It is treated by a convex button,. cork, or hard
rubber compress on a strip of adhesive plaster, which
encircles two-thirds of the child's body. This impro-
vised truss is renewed from time to time, and should
258
ILLINOIS.
be worn six months. In the second variety there is an
exomphalic condition, due to defective development, the
intestines protruding from the umbilicus covered only
by amnion. An immediate plastic operation is indi-
cated even if the mass of protruding intestines is as
large as an apple. The results of this operation have
been excellent." — (Hirst's Obstetrics.)
7. The objective signs of pregnancy at the fifth
month are: Hearing the fetal heart sounds, ballotte-
ment, uterine souffle, and the breast signs.
8. Treatment of edema of the vulva during preg-
nancy : "If the cause can be removed, the edema dis-
appears. The treatment of kidney insufficiency re-
moves the dropsy of the labia associated with that con-
dition, as it does the other dropsies of the body. If the
edema is due to pressure, rest in bed, with the occa-
sional assumption of the knee-chest posture, often gives
relief. If the edema does not yield to general treat-
ment and to hot fomentations locally, the labia may be
punctured. It should be remembered, however, that
even this slight operation may terminate pregnancy.
The vitality of the part, moreover, is so lowered that
infection and even gangrene may follow the puncture."
— (Hirst's Obstetrics.)
9. Presentations and position: Vertex presentations
are most frequent; of these L.O.A., R.O.P., R.O.A., and
L.O.P. are the positions in order of frequency. Breech
presentations are second in order of frequency ; of these
the L.S.A., R.S.P., and then R.S.A. and L.S.P. indicate
the order of frequency. Face and shoulder presenta-
tions are next; of the face, the order is: R.M.P.,
L.M.A., R.M.P., and L.M.P.; of the shoulder, L.D.A. is
the most common. Brow presentation is the most rare.
10. Mastitis. Etiology: Infection, generally due to
handling; cracked or sore nipples and overactivity of
the gland with retained secretion are predisposing
causes. Treatment: This consists in resting the part;
supporting it, applying a hot boracic acid fomenta-
tion; nursing from the affected breast should be
stopped at once.
Prophylactic measures consist in not touching the
breasts (by doctor or nurse or patient) without thor-
oughly clean hands; by washing and drying the nipple
hygienic conditions before labor, and the nipple and
before and after nursing, and by proper attention to
breasts being preserved from pressure.
GYNECOLOGY.
1. Metrorrhagia is a hemorrhage from the uterus at
other than the menstrual periods.
259
MEDICAL RECORD.
Local causes: Uterine displacements, malignant dis-
ease, inflammation of uterus or appendages, fibroids,
cystic degeneration of the cervix, subinvolution, ectopic
gestation, abdominal tumors.
General causes: Hemophilia, scurvy, purpura, ma-
laria, anemia, mitral disease, diseases of kidneys, or
liver, acute infectious fevers.
2. In appendicitis the pain is of sudden onset and is
localized in the right iliac fossa; there is abdominal
rigidity, chiefly of the right rectus muscle, and ten-
derness at McBurney's point; there are usually fever,
nausea, vomiting, and constipation.
In inflammation of the right ovary the pain is not
localized, but may be bilateral, and spreads to the
vagina and rectum; there is no tenderness at McBur-
ney's point; it is usually worse just before the men-
strual period, which sometimes affords relief; on vagi-
nal examination the ovary is found to be tender.
3. "When extrauterine pregnancy exists there are:
(1) The general and reflex symptoms of pregnancy;
they have often come on after an uncertain period of
sterility; nausea and vomiting appear aggravated. (2)
Then comes a disordered menstruation, especially
metrorrhagia, accompanied with gushes of blood, and
with pelvic pain coincident with the above symptoms
of pregnancy; pains are often very severe, with marked
tenderness within the pelvis; such symptoms are highly
suggestive. (3) There is the presence of a pelvic tumor
characterized as a tense cyst, sensitive to the touch,
actively pulsating; this tumor has a steady and pro-
gressive growth. In the first two months it has the
size of a pigeon's egg; in the third month it has the
size of a hen's egg; in the fourth month it has the size
of two fists. (4) The os uteri is patulous; the uterus
is displaced, but is slightly enlarged and empty. (5)
Symptoms No. 2 may be absent until the end of the
third month, when suddenly they become severe, with
spasmodic pains, followed by the general symptoms of
collapse. (6) Expulsion of the decidua, in part or
whole. Nos. 1 and 2 are presumptive signs; Nos. 3
and 4 are probable signs; Nos. 5 and 6 are positive
signs." — (American Textbook of Obstetrics.)
Treatment consists in removal of the product of con-
ception, by a laparotomy, as soon as the diagnosis is
made.
4. Incontinence of urine, in women. Causes:
"This condition may be found in hysteria; in various
injuries or diseases of the brain and spinal cord where
the sphincter power of the neck of the bladder and
260
ILLINOIS.
urethra is lost, e.g. in certain stages of locomotor
ataxia, epilepsy; in advanced tuberculosis impairing
the sphincter action; in vesicovaginal fistula; dilata-
tion of the urethra ; intoxication ; in various forms of
stupor, e.g. typhoid state; it may be due to strong
stimuli acting on the bladder, urethra, or neighboring
parts, e.g. applications to neck of bladder or inner end
of urethra; acute cystitis, calculus, sudden submucous
hemorrhages, caruncle, fissures, inflammation in tubes,
ovaries, uterus, rectum ; it may be found in early preg-
nancy. In childhood there may be a true incontinence
due to sphincter paralysis, hyperesthesia of the vesical
mucosa, some localized trouble, or a nervous condition;
but in the majority of cases the irritation is reflex,
from such conditions as oxaluria, lithemia, worms in
the bowel or vagina, polypi of rectum, eczema of vulva
or perineum, etc., and is in most cases only found at
night. Once the habit is formed, it may remain long
after the cause is removed." — (Webster's Diseases of
Women.) Treatment: Remove the cause; attend to
general health; medication is of but little value; an
operation may be necessary.
5. Causes of downward displacements of the
uterus: (1) Pressure from above (pelvic or abdominal
tumors, ascites, tight or heavy clothing, straining at
stool, muscular exertion, fecal accumulations, habitual
overdistention of the bladder) ; (2) weakening and re-
laxation of the uterine supports (subinvolution, senile
atrophy of pelvic floor, abnormally large pelvis, in-
creased weight of uterus, puerperal traumatisms,
pressure from above, traction from below) ; (3) in-
creased weight of uterus (congestion, subinvolution,
metritis, pregnancy, fluid in the endometrium, uterine
tumors) ; (4) traction from below (vaginal cicatrices,
falling and pelvic floor, contraction and congenital
shortening of vagina, tumors of cervix or vagina.) —
(From Dudley's Gynecology.)
6. Symptoms of fibroids: Hemorrhage,, leucorrhea,
pain, pressure symptoms (disturbances and displace-
ments of bladder, rectum, urethra, and uterus), back-
ache, bearing-down sensation, dysmenorrhea.
The differential diagnosis is as follows:
"(1) Parauterine cellulitic deposits show a history of
a febrile condition, a sudden onset, and the fixation and
sensitiveness of the uterus.
"(2) Hematocele shows itself in a sudden appear-
ance, the tumor being immovable and sensitive. The
tumor is at first semifluid; later it may be tympanitic.
"(3) Ovarian tumors. — Vaginal touch and the use
261
MEDICAL RECORD.
of the sound will show that the tumor is not attached
to the uterus. Percussion of the abdomen will give
fluctuation. There is generally more deterioration of
health. Solid ovarian tumors adherent to the uterus
are almost impossible to differentiate.
"(4) Pregnancy. — There is amenorrhea. The tumor
is symmetric, softer, and of more regular growth. In
doubtful cases the development of fetal heart-sounds
and movements will settle the diagnosis.
"(5) Tubal diseases can be excluded by the shape of
the tumor, the great tenderness, and lessened mobility
of the uterus.
"(6) The area of displacement of a floating kidney
will appear above the pelvic brim, while that of a
fibroid is below the inlet." — (Wells' Commend of Gyne-
cology.)
LARYNGOLOGY AND RKINOLOGY.
1. Abscess of antrum of Highmore. Symptoms:
"There is pain, tenderness on pressing over the canine
fossa or on tapping the teeth of the upper jaw, and
sometimes swelling of the cheek. The complaint of a
bad odor or taste, the reappearance of pus in the mid-
dle meatus after mopping it away and directing the
patient to bend his head well forward, and opacity on
transillumination of the suspected cavity are signs
which strongly suggest an affection of the maxillary
sinus. The withdrawal of pus by a puncture through
the thin outer wall of the inferior meatus of the nose
with a fine trocar and canula will establish the diagno-
sis. The treatment consists in opening and draining
the antrum. If the infection is due to a carious tooth
this should be extracted, the socket opened up and
drainage established through it. If the teeth are sound
the antrum is opened through the canine fossa and its
walls curetted, after which the cavity is packed with
iodoform worsted. To avoid the risk of reinfecting the
cavity from the mouth, an opening may be made into
the nose, by removing the anterior portion of the nasal
wall of the antrum and part of the inferior turbinated
bone, after which the incision in the buccal mucous
membrane is closed with sutures." — (Thomson and
Miles' Surgery.)
2. "Laryngotomy is rarely undertaken except for the
relief of dyspnea arising from some sudden obstruc-
tion to the respiration, and is thus to be looked on as
an operation of urgency. It is required in cases where
the entrance to the larynx is obstructed by a foreign
body, for spasm of the glottis, or for accumulations of
blood in the neighborhood of the larynx during an
262
ILLINOIS.
operation. It is readily performed by making a ver-
tical incision over the situation of the cricothyroid
membrane, which is then divided transversely along
the upper border of the cricoid cartilage, the sterno-
hyoid muscles being, if necessary, drawn aside, and a
tube inserted. Possibly the small cricothyroid artery
arising from the superior thyroid may require a liga-
ture. In cases of great urgency, a simple transverse
incision may be made with a penknife, and the larynx
opened, the margins of the wound being held aside by
a hairpin, or by the handle of a scalpel turned edge-
ways, while a toothpick will serve temporarily as a
cannula. Whenever there is time to operate delib-
erately, a high tracheotomy is the better practice, since
a tube inserted through the cricothyroid space gives
rise to considerable irritation, and the voice may be
subsequently impaired by the contraction of the cica-
trix. A special laryngotomy tube is required, the lumen
of which is not circular, but oval and flattened from
above downward." — (Rose and Carless' Surgery.)
MEDICAL JURISPRUDENCE.
1. If respiration has taken place, its lungs will float
on being put into water. Further, the lungs before
respiration are situated at the back of the thorax and
do not fill the cavity; whereas, after respiration they
fill the whole cavity.
Application of hydrostatic test. — Having opened
chest, note position of lungs (before respiration they
occupy a small space at upper and posterior parts of
thorax) ; their volume (of course increased after
breathing) ; their shape (before respiration, borders
sharp or pointed; after it, rounded) ; their color (be-
fore breathing, brownish-red; after it, pale red or
pink) ; their appearance as regards disease and putre-
faction; and whether they crepitate on pressure (as
they will after respiration).
• "Take out lungs, with heart attached, and place them
in pure water having temperature of surrounding air.
Note whether they float (high or low), or sink (slowly
or rapidly). Separate them from the heart; weigh
them accurately, and then place them in water again,
and note sinking or floating as before. Subject each
lung to pressure with the hand, and note sinking or
floating again. Cut each lung in pieces and test float-
ing again. Take out each piece, wrap it in a cloth, and
compress with fingers as hard as possible, and test
floating, etc., as before. The crucial test of perfect
respiration is each piece floating after the most vigor-
ous compression. " — (King's Manual of Obstetrics.)
263
MEDICAL RECORD.
2. Symptoms of acute poisoning by mercuric chlo-
ride: The nauseous metallic taste is experienced during
the act of swallowing. Within a few moments this is
followed by an intense, burning pain in the mouth,
throat, and stomach. The mouth and tongue are
whitened and shriveled. There are vomitings of a
white material, containing shreds of mucous membrane,
and tinged with blood, and bloody stools. Salivation
occurs if life be sufficiently prolonged." — (Witthaus.)
Mercury may be detected in the urine or vomited
material by the Reinisch test. To the suspected fluid
add a little pure HC1; suspend in the fluid a small strip
of bright copper foil, and boil. If a deposit forms on
the copper, remove the copper, wash it with pure water,
dry on filter paper, but be careful not to rub off the
deposit. Put the copper into a clean, dry glass tube,
open at both ends, and apply heat where the copper is.
If mercury is present it will be deposited in the cold
part of the tube, forming a mirror.
STATE BOARD EXAMINATION QUESTIONS.
Indiana State Board of Medical Registration and
Examination.
ANATOMY.
i. Give the relation of the internal abdominal ring to
surrounding blood-vessels.
2. Give the origin, principal branches, and distribution,
of the superior mesenteric artery.
3. Give the boundaries and contents of the axillary space.
4. What part of the brain is most freely supplied with
blood?
5. Describe the blood supply to the liver structure.
6. Describe the large intestine and tell how it differs
from the small intestine in structural arrangement.
7. Give the names of the (a) temporary teeth in their
order from front to back, (b) permanent teeth in same
order.
8. What nerves unite to form the brachial plexus?
9. Name the most important nerve branch of the cervical
plexus, its point of origin, and its distribution.
10. Give the names and locations of the bones of the
face.
PHYSIOLOGY.
x. (a) What is meant by digestion? (b) Describe the
process of digestion of an egg sandwich.
2. Discuss the factors concerned in venous circulation.
264
INDIANA.
3. (a) Describe a cell, (b) How are cells propagated?
(c) Give the functions of nerve cells.
4. (a) Describe the vasomotor system, (b) Give its
function, (c) What center controls it?
5. (a) Compare voluntary and involuntary muscle, (b)
What is muscular coordination? (c) By what centers is
it controlled? (d) What causes muscular fatigue?
6. (a) Describe the respiratory function, (b) What is
meant by the terms: (1) Residual air? (2) Vital capacity?
7. (a) Give the composition of the blood, (b) Reaction.
(c) Specific gravity, (d) Amount in the body, (e)
Time required for a complete circulation.
MATERIA MEDICA AND THERAPEUTICS.
i. Define solvent. Mention three principal solvents.
2. Dfcfine diaphoresis. Mention three diaphoretics and
state the dose of each.
3. State the name and the dose of each of two cardiac
stimulants.
4. In what form is iodine most frequently administered
internally? What is the antidote for free iodine?
5. What serious results may ensue from the indiscrimin-
ate use of acetanilid ?
6. Mention the conditions which affect the dosage of
medicines.
7. What is cumulative action? Name one drug that
has this tendency, and give symptoms of such action.
8. Name and describe three antiseptics useful for inter-
nal medication.
v 9. Name three indications for the use of opium.
10. How and when would you perform hypodermoclysis ?
CHEMISTRY.
1. Give the formula for the two chief products of yeast
fermentation of sugar and state the differences, if any,
in the action of yeast upon cane sugar, milk sugar, and
grape sugar.
2. State the chief differences between fixed and volatile
oil and name three of each class that are extensively used
in medicine.
3. Give the chemical composition and properties of am-
monia gas.
4. Give the approximate constituents of cow's milk.
5. Give the chemical formula for urea and what is the
normal amount excreted daily by an average adult.
PHYSICAL DIAGNOSIS.
1. Give physical signs of aneurysm of the thoracic aorta.
265
MEDICAL RECORD.
2. Give cardinal symptoms by which you can diagnose
a case of appendicitis.
3; Give topographical anatomy of the heart and its
valves.
4. (a) Give normal temperature of the body. (&) Give
normal pulse (frequency).
5. If a man or woman, past middle age, complaining of
constant slight vertigo, intensified on excitement or exer-
tion, presents sclerosed arteries, arcus senilis, and ringing
aortic closure, with or without moderate cardiac hyper-
trophy, what would be your diagnosis?
PATHOLOGY AND BACTERIOLOGY.
i. Define in contrast infection and intoxication.
2. What do you understand by phagocytosis, and what
is its relation to immunization?
3. From what does thrombosis of the portal vein most
frequently result?
4. From what does chronic gastritis most frequently re-
sult?
5. Name the pathological conditions most commonly
found in the lymphatic glands.
6. How would you demonstrate the presence of the
amoeba coli in a case of amoebic dysentery?
7. How would you demonstrate the efficiency of a germi-
cide?
8. Describe one method by which you can demonstrate
the agglutination of bacteria by blood serum.
9. What bacteria most frequently cause puerperal infec-
tion?
10. Examine and name the pathogenic organisms under
the microscopes No. I, No. 2, No. 3.
ETIOLOGY AND HYGIENE.
1. Give the accredited causes of malaria and yellow
fever and tell what measures afford the best means of
protection from infection.
z How are impurities in water classified; how can they
be detected, and why is the presence of organic material
in drinking water deleterious?
3. Illustrate the theory of immunity by means of anti-
toxin.
4. Is infantile paralysis infectious? If so, give rules
for protecting the community.
5. Give etiology of: (a) hepatic abscess, (b) cardiac
hypertrophy, (c) edema of the lungs. .
PRACTICE.
1. Write in parallel columns the diagnostic symptoms of
measles and smallpox.
266
INDIANA.
2. Write in parallel columns the diagnostic symptoms of
neuralgia and myalgia.
3. Mention the forms of insanity, and give the most com-
mon causes.
4. Give a differential diagnosis of pleurisy and pneu-
monia.
5. What are the average durations of the febrile stages
in the following forms of disease: Typhoid fever, scarlet
fever, measles, rheumatic fever, and pneumonia?
6. Give the symptoms of greatest diagnostic importance
in locomotor ataxia.
7. Give the pathognomonic symptoms of hysteria.
8. Give symptoms and treatment of incipient phthisis.
9. What forms of disease present symptoms during the
first three days resembling variola?
10. With what form of disease may scarlatina be con-
founded prior to the appearance of eruption?
OBSTETRICS.
1. Give the physiology of impregnation.
2. Describe the development of the fertilized ovum.
3. What is meconium, and what are its diagnostic rela-
tions?
4. Describe the human uterus and give its anatomical
relations.
5. Describe the vitellus, allantois, and the amnion.
6. How soon after confinement should a woman men-
struate?
7. State some of the causes of sterility.
8. What conditions have a bearing on the time of life
in the female when menstruation first occurs?
9. Are maternal impressions transmitted to the child in
utero to such an extent as to produce marks, defects, and
abnormalities ?
10. Describe Crede's method of prophylaxis for ophthal-
mia neonatorum.
GYNECOLOGY.
1. Differentiate cystocele from (a) an anterior vaginal
hernia, (b) a tumor situated in the vaginal wall.
2. Define prolapsus of the uterus and give differential
diagnosis and treatment.
3. Define: (a) menorrhagia, (&) amenorrhea, (c) dys-
menorrhea.
4. Give differential diagnosis and treatment of gonor-
rheal vaginitis. ^
5. Give technique for complete abdominal hysterectomy.
6. How would you distinguish shock from secondary
hemorrhage?
267
MEDICAL RECORD.
SURGERY.
1. Define odontoma. Give varieties and origin of each
variety.
2. Give symptoms and signs of cervical rib and how
does cervical rib give symptoms and signs?
3. What is meant by coxa vara? What causes it?
4. Name the chief forms of spina bifida.
5. What is meant by Charcot's disease of a joint? What
are its chief diagnostic features other than the general
signs of tabes?
6. In middle meningeal hemorrhage, what extracranial
treatment do you know of and what is its value? What
caution is to be exercised, and why ?
7. Describe operation for epithelioma of lower lip.
8. Name a few of the most important diagnostic points
in ulcer of the duodenum and explain. Give physiological
reasons.
9. What are the contraindications to surgery in gall-
stone in the common duct, and why?
10. What is a ranula?
PEDIATRICS.
1. Give symptoms and modern treatment for polio-
myelitis.
2. Give cause and proper treatment of acute dysentery.
OPHTHALMOLOGY AND OTOLOGY.
1. Give causes, diagnosis, and treatment of chronic glau-
coma.
2. Give causes, symptoms, and treatment of phlyctenular
keratitis.
3. Give the origin of the acoustic nerve and its distri-
bution in the labyrinth.
MEDICAL JURISPRUDENCE.
1. State fully what are the legal obligations of a physi-
cian or surgeon to his patient and what is his liability for
malpractice.
2. State your ideas as to the conduct of a physician on
a witness stand, including the manner of giving his evi-
dence and the nature of it; also state conditions under
which you would voluntarily testify as an expert witness.
RHINOLOGY AND LARYNGOLOGY.
1. Name seven diagnostic points of chronic hyperplastic
ethmoiditis.
2. Name four contraindications to surgical treatment of
the tonsils.
NEUROLOGY.
I. Give the six most important symptoms of tabes dor-
salis.
268
INDIANA.
2. Give the most significant symptoms of paralysis
agitans.
3. How is migraine distinguished from other forms of
headache?
ANSWERS TO STATE BOARD EXAMINATION
QUESTIONS.
Indiana State Board of Medical Registration and
Examination.
anatomy.
1. Relation of internal abdominal ring to surrounding
blood-vessels: The external iliac artery and vein lie im-
mediately under the ring; the deep epigastric vessels are
internal to the ring; and the deep circumflex iliac artery is
external to the ring.
2. Superior Mesenteric Artery. Origin: Abdominal
aorta. Branches: Inferior pancreatico-duodenal, vasa in-
testini tenuis, Ileo-colic, Right colic, and Middle colic. Dis-
tribution: All the small intestine, except the first part of
the duodenum ; cecum ; ascending and transverse colon. •
3. The axilla is bounded: Anteriorly, by the clavicle,
Subclavius, Pectoralis major, costocoracoid membrane,
Pectoralis minor; posteriorly, by the Subscapularis, Teres
major, and Latissimus dorsi; internally, by the first four
ribs, first three Intercostal muscles, Serratus magnus; ex-
ternally, by the humerus, Coracobrachial, and Biceps.
Contents: Axillary vessels; brachial plexus of nerves
and their branches; some branches of the intercostal
nerves ; lymphatic glands, fat, and loose areolar tissue.
4. The gray matter and the base of the brain are most
freely supplied with blood.
5. The substance of the liver derives its blood-supply
from the hepatic artery and its branches, also from the
small hepatic branch of the gastric artery.
6. The large intestine extends from the termination of
the ileum to the rectum. It differs from the small intestine
in: (1) Its larger size; (2) its more fixed position; (3)
the possession of teniae; (4) in being sacculated; and (5)
in possessing appendices epiploicae.
The colon is divided into ascending, transverse descend-
ing, iliac, and pelvic. The ascending colon extends from
the cecum to the under surface of the liver to the right of
the gall-bladder, where it turns to the left, forming the
hepatic flexure. It lies in the right iliac and right hypo-
chondriac regions. The peritoneum covers the anterior and
lateral surfaces. Length, 8 inches. The transverse colon
passes from right to left, from the gall-bladder to the
269
MEDICAL RECORD.
spleen. It forms an arch, convex anteriorly and below :
the transverse arch of the colon. It is entirely surrounded
by peritoneum, which is attached posteriorly to the spine,
forming the mesocolon. Length, 20 inches. The descend-
ing colon passes from the end of the transverse colon by
a bend, the splenic flexure. Between the splenic flexure
and the diaphragm, opposite the tenth left rib, is a fold
of the peritoneum, the costocolic ligament, which slings
up the spleen. The gut then passes downward to the iliac
crest, ending in the iliac colon. The peritoneum invests
its anterior and lateral surfaces. Length, 4 to 6 inches.
The iliac colon is continuous with the descending colon at
the left iliac, crest, and ends at the inner border of the
left psoas. Peritoneum invests its anterior and lateral
surfaces ; it has no mesentery. Length, 5 to 6 inches. The
pelvic colon extends from the inner border of the psoas
to the level of the third sacral vertebra. Length, 16 or 17
inches; very variable. It has an extensive mesentery. —
(From Aids to Anatomy.)
7. The temporary teeth, from front to back, are : Central
incisor, lateral incisor, canine, first molar, and second
molar.
The permanent teeth, from front to back, are: Central
incisor, lateral incisor, canine, first bicuspid, second bicus-
pid, first molar, second molar, and third molar.
8. The brachial plexus is formed by the union of the an-
terior divisions of the fifth, sixth, seventh, and eighth
cervical and the first dorsal nerves.
9. The most important nerve branch of the cervical
plexus is, probably, the phrenic nerve. It arises chiefly
from the fourth cervical nerve, with filaments from the
third and fifth cervical nerves. It is distributed to the
diaphragm, pericardium, and pleura.
10. The bones of the face. Two nasal, forming the
bridge of the nose. Two superior maxillary, forming up-
per jaw; part of roof of mouth, nasal fossae and orbital
cavities. Two lachrymal, situated at the front and inner
part of the orbit. Two malar, at upper and outer part
of face, forming the cheek bone Two palate, at back part
of nasal fossae; they assist in formation of roof of mouth,
and floor of orbit. Two inferior turbinated, on outer wall
of nasal fossae. Vomer, forming septum of nose. Inferior
maxillary, or lower jaw.
PHYSIOLOGY.
1. Digestion is the name given to the series of changes
occurring in food from the time of its ingestion till it is
ready for absorption.
An egg sandwich consists of bread (proteid, carbohy-
drates and fat), butter (fat), and egg (proteid and fat).
270
INDIANA.
The proteid is digested in the stomach and small in-
testine, where the pepsin (of the gastric juice) and tryp-
sin (the pancreatic juice), respectively, turn it into pro-
teoses and peptones. The carbohydrates are digested in
the mouth, and small intestine, where the ptyalin (of the
saliva) and amylopsin (of the pancreatic juice), respect-
ively, turn it into maltose and dextrose. The fat is digested
in the small intestine, where it is saponified by the steapsin
(of the pancreatic juice) and the bile.
2. The factors concerned in venous circulation are: (i)
The force exerted by the heart; (2) the suction action of
the chest during inspiration; (3) the voluntary muscles;
(4) the valves in the veins.
3. A cell is a mass of protoplasm, with a nucleus, and
sometimes a nucleolus, centrosome, attraction cell and cell-
membrane. It is capable of movement, response to stimuli,
ingestion, egestion, assimilation, and reproduction. Cells
multiply by simple division, but the division of the proto-
plasm is preceded by division of the nucleus. This latter
occurs in two ways : ( 1 ) By direct, or simple, or amitotic
division; and (2) by karyokinesis or indirect division, the
more common way.
The functions of nerve cells are: (1) Receiving nerve
impulses; (2) sending out nerve impulses ; (3) modification
of nerve impulses; and (4) nutrition of itself and its
dendrites and axon.
4. "The vasomotor system may be said to be composed
of the vasomotor center, situated in the medulla, together
with some accessory and subsidiary centers in the spinal
cord, and vasomotor nerves. The nerves are divided into
two classes, according as they increase or diminish the
calibre of the arterioles; those which increase the caliber
are vaso-dilators ; those which diminish the same are
known as vaso-constrictors. All nerves that in any way
influence vessel caliber are classed under the general head
of vasomotor." (Ott's Physiology.)
5. Voluntary muscle is more or less under the control
of the will ; involuntary muscle is not under the control of
the will, it is rhythmical in its contractions, and is also
characterized by peristalsis.
Further, voluntary^ muscle is striated, has long narrow
fibers with cross striations and many nuclei beneath the
sarcolemma. Involuntary muscle is non-striated, has
soindle-shaped fibers, one nucleus centrally located, and no
sarcolemma. The great exception is cardiac muscle, which
is involuntary and also striated. Voluntary muscle is found
in all the skeletal muscles, pharynx, diaphragm, larynx, ex-
ternal ear, and eye. Involuntary muscle is found in the
alimentary tract from the middle third of the esophagus
271
MEDICAL RECORD.
to the anus, in the ducts of glands, jn the trachea and
bronchial tubes, within the eyeball, the internal urinary and
genital systems, circulatory (except the heart) and
lymphatic systems, and the capsules of some organs.
By muscular co-ordination is meant the harmonious ac-
tion of individual muscles in a complicated muscular ac-
tion. It is controlled by centers in the cerebellum.
Fatigue is caused by: (i) The consumption of those
substances (particularly carbohydrates) which supply the
muscle with energy; (2) the accumulation of the waste
products of contraction, particularly sarco-lactic acid and
carbon dioxide.
6. Respiratory function. "Respiration is the process by
which oxygen is absorbed into the blood and carbon dioxide
exhaled. The assimilation of the oxygen and the evolution
of carbon dioxide takes place in the tissues as a part of
the general nutritive process, the blood and respiratory
apparatus constituting the media by means of which the
interchange of gases is accomplished."
Residual air is the air which remains in the lungs after
every effort has been made to empty them; it is equal to
about 100 cubic inches.
Vital capacity is the amount of air which can be expelled
from the lungs after the deepest possible inspiration; it is
the sum of the complemental, tidal, and supplemental air,
and is about 225 to 250 cubic inches.
7. Blood. Composition: Plasma and corpuscles. The
plasma consists of water and solids (proteids, extractives,
and inorganic salts). The red corpuscles consist of water
and solids (hemoglobin, proteids, fat, and inorganic salts).
The white corpuscles consist of water and solids (proteid,
leuconuclein, lecithin, histon, etc.). There are also plate-
lets^ which are very small, colorless, irregular shaped
bodies, about one- fourth the size of the red corpuscle.
Specific gravity: 1055 to 1062. Reaction: Alkaline.
Amount in body: About one-thirteenth of the body weight.
Time required for a complete circulation: About 23 sec-
onds.
MATERIA MEDICA AND THERAPEUTICS.
i. A solvent is a liquid which holds another substance in
solution. Three principal solvents: Water, alcohol, and
glycerine.
2. Diaphoresis is the process of perspiring. Three diaph-
oretics: Spirit of nitrous ether, dose 30 minims; Dover's
powder, dose 7 grains; alcohol, dose of whiskey, 2 ounces,
diluted.
3. Two cardiac stimulants: Aromatic spirit of ammonia,
dose 30 minims ; nitroglycerine, dose 1 minim.
4. Iodine is most frequently administered internally as
272
INDIANA.
the iodide of potassium or sodium. Starch is the antidote
to free iodine.
5. The indiscriminate use of acetanilide may cause : Col-
lapse, chills, cyanosis, fatty degeneration of heart, liver, and
kidneys, and destroys the hemoglobin-carrying efficiency of
the red blood corpuscles.
6. The dosage of medicines is influenced by : Age,
sex, weight, nationality or race, disease, pain, idiosyncrasy,
body temperature, drug habits, method of administration,
and the cumulative action of the drug.
7. Cumulative action is the property which some drugs
have of producing more or less sudden and violent action,
after single and successive doses have been taken with no
untoward effect. Example: Digitalis; this produces fast
and irregular pulse, gastroenteritis, small pulse, low blood
pressure.
8. Three antiseptics useful for internal medication: Uro-
tropin, salol, and thymol.
Urotropin is a white, crystalline powder, soluble in water,
prepared by the action of ammonia on formic aldehyde. It
is usef as a genitourinary antiseptic.
Salol is the salicylic ether of phenol ; it is a white, crys-
talline powder, nearly insoluble in water, but is very soluble
in ether. It is used as an intestinal antiseptic, owing to its
power of splitting up (in an alkaline medium) into salicylic
acid and phenol.
Thymol is a phenol contained in oil of thyme; it occurs
in large crystals, of aromatic odor; it is soluble in fats
and oils; and liquefies when treated with chloral or cam-
phor.
9. Three indications for use of opium: To relieve pain,
to produce sleep, and to check excessive secretion.
10. Hypodermoclysis "is a method of applying remedial
agents through the skin. As a rule, 0.6 per cent, normal
salt solution is used — a dram of table salt to a pint of
boiled and filtered water. The site preferred is the ante-
rior wall of the abdomen or the ilio-lumbar region, above
the ilium and below the ribs. Thorough asepsis is neces-
sary in the technique. An ordinary fountain syringe with
a moderate sized needle is all that is required. The solu-
tion is best used at a temperature of from no° to 115 F.,
and from four to eight ounces are employed. The method
is extremely useful in conditions of shock, hemorrhage,
diarrhea, uremia and in toxic states generally." (Butler's
Materia Medica, etc.)
CHEMISTRY.
1. Yeast fermentation of sugar produces alcohol
(GHbOH) and carbon dioxide (C0 2 ).
273
MEDICAL RECORD.
Cane sugar, under the influence of yeast, is slowly con-
verted into dextrose and levulose, which are then fermented
to alcohol and carbon dioxide.
Milk sugar is first inverted by yeast, and then alcohol is
formed; this occurs slowly.
Grape sugar, under the influence of yeast, is converted
into alcohol and carbon dioxide.
2. The fixed oils are glycerides, and are capable of
saponification. The volatile oils art mostly hydrocarbons,
and are not subject to the same decompositions as the
glycerides.
Three fixed oils used in medicine: Castor oil, glycerine
and oleic acid.
Three volatile oils used in medicine: Oil of peppermint,
oil of anise, oil of cinnamon, and oil of gaultheria.
3. Ammonia gas. The molecule consists of three atoms
of hydrogen chemically united to one atom of nitrogen,
NH 8 . It is a colorless gas, with a pungent and irritating
odor and a caustic taste; it is very soluble in water, also
in alcohol; it does not burn ^ readily. It combines with
water to form an alkaline liquid containing ammonium hy-
droxide. It combines directly with acids, without separa-
tion of hydrogen, to form ammonium salts:
NH 3 + HC1 = NH 4 C1.
4. Cow's milk consists of :
Water 87.00
Solids 13.00
Fat 366
Milk sugar 4.92
Casein 3.01
Albumin 0.75
Proteins 3.76
Ash ...0.70
5. Urea. Chemical formula: CO(NH 2 ) 2 . About 500
grains of urea are excreted daily by an average adult.
PHYSICAL DIAGNOSIS.
1. Physical signs of aneurysm of the thoracic aorta:
Sometimes a bulging in the precordial region, visible pulsa-
tion, with a thrill on palpation, localized dulness on percus-
sion, and a "bruit" on auscultation. One radial pulse may
show diminished volume and irregular rhythm. There may
be tracheal tugging.
2. Cardinal symptoms in diagnosis of appendicitis: Pain,
beginning near the umbilicus, and settling in right iliac
fossa, near McBurney's point; rigidity of right rectus
muscle; tenderness on pressure over McBurney's point;
nausea or vomiting ; obstruction to passage of feces or gas.
3. Topography of heart and its valves. A line from
274
INDIANA.
the lower border of the second left costal cartilage (one
inch from sternum) to upper border of third right costal
cartilage represents the base line; the right side will be a
line drawn from right side of upper limit to seventh
right chondrosternal articulation; the lower limit is a line
from this last point to the apex (in fifth intercostal space,
three and one-half inches from mid-line) ; the left side,
from left end of upper border to left of apex. The valves
are: Aortic, mitral, tricuspid, pulmonary (and Eustachian
and coronary).
The aortic valves are behind the third intercostal space,
close to the left side of the sternum. Pulmonary valves,
in front of the aortic, behind the junction of the third rib,
on the left side, with the sternum. Tricuspid valves, be-
hind the middle of the sternum, about the level of the
fourth costal cartilage. Mitral valves behind the third in-
tercostal space, about one inch to the left of the sternum.
4. Normal temperature of the body is 98.6 F. Normal
pulse rate is about 16 to 18 per minute.
5. Arteriosclerosis.
PATHOLOGY AND BACTERIOLOGY.
i. Intoxication and infection. "In one class of diseases
the infecting microbe remains localized at the point of
inoculation, and is never or only exceptionally found in
the fluids of the body, the general symptoms of the disease
being due to absorption of the toxic products. Such are
true Intoxications. In other cases the microbe is found
circulating in the blood throughout the body and finds
lodgment in most of the organs. These are called Infec-
tions. Tetanus is the type of the first class; anthrax, of
the second." (Stengel's Pathology.)
2. Phagocytosis is the property of certain cells (such
as some of the white corpuscles) to ingest and destroy bac-
teria. Metchnikoff believes that immunity is due to the
chemotaxis which exists between the phagocytic cells and
microorganisms.
3. "Thrombosis of the portal vein is most frequently the
result of infective inflammation of the vein (pylephlebitis),
resulting from ulcerative enteritis, appendicitis, or similar
processes involving the parts from which the portal blood
is received." — (Stengel's Pathology.)
4. Chronic gastritis ^ is most frequently the result of
improper food (including alcoholic drinks).
5. Pathological conditions of the lymphatic glands: In-
flammation, tuberculosis, syphilis, tumors, Hodgkin's dis-
ease, leukemia, lymphosarcoma, status lymphaticus, atrophy,
hypertrophy, and degenerations.
6. To demonstrate the amaba coli in a case of amebic
dysentery: "A satisfactory recognition of the parasite,
275
MEDICAL RECORD.
particularly in the hands of the novice, demands that he
should see it send out pseudopodia; he should observe
active movement. In order to do this, the material should
be reasonably fresh. In the case of feces admixture with
urine is to be avoided. A drop of the suspected material is
placed upon a slide and a cover-glass applied. The slide
may be gently warmed, or the microscope may be kept in
a reasonably warm place, under which conditions move-
ment will be more active. Fresh specimens may be best
stained by mixing with the suspected material, placed upon
a slide, a drop of a watery solution of toluidin blue. This
reagent acts as a fixative and at the same time stains the
amebas intensely and rapidly." — (Coplin's Pathology.)
7. To demonstrate the efficiency of a germicide: "Koch's
original method of determining this was to dry the micro-
organisms upon sterile threads of linen or silk, and then
soak them for varying lengths of time in the germicidal
solution. After the bath in the reagent the threads were
washed in clean, sterile water, transferred to fresh culture
media, and their growth or failure *to grow observed.
This method also determines the time in which a certain
solution will kiil microorganisms, so is advantageous."
(Macfarland's Bacteriology.)
8. The Widal reaction: "Three drops of blood are taken
from the well-washed aseptic finger tip or lobe of the ear,
and each lies by itself on a sterile slide, passed through
a flame and cooled just before use; this slide may be
wrapped in cotton and transported for examination at the
laboratory. Here one drop is mixed with a large drop of
sterile water, toredissolve it. A drop from the summit
of this is then mixed with six drops of fresh broth culture
of the bacillus (not over twenty-four hours old) on a
sterile slide. From this a small drop of mingled culture
and blood is placed in the middle of a sterile cover-glass,
and this is inverted over a sterile hollow-ground slide and
examined. ... A positive reaction is obtained when all
the bacilli present gather in one or two masses or clumps,
and cease their rapid movement inside of twenty minutes/'
(From Thayer's Pathology.)
9. Bacteria most frequently causing puerperal infection
are: Streptococcus pyogenes, staphylococcus pyogenes au-
reus, gonococcus, bacillus coli communis, bacillus diphthe-
ria, bacillus aerogenes capsulatus, bacillus typhosus.
ETIOLOGY AND HYGIENE.
I. Malaria, is caused by the Plasmodium malariae, but
carried by the anopheles mosquito. The cause of yellow
fever is not yet determined, but it is carried by the stego-
myia mosquito.
Prophylaxis of malarial fever. Individuals should use
276
INDIANA.
mosquito netting around their beds and wire gauze in doors
and windows so as to keep out the mosquitos as much as
possible. During residence in malarial districts quinine
should be taken every morning before breakfast. All
pools, stagnant water, etc., where anopheles may breed,
skould be removed. All mosquitos, larvae, etc., should be
destroyed as far as possible. By staying indoors during
dusk and darkness, opportunities for infection may be
avoided. Occasional fumigation with formaldehyde or sul-
phur is also efficacious.
To prevent yellow fever in the tropics: All cases of
the disease should be isolated; houses should be protected
by mosquito netting; mosquitos should be killed; swamps
should be drained.
2. Impurities in water may be classified as: (i) Mineral,
(2) vegetable, and (3) animal. The presence of organic
matter is deleterious, because it may indicate fecal matter,
with pathogenic bacteria. The processes employed for
the detection of the various impurities are too lengthy for
description here, and also too technical and complicated
for use by the practising physician.
3. How antitoxin produces immunity and effects cure is
not known, but theories deduced from observed facts are
as follows : "As the various pathogenic bacteria produce
the causative toxins of their respective diseases, so the
organic cells of the body, reacting under the stimulus of
the poisons thus introduced, immediately proceed to elab-
orate defensive bodies, which if produced in sufficient
quantities will neutralize the effects of the toxins. Residual
antibodies remaining in the blood after recovery render
the animal immune for a time against the disease. The
immunizing and curative effects obtained by the injection
of the blood serum of an immunized animal into the
circulation of another animal are due either to direct
chemical neutralization of the toxins themselves by the
antibodies so introduced (Behring, Kitasato), or to a par-
ticular influence exerted by the antibodies upon the living
cells of the organism which, being affected in two opposite
directions, remain neutral to the disease (Buchner). Some
authorities hold that these results are due to the conjoint
action of leucocytic and chemical forces. Ehrlich's side-
chain theory assumes that every toxin contains toxophore
molecules having direct toxic action, and haptophore mole-
cules which combine the toxophores with a similar com-
bining group of molecules in the tissue cell of the attacked
organism. The tissue cell molecules being destroyed by
the toxophores, a rapid and profuse regeneration of similar
molecules occurs in side chains, and. these molecules over-
growing are carried into the circulation, becoming the
277
MEDICAL RECORD.
antitoxin, which acts by combining with the haptophores
of newly arrived toxin, using up their combining power
before they can reach the tissue cells." (Potter's Materia
Medica, etc.)
4. Infantile ^ paralysis is believed to be infectious, but
the specific microorganism is not yet demonstrated. Quar-
antine, as for any other infectious disease, affords the best
way of protecting the community.
5. Hepatic abscess is caused by: Microbes, ameba coli,
parasites, biliary calculi, cholangitis, traumatism, and em-
bolism, septic processes of circulatory or digestive tract.
Cardiac hypertrophy is caused by: Arteriosclerosis, neph-
ritis, prolonged muscular exertion, exophthalmic goiter,
aortic disease, mitral regurgitation. Edema of the lungs is
caused by : Infections, nephritis, arteriosclerosis, some car-
diac lesions, pregnancy, and alcoholic excesses.
1. PRACTICE.
Incubation
Prodromes
Character of erup-
tion.
Parts first affected
Desquamation
Duration
Complications and
sequels.
MEASLES.
10 days.
3 days. Coryza,
cough, etc. Kop-
lik's spots.
Bluish papules;
swelling of face;
discrete or con-
fluent circular
outlines.
Forehead, face, or
neck.
Furfuraceous
7 to 10 days
Eye and lungs ;
tuberculosis.
SMALLPOX.
12 days.
3 days. Rigor, high
fever, headache,
lumbar pains.
Macules, papules,
vesicles, and
pustules ; d i s -
crete or conflu-
ent.
Forehead.
Large crusts.
3 weeks.
Larynx and lungs.
MYALGIA.
Skin is normal.
Pain is increased by mus-
cular contractions.
No skin eruptions.
NEURALGIA.
Skin may be inflamed.
Pain is increased by pres-
sure.
Frequently skin eruptions
are present.
3. Principal forms of insanity: Mania, melancholia, para-
noia, idiocy, imbecility, paresis, dementia, delirium. Most
common causes: Heredity, civilization, alcohol, syphilis,
narcotic drugs, severe mental strains, depressing emotions,
shock, trauma, autotoxemia, organic brain diseases.
278
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279
MEDICAL RECORD.
5. Average duration of the febrile stage, in typhoid
fever, is about three or four weeks; of scarlet fever, is
about five or six days; of measles, is about five days; of
rheumatic fever, is about one or two weeks; of pneumo-
nia, is about nine or ten days.
6. Lightning pains, loss of knee-jerk, Argyll-Robertson
pupil, optic atrophy and ptosis, gastric and other crises,
ataxia, incoordination, and Romberg's sign.
7. Hysteria. The following summary of diagnosis is
given by Anders and Boston: "A peculiar mental and
physical condition, characterized by suggestibility of symp-
toms which may be of any character. The patient is usually
a young adult who is emotional, irritable, and one who
constantly complains and thinks of herself, and perverts
everything which may occur as having something to do
with her own condition. There may be headache, back-
ache, pains in various portions of the limbs, numbness or
pin-and-needle-like sensations, hemianesthesia or anesthe-
sia anywhere, points of tenderness in the back, ovarian and
mammary region, increases of reflexes, paralyses of va-
rious sorts, contractures, tremors, disturbance of vision,
smell, and taste, and convulsive attacks which may assume
almost any character. The most important point of all is
the suggestibility of all the symptoms, their variance from
day to day, and the fact that any or all may be removed
by persuasion."
8. The early manifestations of pulmonary tuberculosis
are: (1) Physical signs: Deficient chest expansion, the
phthisical chest, slight dullness or impaired resonance over
one apex, fine moist rales at end of inspiration, expiration
prolonged or high pitched, breathing interrupted. (2)
Symptoms: General weakness, lassitude, dyspnea on exer-
tion, pallor, anorexia, loss of weight, slight fever, and
night sweats, hemoptysis.
The treatment consists of : Plenty of fresh air, sunshine,
and sunlight, pure water, good food, exercise in modera-
tion, and proper hygiene in general.
9. Scarlet fever, measles, and typhus fever.
10. Tonsillitis.
OBSTETRICS.
1. Impregnation is the result of the meeting of a live
and healthy spermatozoon, with a live and healthy ovum,
in a suitable medium (generally the Fallopian tube). Dur-
ing coitus the seminal fluid is ejected into the^upper part
of the vagina and against^ the cervix of the uterus ; the
spermatozoa enter the uterine cavity (either by the suction
of the uterus or by their own vibratile motion) and so
pass on to the Fallopian tube.
280
INDIANA.
2. Development of the fertilised ovum, "(i) When the
ovum is mature, two small cells are detached from the
main body of cells ; these are called polar globules. It was
formerly supposed that these were associated with the dis-
appearance of the germinal vesicle, but recent experiments
have demonstrated that the germinal vesicle plays an active
part in their formation. This can take place independently
of fecundation. (2) The portion of the ovum remaining
after the throwing off of the polar globules is called the
'female pronucleus/ (3) Fecundation is effected by the
penetration of the head of one spermatozoon. This is
called the 'male pronucleus/ (4) The male and female
pronucleus coalesce. The ovum is now called the oosperm,
or blastosphere. (5) The segmentation of the nucleus and
vitellus, i.e. they both split into two masses, these into
four, and so on until a large number of segments are
formed. This is known as the morula, moriform body,
or mulberry mass. (6) A clear fluid is secreted within
the ovum, which presses these segments to the surface of
the ovum, where they form a double layer of cells, differing
somewhat in size. The outer and larger is termed the
epiblast or ectoderm, and the inner and smaller the hypo-
blast or endoderm. Together they are known as the blas-
todermic vesicle. (7) There then appears upon the outside
of the vitellus a small oval elevation, surrounded by a de-
pression, which is called the area germinativa. (8) There
appears in the area germinativa a small, dark line called the
primitive trace. About this line will be grouped the va-
rious parts of the embryo, the rest of the ovum serving
only as a covering and for nutriment. (9) A covering for
this trace or embryo is now formed. Thus far the vitelline
membrane has been sufficient. The embryonic line sinks
into the center of the ovum, while the edges of the exter-
nal blastodermic layer about the area close around it, in-
closing it in a sac called the amnion. Between the amnion
and the embryo, fluid at a later period is deposited; this
constitutes the liquor amnii. The vitelline membrane then
disappears/' — ( Landis's Obstetrics. )
3. Meconium is the name given to the stools of the new-
born (or unborn) infant; they are of a green-black color,
and are composed of intestinal mucus, bile, epithelial cells,
cholesterin, vernix caseosa and phosphates. The continu-
ous passage of meconium from the vagina of the parturi-
ent woman during labor indicates a breech presentation.
Its discharge in undoubted head or transverse presenta-
tions is indicative of impending or actual death of the
fetus.
4. In the nulliparous adult the uterus is about three
inches long, about two inches wide at the upper part, and
281
MEDICAL RECORD.
about one inch thick. It is pear-shaped, and lies between
the rectum behind and the bladder in front; it is below
the abdominal cavity and above the vagina. Its position
is one of slight anteflexion, with its long axis at right
angles to the long axis of the vagina. The anterior sur-
face of its body rests on the bladder, and the cervix points
backward toward the coccyx. The uterus is not fixed, but
moves freely within certain limits. It is held in place by
ligaments — broad ligaments, round ligaments, vesicouter-
ine, rectouterine, ovarian, and uterosacral. The arteries are
the uterine and ovarian ; the nerves are from the uterovagi-
nal plexus, the hypogastric plexus, and the vesical
plexus.
5. The vitellus is the yolk or germinal part of the ovum
together with the substance intended for the nutrition of
the embryo. The allantois is a fetal membrane developing
from the lower part of the alimentary canal very early in.
fetal life; it enters into the formation of the urinary blad-
der and also of the umbilical cord and placenta.
The amnion is the innermost of the fetal membranes ; it
surrounds the fetus and is continuous with it at the um-
bilicus; it secretes the liquor amnii, and forms the sheath
of the umbilical cord.
6. A woman usually menstruates about two or three
months after her confinement if she is not nursing her
child, and about seven months after the confinement if she
is nursing her child.
7. Causes of sterility: Gonorrhea, absence or errors in
development of any part of the genital tract, malforma-
tions of genitals, fistulae, lacerations, obesity, alcoholism,
pelvic inflammations, dyspareunia, inflammations of
uterus, tubes, or ovaries, elongated cervix. The above
all refer to the female, but the trouble may be with the
male.
8. Climate, race, occupation, and mode of life.
9. It is not proved that maternal impressions will pro-
duce marks, defects and abnormalities in the fetus. Some
coincidences have been observed.
10. Crede's method of prophylaxis consists in cleansing
the eyes with warm sterile water, and then instilling into
each eye a few drops of a two per cent solution of nitrate
of silver. The eyes should be treated in this way two or
three times a day so long as there is any danger of con-
tracting ophthalmia.
GYNECOLOGY.
1. In cystocele, part of the bladder projects into the an-
terior vaginal wall, and a sound passed through the urethra
into the bladder can be freely felt through the anterior
vaginal wall; further, it may be impossible to empty
282
INDIANA.
the bladder without pushing up the anterior vaginal
wall.
In vaginal hernia, the bladder is not involved, the hernia
will contain intestine or omentum or both, there may be an
impulse on coughing.
In a vaginal tumor there will be none of the positive
symptoms of the two other conditions.
2. Prolapse of the uterus is the condition in which the
uterus lies low down in the vagina, but does not protrude
through the vagina.
Differential diagnosis: In the case of polypus the body
and fundus of the uterus are in their normal position in
the abdomen, a sound can be passed into the uterus, the
uterine and cervical canals are not obliterated, the polypus
does not bleed easily, and is not particularly sensible to
pain. The inverted uterus: shows absence of body and
fundus from normal position, will not permit passage of
a sound into uterine cavity, the uterine and cervical canals
are absent, the inverted uterus tends to bleed easily, and is
very sensible to pain. In prolapse the largest part of the
tumor is above; the opening of the Fallopian tubes cannot
be seen; a sound can be passed into the uterine cavity.
Treatment: The uterus should be replaced; the vagina
packed with a tampon; a pessary or colpeurynter may be
employed ; where the round ligaments are relaxed Alexan-
der's operation may be performed.
3. Menorrhagia is an excessive hemorrhage from the
uterus at the ordinary menstrual periods.
Amenorrhea is absence of menstruation.
Dysmenorrhea is unduly painful menstruation.
4. Gonorrheal vaginitis. Symptoms: Pain and burning
in the vulva; pain and burning on micturition; dyspareu-
nia; yellowish or greenish discharge, in which the gono-
coccus can be found; the vagina is hot, red, swollen, and
tender. Differential diagnosis is made by the rinding of
the gonococci. Treatment: Rest in bed, salines, mild un-
irritating diet, bathing of external genitals, copious vaginal
douches of bichloride of mercury 1 :2000 three or four
times a day; later, the vagina may be swabbed daily with
a solution of nitrate of silver 1 to 5 per cent., or with a
solution of potassium permanganate 1 per cent. Complica-
tions: Cystitis, urethritis, vulvitis, endometritis, salpingitis,
septic peritonitis, sterility, condylomata of vulva, abscess
of Bartholin's glands.
5. Abdominal hysterectomy. "The patient must be care-
fully prepared as for any other abdominal operation, but in
addition the pubes and vulva must be shaved and thor-
oughly purified ; the vagina should be douched for some
283
MEDICAL RECORD.
days previously, and an antiseptic dressing worn, and if
need be the uterine canal should be curetted and disin-
fected with some powerful antiseptic.
"After anesthesia has been induced the Trendelenburg
position is adopted, and an incision of suitable length made
in the median line. The parts are then carefully explored,
and if no adhesions exist an abdominal cloth is packed in
over the intestines in order to protect and keep them from
exposure and injury. If adhesions to omentum or gut are
present they must be carefully divided; it is, of course,
most desirable that a complete peritoneal covering should
be secured for any adherent organs; omental grafts may
be sometimes useful in this direction. The broad liga-
ments are then examined, and a decision made as to
whether or not the ovaries and tubes are to be saved.
"A pedicle needle carrying a sufficient length of well-
boiled silk is carried through the round ligament so as to
secure the ovarian artery and veins, and tied as far away
from the uterus as possible. A broad ligament clamp may
then be placed in position close to the uterus, so as to
prevent venous regurgitation, and the broad ligament is
divided half-way down. It is often possible and desirable
to pick up the divided end of the ovarian artery on the
face of this section and secure it separately, while the little
artery which accompanies the round ligament should also
be carefully secured. The ovarian artery on the other
side is next dealt with in a similar fashion. A transverse
cut is now made across the front of the uterus, involving
merely the serous membrane and connecting the two ends
of the incisions in the broad ligaments ; the peritoneum be-
low this transverse cut is detached, together with the blad-
der, from the cervix, and the intraligamentary space is
thereby opened up on either side. In this will be found the
uterine vessels, and it may be possible to see and isolate
the uterine artery before securing it by ligature. Care must
be taken in this part of the operation to keep close to the
uterus, as the ureter comes forward from behind under
the uterine artery to reach the bladder, lying about the
level of the os internum. The uterine vessels are in this
way carefully secured and divided.
"The uterus is now merely held by the connection be-
tween the vagina and cervix and the peritoneal reflection
in Douglas's pouch. If a supra-vaginal operation will suf-
fice, the surgeon cuts across the neck of the uterus in such
a way as to fashion two flaps, and finally the peritoneum
behind is divided. A few small vessels will probably need
to be secured on the face of the uterine stump. This
having been effected, the uterine flaps are stitched carefully
together so as to bury the open cervical canal; the uterine
284
INDIANA.
stump is then covered in by uniting the divided portions
of peritoneum. This line of sutures is carried up on either
side so as to secure the two layers of the broad ligament;
the final result is that the pelvic floor is covered in by a
continuous layer of peritoneum, showing a sutured in-
cision which runs transversely from one side to the other.
The usual peritoneal toilette follows, and the abdomen is
generally closed entirely, no drainage being required." —
(Rose and Carless' Surgery.)
6.
SHOCK.
i. Generally follows a
prolonged operation or one
in which the abdominal
viscera have been exposed
to the air or more or less
roughly handled; it is also
likely to occur in women
who are weak and ex-
hausted physically.
2. The patient is listless
and apathetic and there is
seldom any tendency to
toss about in the bed.
3. Seldom recurrent at-
tacks of syncope.
4. Pulse and general con-
dition not satisfactory im-
mediately after operation
and the symptoms of col-
lapse come on suddenly.
5. General stimulating
treatment tends to improve
the pulse.
6. The blood findings are
negative.
SECONDARY HEMORRHAGE.
i. May follow either a
severe or a simple opera-
tion; the general condition
of the patient does not in-
fluence its occurrence.
2. The patient is restless
and her mind apprehensive
and anxious.
3. Recurrent attacks of
syncope frequent.
4. The patient recovers
from the anesthetic in a
good condition, but later on
the pulse gradually becomes
accelerated, the tempera-
ture falls below normal,
and collapse finally inter-
venes.
5. The pulse progressive-
ly grows worse despite all
that is done to stimulate
the heart and secure re-
action.
6. There is a moderate
leukocytosis (15,000 to 25,-
000) ; the number of red
cells and the percentage of
hemoglobin are diminished
(Martin and Hare) ; the
blood-plaques are increased
in number; and the coagu-
lation time of the blood is
more rapid.
285
(Ashton's Gynecology.)
MEDICAL RECORD.
SURGERY.
i. An odontoma is a tumor composed of tooth tissue.
Varieties: (i) Follicular odontomes, or dentigerous cysts,
generally arise from the follicles of the permanent molars.
(2) Fibrous odontomes, due to thickening of the tooth-
sac (3) Cementome, due to enlargement and ossification
of the capsule. (4) Compound follicular odontome, from
the capsule. (5) Redicular odontome, from the papilla.
(6) Composite odontome, from dentine, cement, and
enamel.
2. A cervical rib may not give any signs or symptoms;
when such are present they are due to pressure on brachial
plexus or some blood-vessel. It may cause subclavian
aneurysm, neuritis, or gangrene of hand. There may be
pain, weakness of the arm, trophic disturbances, or oblitera-
tion of the pulse. The .r-rays confirm the diagnosis.
3. Coxa vara is a condition in which the neck of the
femur is bent downwards so that the angle between the
neck and shaft of femur is lessened; the hip joint is
healthy. Causes: Rickets, impacted fracture of neck of
femur, slipping of the epiphysis, and atrophy of the neck
of the femur, with osteoarthritis.
4. Varieties of spina bifida: (1) Myelocele, in which the
central canal of the spinal cord lies open on the skin sur-
face of the body (incompatible with life). (2) Syringo-
myelocele, in which the central canal is dilated, so that a
portion of the spinal cord is spread out over the interior
of the sac. (3) Meningomyelocele, in which the meninges
remain adherent to the skin, fluid collects within them,
and the spinal cord and nerves run down the posterior part
of the sac. (4) Meningocele, which is a protrusion of
the membranes containing cerebrospinal fluid but neither
nerves^ nor spinal cord. (5) Spina bifida occulta, in which
there is no tumor except perhaps a lipoma or a dermoid
with hair.
5. Tabetic arthropathy, or an osteoarthritis.
The joint signs are: "(1) Very rapid and painless onset
usually occurs. (2) A great synovial distention is the first
feature. (3) All the signs of osteoarthritis, viz., enlarge-
ment of the bone ends, clipping of articular margins
coarse grating, quickly follow. (4) Marked absorption oi
bone, with consequent shortening or deformity. (5) Mas-
sive heaping up of new bone as an outgrowth round the
articular margins, in the hypertrophic varieties. (6) Dis-
organization or dislocation of the joint from a yielding
of the ligaments and destruction of the joint surfaces.
(7) Absence of all pain or tenderness is a conspicuous
and characteristic feature." — (Synopsis of Surgery.)
286
INDIANA.
6. In middle meningeal hemorrhage trephining is often
of value because the hemorrhage may be located, the clot
turned out, and the artery ligated. It is often difficult
to know exactly where to trephine, for the main hemor-
rhage often occurs not at the point of application of the
injury, but on the other side of the cranium.
7. In epithelioma of the lower lip there should be
thorough and early excision; incisions should be at least
half an inch from the tumor. The glands in the submaxil-
lary and submental triangle should also be removed.
Dowd's operation is recommended.
8. In ulcer of the duodenum the symptoms are very simi-
lar to those found in ulcer of the stomach; but in the
former condition there is less tendency to vomit, the pain
does not come on till some time ofter food has been
swallowed (and has had time to pass the pylorus), and
blood in the stools is more common. All of these points
are due to physiological and anatomical reasons based on
the relative position of the stomach and duodenum. A
special sign of duodenal ulceration is the so-called "hunger
pain" which occurs at the end of digestion, when the un-
mixed acid of the gastric juice is passing into the duode-
num. This pain is relieved by taking food, for when
this occurs the pylorus closes, and the gastric juice is
for the time retained in the stomach to be mixed with the
food, while the alkaline duodenal and pancreatic secre-
tions are stimulated.
9. Contraindications to surgery in gallstone in the com-
mon duct: (1) Obstructive jaundice, because operation is
then dangerous, owing to the possibility of fatal oozing of
blood. (2) In non-patency of the common duct.
10. A ranula is a cyst under the tongue, due to dilata-
tion of one of the sublingual ducts.
PEDIATRICS.
1. Poliomyelitis. Symptoms: "The onset of the affec-
tion varies; it may be acute, subacute, or chronic; it is
usually sudden, with an attack of mild fever of a remit-
tent type, of a few days' duration, on recovery from which
it is noticed that the child is paralyzed. Rarely the paraly-
sis may be preceded by convulsions. The paralysis may
affect both arms and both legs, the legs alone, or only one
of the four extremities; it may, very rarely, be a hemi-
plegia. As a rule, however, the leg suffers more fre-
quently than the arm; in paralysis of the leg the muscles
below the knee suffer more severely than those above. The
bladder and rectum are not affected, or, if so, only tem-
porarily, and anesthesia or numbness cannot be detected.
The temperature of the paralyzed limb is low and the
287
MEDICAL RECORD.
part is cyanosed in appearance. After a few days there
is a slight improvement in the paralyzed parts, although
the muscles show a rapid wasting, which is progressive
until all muscular tissue is gone. The reflex movements
are impaired or abolished. The electro-contractility by the
faradic current is abolished in the paralyzed parts. With
the galvanic or constant current the 'reactions of de-
generation* are developed." — (Hughes' Practice of Medi-
cine,)
Treatment: "During the febrile stage the patient should
be placed at rest in bed and all the secretions rendered
free. If the affection is suspected at this period the limbs
should be wrapped in cotton-wool and ergot administered
to lessen the spinal congestion. Counterirritation is un-
necessary. As soon as the febrile reaction has subsided
and the paralysis becomes manifest the child should be
well fed and taken outdoors once daily. Gentle friction
should be applied to the affected muscles at first, followed
later by the hot spinal douche and mild galvanism. In-
ternally, quinine, belladonna, ergot, and potassium iodide
may be of value. Later, as improvement takes place,
tincture of nux vomica, 11#i to iii, three times daily, or
hypodermic injections of strychnine sulphate, gr. i/ioo to
1/16, according to the age, twice a week, and faradism
to the paralyzed muscles, are to be used. Means should
be taken to prevent deformities." — (Hughes' Practice of
Medicine.)
2. Dysentery. Cause: The Bacillus dy sentence. Treat-
ment: Rest in bed, a dose of salts, castor oil, with lauda-
num, irrigation of the colon, liquid diet, ipecac, and serum
treatment.
OPHTHALMOLOGY AND OTOLOGY.
i. Glaucoma is a diseased condition of the eye, produced
by increased intraocular pressure, and resulting in exca-
vation and atrophy of the optic disc, and blindness. It is
due to increase of the contents of the eye, hypersecretion,
retention, old age, gout, rheumatism, nephritis. Symptoms:
Visual disturbances, increased ocular tension, hazy and
anesthetic cornea, sluggish and dilated pupil, shallow an-
terior chamber, ciliary neuralgia, cupping of optic disc,
blindness. Treatment: Miotics, such as eserine or pilo-
carpine ; massage of the eyeball ; mydriatics are contrain-
dicated; operative treatment may include paracentesis,
iridectomy, or sclerotomy.
2. Phlyctenular keratitis "is usually associated with phlyc-
tenular conjunctivitis in children of scrofulous diathesis,
but may occur in others. It is characterized by one or
more small cysts found on the limbus of the conjunctiva
288
INDIANA.
and extending upon the cornea. The symptoms are acute
pain, photophobia, lacrimation, and the characteristic bun-
dle of vessels, with a yellow crescent at the apex, its con-
cavity toward the apex. Blepharospasm is present and may
be severe. The treatment consists of good food, fresh air,
and the administration of tonics and stimulants. Locally,
atropin and warm compresses should be used, and the eye
douched with mercuric chlorid solution 1:8000. Later,
iodoform or calomel may be dusted in the eye and mas-
sage with the yellow salve may be practised. Absorption
of the vessels may be hastened by the instillation of eserin,
dusting with iodoform, and the application of a binder." —
(Gould and Pyle's Pocket Cyclopedia.)
3. The acoustic nerve has its superficial origin between
the pons and restif orm body, the floor of the fourth
ventricle, by the linear transversa?. Its deep origin is from
the lateral angle of the fourth ventricle and from the inner
auditory nucleus. At the bottom of the internal auditory
meatus it divides into the cochlear and vestibular nerves.
The cochlear supplies the cochlea and posterior semicircular
canal ; the vestibular supplies the vestibule and superior and
external semicircular canals.
MEDICAL JURISPRUDENCE.
i. A physician is not at all bound to accept a professional
call ; but if he accepts he is bound to continue in attendance
until the patient no longer requires his services, or he is
discharged. He can leave during the continuance of the
condition for which he was called only after giving ample
notice of his intention to discontinue his services, and
allowing a reasonable time for the patient^ to obtain the
services of another physician. The physician undertakes
to use proper skill, care, and judgment in diagnosing and
treating the case, and also to give full instructions as to
how the patient may be best cared for. The patient under-
takes to allow the physician ample opportunities to make
his diagnosis, to give him alt information in his power,
to obey instructions, and to pay a proper fee. The physi-
cian is not allowed to divulge anything that he learned
while in professional attendance, provided such knowledge
was necessary to the successful conduct of the case.
Malpractice is a failure on the part of the medical practi-
tioner to use such skill, care, and judgment in the treatment
of a patient as the law requires; and thereby the patient
suffers damage. If due to negligence only, it is civil mal-
practice. But if done deliberately, or wrongfully, or if
gross carelessness or neglect have been shown, or if some
illegal operation (such as criminal abortion) be performed,
it is criminal malpractice.
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MEDICAL RECORD.
2. The following, which admirably answers this question,
is from Witthaus and Becker's "Medical Jurisprudence" :
(i) A physician should refuse to testify as an expert
unless he is conscious that he is really qualified as an ex-
pert
(2) After accepting the responsibility, his first duty
should be to make a diligent examination and preparation
for his testimony, unless it be upon a subject with which
he is familiar, and which he is satisfied that he has already
exhausted, by reading the best authorities that he can find,
and by careful reflection upon particular questions as to
which his opinion will be asked.
(3) Where he is to make an examination of facts, such
as the post-mortem examination of a body, a chemical
analysis, or an examination of an alleged insane person,
he should insist upon having plenty of time and full op-
portunity for^ doing his work thoroughly. He should take
particular pains to make his examination open and fair,
and, if possible, should invite opposing experts to cooperate
with him in it.
(4) He should be honest with his client before the trial
in advising him and giving him opinions, and upon the trial
should observe an absolutely impartial attitude, concealing
nothing, perverting nothing, exaggerating nothing.
(5) On the preliminary examination as to his qualifica-
tions as a witness, he should be frank and open in answer-
ing questions. He should state fully the extent and the
limits of his personal experience and of his reading upon
the subject, without shrinking from responsibility, yet with-
out self-glorification.
(6) He should be simple, plain, and clear in his state-
ment of scientific facts and principles, avoiding the use of
technical language, and trying to put his ideas in such form
that they will be grasped and comprehended by men ot
ordinary education and intelligence.
(7) He should avoid stating any conclusions or princi-
ples of which he is not certain, but having an assurano
that he is right he should be firm and positive. He should
admit the limitations of his knowledge and ability. Where
a question is asked that he cannot answer, he should not
hesitate^ to say so, but he should refuse to be led outside
the subject of inquiry, and should confine his testimony tv'
those scientific questions which are really involved in the
case, or in his examination of the case.
(8) He should always bear in mind that at the close 01
his testimony an opportunity is usually given him to ex-
plain anything which he may be conscious of having saic
which requires explanation, and partial statements which
need a qualification to make them a truth. This is the
290
KENTUCKY.
physician's opportunity to set himself right with the court
and with the jury. If the course of the examination has
been unsatisfactory to him, he can then, by a brief ant*
plain statement of the general points which he has intendeo
to convey by his testimony, sweep away all the confusion
and uncertainty arising from the long examination and
cross-examination, and can often succeed In producing foi
the first time the impression which he desires to produce :
and can present the scientific aspects of the case briefly and
correctly.
STATE BOARD EXAMINATION QUESTIONS.
Kentucky State Medical Board.
anatomy
1. (a) Describe the spinal cord, and (b) give its
length, weight, points of beginning and ending in the
spinal canal.
2. How many pairs of nerves are given off from the
spinal cord?
y 3. (a) Locate and describe Peyer's glands, and (6)
state where they are largest and most numerous.
4. What blood-vessels carry blood from the heart to
and from the lungs?
5. Give the origin and distribution of the great
sciatic nerve.
6. Describe the lymphatics of the liver.
7. Locate and describe the small intestine; state
where it begins, where it terminates, and name the
divisions.
8. Describe the esophagus, its structure, length, place
of beginning and termination.
9. Name, locate and describe the bones of the arm
and forearm.
10. (a) What bones form the pelvis, and (b) state
the difference between the false and true pelvis.
PHYSIOLOGY.
1. Describe the medulla oblongata and discuss its
functions.
2. Describe the digestion and assimilation of proteins.
3. Tell what you know of (a) the manufacture,
(6) functions and (c) final disposition of white blood
corpuscles.
4. Give in detail the functions of the kidneys.
5. Give the structure and functions of bone marrow.
6. (a) Discuss the essentials in the ventilation of a
291
MEDICAL RECORD.
school room, (6) a bed room, and (c) the dangers of,
and (d) tests for impure air.
7. (a) Differentiate between striated and non-stri-
ated muscles, (b) Give examples.
8. (a) Describe the sympathetic nervous system.
(6) Give its functions.
9. (a) Describe the development of the humerus.
(b) Of the temporal bone.
10. (a) Describe the most important vestibule of
the body, and (6) give its functions.
BACTERIOLOGY.
1. (a) Describe in detail the method of immunizing
a person against typhoid fever. (6) What is the dose
for a child weighing 50 pounds?
2. (a) Describe the Widal reaction, (b) Give its
value as a diagnostic symptom in typhoid fever.
3. (a) Describe the diphtheria organism; (6) its
staining characteristics, (c) Give method of detecting
diphtheria carriers.
4. Describe the organism of syphilis.
5. (a) Describe method of securing specimen for ex-
amination for malaria, (b) Differentiate the three va-
rieties of the malarial organism.
6. Differentiate the ova of (a) Ascaris lumbricoides,
(b) hookworm, (c) Oxyuris vermicularis.
7. How would you identify gonococci?
8. Give method of staining sputum for tubercle
bacilli.
9. Describe the tetanus bacillus.
10. Describe the meningococcus.
SURGERY.
1. (a) Differentiate between hydrocele, scrotal
hernia, and varicocele, (b) What treatment would you
advise in each?
2. How would you treat a compound, comminuted
fracture of the olecranon process?
3. (a) Differentiate between fracture of the vault
and base of the skull, (b) What treatment would you
advise in each?
4. (a) How would you diagnose an hypertrophied
prostate gland? (6) What treatment would you advise?
5. Differentiate between intestinal obstruction, acute
appendicitis and tubercular peritonitis.
PATHOLOGY.
1. (a) Describe healing by granulation. (6) To
what conditions does it lead?
292
KENTUCKY.
2. Give the pathology of a gangrenous, perforated
gall-bladder.
3. (a) Describe the gross appearance in pyosalpinx,
and (6) what is the usual infecting organism?
4. Name and describe three varieties of malignant
tumors.
5. (a) Describe bone necrosis, (b) What is a se-
questrum, (c) An involucrum?
SKIN, HYGIENE, MEDICAL JURISPRUDENCE, MENTAL AND
NERVOUS DISEASES.
1. Discuss and diagnose lupus vulgaris.
2. Discuss and diagnose psoriasis.
3. Name the varieties of eczema.
4. What are the conditions necessary for a model
sleeping room?
5. Give special hygienic conditions required for fac-
tories in which women and children are employed.
6. What would you say as to the fitness of water
for drinking purposes which contains nitrites and
nitrates?
7. (a) Name as many nuisances dangerous to health
as you can which are frequently found about cities.
(6) About country homes.
8. What principal measure would you use to prevent
the spread of the infectious diseases?
9. (a) What medico-legal complications might arise
due to an erroneous diagnosis of pregnancy? (6) How
would you avoid them?
10. Give the etiology of multiple neuritis.
OPHTHALMOLOGY, OTOLOGY, AND LARYNGOLOGY.
1. Give some of the conditions that would cause you
to advise iridectomy.
2. (a) What is a staphyloma? (b) Give cause.
3. Give cause and symptoms of chronic dacryocystitis.
4. (a) Diagnose a case of empyema of frontal sinus.
(b) How would you manage it?
5. (a) Define aphonia. (6) Give some of its causes.
6. Give etiology and symptoms of hyperemia of the
labyrinth.
7. (a) What are the usual causes of rupture of the
membrana tympani? (b) What symptoms would you
expect to follow?
8. What symptoms would lead you to make a diag-
nosis of acute circumscribed otitis?
9. What are the symptoms of postnasal adenoids?
(6) What means would you employ for relief?
10. (a) Under what conditions would you intubate?
(b) Give detailed technique.
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MEDICAL RECORD.
ETIOLOGY AND PHYSICAL DIAGNOSIS.
1. Give the etiology of vertigo.
2. What are most common causes of varicose ulcers
of the leg?
3. Give the etiology of rachitis.
4. Give the etiology of lung abscess.
5. Give the most probable etiological factors in the
causation of cholelithiasis.
6. Give the diagnosis of Grave's disease.
7. Give the diagnosis of psoriasis.
8. Give the diagnosis of spontaneous intracerebral
hemorrhage (apoplexy).
9. Describe the various kinds of pulmonary rales and
give the significance of each.
10. Give diagnosis of aortic regurgitation.
PRACTICE AND MATERIA MEDICA.
1. (a) Give etiology of acute lobar pneumonia in the
adult, with physical signs of the different stages. (6)
How many stages" of the disease, in order of occurrence?
(c) Give treatment for all. (d) What remedy is con-
sidered a specific by some authors?
2. (a) Name different kinds of pneumonia in chil-
dren, (b) Give diagnosis and treatment of each kind.
3. (a) Define hookworm disease. (6) Give causa-
tion, (c) Mode of infection, (d) Treatment. (e)
What new remedy have we, and how is it used?
(/) Does hookworm ever simulate other diseases, and
of so, what?
4. (a) Diagnose and treat acute indigestion, (b) If
at all, when would you administer opiates? (c) By
what method would you use them?
5. (a) Differentiate between acute and chronic ne-
phritis. (6) Differentiate between chronic interstitial
and parenchymatous nephritis, (c) Give treatment for
acute and chronic nephritis, both medical and dietetic.
6. (a) Discuss the use of radium as a therapeutic
agent. (6) In what diseases would you prescribe digi-
talis, and what precautions, if any, would you take in
its use?
7. (a) Do you know of any specifics in medicine?
(6) If any, name three of them, giving dose and indi-
cations for their use.
8. (a) How would you avoid salivation after giving
calomel? (6) What is the usual dose of calomel?
(c) Would you give the entire dose at once or divide it?
9. (a) How would you prepare a tasteless dose of
ca,stor oil? (6) How best give turpentine in typhoid
fever, if used for some time?
294
KENTUCKY.
10. Would you recommend any drug or drugs to dif
ferentiate between typhoid and malarial fever? If
so, name them, and how would you use them?
OBSTETRICS AND GENECOLOGY.
1. Name (a) the female internal organs of genera-
tion, (b) giving function of each.
2. (a) What is podalic version? (b) Cephalic
version?
3. (a) Give etiology of adherent placenta, (b) What
precautions would you use in delivering one?
4. Give symptoms of pregnancy at fifth month.
5. What changes take place in the female economy
at puberty?
6. How would you manage a case of antepartum
hemorrhage?
7. (a) Give symptoms of ovarian cyst. (6) What
treatment would you advise and (c) why?
8. (a) What is the most frequent cause of cervical
ulceration? (b) What are the symptoms?
9. Define (a) menopause, (b) metritis, (c) salpin-
gitis, (d) mastitis and (e) menstrual cycle.
10. (a) What antiseptic precaution would you use in
the eyes of the new born, and (b) why?
ANSWERS TO STATE BOARD EXAMINATION
QUESTIONS.
Kentucky State Medical Board,
anatomy.
1. "The spinal cord is the elongated portion of the
cerebrospinal axis contained in the spinal canal. Its
length is about sixteen to eighteen inches, extending
from the medulla above to the lower border of the first f~
lumbar vertebra below, where it terminates in the
cauda equina by a slender prolongation of gray sub-
stance, called the conus medullaris. It presents two
enlargements, the upper or cervical, extending from
the third cervical to the second dorsal vertebra, and
the lower about the position of the ^second or third
dorsal vertebra. It is divided into two lateral halves
by the anterior and posterior median fissures, united
in the center by the commissure. The lateral portions
are again subdivided by the antero-lateral and postero-
lateral fissures into the anterior lateral and posterior
lateral columns, and posteriorly a narrow fissure sep-
arates the posterior median column from the posterior
median fissure. The gray substance occupies the center
295
MEDICAL RECORD.
of the cord, and is arranged into two crescentie masses
connected together by the gray commissure. The pos-
terior horn forms the apex cornu, from which arises
the posterior root of the spinal nerves. The anterior
horn is thick and short, and affords origin to the an-
terior root of the nerves. The gray commissure con-
tains throughout its whole length a minute canal the
central canal, or ventricle of the cord, continuous above
with the fourth ventricle." (Young's Handbook of
Anatomy.) The spinal cord weighs about one and a
half ounces.
2. Thirty-one pairs of spinal nerves are given off
from the spinal cord.
3. Peyer's patches are aggregations of solitary
glands, measuring from about half an inch to three
inches in length; they are found mainly in the ileum,
but also occur in the duodenum, and jejunum; they are
situated lengthwise in the intestine, and are located
opposite to the mesenteric attachment. Each patch is
surrounded by a group of the crypts of Lieberkiihn.
There are said to be from 30 to 50 of these patches
in the human intestine. As a rule, they have no villi
on their surface.
4. The pulmonary artery conveys the venous blood to
the lungs. The pulmonary veins convey oxygenated
blood to the heart. The bronchial arteries supply blood
for the nutrition of the lungs.
5. The great sciatic nerve arises from the sacral
plexus, and passes out of the pelvis through the great
sacrosciatic foramen, below the pyriformis muscle; it
extends down the back of the thigh, passing between
the great trochanter of the femur and the tuberosity
of the ischium ; at the lower third of the thigh it divides
into the internal and external popliteal nerves. It sup-
plies the hip-joint and the biceps, semitendinosus,
semimembranosus, and adductor magnus muscles.
6. "The lymphatics of the liver are numerous, and
consist of a superficial and a deep set. The former
pass in various directions. Thus a large number go to
the hepatic glands in the lesser omentum; others pierce
the diaphragm and finally end in the right lymphatic
duct; others (a few) go to the lumbar glands. As
regards the deep set, some following the hepatic veins
and inferior vena cava, end in the thoracic duct ; others,
following the portal veins, end in the hepatic glands.
The efferents from the hepatic glands in the lesser
omentum accompany the hepatic artery, and end in the
celiac glands." (McLachlan and Skirving's Applied
Anatomy.)
296
KENTUCKY.
7. The small intestine is situated in the abdominal
cavity. It begins at the pyloric end of the stomach, in
the epigastric region and ends at the ileocecal valve in
the lower part of the right lumbar region. Its average
length is about 23 to 25 feet. It is divided into three
portions, the duodenum, the jejunum, and the ileum.
The duodenum is the first part of the small intestine,
it is about ten inches long, and extends from the pylorus
to the left side of the body of the second lumbar ver-
tebra. The jejunum and ileum form the coils of the
small intestine and are covered by the great omentum;
they form the remainder of the small intestine,' the
upper two-fifths being the jejunum and the lower three-
fifths the ileum; there is no line of demarcation between
these two parts. The coils of the jejunum and ileum
are suspended from the posterior abdominal wall by
the mesentery. The wall of the small intestine is com-
posed of four coats, a serous, muscular, submucous, and
mucous.
8. The esophagus is a muscular canal, about nine
or ten inches long, and extending from the lower border
of the pharynx (at the upper border of the cricoid
cartilage) to the stomach. It passes down along the
front of the spine, through the superior and posterior
mediastina, through the esophageal opening in the dia-
phragm, and ends in the cardiac orifice of the stomach
(opposite the tenth dorsal vertebra). It is generally
in the median line, but it curves to the left at the
root of the neck and again at the esophageal opening
in the diaphragm. It is composed of a general fibrous
covering on the outside, then a muscular coat consisting
of two layers, an outer longitudinal layer and an inner
circular layer ; inside this is a submucous coat of areolar
tissue; and the esophagus is lined by a mucous coat
which is covered by stratified squamous epithelium.
9. "The humerus, or arm-bone, the largest and long-
est bone of the upper extremity, consists of a shaft,
head, neck, greater and lesser tuberosities, and lower
extremity.
"The shaft, cylindrical above, flattened and prismoid
below, becomes twisted in the middle, and presents: A
rough triangular surface about the middle of its outer
surface for insertion of the deltoid muscle, and a mus-
culo-spiral groove for the musculo-spiral nerve and su-
perior profunda artery, on each side of which arise the
external and internal heads of the triceps muscle.
"The upper extremity presents — the head, forming
nearly a sphere, projecting upward, backward, and in-
ward, articulating with the glenoid cavity ; the anatom-
297
MEDICAL RECORD.
ical neck, immediately beneath, is slightly grooved for
the attachment of the capsular ligament ; greater tuber-
osity, external to the head and lesser tuberosity, with
three facets from before backward for attachment of
supraspinatus, infraspinatus, and teres minor muscles;
lesser tuberosity, smaller but more prominent than
greater, is anterior to head, for the subscapular muscle ;
biciptal groove, passes downward and inward between
the two tuberosities and lodges the long tendon of bi-
ceps; the anterior biciptal ridge, bounds the groove in
front and receives insertion of pectoralis major muscle ;
the posterior biciptal ridge receives the latissimus dorsi
and teres major; the surgical neck, including the head,
neck, and both tuberosities; a rough impression near
the center of the inner border for the coraco-brachialis
muscle; nutrient canal, below and directed toward the
lower extremity.
"The lower extremity presents from within outward
the following: Internal condyloid ridge, extending up-
ward from the condyle; internal condyle, more promi-
nent than external, gives origin to the flexors and pro-
nator radii teres; epitrochlea, an eminence separating
the trochlea from the internal condyle; trochlea, a pul-
ley-like articulating surface for greater sigmoid cavity
of ulna ; coronoid fossa, a small depression bounding the
trochlea in front, and receiving the coronoid of the ulna
in flexion ; olecranon fossa, a larger depresssion behind,
and receiving the olecranon process of ulna in exten-
sion; supra-trochlear foramen, sometimes formed by
perforation of one fossa into the other; radial head, or
capitellum, a smooth, rounded eminence articulating
with cup-like depression on head of radius; external
condyle, less prominent, gives origin to the extensors
and supinators ; external condyloid ridge, extending up-
ward on the shaft from the condyle.
"It articulates with three bones — scapula, radius, and
ulna. (Young's Handbook of Anatomy,)
"The radius is a long bone, shorter than the ulna,
situated on the outer side of the forearm, the upper end
small, the shaft slightly curved, and the lower end ex-
panded to form part of the wrist joint. It consist of
shaft, upper and lower extremity. The shaft is pris-
moid, slightly curved, and presents : An internal border,
sharp and prominent, for interosseous membrane; an
anterior border , marked at its upper third by an oblique
line, for attachment of flexor longus pollicis, supinator
brevis, and flexor sublimis digitorum; anterior surface,
affords attachment above for flexor longus pollicis, be-
low for pronator quadratus, and presents at the junc-
298
KENTUCKY.
tion of middle and upper two-thirds a nutrient foramen
directed upward; posterior surface gives attachment
at upper third to supinator brevis, and at middle third
to extensors of thumb.
"The upper extremity presents: Head — a cup-like
cylindrical cavity, for articulation with capitellum of
humerus, and on its side an articulating surface for
lesser sigmoid cavity of ulna and orbicular ligament,
which nearly surrounds it; neck, the constricted portion
below the head; bicipital tuberosity, below and to inner
side, divided by a vertical line into a rough surface
posteriorly, for attachment of biceps tendon, and smooth
surface anteriorly for bursa.
"The lower extremity, large, expanded, and quadri-
lateral, presents: Carpal articular surface, smooth,
concave, triangular depression divided by an antero-
posterior ridge into an outer facet for scaphoid bone
and inner for semilunar; sigmoid cavity, a shallow
concavity at inner side of carpal end, for articulation
with ulnar head; styloid process, projects obliquely
downward from the external surface, for attachment
by its apex to external lateral ligament of wrist-joint,
and by its base to insertion of supinator longus muscle.
Its outer surface is marked by two grooves for ex-
tensors of thumb. The posterior surface of the lower
extremity is also marked by three grooves from without
inward for the following: Ext. carpi radialis longior
and brevior in first, ext. secundi internodii in second,
and ext. indicis, ext. communis digitorum, and ext.
minimi digiti in third. This surface has also attach-
ment of posterior ligament of wrist." — (Young's Anat-
omy.)
"The ulna is a long bone to the inner side of the
forearm, and consists of a shaft and an upper and
lower extremity. It forms the greater part of the
articulation with the humerus, but does not enter into
the formation of the wrist-joint, being excluded by the
interarticular fibro-cartilage.
"The shaft is prismatic above, smooth and rounded
below, and presents: Anterior surface, gives attach-
ment to the deep flexors and pronator quadratus;
nutrient foramen on anterior surface, directed upward
toward the elbow-joint; posterior surface marked above
by an oblique line for part of supinator brevis, above
which is smooth triangular surface for anconeus mus-
cle, and the lower third for extensor muscles of the
thumb; external border, sharp in middle two-thirds, for
attachment of interosseous membrane.
"The upper extremity is large and irregular, and
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MEDICAL RECORD.
presents: Olecranon process (head of elbow), projects
upward and forward, its apex being received into the
olecranon fossa of the humerus in extension of the fore-
arm; its upper border has rough impression for the
triceps muscle; its lateral borders are grooved for ex-
ternal and internal lateral ligaments; coronoid process,
smaller than olecranon, projects forward from anterior
surface, being received into coronoid fossa of humerus
in flexion. Its supper surface forms part of the great
sigmoid cavity. Its under surface has rough impres-
sion for insertion of brachialis anticus, and has, at its
junction with the shaft, the tubercle of the ulna for
the oblique ligament. Its outer surface is the lesser
sigmoid cavity. Its inner surface gives attachment to
the internal lateral ligament, and the flexor di^itorum
sublimis, flexor profundus digitorum, and one head of
pronator radii teres. Greater sigmoid cavity is a large,
semi-lunar depression between the olecranon and coro-
noid processes, divided into two unequal lateral parts
by an elevated ridge. It is continuous on the outer side
with the lesser sigmoid cavity and articulates with the
trochlear surface of the humerus. Lesser sigmoid
cavity is an oval, concave, articular depression, external
to the coronoid process, for articulation with the head
of the radius. Its prominent extremities give attach-
ment to the orbicular ligament.
"The lower extremity is small and cylindrical and
presents : Head, an external, rounded, articular process,
for the triangular fibro-cartilage below and the sig-
moid cavity of the radius externally; Styloid process,
projects from the posterior and internal part of the
extremity, its apex gives attachment to the internal
lateral ligament of the wrist, and it is marked at its
root by a depression between it and the head, for at-
tachment of the fibro-cartilage; groove, upon the
posterior surface, for passage of extensor carpi ulnaris
It articulates with two bones — humerus and radius."
(Young's Anatomy.)
10. The pelvis is formed by the two ossa innominata,
the sacrum and the coccyx; each os innominatum is
made up of ilium, ischium, and pubis.
The false pelvis is that expanded portion of the
pelvis above the iliopectinal line and the upper margin
of the symphysis pubis. The true pelvis is the part
beneath this plane. II is smaller, and has more perfect
walls than the false pelvis.
PHYSIOLOGY
1. The medulla oblongata is the lowest part of the
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encephalon, and is continuous below with the spinal
cord. It extends from the lower margin of the pons to
the lower margin of the foramen magnum. It lies in
the basilar groove of the occipital bone; its dorsal sur-
face is between the cerebellar hemispheres. It forms the
lower part of the floor of the fourth ventricle. It is
about one inch long, half inch wide, and half inch thick.
It has anterior and posterior median fissures, which are
continuous with those of the spinal cord.
The functions of the medulla oblongata are: (1) It
is a conductor of nervous impulses or impressions from
the cord to the cerebrum, from the brain to the spinal
cord, also of * co-ordinating impulses from the cere-
bellum to the cord; (2) it contains collections of gray
matter which serve as special nerve centers for the
following functions or actions; respiration, salivary se-
cretion, mastication, sucking, deglutition, speech pro-
duction, facial expression; it also contains the cardiac
and vasomotor centers.
2. Proteids are digested in the stomach (by the pepsin
of the gastric juice) and in the small intestine (by the
trypsin of the pancreatic juice).
During digestion the proteids are split up into pro-
teoses, peptones, polypeptides and amino-acids. The
amino-acids are believed to be taken as such by the
epithelial cells and carried to the blood of the portal
capillaries. Another view is that in the intestinal
epithelium the amino-acids are built-up again into
proteins such as are found in the blood. There are
three theories of the further history of the proteids.
According to one of them (the theory of Voit), "the
protein of the tissues, living or organized protein, is to
be differentiated from the absorbed circulating protein.
It is only in this circulating protein, which is assumed
to be present in the fluids of the body, the blood and
lymph, that catabolic changes take place. These
changes take place under the influence of the living
cells. The more resistant organized protein is not sup-
posed to undergo catabolic changes. If any of it does,
it is cast off into the fluids of the body, and thus be-
comes circulating protein, undergoing catabolic changes
in precisely the same manner. It is obvious that a small
part of the absorbed protein must be utilized to re-
place the waste of the organized protein and to sub-
serve the process of growth. This portion is termed
tissue protein." (Lyle's Physiology.)
3. White blood corpuscles are formed in the spleen,
lymph glands, and lymphoid tissue; also from other
white cells by direct cell-division in the blood stream;
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MEDICAL RECORD.
the eosinophils may be derived from the bone marrow.
Their fate is uncertain: it has been asserted that they
are converted into red blood cells; they play a part in
the formation of fibrin ferment; they are sometimes
converted into pus cells. Their functions are (1) to
serve as a protection to the body from the incursions
of pathogenic microrganisms ; (2) they take some part
in the process of the coagulation of the blood; (3) they
aid in the absorption of fats and peptones from the
intestine, and (4) they help to maintain the proper
proteid content of the blood plasma.
4. The functions of the kidney are: (1) To secrete
(or excrete) urine; (2) to regulate the reaction of the
urine; (3) the formation of hippuric acid; (4) regu-
lation of the composition of the blood plasma by ex-
cretion of abnormal or toxic substances; and (5) the
production of an internal secretion. The mechanism of
the secretion of urine by the kidneys is twofold: (1) By
filtration, most, if not all, of the fluid is eliminated,
and also inorganic salts; this depends upon blood pres-
sure, and takes place in the glomeruli. (2) By cell
activity and selection, in the cells of the convoluted
tubules, the urea, and principal solids are eliminated.
5. Bone marrow. "Red marrow is the connective
tissue which occupies the spaces in the cancellous tis-
sue; it is highly vascular, and thus maintains the
nutrition of the spongy bone, the interstices of which
it fills. It contains a few fat-cells and a large number
of marrow-cells. The marrow cells are ameboid, and
resemble large leucocytes ; the granules of some of these
cells stain readily with acid and neutral dyes, but a
considerable number have coarse granules which stain
readily with basic dyes like methylene blue. Among
the cells are some smaller nucleated cells of the same
tint as colored blood corpuscles. These are termed
erythroblasts. From them the colored corpuscles of
the blood are developed. There are also a few large
cells with many nuclei, termed giant cells or myelo-
plaxes. Yellow marrow fills the medullary cavity of
long bones and consists chiefly of fat-cells with nu-
merous blood-vessels; many of its cells also are the
colorless marrow-cells just mentioned." (Halliburton's
Physiology.)
6. (a) The essentials in the ventilation of a school-
room are that there must be 1,000 cubic feet of space
for each individual, that the air in this space must be
changed three times in an hour, that the air must be
warmed to 60° to 65° Fahr., and that it must be mois-
tened and purified (or at least strained to remove ex-
cessive dust. "There is considerable difference of opin-
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ion as to the best locations for inlets and outlets, and
as the conditions are necessarily different in every case
and so many factors are to be considered, it is difficult
to lay down any general rules. It should be an aim,
however, to have the air well distributed and to have
no direct draughts from the inlets either upon the oc-
cupants or to the outlets. Usually the outlets should be
located near the top of the room, owing to the tendency
of the used air to rise, and because, in unventilated
rooms, the foulest air for some time after its contamina-
tion will be found nearest the ceiling. The products
of combustion from lights, etc., will also practically
all be in the* upper strata of air. If, however, pro-
vision is or can be made for a constant and sufficiently
strong aspirating force in the outlet ducts, it may be
advisable to withdraw the used air from near the floor
level and below the inlet openings, though not in too
close proximity to them, since |n this way a more
thorough distribution of the incoming air and a greater
dispersion of its contained heat are secured. The loca-
tion of the inlets should depend on the temperature of
the incoming air ; if it is cold it should be admitted near
the ceiling, so that it may diffuse and be partially
warmed before reaching the inmates of the room; if it
is warmed it may come in near the floor or below the
middle level of the room." (Egbert's Hygiene and
Sanitation.)
(b) In a bedroom, for adults, proper ventilation may
be secured by having double windows, or double panes
of glass, with an opening at the bottom of the outer
and at the top of the inner one, so that the fresh air
may enter in an upward current; or by placing a board
under the lower sash so that fresh air can enter in the
middle.
(c) The dangers of impure air are: Drowsiness,
headache, digestive disturbances, mental dullness, and
disease or liability to take disease. The chief danger
to health is in the increase of carbon dioxide> the
presence of crowd-poison, dust, irrespirable gases, and
bacteria.
(d) The relative amount of carbon dioxide in the
air is taken as an indication of its purity; not because
the carbon dioxide is itself harmful in the amounts
generally encountered, but because it is readily esti-
mated and is a fair indicator of the purity of the air.
Pettenkofer*8 m method of determining the percentage
of carbon dioxide in the air: A large cylindrical con-
tainer of known capacity, say, 15 liters, is filled with
the air to be examined; a known volume of barium
hydroxide is then added and shaken up with the air.
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MEDICAL RECORD.
The carbon dioxide combines with the barium hydroxide
to form a barium carbonate, which is insoluble, and
also incapable of acting upon an indicator. The barium
hydroxide employed is of known strength, e.g., it may
be of such strength that 1 c.c. of the solution neutral-
izes 1 c.c. of carbon dioxide at normal temperature and
pressure. If then we find that 10 c.c. of the barium
hydroxide has been neutralized by the carbon dioxide
present in the air, we know that 10 c.c. of carbon di-
oxide is present in 15 liters or 15,000 c.c. of the air
examined.
7. Voluntary muscle is more or less under the control
of the will, does not contract rhythmically, does not
evince peristalsis; involuntary muscle is not under the
control of the will, it is rhythmical in its contractions,
and is also characterized by peristalsis.
Further, voluntary muscle is striated, has long nar-
row fibers with cross striations and many nuclei be-
neath the sarcolemma. Involuntary muscle is non-
striated, has spindle-shaped fibers, one nucleus cen-
trally located, and no sarcolemma. The great excep-
tion is cardiac muscle, which is involuntary and also
striated. Voluntary muscle is found in all the skeletal
muscles, pharynx, diaphragm, larynx, external ear, and
eye. Involuntary muscle is found in the alimentary
tract from the middle third of the esophagus to the
anus, in the ducts of glands, in the trachea and bron-
chial tubes, within the eyeball, the internal urinary and
genital systems, circulatory (except the heart) and
lymphatic systems, and the capsules of some organs.
8. "The sympathetic nervous system consists of (1) a
series of ganglia connected together by a great gan-
glionic cord, the gangliated cord, extending from the
base of the skull to the coccyx, one gangliated cord on
each side of the middle line of the body, partly in front
and partly on each side of the vertebral column; (2) of
three great gangliated plexuses or aggregations of
nerves and ganglia, situated in front of the spine in the
thoracic, abdominal, and pelvic cavities respectively;
(3) of smaller or terminal ganglia, situated in relation
with the abdominal viscera; and (4) of numerous
fibers." — (Gray's Anatomy.)
Function: It has a controlling influence over the se-
cretion of most of the glands, the lacrimal, the salivary,
the sweat glands, the glands of the stomach and intes-
tines, the liver, the kidney, etc.; it presides over the
circulation by regulating the caliber of the blood-vessels
and the action of the heart; it influences respiration;
and, all involuntary muscles, those of the digestive ap-
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paratus, of the genitourinary system, of the hair folli-
cles (pilomotor nerves), are under its control to a great
extent.
9. Development of the humerus. "Ossification occurs
from a primary center in the shaft and six or seven
secondary centers in the extremities. In the upper
extremity centers appear in the head, great tuberosity,
and sometimes in the small tuberosity, which, after
fusing together, join the shaft about the twentieth
year. In the lower extremity centers appear in the
trochlea, capitelluin, and outer and inner condyles, the
three former of which, after coalescing, unite with the
shaft in the seventeenth year. The inner condyle forms
a distinct epiphysis which unites somewhat later."
(Gerrish's Anatomy.)
Development of the temporal bone. "The squamosal
and tympanic bones ossify in membrane, each from a
single center; the petrous portion and styloid process in
cartilage, the former from four centers, the latter from
two. The fetal tympanic bone forms an incomplete
ring, which incloses the tympanic membrane. It is
open above with its free ends united to the squamosal.
The defect in the ring due to this opening above is
known as the notch of Rivinus. Two tubercles, one
growing from the front and the other from the back
of this ring, meet in the floor of the meatus, enclosing
a foramen, which is gradually (though not always)
closed, and thus the tympanic plate is formed. At
birth the mastoid process, articular eminence, and
tympanic ring are flat, the glenoid fossa is shallow,
and the hiatus Fallopii opens at the genu of the canal."
(Gerrish's Anatomy.)
10. The vestibule of the internal ear. "The vestibule
is situated on the inner side of the tympanum, behind
the cochlea and in front of the semi-circular canals. It
is somewhat ovoid in shape, and measures about one-
fifth of an inch in length. On its outer wall is the
fenestra ovalis, closed by the base of the stapes and
membrane; on its inner wall is the fovea hemispherica,
pierced by minute holes, for the filaments of the audi-
tory nerve and opening of the aqueductus vestibuli; on
its roof is a small depression, the fovea semi-elliptica ;
behind are the five openings of the semi-circular canal,
and in front an opening which communicates with the
cochlea." (Ashby's Notes on Physiology.) The func-
tion of the vestibule — It is supposed to be concerned
with equilibrium.
BACTERIOLOGY.
1. Method of immunizing against typhoid. The vac-
cine is administered subcutaneously over the insertion
305
MEDICAL RECORD.
of the deltoid muscle; the site of the injection should
have been previously painted with tincture of iodine;
intramuscular injections are to be avoided; after the
injection has been given the iodine is wiped off with
a pledget of cotton and alcohol; no dressing is needed;
the syringe and needle must be sterile; three such in-
jections are given at intervals of about ten days; the
dosage for adults (of 150 pounds weight) is 500 million
bacilli for the first injection, and 1000 million bacilli
for the second and third injections; each of these
amounts is contained in about fifteen minims or one
cubic centimeter; for a child weighing fifty pounds the
dosage should be about one-third of the above, or a
little more, for children take the injections very well.
2. (a) The Widal test for typhoid fever "depends
upon the fact that serum from the blood of one ill with
typhoid fever, mixed with a recent culture, will cause
the typhoid bacilli to lose their motility and gather in
groups, the whole called 'clumping/ Three drops of
blood are taken from the well-washed aseptic finger tip
or lobe of the ear, and each lies by itself on a sterile
slide, passed through a flame and cooled just before
use; this slide may be wrapped in cotton and trans-
ported for examination at the laboratory. Here one
drop is mixed with a large drop of sterile water, to re-
dissolve it. A drop from the summit of this is then
mixed with six drops of fresh broth culture of the
bacillus (not over twenty-four hours old) on a sterile
slide. From this a small drop of mingled culture and
blood is placed in the middle of a sterile cover-glass,
and this is inverted over a sterile hollow-ground slide
and examined. ... A positive reaction is obtained
when all the bacilli present gather in one or two masses
or clumps, and cease their rapid movement inside of
twenty minutes." — (From Thayer's Pathology.)
(b) Its diagnostic value is believed by some to be
great; others place little reliance on it. It may be
absent in cases of typhoid fever; it may be present for
several months after an attack of typhoid; the reac-
tion may not be obtained till the third week of the dis-
ease; it may be present in other diseases or in per-
fectly healthy persons. The above have all been urged
as objections; certainly only positive results have any
value at all.
3. The characteristics of the bacillus of diphtheria:
The bacilli are from 2 to 6 mikrons in length and from
0.2 to 1.0 mikron in breadth; are slightly curved, and
often have clubbed and rounded ends; occur either
singly or in pairs, or in irregular groups, but do not
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form chains; they have no flagella, are non-motile, and
aerobic; they are noted for their pleomorphism ; they
do not stain uniformly, but stain with any aqueous
solution of an anilin dye, they also stain well by Gram's
method and very beautifully with Loeffler's alkaline-
methylene blue; Neisser's stain is also recognized.
Diphtheria carriers can only be detected by the find-
ing of the diphtheria bacilli in the secretions of their
nose and throat. A sterile swab is rubbed over any
visible membrane on the tonsils or throat and is then
immediately passed over the surface of the serum in a
culture tube. The tube of culture, thus inoculated, is
placed in an incubator at 37° C. for about twelve hours,
when it is ready for examination. A sterile platinum
wire is inserted into the culture tube, and a number
of colonies of a whitish color are removed by it and
placed on a clean cover slip and smeared over its sur-
face. The smear is allowed to dry, is passed two or
three times through a flame to fix the bacteria, and is
then covered for about five or six minutes with a
Loeffler's methylene-blue solution. The cover slip is
then rinsed in clean water, dried, and mounted. The
bacilli of diphtheria appear as short, thick rods with
rounded ends; irregular forms are characteristic of this
bacillus, and the staining will appear pronounced in
some parts of the bacilli and deficient in other parts.
Methods of culture: The bacillus of diphtheria grows
upon all the ordinary culture media, and can be readily
obtained in pure culture. Loeffler's blood serum, par-
ticularly with the addition of a little glucose, is an
admirable medium for the rapid growth of this bacillus.
The medium should be alkaline and not less than 20° C.
4. Syphilis is due to infection by the Treponema
pallidum, also called the Spirochseta pallida. This is a
slender spirillum, with regular turns, the curves vary-
ing in number from three or four to twelve or even
twenty; it is about 4 to 20 mikrons long, actively motile,
with a fine flagellum at each pole; it is flexible, hard to
stain, and has not been cultivated on artificial media.
How it divides is not known. It stains best with
Giemsa's eosin solution and azur.
5. In examining for malaria: "Prepare some per-
fectly clean and very thin cover slips, and remove all
traces of grease. Cleanse the skin of the finger-tip or
ear with soap and water, and then with alcohol and
ether. Make a small prick in the skin. Wipe away the
first drop of blood, leaving a perfectly dry surface, so
that subsequent drops will not run. Squeeze out a
tiny drop about the size of a large pin's head. Touch
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MEDICAL RECORD.
the apex of this drop with the center of a cover glass,
and immediately drop it, face downward, on a perfectly
clean slide. Make several such preparations, and reject
all those in which rouleaux are present. It is abso-
lutely essential that the red corpuscles should lie flat.
Examine with a 1/12 immersion lens and rather feeble
illumination. Look in the red corpuscles for the pres-
ence of small black specks, often rod-like and showing
slow movements of translation. These are surrounded
by clear areas. One may also see in the center of some
of the red cells clear ameboid areas which show no
pigment. Rosette forms may also be visible. These
forms of the parasite are always present in cases of
malaria which have not had quinine. Other varieties
are only met with in some chronic cases. Of these there
are two chief forms: (1) The crescentic, (2) the flagel-
lated. These are easily recognized. The crescentic
bodies are highly refractile, rather longer than a red
blood corpuscle, and about 2m in diameter. Particles of
pigment may be recognized in the parasite and also in
some of the ordinary leucocytes." — (Hutchinson and
Rainy.)
TERTIAN.
QUARTAN.
ESTIVO-
AUTUMNAL.
Cycle in man 48
hours.
Ameba in red cell
3 days.
24-48 hours.
Sluggish.
Smaller than ter-
active. •
tian.
Decolorizes red
Slowly.
Hemoglobin deep-
cell rapidly.
er in tint.
Causes red cell to
Size preserved or
Red cells shrivel.
swell.
diminished.
Outlines not
Sharp.
sharply defined.
Pigment in fine
Coarser, fewer.
Pigment in fine
granules, abun-
peripheral
dant, in motion.
granules, not
often in motion.
Spores 15-20, usu-
6-12, larger.
Small, 6-30, usu-
ally 18, small.
ally 18.
Flagella more nu-
Less numerous.
merous.
Ring forms com-
Common, ring
m o n, early,
and disk form
more distinct
less distinct.
than those of
estivo - autum-
nal.
308
— (Thayer.)
KENTUCKY.
6. The ova of Ascaris lumbricoides "are elliptical
with a thick (4m) transparent shell and an external
albuminous coating which forms protuberances ; the ova
measure 50m to 70m in length, 40m to 50m in breadth;
they are deposited before segmentation ; the albuminous
coating is stained yellow by the coloring matter of the
feces, but it is sometimes absent. The egg cell is un-
segmented, it almost completely fills the shell, and its
nucleus is concealed by the large amount of coarse yolk
granules."
> The ova of Ancylostoma duodenale "appear to have a
single contour. Under high powers this appears double,
but they are the outer and inner surface of the true
(chitinous) egg-shell.' Internal to this is the extremely
delicate yolk-envelope, a kind of skin secreted by the
egg cell around itself for protection. The eggs are oval,
with broadly rounded poles, 56m to 6lM by 34m to 38m.
In fresh feces they contain four granular nucleated seg-
mentation masses of the ovum separated by a clear
space from the shell."
The ova of Oxyuris vermicularis "are oval, asym-
metrical, with double-contoured shells, and measure 50m
to 55m by 16m to 25m; they are deposited with clear,
non-granular tadpole-like embryos already developed."
(From The Animal Parasites of Man, by Fantham,
Stephens, and Theobald.)
7. Gonococci are recognized by their form (diplo-
cocci), their location (intracellular), and their staining
properties (eosin and methylene blue, and being decolor-
ized by Gram's method) ; they are exceedingly difficult
to cultivate, and this feature renders differentiation
from the Micrococcus catarrhalis easy, inasmuch as the
latter grows readily on simple culture media.
8. To demonstrate the existence of tubercle bacilli
in the sputum: The sputum must be recent, free from
particles of food or other foreign matter; select a
cheesy-looking nodule and smear it on a slide^ making
the smear as thin as possible. Then cover it with some
carbolfuchsin, and let it steam over a small flame for
about two minutes, care being taken that it does not
boil. Wash it thoroughly in water and then decolorize
by immersing it in a solution of any dilute mineral acid
for about a minute. Then make a contrast stain with
solution of Loeffler's methylene blue for about a minute ;
wash it again and examine with oil immersion lens.
The tubercle bacilli will appear as thin red rods while
all other bacteria will appear blue. The tubercle
bacillus is rod shaped, is from W* to 3% mikrons in
length and about one-third to one-half a mikron in
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MEDICAL RECORD.
breadth, is a strict parasite, is not motile, and has no
flagella. It is slightly curved, does not form spores, is
not liquefying; is nonchromogenic ; is aerobic; it re-
sists acids; it grows well on blood serum; stains well by
Ehrlich's, Ziehl-Neilsen's, or Gabbett's method; it is.
Gram-positive.
9. The bacillus of tetanus is characterized by its
peculiar spore, formed at one end of the bacillus and
giving it the appearance of a pin ; it is purely anaerobic,
and cannot be developed at all in the presence of oxygen.
It generally comes from the soil, and is found in pene-
trating wounds. It appears in two forms, the spore-
bearing form, as described above, and the vegetative
form, which is a short bacillus with rounded ends, and
which may occur singly or in pairs, or may form long
filaments. It grows in gelatin stab cultures in the
middle of the medium and the colonies look something
like a fir tree; its growth is slow, and a disagreeable
odor is at the same time emitted. In bouillon, it grows
near the bottom of the tube, and produces gases.
10. The meningococcus is a small, non-motile, non-
flagellate coccus; it does not form spores^ does not
liquefy gelatin, is aerobic, and pathogenic; it appears
in diplococcus groups, and may be found within or out-
side the cells ; it stains readily with the ordinary anilin
dyes, but is Gram negative. It grows readily upon meat
infusions, and especially so on media to which ascitic
fluid or blood serum has been added.
SURGERY.
1. In hydrocele the tumor begins in the scrotum and
may ascend to the inguinal region; does not vary very
much in size, except to steadily increase ; is translucent ;
is dull on percussion; gives no impulse on coughing.
In hernia the tumor begins in the inguinal region and
may descend to the scrotum; is very variable in size,
and may be reducible, or disappear on lying down; is
not translucent; is not dull on percussion; gives an
impulse on coughing as a rule.
In varicocele the swelling feels like a bag of worms;
it may empty when the patient lies down; there is an
impulse on coughing or straining, but no translucency.
Treatment of hydrocele. — The fluid may be withdrawn
with trocar and cannula; this will have to be repeated.
Tapping, followed by injection of strong antiseptics,
such as carbolic acid, or iodine. The sac may be ex-
cised either wholly or partially.
For hernia, Bassini's operation (or some modification
of it) is recommended.
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For varicocele the best treatment is to remove the
varicose veins between double ligatures.
2. In compound comminuted fracture of the olecranon
process "the wound should be irrigated with a few
gallons of physiological sterile salt solution, and the
edges of the wound trimmed of devitalized tissue. In-
ternal fixation of the fragments should not be per-
formed at the initial operation in compound cases,
though it may be possible to retain the fragments in
position by suturing the fascia covering the posterior
surface of the process in closing the wound. A sec-
ondary operation may be done after the wound (ren-
dering the condition compound) has healed and the
danger of infection has passed. Following a firm in-
ternal fixation of the fragments the upper extremity
may be immobilized with an internal right angle splint."
(Preston's Fractures and Dislocations.)
3. Fracture of base of the skull. The Signs are
those of (1) injury to the brain, (2) escape of cranial
contents, (3) injury of cranial nerves. (1) Injury to
the brain may be of the nature of concussion, compres-
sion, or laceration. (2) Escape of crajiial contents,
which may be blood, cerebrospinal fluid, or rarely brain
itself. 1. Hemorrhage manifests itself in various situ-
ations, according to the position of the fracture. In the
anterior fossa the bleeding may be from the nose or
into the orbit, or may pass back into the pharynx, be
swallowed, and subsequently vomited. The eye may be
pushed forward and pulsate if the cavernous sinus be
ruptured. In the middle fossa blood usually runs from
the ears ; but slight bleeding from the ear may be caused
by minor injuries, such as rupture of the membrana
tympani, tearing of the lining of the auditory canal,
and fracture of the tympanic bone. In the posterior
fossa a hematoma may form behind the mastoid process.
2. The escape of cerebrospinal fluid is a certain sign
that a fracture communicates with the subdural space.
It may appear in the same situations as hemorrhage,
but is usually found escaping from the ear owing to
fracture of the petrous bone. The fluid is limpid, spe-
cific gravity 1005, with no albumin, but containing pyro-
catechin, which gives the same reaction as sugar with
Fehling's solution. The amount which escapes may be
small or very large, but as a rule it soon ceases. (3)
Injuries to the cranial nei^ves vary according to the site
of fracture. That most commonly involved is the facial,
in the aqueductus Fallopii, and the paralysis may come
on immediately from rupture, or after two or three
weeks from the pressure of callus.
311
MEDICAL RECORD.
Treatment: The chief aim of treatment is to prevent
sepsis. The ear must be mopped out with an antiseptic,
and then kept covered with an antiseptic dressing, as if
it were a wound. The patient must then be kept quiet,
the bowels opened with a purge, and an icebag applied
to the head. The diet should be low, and a return to
active life not permitted for six weeks. If septic menin-
gitis occurs the patient is bound to die. (From Aids to
Surgery.)
Fissured fractures of the vault are due to direct in-
juries, such as blows, or to indirect injury, such as com-
pression, which bursts the skull. If simple there are no
definite signs; if compound the fissure can be seen and
felt. The prevention of sepsis forms the main line of
treatment. Callus may form at the site of fracture and
produce traumatic epilepsy.
Depressed and punctured fractures are due to direct
violence; usually affect the vault; may be simple, com-
pound, or comminuted. The outer table may be de-
pressed without the inner being broken, in such places
as the frontal sinus. Rarely the inner table is broken
and depressed without fracture of the outer. As a rule
both tables are broken. The inner suffers most damage,
as it is less supported; the force of the blow is more
diffused by the time it reaches the inner; also the
momentum of the striking body is less, and the debris
of the outer table increases the size of the penetrating
body.
Symptoms: 14 there is a wound, the fracture and de-
pression may be seen, and blood, cerebrospinal fluid, or
brain, may be escaping. If there is no wound a care-
ful examination is necessary, as a hematoma may form
and obscure the depression. In cases of doubt an in-
cision should be made.
In a simple depressed fracture there is usually some
concussion, which is followed by compression from
hemorrhage in the neighborhood. The depressed bone
also causes compression later by the spreading edema it
sets up in the brain. Death may result quickly, or the
patient may recover and then become the subject of
traumatic epilepsy from irritation of the cortex. If the
depression is over the motor area convulsions or
paralysis are quickly induced.
In a compound depressed fracture the blood escapes
and does not produce compression. Concussion may or
may not be present. The advent of sepsis produces in-
flammation of the bone, membranes, and brain, which
may be limited if the drainage is free; but if not death
soon follows from compression by the inflammatory
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exudation. During the stage of compression a hernia
cerebri is formed. If the depressed fragments are early
removed and asepsis is maintained the patient has a
good chance, unless the brain itself is severely injured.
Treatment. — In all cases, except the saucer-like de-
pressions which occur in young infants, it is necessary
to elevate or remove the depressed fragments, stop all
bleeding, and disinfect the wound. Symptoms should
never be waited for, because, although the patient may
recover without operation, the depressed bone may cause
traumatic epilepsy or insanity. The skin is shaved and
purified, and a large flap is turned down to expose the
fractured area, or if a wound is present it is enlarged.
Comminuted fragments are removed, and sharp edges
which press on the dura mater are clipped away with
Hoffmann's forceps. If an elevator cannot be introduced
under the depressed bone a trephine hole is made
through the nearest sound bone, the elevator intro-
duced, and the bone prised up. The piece of bone
removed with the trephine should be replaced. If the
dura mater is torn it should be stitched up and then the
scalp flap is sutured without a drain, unless oozing is
still going on. If the fracture has been compound it is
better to drain it for twenty-four hours. In punctured
fractures the hole must be enlarged by trephining, so
as to remove the depressed spicules. After operation
the patient must be kept quiet in a darkened room on
Hquid diet for a few days. — (Aids to Surgery.)
4. Prostatic hypertrophy is characterized by: Slow-
ness in starting urination; difficult micturition; fre-
quency of micturition, particularly at night; the pres-
ence of residual urine, as may be demonstrated by cathe-
terizing the patient just after he has urinated; dull,
aching pain in the perineum and above the pubes; en-
largement of the lateral lobes of the prostate; there
may be cystitis and retention of urine. Palliative treat-
ment consists in: Mild and unirritating diet, avoidance
of alcohol, taking plenty of milk or water, or other
diluent. Alkalies and sedatives should be taken, also
urotropin or other antiseptic so as to prevent cystitis.
Regular catheterization, at least once a day, preferably
in the evening, and with due aseptic precautions. Oper-
ative treatment is excision of the prostate gland.
5. Acute appendicitis. — The recognition of a typical
case depends upon a few cardinal symptoms — viz., the
acute development of severe pain in the right iliac fossa,
coming on in a person previously healthy and usually
under forty years of age; appendicular tenderness,
unilateral induration, fever, vomiting and constipation,
or, more rarely, diarrhea.
313
MEDICAL RECORD.
Acute tuberculous peritonitis. — As in appendicitis, so
in tuberculous peritonitis, pain, tenderness, and fever
are present, but in the latter the onset is more gradual,
and the signs of tumor and increased resistance in the
ileocecal region are absent. Movable dulness may be
present in the tuberculous affection, but not in appen-
dicitis until the peritonitis is general. The lungs gen-
erally show lesions in tuberculous peritonitis.
Acute intestinal obstruction. — When this is due to
intussusception there may be signs of a tumor, but not
at McBurney's point; the tenderness over the site of
the mass is less intense, while the frequent bloody dis-
charges that are seen in this condition, accompanied by
tenesmus, do not characterize appendicitis. When ob-
struction is caused by strangulation stercoraceous vom-
iting is apt to occur ; pain, local tenderness, and signs of
a tumor appear, but not at McBurney's point. (Anders*
Practice of Medicine.)
PATHOLOGY.
1. (a) Healing by granulation occurs (1) when the
edges of the wound have not been brought together, (2)
when the edges have been so damaged that sloughing
occurs, (3) when sepsis has prevented healing by first
intention. Exudation of plasma and leucocytes occurs,
followed by fibroblasts and budding from the capillaries,
thus forming granulation tissue. The dead tissues or
sloughs are separated, and a red area of granulation is
then exposed. The deeper layer of granulation tissue is
converted into fibrocicatricial tissue, which contracts,
and so the wound gradually lessens in size. In the
meantime epithelium spreads in from the edge over the
surface, and so the scar is completed. — (Aids to Sur-
gery.)
(b) It leads to cicatrization.
2. Pathology of gangrenous perforated gall-bladder. —
Should the gall-bladder have been previously normal
or only slightly diseased and non-adherent it may be-
come considerably, sometimes very much, enlarged ; but
if previously the seat of cicatrization from chronic in-
flammation no enlargement may occur; in this case it
is usually united to adjacent tissues and organs by
adhesions. The wall of the gall-bladder is softened,
swollen, edematous, congested, and usually very dark
reddish, greenish, or blackish in color. The mucosa is
congested and desquamated and covered with a fibrino-
purulent, sometimes also hemorrhagic, exudation. ^ In
many cases there is more or less ulceration, especially
toward the fundus in consequence of the relatively
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poorer vascular supply of the fundus and the gravita-
tion of gallstones. The ulceration may proceed through
the wall and lead to perforation. The cystic duct is
usually occluded even in the absence of gallstones. The
contents consist of turbid, bile-stained, fibrinopurulent,
sometimes sanguinolent fluid; gallstones are present in
about 80 per cent. . . . The infiltration of the gall-
bladder is widespread and may lead to extensive dissec-
tion of the different coats, the separation, for instance,
of the mucosa from the underlying coats or extensive
sloughing. . . . When a large section of the gall-
bladder becomes necrotic the term gangrenous cholecys-
titis is not inaptly applied. The lesions resemble those
just described, with the addition of complete necrosis or
gangrene of a variable portion of the gall-bladder; the
gangrene usually begins at or near the fundus and
spreads toward the neck; in some cases it begins about
a gallstone more or less firmly embedded in the wall of
the gall-bladder. — (From Modern Medicine, by Osier
and McCrae.)
3. Pyosalpinx. — "The dilation of the tube into a cyst
is the final stage of salpingitis. The tumor formed by a
dilated tube is seldom larger than a pear, although a
pyosalpinx may reach to the umbilicus. The tube is
commonly contorted, winding round the upper and back
part of the ovary, the outer part of the tube being the
more dilated. The wall is generally thickened, but at
one or more spots it may be thinned. The thinning is
not due to tension, but to ulceration, and this ulceration
may take place at a part where the tube is not dilated,
and may perforate and cause death. The mucous mem-
brane is overgrown, thickened, edematous, injected so as
to be purple in color, and ecchymosed, or it may be
slate colored; there maybe calcareous plates and nodules
in the mucous membrane. In some cases there has been
overgrowth of gland tissue. The ovary is generally
enlarged." — (Herman's Handbook of Gynecology.)
The usual infecting organism is the gonococcus.
4. A sarcoma is a malignant connective tissue tumor ;
the others are all innocent. A sarcoma consists of cells,
between each of which a minute quantity of intercellu-
lar tissue can be demonstrated. The cells differ in size
and shape in different growths. Bone and cartilage
may be developed in any of them. It is always devel-
oped from mesoblastic tissue ; it may be at first defined
or encapsuled, but always in its later stages infiltrates
the surrounding tissues. The blood supply is always
abundant, even to producing a pulsating tumor. The
vessels are only clefts between the cells of the growth,
315
MEDICAL RECORD.
so that interstitial hemorrhage is frequent, and dissemi-
nation by the veins is rendered easy. It follows from
this that secondary growths occur first in the lungs, un-
less the primary growth is in the portal area. Other
organs may be affected after the lungs. Occasionally
lymphatic glands are implicated, especially in melan-
otic sarcoma, lympho-sarcoma, sarcoma of tonsil, testis,
and thyroid. Secondary changes, such as myxomatous,
fatty and hemorrhagic, may occur. A sarcoma when
cut appears homogeneous and varies according to its
vascularity from the grayish-white of a fibrosarcoma
to the deep maroon of a myeloid sarcoma. Sarcoma
may be congenital or appear at any age. The species
are determined according to the prevailing type of cell.
Rodent ulcer is a carcinoma beginning- in sebaceous
glands. It generally occurs in patients over forty and
is of very slow growth. It begins as a smooth, rounded
knob in the skin about the nose, eyelids, orbital angles or
cheeks, slowly increasing in size. In time ulceration
occurs. The ulcer has a smooth, depressed base covered
with ill-formed granulations and bounded by a slightly
raised, indurated, rolled over edge. There is little dis-
charge if sepsis is prevented and little or no pain. The
lymphatic vessels and glands are not affected, and dis-
semination does not occur. The ulcer spreads and de-
stroys surrounding structures ; even bone is not spared,
so that the brain may ultimately be exposed.
Epithelioma, or squamous-celled carcinoma, may .arise
on any surface covered with stratified epithelium. It
usually arises in the middle aged or elderly, but may
also occur in the young. It often results from long con-
tinued irritation and may arise in old scars or ulcers.
It may appear in one of three forms: (1) A wartlike
growth with an indurated base; (2) a small circular
ulcer with raised, rampartlike edges; (S) an indurated
fissure. The growth extends to the deeper structures;
the surface ulcerates and becomes foul from contamina-
tion with putrefactive organisms. The nearest lym-
phatic glands always become infected sooner or later,
and a fatal termination occurs rapidly unless treatment
is early and thorough. Secondary deposits, except in
the glands, are rarer than in glandular carcinoma. The
glands sometimes undergo cystic change, invade the
skin, ulcerate, become foul, and may cause death by
scondary hemorrhage from ulceration into large blood
vessels. — (Aids to Surgery.)
5. "Necrosis, or gangrene of bone, is death of a portion
of bone en masse. The dead portion (sequestrum) varies
in size from a small superficial flake, such as follows
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suppurative periostitis, to a mass representing the en-
tire shaft of the bone, such as not infrequently follows
acute osteomyelitis. The causes are acute and chronic
inflammations of the periosteum, bone and medulla. The
sequestrum separates from the living bone by a line of
ulceration or demarcation much the same as in gan-
grene of soft parts. The surrounding living bone
usually undergoes a condensing ostitis and becomes
much harder than normal. Small and superficial se-
questra may be discharged spontaneously through a
sinus, which inevitably exists in all but very small
aseptic sequestra, in which complete absorption without
suppuration is possible. If the necrotic mass is large
or centrally located spontaneous discharge is impossible
and suppurative inflammation may continue for years.
The dense bone which surrounds the sequestrum in
these cases is called the involucrum, and the sinus lead-
ing from the surface down to the cavity fn which the
sequestrum lies is called the cloaca" — (Stewart's Sur-
gery.) -:^wm
SKIN, HYGIENE, MEDICAL JURISPRUDENCE, MENTAL AND
NERVOUS DISEASES.
1. Lupus vulgaris is a tuberculous cellular new
growth, characterized by reddish or brownish patches
consisting of papules, nodules, and flat infiltrations,
usually terminating in ulceration and scarring. The
affection occurs most often upon the face and is due to
local infection by the tubercle bacillus. It is distin-
guished from syphilis and epithelioma by its occurrence
before puberty, slow course, history and concomitant
signs of the tuberculous diathesis, soft nodules, multiple
and superficial ulcers, absence of pain, yellowish,
shrunken and hard scars and slight discharge. The
condition is chronic and in small patches may be en-
tirely cured. — (Pocket Cyclopedia.)
2. Psoriasis is a common chronic inflammatory dis-
ease of the skin, characterized by variously sized lesions,
having red bases, covered with white scales resembling
mother of pearl. It affects by preference the extensor
surface of the body. The lesions are infiltrated, ele-
vated, clearly defined, covered with white, shining, easily
detachable scales which, upon removal, reveal a red,
punctate, bleeding surface. The eruption is absolutely
dry, and itching is usually absent. — (Pocket Cyclo-
pedia.)
The special points of value in reference to diagnosis
are the lesions of variable dimensions, all being capped
with pearly white scales ; borders severely outlined ; ten-
317
MEDICAL RECORD.
dency to convalescence, with the presentation of bleed-
ing points upon removal of scale.
3. Varieties of eczema. — Eczema erythematosum, E.
papillosum, E. vesiculosum, E. pustulosum, E. rubrum,
E. squamosum, E. fissum, E. sclerosum, E. verrucosum,
E. papillomatosum.
4. The sleeping room should be as large as possible,
with the maximum of sunshine and fresh air; it should
face the south, or east, or southeast, and should contain
no hangings and have as few "dust catching" contri-
vances as possible; it should not lead into a bathroom.
There should be a separate bed for each person, and,
preferably, each person should have his own room.
There should be .provision for moderate heating of the
bedroom and a warm dressing room may be necessary
in cold weather.
5. "In addition to the ordinary hygiene of factories
and workshops, such as proper space, air, ventilation,
water supply, lighting, heating, drainage and plumb-
ing, ordinary cleanliness and absence of dust care
should be taken that women and children do not work
too long at a time or at occupations involving the use
of poisonous or deleterious materials; that there are
ample toilet and lavatory accommodations, and that
these are separate and away from those used by men;
there should also be opportunity to sit, and women
should not be expected to remain standing for long
periods of time." — (Scott's State Board of Physiology
and Hygiene.)
6. "Nitrates may be found in pure water from deep
wells in the chalk, but as a rule are due to oxidation of
organic matter of animal origin. Even if accompanied
by only a small proportion of organic matter nitrates
in water from a source open to suspicion must be re-
garded as oxidized filth, which may at any time be fol-
lowed by unoxidized filth. A trace of nitrates not ex-
ceeding N = 0.35 per 100,000 would not suffice to con-
demn a water otherwise pure.
"Nitrites must be considered as pointing to sewage
contamination, and their presence should condemn the
water. They indicate more recent and therefore more
dangerous contamination than nitrates." — (Aids to
Sanitary Science.)
7. The chief city nuisances are: Noise, smoke, dust,
waste matters, gases and fumes, odors and various of-
fensive trades (such as the keeping of live animals, the
killing of animals, the sale of animals, the manufac-
ture of animal products, carpet beating, smelting and
chemical manufactures). About country homes the
818
KENTUCKY.
nuisances which are the most in evidence are the im-
proper disposal of waste or refuse material and the
keeping of live animals.
8. To prevent the spread of infectious diseases: They
should be reported to the health authorities; adequate
isolation and quarantine (when necessary) should be
enforced; proper prophylactic measures (as vaccina-
tion) should be ordered; children, from houses where
there is such disease, should not be allowed to mingle
with other children; proper disposal should be made of
sputum and excreta; details bearing upon the preven-
tion of each disease can be learned from special man-
uals on the subject.
9. (a) Medicolegal^ complications ivhich may arise
from an erroneous diagnosis of pregnancy : The char-
acter of the woman may be involved; the legal rights
of the child may be involved ; the paternity of the child
and the mother's right to demand from the father sup-
port for the child are also involved; inheritance of
titles and property are also to be considered.
(b) The practitioner should be very careful in mak-
ing a diagnosis of pregnancy ; he should remember that
the positive signs of pregnancy are not present during
the first few months ; in doubtful cases he should mam-
tain a strict silence, remembering that time will aid in
making the diagnosis sure.
10. Etiology of multiple neuritis: The disease is said
to be due to the action of poisons (in the blood) on
the peripheral nerves. These poisons may be : Alcohol,
lead, arsenic; diseased conditions as gout or syphilis;
and bacterial toxins, such as are found in specific fevers,
sepsis, etc.
OPHTHALMOLOGY, OTOLOGY, AND LARYNGOLOGY.
1. Indications for iridectomy: (1) Glaucoma; (2)
some cases of chronic and recurrent iritis and irido-
cyclitis; (3) complete circular synechia; (4) partial
corneal staphyloma; (5) tumors and foreign bodies in
the iris; (6) recent prolapse of the iris. (From May's
Diseases of the Eye.)
2. Staphyloma is a bulging of the cornea or sclera.
It is due to inflammation.
3. Chronic dacryocystitis is caused by obstruction of
the nasal duct. The symptoms are: Epiphora, fulness
in the region of the lacrymal sac and the escape of a
viscid fluid when pressure is made on the distended
lacrymal sac.
4. <( Suppuration in the frontal sinus is attended with
frontal headache, vertigo, especially on stooping, and
319
MEDICAL RECORD.
tenderness on pressure, particularly over the internal
orbital angle, or on percussion over the frontal region.
Pus escapes into the middle meatus of the nose, and if
wiped away will reappear if the head is bent forward
for a few minutes. After removal of the anterior end
of the middle turbinated bone it may be possible to
catheterize the sinus and wash out pus from its interior.
The diseased sinus may present a darker shadow than
the healthy one on transillumination or in an a?-ray
photograph. The treatment consists in exposing the
anterior wall of the sinus by an incision in the line of
the eyebrow, chiseling away sufficient bone to admit of
free removal of all infected tissue and establishing ef-
ficient drainage through the infundibulum into the
nose." — (Thomson and Miles' Manual of Surgery.)
5. Aphonia is loss of voice due to some interference
with the vocal cords. Causes : Laryngitis, edema of the
glottis, retropharyngeal abscess, excessive use of the
voice, tumors of the larynx, foreign bodies in larynx,
inflammation of the laryngeal nerves, paralysis of the
laryngeal muscles, and hysteria.
6. "Hyperemia of the labyrinth may result from middle
ear inflammation, exanthematous diseases, mumps, some
intracranial disease, cessation of menstruation, disease
of the heart, excessive use of alcoholic liquors, quinine,
amyl nitrite, prolonged irritation from the use of the
telephone receiver and vasomotor disturbances. Symp-
toms: There is present a sense of fullness in the ear,
with ringing and roaring sensations and sometimes
giddiness, nausea and vomiting. The symptoms are
somewhat intensified by the horizontal position." —
(Kyle's Diseases of Ear, Nose and Throat.)
7. Rupture of the membrana tympani may be caused
by direct violence, such as blows or by instruments in-
troduced into the meatus ; or by indirect violence, such
as the sudden condensation of air in the meatus, which
may be produced by an explosion or the firing of a
heavy gun in the immediate neighborhood; traction on
the auricle, inflammation, irritating substances, and
vegetable growths may also cause rupture of the mem-
brane. Symptoms: Sudden and severe pain, impaired
hearing, hearing subjective noises, vertigo, a watery
discharge in the meatus, a whistling sound in the ear
when the patient blows his nose.
8. Acute circumscribed otitis. — The symptoms are a
feeling of fullness in the ear, a slight itching sensation,
pain in the ear with tenderness on pressure, swelling in
the auditory meatus which causes stenosis and slight
deafness, tinnitus, pain on mastication, and increase of
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the pain and discomfort; the neighboring lymphatics
may become involved, in which case there will be rise
of. temperature to about 100 c to 101 ' F. There may
be slight constitutional symptoms,
9. Postnatal adenoids. Symptoms: Mouth breath-
ing; snoring; open mouth; a vacant, dull expression of
the face; modification of the voice (nasal twang), with
inability to pronounce certain letters.
Treatment consists in early and complete removal by
curette or forceps.
10. Intubation. Indications. Dyspnea from diph-
theria or membranous laryngitis, stenosis, tumors, and
some forms of paralysis of the larynx, and edema of
the larynx.
Method: The child is wrapped in a blanket to control
the arms and legs and is held upright by a nurse seated
in a chair, while an assistant holds the head upon the
nurse's -left shoulder and prevents the mouth gag from
slipping. A long piece of silk is passed through the
small opening in the upper part of the tube, the tube
fastened to the introducer, and the silk looped around
the little finger. The left index linger is passed into
the throat and lifts the epiglottis while the tube is
passed along it into the glottis. The left index finger is
then made to press upon the head of the tube, which is
released by pulling the trigger on the introducer, which
is then withdrawn. When one is assured that the tube
is in the right place and that the symptoms are re-
lieved, the silk loop may be cut and withdrawn while
the finger is again made to press down on the tube. —
(Stewart's Surgery.)
etiology and physical diagnosis.
1. Etiology of vertigo. — Eyestrain or paresis of one
or more of the muscles of the eye, disease of the semi-
circular canals, dyspepsia, constipation, disordered
hepatic function, migraine, excesses (in the way of
exercise, alcohol, tobacco, tea, coffee), organic diseases
of the brain and disturbances of the cerebral circula-
tion.
2. Varicose ulcers of the leg are caused by some in-
jury to a varicose vein; the tissues are edematous,
poorly nourished, and have diminished resisting power.
The injury may be very slight, but the poorly nourished
tissues break down and an ulcer results. Bad hygienic
surroundings and neglect are predisposing factors.
3. Etiology of rachitis. — Improper food, want of sun-
light, improper hygienic conditions; generally, insuffi-
cient food, with the diet deficient in fats and proteins;
321
MEDICAL RECORD.
recently, lack of mineral constituents and vitamines has
been advocated as a cause of rickets.
4. Etiology of lung abscess. — Lobar pneumonia; lobu-
lar pneumonia; pyemia; trauma; rupture into the lung
of suppuration in neighboring tissues, such as em-
pyema, subphrenic acid, gastric ulcer, cancer of eso-
phagus.
5. The most probable factors in the causation of gall-
stones are: Bacteria; inflammation of gall-bladder and
ducts ; stagnation of bile. The predisposing factors are
age, sedentary occupations, and some specific fevers,
such as typhoid.
6. The diagnosis of Graves' disease is made by the
tachycardia, exophthalmos, goiter, and intentional
tremor; in addition there may be widening of the pal-
pebral fissure and failure of the upper lid to follow the
eyeball when it is rolled downward.
7. Diagnosis of psoriasis. — The patches are chiefly on
the extensor aspect of the limbs, especially on the elbows
and knees; the borders of the patches are well defined;
the scales are white and adherent to the crusts ; there is
no inflammatory exudation; on removal of the crusts
red, bleeding points are visible.
8. In spontaneous intracerebral hemorrhage {apo-
plexy). — "Usually the onset is sudden, the patient be-
coming unconscious and deeply cyanosed. After the
irritation stage, which occurs during the bleeding, has
subsided paralysis of the opposite side of the body sets
in with conjugate deviation, and often hemianesthesia.
The muscles of the affected side lose tone, as is shown
by raising the limbs. The reflexes are lost, but return
with consciousness; Babinski's sign is present. The
pupils vary ; they may be contracted, dilated, or unequal,
in which case the larger pupil is on the affected side.
Various localizing signs may be present, according to
the position of the hemorrhage. The temperature is
normal or subnormal. Urine and feces are passed in-
voluntarily. The pulse is full and slow and the breath-
ing is stertorous. A lumbar puncture yields a fluid
containing blood or altered blood. Within forty-eight
hours of the onset the stage of reaction sets in. The
temperature rises, the sphincters become normal and
the reflexes return. Early rigidity, in which the
muscles resist flexion and extension, may sometimes de-
velop."— (Woodwark's Manual of Medicine.)
9. Rales may be dry or moist. Dry rales occur in
bronchitis and asthma and may be low pitched snoring
sounds (sonorous rales) or high pitched whistling
sounds (sibilant rales). Moist rales are produced by
822
KENTUCKY.
the passage of the air through liquid and may be crepi-
tant, subciepitant, or gurgling in character. Crepitant
rales are extiemeiy fine and occur at the end of inspira-
tion; they are heard in the first stage of pneumonia
and in engorgement and edema of the lungs. Subcrepi-
tant rales are comparatively few in number and are
heard during inspiration and expiration, in capillary
bronchitis, pulmonary edema, hypostatic pulmonary
congestion and incipient phthisis. Gurgling rales may
be large or small and are heard during inspiration and
expiration in phthisical cavities, bronchial hemorrhage,
in the stage of secretion in bronchitis and over the
trachea.
10. Aortic regurgitation is diagnosed by: A diastolic
murmur heard best over the aortic area ; the pulse is
peculiar, being the Corrigan or water hammer pulse;
the heart beat is strong and the precordium may bulge;
the carotid, bronchial, and femoral arteries may pulsate
violently; the apex beat is displaced outward, owing to
the hypertrophy of the left ventricle.
PRACTICE AND MATERIA MEDICA.
1. (a) Lobar pneumonia is caused by the Micrococcus
lanceolatus (or Diplococcus pneumoniae) ; Friedlander's
pneumobacillus is often found. Predisposing causes are
exposure to draughts or inclement weather, intemper-
ance and winter weather.
Physical signs of lobar pneumonia. — u Inspection re-
veals during the first stage deficient movement of the
affected side, due to pain. The apex beat is normal in
situation and the interspaces do not bulge. In the sec-
ond stage the healthy side rises normally, the affected
side lagging behind. If both lower lobes are impervious
to air, the diaphragm cannot descend and the epigas-
trium does not project during inspiration, the breath-
ing being conducted by the upper part of the chest
(superior costal respiration). Palpation during the
first stage shows the vocal fremitus to be more distinct
than normal, especially over the diseased portions. In
the second stage, the vocal fremitus is markedly exag-
gerated, except in those rare instances of occlusion of
the bronchi by secretion. The cardiac impulse is felt in
the normal position. Percussion : In the first stage, the
percussion note is slightly impaired at times, having a
hollow or tympanitic quality. In the second stage there
is dullness over the . affected parts, with an increased
sense of resistance. Over unaffected adjoining areas
the resonance is increased (Skoda's resonance). Auscul-
tation : In the first stage there is heard over the af -
323
MEDICAL RECORD.
fected part a feeble vesicular murmur, associated with
the true vesicular or crepitant (crackling) rale, heard
at the end of inspiration only. In the second stage
there is harsh, high pitched, bronchial respiration, at
times resembling a to-and-fro metallic sound, except in
those rare instances in which the bronchi are more or
less filled with secretion. Bronchophony, or distinctly
transmitted voice, is present and at times pectoriloquy,
or distinct transmission of articulated sounds, may be
heard. In the third stage, the breathing changes from
bronchial to bronchovesicular and the crepitant rale
(crepitatio redux) returns. As resolution proceeds the
breath sounds are associated with large and small moist
and bubbling rales. — (Hughes' Practice of Medicine.)
(b) There are three stages: (1) Hyperenia or en-
gorgement; (2) red hepatization or exudation; and (3)
resolution or gray hepatization.
(c) Treatment. — Consists in rest in- bed, milk diet and
the administration of fractional doses of calomel fol-
lowed by a saline in the early stage. The nervous
symptoms and temperature may be controlled by apply-
ing ice bags or compresses wrung out of cold water
(60°-70° F.) to the chest or by the use of the warm
or cold wet pack. The heart and pulse should be sus-
tained by the administration of alcohol, strychnine (gr.
1/60-1/20), atropine, caffeine, strophanthus, and nitro-
glycerin. Digitalis may also be employed. Inhalations
of oxygen afford temporary relief when the dyspnea
and cyanosis are extreme. In young, vigorous and ple-
thoric adults, with hyperpyrexia and a high tension
pulse, bleeding may be beneficial in the first 48 hours.
Convalescence should be guarded, and tonics, stimulants,
etc., will be found very useful in this period of the dis-
ease. — (Pocket Cyclopedia.)
(d) Serum or vaccine treatment is considered a
specific by some authors.
2. (a) Children may suffer from lobar pneumonia,
lobular or bronchopneumonia and hypostatic pneumonia.
(b)
LOBAR PNEUMONIA.
Generally a primary dis-
ease.
Age has little influence.
Sudden onset.
Fever is high and regular.
BRONCHOPNEUMONIA.
Generally secondary (to
bronchitis or an infec-
tious disease) .
Generally found in very
young or very old.
Gradual onset.
Fever is not so high, and
is irregular.
KENTUCKY.
LOBAR PNEUMONIA. BRONCHOPNEUMONIA.
Ends by crisis between I Ends by lysis, at no par-
sixth and tenth day. ticular date.
Generally only one lung ! Generally both lungs af-
affected. fected.
The physical signs are \ Physical signs indistinct,
distinct, and there is a I and the evidences of
large area of consolida- j consolidation are in-
tion.
Sputum is rusty.
definite.
Sputum is rather streaked
with blood.
The symptoms of hypostatic pneumonia are those of
a low grade lobar pneumonia.
For treatment of lobar pneumonia see question 1.
Treatment of bronchopneumonia. — Absolute rest in
bed and a nutritious diet; the chest should be enveloped
in a thick cotton jacket; the temperature of the room
should be equable— about 65° or 70° F. If the bowels
are inclined to be constipated, fractional doses (gr. 1/6)
of calomel are advisable every hour until six or seven
doses have been taken. In the earliest stages the tinc-
ture of aconite is of service. Its action should be cau-
tiously watched, and as soon as the pulse becomes soft
the drug may be omitted. Usually six or seven doses
are sufficient. After the second or third day its action
is too depressing and is not recommended. If the tem-
perature rises above 102.4° F. it should be reduced by
means of a cold bath. Phenacetin may be given to con-
trol the temperature, but should not be used routinely.
After the third or fourth day a flaxseed poultice con-
taining mustard (3 1%) may be applied to the chest
and renewed every hour. After the poultice has re-
mained on the chest about two hours give the syrup of
ipecacuanha (v® 15) every ten minutes until emesis is
produced. Both these procedures should be repeated
on the following day. When the poultice is removed
replace it by a cotton jacket. If the heart is weak give
cardiac stimulants. — (Pocket Cyclopedia.)
The treatment of hypostatic pneumonia is that of the
original condition, with the addition of stimulants (such
as nitroglycerin or strychnine) ; their position in bed is
to be frequently changed.
3. (a) Hookworm disease is a severe malady in the
South, characterized by profound anemia, protruding
abdomen, dropsy, weakness, lack of energy, shortness of
breath, and maldevelopment.
(6) It is caused by the Ankylostoma duodenale or the
Necator Americanus.
325
MEDICAL RECORD.
(c) The ova arc voided in the feces; the latter are
scattered on the ground, and the ova then come in con-
tact with the feet and hands of the poorer inhabitants,
and are then conveyed to the month.
(d) and (c) Thymol is the new remedy. Treatment
(Prophylactic) — Shoes should be worn, and proper toilet
facilities should be provided. Indiscriminate scattering
of fecal matter is responsible for the prevalence of the
disease, and the most stringent rules should be adopted
to correct this unhygienic nuisance. Flies should be ex-
cluded. Treatment (Active) — On the day before the
treatment is to be begun the patient is advised to eat
little dinner and no supper at all. Late in the afternoon
he is given a full dose of calomel (2 to 10 grains, de-
pending upon the age and strength of the patient). If
the calomel does not act freely during the night a full
dose of Epsom salt in hot water should be given as soon
as the patient wakes up the next morning. After the
bowels have thoroughly acted, finely powdered thymol
in capsule is given. The dose of thymol should be di-
vided into two equal parts, the first half being given at
once and the second at the expiration of an hour. Fol-
lowing the administration of the medicine the patient
should be instructed to remain in bed. Harris suggests
that the drug should be given in the following quan-
tities:
Up to 5 years of age, 10 to 15 grains.
From 5 to 10 years, 15 to 30 grains.
Ten to 15 years, 30 to 60 grains.
Fifteen and over, 60 to 120 grains.
In advanced age the quantity should be somewhat les3
than during middle life. The patient should be allowed
no breakfast and no dinner on the day of treatment, a
cup of coffee once or more during the day is permissible,
but nothing in the nature of food. If the patient ex-
periences no ill effects from the thymol, it is well to put
off the administration of a laxative until four or five
o'clock in the afternoon, at which time some saline
should be administered in hot water. After the bowels
have acted well the patient may be allowed to have food.
When the treatment is carried out faithfully it is rarely
necessary to repeat it. It is well after a couple of
weeks to again make a thorough examination of the
feces, and should the microscope reveal the presence of
eggs the treatment should be repeated, and this should
be done over and over again until exhaustive examina-
tions of the feces show by absence of the eggs of the
parasite that all have been expelled. The public should
be especially warned against patent and proprietary
326
KENTUCKY.
medicines for hookworm disease, as they all have as a
basis thymol, or some other poisonous drug, and are
therefore unsafe in the hands of those unacquainted
with their proper use. — (Pocket Cyclopedia.)
(/) Hookworm may simulate pernicious anemia.
4. (a) Acute indigestion is characterized by: Nausea;
vomiting of undigested, or partly digested, sour-smell-
ing matter, which later assumes a bilious character;
pain and tenderness in epigastrium; anorexia; some-
times severe cramps or burning pain in abdomen ; tem-
perature normal ; pulse accelerated ; sometimes prostra-
tion and cold perspiration. It is to be differentiated
from Appendicitis, in which the greatest tenderness
is in the right iliac fossa, and right-rectus muscle, is
often rigid, and a leucocytosis may be present.
Cholelithiasis, in which the pain is paroxysmal, and is
referred to the region of the right shoulder, emaciation
and jaundice may be present, and there may be a his-
tory of such attacks. Intestinal obstruction, in which
the prostration is more marked, there is absolute
o^stination, tympanites, and uncontrollable vomiting
which becomes stercoraceous. Uremia, in which a
uranalysis shows albumin, and diminished urea, and the
blood pressure is high.
Treatment — Evacuate stomach and bowels; give an
emetic (a hypodermic of apomorphine hydrochloride)
or use a stomach tube. Then give divided doses of
calomel followed by castor oil or a saline. Apply heat
externally to the abdomen. The stomach must be kept
at rest and no food given for from 12 to 24 hours;
during this time small sips of very hot water may be
allowed. Later, light diet for a few days. For the
vomiting, bismuth subnitrate, or creosote, or phenol
may be administered.
(b) Opiates may be administered for severe pain
which is uncontrolled by the foregoing remedies; but
one must be sure that the case is not one of appendi-
citis, intestinal obstruction, or uremia. Codeine sulphate.
or morphine sulphate with atropine sulphate may be
given, (c) By hypodermic injection.
.5".
ACUTE PAREN-
CHYMATOUS
NEPHRITIS.
1. Most common
in children, from
exposure or in-
fectious fevers.
CHRONIC PAREN-
CHYMATOUS
NEPHRITIS
1. Later life ;
often the conse-
quence of acute
attack.
327
CHRONIC INTER-
STITIAL.
NEPHRITIS.
1. Late life; of-
ten results from
alcoholism, gout,
lead-poisoning.
MEDICAL RECORD.
ACUTE PAREN-
CHYMATOUS
NEPHRITIS.
2. Edema of low-
er eyelids; then
of upper ex-
tremities, trunk,
and, lastly, low-
er extremities.
3. Urine scanty,
dark or smoky
color, high
specific gravity,
1025 or over.
4. Large amount
of albumin.
6. Variety of
casts, such as
hyaline, blood,
epithelial, and
waxy casts, also
free red blood
globules, and
epithelial cells.
6. Urea dimin-
ished.
7. Recoveries fre-
quent.
CHRONIC PAREN-
CHYMATOUS
NEPHRITIS,
2. In early stage
same as acute
form; later,
dropsy may di-
minish.
3. Urine normal
or increased
amount; specific
gravity may fall
to 1010; urine
pale.
4. Late in attack,
greatly dimin-
ished ; occasion-
ally absent.
5. Large and
small granular
casts; compound
granule cells,
and fatty epi-
thelium.
6. Urea dimin
ished.
7. Recoveries!
rare.
CHRONIC INTER'
STITIAL
NEPHRITIS.
2. Dropsy slight
or entirely ab-
sent.
3. Urine greatly
increased ; spe-
cific gravity low,
1005; urine pale
in color.
4. Albumin great-
ly diminished,
often absent.
5. Hyaline or
finely granular-
casts, occasion
ally dark in
color: infre-
quently blood
casts and oil
droplets.
6. Urea dimin
ished.
7. Indefinite dur-
ation, but never
cured.
The treatment of acute nephritis consists largely in rest
in bed, warmth, milk diet, and attempts at elimination of
waste products. Free purgation should be secured by
means of the salines, calomel, or compound jalap pow-
der. Diaphoresis may be favored by the administration
of sweet spirits of niter, and in severe cases, pilocarpine,
and by the use of warm baths, warm applications, or
the vapor bath. Tincture of digitalis (tie 5-20 every
4 hours), tincture of strophanthus, or sparteine (gr. Vt-
1 At) may be given as diuretics. Infusion of cream of
tartar and juniper berries may be employed. The oc-
currence of uremia will require prompt and energetic
measures.
The treatment of chronic parenchymatous nephritis
consists in rest, regulated diet, and the administration
328
KENTUCKY.
of tonics. The diet should be made up of milk, vege-
tables, rice, and a small amount of meat, fish, and eggs.
Iron, quinine, and strychnine are indicated, Constipa-
tion should be avoided by the administration of the
salines. Bathing and massage are important items in
the treatment. Uremia may occur in this affection.
The treatment of chronic interstitial nephritis should
be directed to the cause, and in addition the diet and
hygiene should receive attention. The food should be
largely of milk, vegetables, and fruit. High arterial
tension should be controlled by nitroglycerin and
aconite. The bowels should be always kept free.
Diuretics are not indicated so long as secretion is free.
The recurrence of uremia will require special treat-
ment. (Pocket Cyclopedia.)
6. (a) Whatever therapeutic value radium may pos-
sess is due to its radioactivity. It has been claimed
that radium emanation is of value in all kinds of non-
suppurative arthritis (except luetic and tuberculous),
in chronic muscular and joint rheumatism, in arthritis
deformans, in acute and chronic gout, in neuralgia,
sciatica, lumbago, and in tabes dorsalis for the relief
of pain. Its chief value is in the relief of pain. In
certain new growths, both benign and malignant, a
favorable influence is exerted; so, too, in epithelioma,
birthmarks, and scars. (From New and Nonofficial
Remedies.)
(b) Digitalis is indicated in diseases of the heart:
(1) When the heart action is rapid and feeble, with
low arterial tension; (2) in mitral lesions when com-
pensation has begun to fail; (3) in non valvular cardiac
affections; (4) in irritable heart, due to nerve exhaus-
tion. Digitalis is contraindicated in diseases of the '
heart: (1) in aortic lesions when uncombined with
mitral lesions; (2) when the heart action is strong, and
arterial tension high. Digitalis is also a diuretic; and
it is also used in some forms of nephritis, exophthalmic
goiter, pneumonia, chronic bronchitis, etc. Dangers:
Overdose or constant use will cause irregularity of the
heart, headache, vomiting; and hobbling dicrotic pulse,
particularly when the patient changes from the recum-
bent to a sitting posture.
7. Specifics: (1) Mercury is said to be specific for
syphilis; it is said to exterminate the treponema; the
administration of mercury should begin early in the
disease and be continued for two or three years. It
may be administered by intramuscular injection, by
inunction, or in combination with potassium iodide.
(2) Quinine is specific for malaria; a ten grain dose
329
MEDICAL RECORD.
of sulphate of quinine should be given in the sweating
stage, and again five hours before the next paroxysm
is expected.
(3) Diphtheria antitoxin is specific for diphtheria;
the prophylactic dose for children is 500 to 1,000 units,
by hypodermic injection; the. therapeutic dose is 2,000
to 4,000 units.
8. (a) To avoid salivation, give small doses of
calomel, carefully watch the effect, and let the patient
use a mouth-wash of a saturated solution of potassium
chlorate with a little tincture of myrrh.
(b) The usual dose of calomel is about one grain as
an alterative, or two grains as a laxative.
(c) Divided doses are recommended.
9. (a) Castor oil may be rendered tasteless by being
administered in capsules; or by being floated on orange
juice or strong coffee, and covered with the same
vehicle.
(6) In typhoid, turpentine stupes may be placed on
the abdomen, or a few drops may be given on a lump
of sugar, or it may be given by enema, in emulsion.
10. The administration of quinine would differentiate
typhoid from malaria. See question 7, above.
OBSTETRICS AND GYNECOLOGY.
1. (a) The female internal organs of generation are:
The ovaries, Fallopian tubes, uterus, and vagina.
(6) Function of ovaries: To develop ova, and an
internal secretion.
Function of Fallopian tubes: To carry ova to the
uterine cavity.
Function of uterus: To receive and lodge the fe-
cundated ovum; to retain the fetus till it is mature,
then to expel it.
Function of vagina: During coitus it receives the
penis; during parturition it becomes part of the birth
canal ; it also serves as a channel for the escape of the
menstrual and other uterine secretions.
2. (a) Podalic version is that form of version in
which the breech or foot of the fetus is made to pre-
sent.
(b) Cephalic version is that form of version in which
the head of the fetus is made to present.
3. (a) Adherent placenta is probably due to some
diseased condition of the endometrium, resulting in in-:
flammation of the decidua or placenta. The diseased
condition probably antedates pregnancy. There may
be partial absence of the decidua serotina, so that the
chorionic villi are in direct contact with the uterine
muscle.
380
KENTUCKY.
(b) Treatment of adherent placenta: "A finger — one
or two — must be insinuated between the uterus and
placenta at some point already partially separated, or,
if no partial separation exist, at a point where the pla-
cental border is thick, and then passed to and fro trans-
versely through the uteroplacental junction, acting like
a sort of blunt paper knife, until separation be com-
plete. Another mode is to find or make a margin of
separation as before, and then peel up the placenta
with the finger-ends, rolling the separated portion
toward the palm of the hand upon the surface of the
still adherent part. Great care is necessary to avoid
peeling up an oblique layer of uterine muscular fiber,
which might split deeper and deeper until leading the
finger-ends through the uterine wall into the peritoneal
cavity. Should such a splitting begin, leave it alone
and recommence the separation at some other point on
the placental margin. It is sometimes only possible to
get the placenta away in pieces. These should be after-
ward put together and examined to indicate what rem-
nants are left behind. It may be quite impracticable to
get out every bit, but small remnants or thin layers too
firmly adherent for removal do not distend the womb
enough to create hemorrhage from their bulk, and the
subsequent danger of septicemia from their decomposi-
tion may be obviated by injecting warm (2 per cent.)
creolin water into the uterus twice daily until every-
thing has come away." (King's Obstetrics.)
4. Symptoms of pregnancy at the fifth month: Ces-
sation of menstruation, quickening, mammary signs
with secondary areolae, enlarged and pigmented abdo-
men, intermittent uterine contractions, active fetal
movements, uterine souffle, and (possibly) the fetal
heart sound.
5. Changes that take place in the female at puberty:
Development of the reproductive organs, enlargement
of the breasts, hair on pubis and axilla; the form be-
comes rounded, the hips widen, menstruation occurs;
there are certain mental and emotional changes: and
"the development of those womanly beauties physiolog-
ically designed to attract the male."
6. Severe ante vcirtum hemorrhage is most likely to
be due to (1) accidental hemorrhage, due to premature
separation of the placenta; (2) to placenta prsevia.
The treatment is practically the same in each case,
namely, to check the hemorrhage and promote delivery.
In accidental hemorrhage the membranes should be rup-
tured and the vagina packed, or accouchement force
performed ; vaginal cesarean section has been employed.
331
MEDICAL RECORD.
In placenta prasvia: (1) Introduce one or two fingers
within the os (the hand being in the vagina) and dis-
sect the placenta from the uterine wall for about 3
inches from the os uteri in all directions, pushing it to
one side if necessary. (2) Rupture the membi'anes, and
if there is an unfavorable presentation turn the child
and make the breech engage in the os ; or if the head
presents, forceps may be used if speedy delivery is nec-
essary. The strength of the woman is then the main
point to be cared for, and if in a reasonable time the
uterus seems to be incompetent, the child may be de-
livered by art. In some cases of central placenta
praevia, where rapid delivery is required, cesarean sec-
tion may give good results for mother and child.
7. (a) An ovarian cyst is generally accompanied by
menorrhagia or metrorrhagia, sterility, bearing-down
pain in the pelvis, which may radiate to the back or
thighs, hemorrhoids or constipation, frequent micturi-
tion, and various other pressure symptoms of the di?
gestive or respiratory apparatus if the cyst becomes
sufficiently large. Later on there may be the fades
ovariana, general impairment of health, and ascites.
There are no pathognomonic symptoms. The diagnosis
is made by bimanual palpation and (sometimes) ex-
ploratory incision. The condition is to be particularly
differentiated from pregnancy and ascites.
(b) The treatment is ovariotomy.
(c) No other method of treatment produces any
beneficial effect.
8. An ulcer of the cervix presents a clear-cut border,
sometimes raised and indurated, and the base of the
ulcer is formed by granulation tissue; the cervix has
lost some of its epithelial covering. It may be caused
by irritation from pessary or discharge, chancroid in-
fection, syphilis, tuberculosis, or malignant disease.
The chief symptoms are pain, discharge, and hemor-
i-hage. By many ulcer of the cervix is regarded as the
precursor of epithelioma or carcinoma.
9. (a) Menopause is the period of a woman's life
when menstrual activity ceases.
(b) Metritis is inflammation of the uterus.
(c) Salpingitis is inflammation of the oviduct, or
Fallopian tube.
(d) Mastitis is inflammation of the mammary gland.
(e) Menstrual cycle is the series of changes occur-
ring in the uterus during the interval between the com-
mencement of one menstrual period and that of the
next following.
10. (a) Immediately after birth the eyelids of the
332
LOUISIANA.
newborn child should be washed with clean warm water
and onto the cornea of each eye should be dropped one
or two drops of a 1 or 2 per cent, solution of nitrate
of silver.
(6) This procedure will prevent ophthalmia neona-
torum in doubtful cases; it will do no harm in inno-
cent cases; and it is the first stage in treatment if gon-
orrheal infection is present.
STATE BOARD EXAMINATION QUESTIONS.
Louisiana State Board of Medical Examiners.
ANATOMY.
1. What bones form the roof of the orbit?
2. Name the carpal bones that articulate with the
radius.
3. Name and bound the triangles of the neck.
4. What muscles are inserted into (a) the outer
ridge, (6) the inner ridge, of the bicipital groove?
5. Name the principal branches of the external
carotid.
6. How is the jugular foramen formed? What im-
portant structures pass through it?
7. Name (a) the sensory, (b) the motor, nerves of
the tongue.
8. Give origin and function of spinal accessory nerve.
9. Describe briefly the blood supply of the intestines.
10. What important structures are found between
the layers of the broad ligament?
PHYSIOLOGY.
1. Describe the character of contractions observed
(a) in striated muscles, (b) in non-striated muscles;
give examples of each.
2. Give one example of a (a) nitrogenous food, (b)
carbonaceous food, (c) carbonitrogenous food; state
what part each plays in nutrition.
3. Where, and how, are the nitrogenous foods
digested?
4. Give the distribution and functions of (a) the
hypoglossal nerve, (6) the spinal accessory nerve, (c)
the superior laryngeal nerve.
5. What is the vasomotor system, and how does it in-
fluence the blood supply of the body?
6. Name the chief waste products of proteid met-
abolism, and state where they are formed.
7. State the functions of the (a) anterior nerve-
roots of the spinal cord, (6) the posterior nerve-roots
of the cord.
333
MEDICAL RECORD.
8. What factors are concerned in the heart sounds
(a) in diastole, (b) in systole?
9. State briefly the influence on the body tempera-
ture of (a) muscular work, (6) mental work, (c) age,
(d) sleep.
10. Give briefly the action of (a) trypsin, (6) lipase,
(c) succus entericus.
CHEMISTRY.
1. What is understood by the conservation of energy,
and give an example.
2. What are the special characteristics of alkaloids
in general; name three alkaloids.
3. Give examples of (a) oxides, (b) hydroxides, (c)
normal salts, (d) basic salts. These can be stated
either in ordinary language or by f ormulse.
4. Describe the contact method in testing for albumin
in the urine.
5. What is the chemical composition of human milk?
6. What is ptyalin and explain its action?
7. What is hemoglobin ; state some of its chief prop-
erties?
8. Give the most reliable chemical test for detecting
blood.
9. What are the general properties of proteins?
10. Name two biliary pigments and by what test can
they be recognized?
MATERIA MEDICA.
1. Name three emetics and give dose of each.
2. Give source and average dose of atropine.
3. How much opium is there in the following prepa-
rations : Pulvis ipecacuanhas et opii ; tincture opii cam-
phorata.
4. Give the composition of lotio hydrargyri nigra.
5. How is nitroglycerin prepared? What precau-
tions should be taken in handling it, and in what doses
would you give it?
6. What is eserin? Give the average dose.
7. Write a prescription for a diuretic mixture.
8. Give dose properties and uses of santonin.
9. What action has ergot on the circulation; on the
muscles? What is the dose of the fluid extract?
10. What is emetine? What is its dose and what is
its action?
PATHOLOGY.
1. Explain the difference between secretion and ex-
cretion, giving example of each.
2. Give the difference between exudate and transu-
date, with an example of each.
3. Pus is the result of what?
334
LOUISIANA.
4. Define atrophy. Give the varieties of atrophy.
5. What is an embolus; how formed, and state some
of the sequels of embolism.
6. Give the pathology in gonorrheal arthritis:
7. What is the difference between stock vaccine and
autogenous vaccine?
8. Describe the Amoeba coli, and give method most
used in the examination for the Amoeba coli.
9. Describe a Paget's cancer, and where most found?
10. Describe a Charcot's joint.
THEORY AND PRACTICE OF MEDICINE.
1. Name five reflexes, and describe the manner of
eliciting them.
2. State the symptoms, diagnosis, and treatment of
amebic dysentery.
3. (a) What is the import of hematuria? (b) What
conditions may give rise to it? y
4. State the diagnostic value of a blood count. \^
5. Treat a case of endocarditis complicating rheu-
matic fever.
6. Differentiate acute morphinism, acute alcoholism,
and apoplexy.
7. Treat a case of pernicious malaria.
8. Outline briefly the dietetic management of a case
of chronic nephritis.
9. State the diagnosis and treatment of impetigo
contagiosa.
10. (a) Describe locomotor ataxia; (6) state briefly
the symptoms and physical signs in the initial and
ataxic stages.
OBSTETRICS.
1. Name and describe the signs of pregnancy as de-
termined by touch.
2. State the diagnosis and treatment of an inevitable
abortion.
3. Diagnose by abdominal palpation and vaginal
touch an R. 0. P. presentation.
4. (a) What is the second stage of labor? (6) What
conditions may cause delay in this stage? (c) How
should such conditions be managed?
5. A primipara at the fourth month of pregnancy
presents evidences of albuminuria, with no uremic
manifestations; what treatment is indicated?
6. Should delivery become imperative, the head being
only partially engaged, and the cervix partially dilated,
how is delivery best effected?
7. (a) What is prolapse of the funis? (b) What
the dangers? (c) Management?
8. (a) What conditions would necessitate artificial
335
MEDICAL RECORD.
feeding? (6) Describe the proper modification of
cow's milk for the newly born.
9. (a) What drugs are of use in labor? (6) State
their indications and contraindications.
10. (a) State the maternal and fetal indications for
the use of forceps, (b) What are the prerequisites
necessary for their safe application?
GYNECOLOGY.
1. Mention the changes of cervix uteri which may be
felt on vaginal examination.
2. Give differential diagnosis of syphilitic, tubercu-
lous, and malignant ulcer appearing about the external
genitals.
3. Give the principal points of diagnostic importance
in connection with an abdominal examination.
4. A patient presenting herself for examination with
a mass in right lower abdomen — what might it be?
5. Give special symptoms pointing to tubal preg-
nancy.
6. Of what use is the uterine sound?
7. What symptoms may follow retroversion of the
uterus?
8. Name the causes of dysmenorrhea.
9. Why is gonorrhea in women a grave disease?
10. What is a urethral caruncle, and its treatment?
SURGERY.
1. Describe briefly the technique you would employ
for a punctured wound of the foot caused by a pitch-
fork.
2. Give symptoms and treatment of acute catarrhal
otitis media.
3. Differentiate between trachoma and conjunctivitis.
4. What is a carbuncle? How would you treat one?
5. Differentiate between typhoid fever and appends
citis.
6. What arteries need ligating in an amputation at
the middle third of the leg?
7. What part of the vertebrae is usually affected in
Pott's disease. Describe the pathological changes that
take place.
8. Give diagnosis and treatment of acute osteomye-
litis.
9. Name some of the bacteria of suppuration. W y hich
ones are the most virulent?
10. Make a differential diagnosis between coma due
to (a) injury, (b) apoplexy, (c) opium poisoning, (d)
acute alcoholism.
336
LOUISIANA.
PHYSICAL DIAGNOSIS.
1. Name the various abnormal respiratory sounds
(rales), and indicate the physical conditions giving ris«
to each.
2. Differentiate pulmonary hepatization and pleurisy
with effusion.
3. Differentiate impacted stone in the right ureter
from other similar conditions.
4. What are the physical signs of pyloric stenosis?
5. What are the early symptoms and physical sign*
in pulmonary tuberculosis?
HYGIENE.
1. Name and describe briefly the methods of purifica-
tion of public water supply.
2. (a) What is natural immunity? (b) Acquired
immunity? Explain each.
3. Describe the disinfection of a room occupied by a
careless consumptive.
4. State briefly the sanitary supervision necessary
for the production of pure milk.
5. How are mortality rates calculated?
ANSWERS TO STATE BOARD EXAMINATION
QUESTIONS.
Louisiana State Board of Medical Examiners.
anatomy.
1. Bones forming the roof of the orbit: Frontal and
sphenoid.
2. Carpal bones that articulate with the radius:
Scaphoid and semilunar.
3. The anterior triangle of the neck is bounded:
In front by a line from the chin to the sternum ; behind
by the anterior margin of the sternomastoid ; base is
upward, and is formed by the lower border of the body
of the lower jaw and a line from the angle of the jaw
to the mastoid process. It is divided into three smaller
triangles (inferior carotid, superior carotid, and sub-
maxillary) by the digastric muscle and the anterior
belly of the omohyoid. The inferior carotid triangle
is bounded, in front by the median line of the neck;
behind, by the anterior margin of the sternomastoid;
and above, by the anterior belly of the omohyoid. The
superior carotid triangle is bounded, behind by the
sternomastoid; below by the anterior belly of the
omohyoid ; and above by the posterior belly of the digas-
337
MEDICAL RECORD.
trie. The submaxillary triangle is bounded, above by
the lower border of the body of the mandible and a line
drawn from its angle to the mastoid process; below,
by the posterior belly of the digastric and the stylo-
hyoid; and in front, by the anterior belly of the digas-
tric,
The posterior TRIANGLE OF the neck is bounded: In
front by the sternomastoid; behind, by the anterior
margin of the trapezius: and its base corresponds to
the middle third of the clavicle. It is divided into two
smaller triangles (the occipital and the subclavian) by
the posterior belly of the omohyoid. The occipital tri-
angle is bounded in front, by the sternomastoid; behind,
by the trapezius; and below, by the omohyoid. The
subclavian triangle is bounded above, by the posterior
belly of the omohyoid; below, by the clavicle; and in
front, by the sternomastoid.
4. To the outer bicipital ridge is attached the Pec-
toralis major; to the inner bicipital ridge is attached
the Teres major.
5. Branches of the external carotid artery: Superior
thyroid, lingual, facial, occipital, posterior auricular,
ascending pharyngeal, superficial temporal, and in-
ternal maxillary.
6. The jugular foramen is formed by the temporal
bone in front and externally, and the occipital bone
behind and internally; it transmits: The inferior
petrosal sinus, lateral sinus, meningeal branches of
occipital and ascending pharyngeal arteries, and the
glossopharyngeal, vagus, and spinal accessory nerves.
7. TONGUE. Sensory nerves: Lingual branch of the
inferior maxillary division of the trigeminal (ordinary
sensation to anterior two-thirds), chorda tympani
(nerve of taste for anterior two-thirds), glosso-pharyn-
geal (general sensation and taste to posterior third).
Motor nerve : Hypoglossal.
8. Spinal accessory nerve. Superficial origin:
From the lateral tract, inferior to the pneumogastric ;
and from the side of the spinal cord as far down as the
sixth cervical nerve. Deep origin: From the anterior
horn of gray matter of the medulla, and of the spinal
cord as far down as the fifth cervical nerve. Function:
Motor nerve to the sternomastoid and trapezius muscles.
9. Blood supply of the intestines. Duodenum:
Pyloric and pancreatico-duodenal (of the hepatic), and
inferior pancreatico-duodenal (of superior mesenteric).
Jejunum and ileum: Branches of the superior mesen-
teric artery. Cecum and appendix: Ileocolic and an-
pendicular arteries. Colon: Right colic and middle
S38
LOUISIANA,
colic (of superior mesenteric), left colic and sigmoid
branches (of inferior mesenteric). Rectum: Superior
hemorrhoidal (of inferior mesenteric), middle hem-
orrhoidal (from internal iliac), and inferior hem-
orrhoidal (from internal pudic artery).
10. Structures between the layers of the broad liga-
ment: Fallopian tube, round ligament, ovary, ovarian
ligament, parovarium, loose connective tissue, vessels
and nerves.
PHYSIOLOGY.
1. During contraction, the following changes take
place in a voluntary (striated) muscle: (1) It becomes
shorter and thicker, but (2) there is no change in vol-
ume; (3) there is an increased consumption of oxygen;
(4) more carbon dioxide is set free; (5) sarcolactic acid
is produced; and hence (6) the muscle becomes acid in
reaction; (7) it becomes more extensible, and (8) less
elastic; (9) there is an increase in heat production and
consequently a rise of temperature; (10) the electrical
reaction becomes relatively negative, and (11) a sound is
produced. Further, a single stimulus produces a simple
contraction; a series of rapid stimuli produces a condi-
tion of tetanus, but of an incomplete kind. Involuntary
(non-striated) muscle acts differently: The duration of
the contraction is prolonged; there is a tendency to
rhythmical contraction; peristalsis is also a character-
istic of this class of muscle; involuntary muscle cannot
be thrown into tetanus. Voluntary muscle is found in
all the skeletal muscles, pharynx, diaphragm, larynx,
external ear, and eve. Involuntary muscle is found in
the alimentary tract from the middle third of the esoph-
agus to the anus, in the ducts of glands, in the trachea
and bronchial tubes, within the eyeball, the internal
urinary and genital systems, circulatory (except the
heart) and lymphatic systems, and the capsules of some
organs.
2. A nitrogenous food, peas; a carbonaceous food,
sugar; a carbonitrogenous food, sweetbread.
FOOD.
Proteids.
1. All substances contain-
ing nitrogen, of a com-
position identical with,
or nearly that of al-
bumin; proportion of
N to C being nearly
as 2 to 7.
FUNCTIONS.
Formation and repair of
tissues and fluids of the
body.
Regulation of the absorp-
tion and utilization of
oxygen.
May also form fat and
carbohydrate, and yield
energy sometimes.
339
MEDICAL RECORD.
FOOD.
Substances containing a
larger proportion of
N are apparently less
nutritious; proportion
of N to C about 2 to
BY2.
Extractive matters, such
as are contained in
the juice of the flesh.
Carbohydrates.
Substances containing no
N, but made up of C,
H and ; the O being
exactly sufficient to
convert all the H into
H 2 0.
FUNCTIONS.
These perform the above
functions less perfectly,
or only under particular
circumstances.
These substances appear
essentially as regulators
of digestion and assimi-
lation, especially with
reference to the gelatin
group.
Production of energy and
animal heat by oxida-
tion. Form fats and pos-
sibly some proteids.
3. Nitrogenous foods are digested : ( 1 ) In the stomach
where the pepsin, in the presence of cjilute hydrochloric
acid, causes hydrolysis of the protein molecule, splitting
it up into smaller and more soluble molecules. The
stages: of gastric digestion are from protein to globulin,
to metaprotein, proteoses and peptones. (2) In the in-
testine, where the trypsin of the pancreatic juice, in a
slightly alkaline medium, performs a somewhat similar
function as the pepsin of the gastric juice; only, here,
the process is continued further, and the proteoses and
peptones are further broken up into polypeptides and
amino-acids.
4. The hypoglossal nerve is distributed to the mus-
cles of the tongue, to the thyrohyoid, and to the omo~
hyoid, sternohyoid and sternothyroid muscles. Function :
Motor to the tongue. Spinal accessory nerve. Dis-
tribution: After emerging from the cranial cavity the
nerve soon separates into two branches: (1) An internal
or anastomotic branch, consisting chiefly of filaments
coming from the medulla oblongata. It soon enters the
trunk of the vagus, from which fibers pass to the mus-
cles of the pharynx, to the muscles of the larynx through
the inferior laryngeal nerve, and to the heart according
to most authorities. (2) An external branch, consisting
chiefly of the accessory fibers from the spinal cord. It
is distributed to the sternocleidomastoid and trapezius
muscles.
Function: The transmission of nerve impulses from
340
LOUISIANA.
the cells from which they take their origin to the mus-
cles to which they are distributed. They therefore ex-
cite to action some of the muscles of deglutition, the
muscles which regulate the tension of the vocal bands
during phonation, and the muscles which control the
respiratory movements associated with sustained or
prolonged muscle efforts; the fibers also convey nerve
impulses which exert an inhibitory influence on the
heart; it is the motor nerve to the trapezius and sterno-
mastoid. (From Brubaker's Physiology,)
Superior laryngeal nerve. Distribution: Larynx,
cricothyroid muscle. Function: Sensory to the larynx,
and motor to the cricothyroid muscle.
5. The vasomotor nervous system consists of (1) a
vasomotor center in the bulb, (2) of some subsidiary
centers in the spinal cord, and (3) of vasomotor nerves,
which are of two kinds: (a) those causing constriction
of the vessels, and so-called vasoconstrictor nerves; and
(b) those causing dilatation of the vessels, and so-called
vasodilator nerves. These nerves supply the muscle
tissue in the wails of the blood-vessels and regulate their
caliber, thus influencing the quantity of blood supplied
to a part; at the same time they regulate the quality
of blood supplied to a part; they also regulate the
nutrition of a part, also secretion and heat production.
They are concerned, too, in the control of the heart-
beat. The center is in the medulla, in the floor of the
fourth ventricle, near the calamus scriptorius.
6. The chief waste products of proteid metabolism
are: Urea, ammonia, creatin, creatinin, hippuric acid,
sulphates, various purin bases (chiefly uric acid) .
Most of the urea is formed in the liver, from (1) the
amino acids which have been absorbed from the small-
intestine, and which are not needed by the body; and
(2) from the ammonium carbonate which is derived
from the tissues, and from the action of a uricolytic
enzyme upon uric acid. These two sources give respec-
tively what is known as exogenous urea and endogenous
urea.
Uric acid: "In man uric acid has a twofold origin;
one portion, coming from the breaking down of the
nuclein-containing tissues or cell elements of the man's
own body, and hence is of endogenous origin, white the
other portion — usually the larger — is of exogenous
origin, coming from the transformation of free: and com-
bined purin compounds present in the food." — (Chitten-
den.)
Hippuric acid has its origin in the kidney; and creatin
and creatinin in muscle and other tissues.
341
MEDICAL RECORD.
7. The anterior nerve roots of the spinal cord are
motor; the posterior nerve roots are sensory.
8. The causes producing the first sound of the heart
are not definitely ascertained. The following are sup-
posed to be causatory factors: (1) The vibration and
closure of the auriculo-ventricular valves, (2) the mus-
cular sound produced by the contraction of the ven-
tricles, and (3^ the cardiac impulse against the chest
wall.
The second sound is caused by the vibration due to
the closure of the semilunar valves.
The first sound is synchronous with the ventricular
systole; and the second sound with the first part of the
ventricular diastole.
9. Muscular work increases the body temperature;
mental work slightly increases the body temperature;
age exerts a slight influence, as the temperature of the
child is generally a little higher than that of the adult;
and the temperature of an old person is a little lower
than that of the adult; sleep diminishes the body tem-
perature by lessening the production of heat.
10. Trypsin converts proteins into proteoses, peptones,
polypeptides, and amino-acids, in an alkaline medium.
Lipase splits fats into glycerol and fatty acids.
Succus entericus converts starch into dextrin and
then into dextrose and levulose; it also splits polypep-
tides into amino-acids and ammonium compounds; it
converts sugars into dextrose, levulose, and galactose.
CHEMISTRY.
1. Conservation of energy. When one form of energy
disappears, an exact equivalent of another form of
energy takes its place. Thus heat may be converted
into motion, and motion into chemical energy; but in
each case there is exactly the same amount of energy
present.
2. Alkaloids are nitrogenous, basic substances, of al-
kaline reaction, and capable of uniting with acids to
form salts in the same way that ammonia does. Most
alkaloids are solid, crystalline, contain carbon, hydrogen,
nitrogen, and oxygen, are sparingly soluble in water,
but are soluble in alcohol, their salts are freely soluble
in water, they are generally bitter in taste. Three al-
kaloids : Morphine, atropine, Quinine.
3. Oxides: Sulphur dioxide, S0 2 ; ethyl oxide
(C 5 H 5 )*0.
Hydroxides : Potassium hydroxide, KOH; ethyl hy-
droxide, C 2 HsOH.
Normal salts: Dipotassic sulphate, K 2 S0 4 ; calcium
earbonate, CaCOs.
342
LOUISIANA.
i
Basic salts: Lead carbonate (of the pharmacopoeia) f
(PbC0 8 )a PbH 2 O a ; so-called, bismuth subnitrata*
BiON0 3 .
4. The contact method in testing for albumin in the
urine: Put a small amount of nitric acid into a test-
tube; fill a pipette with the filtered urine; hold the test-
tube at a small angle to the horizontal and allow the
urine to flow slowly from the pipette upon the surface
of the nitric acid. Remove the pipette, and gently
turn the test-tube into the vertical position; a milky
zone at the junction of the nitric acid and urine de-
notes the presence of albumin.
5. Human milk is composed of almost 87 per cent,
of water and 13 per cent, of solids. The latter are:
Fat, about 3.5 per cent.; milk sugar, about 6 per cent.;
protein about 4 per cent.
6. Ptyalin is an enzyme found in the saliva. Its
action is to turn starches into maltose. It acts only in
an alkaline medium, and acts best at about the body
temperature; it is necessary to remove the products of
its activity.
7. Hemoglobin is a proteid coloring matter contain-
ing iron, and is present in the red blood corpuscles.
It is of very complex constitution; it readily absorbs
oxygen from the air, and forms oxyhemoglobin ; it is
the oxygen-carrying part of the blood, conveying the
oxygen from the lungs to the various tissues of the
body; it gives a characteristic spectrum band.
8. The best chemical test for blood, is the formation
of hemin crystals. These crystals are obtained by
boiling a fragment of dried b^od with a drop of glacial
acetic acid on a slide; the characteristic crystals may
be seen with the microscope.
9. Proteins are very complex organic compounds,
consisting of carbon, hydrogen, oxygen, nitrogen, sul-
phur, and other elements. They are split up by pepsin
and trypsin into proteoses, peptones, polypeptids and
amino acids; they are insoluble in alcohol and ether,
most of them are insoluble in water, but some are
capable of entering into a state of colloidal solution;
they are soluble in the gastric and pancreatic juices.
Most, of them are coagulated by heat; they are col-
loids, are levorotatory* and give many color reactions.
10. Two biliary pigments: Bilirubin and biliverdin.
Gmelin's test for bile pigments consists of a play of
colors — green, blue, red, and yellow — produced by the
action of fuming nitric acid.
MATERIA MEDICA.
1. Three emetics: Apomorphine hydrochloride, dose
848
MEDICAL RECORD.
1/10 grain used hypodermatically. Copper sulphate,
dose gr. iv. Zinc sulphate, dose gr. xv.
2. Atropine is an alkaloid of Atropa Belladonna;
the average dose is 1/160 grain.
3. Pulvis ipecacuanha et opii contains 10 per cent,
of opium ; Tinctura opii camphorata contains about one
grain of opium to the half ounce.
4. Lotio hydrargyri nigra contains thirty grains of
calomel to ten ounces of lime water.
5. Nitroglycerin is prepared by the action of a mix-
ture of nitric and sulphuric acids upon glycerin. The
spirit of nitroglycerin is given in doses of one minim,
It should be kept in well-stoppered tin cans, in a cool
place, away from lights and fires, and should be very
carefully handled because, if a considerable quantity
of it is spilled a violent explosion may occur.
6. Eserine is an alkaloid of physostigma. The dose
of the salicylate and sulphate is 1/64 grain.
7. Prescription for a diuretic mixture:
5.
Potassii acetatis.
Potassii bitartratis.
Potassii citratis aa 3ij.
Aquae q.s. ad Sviij M.
Sig.: — Take one tablespoonful, well diluted, three
times a day.
8. Santonin is obtained from Santonica, which is de-
lived from Artemisia pauciflora; it is used as an an
thelmintic to round worm and thread worm; dose, for
a child, gr. %-%; for an adult, gr. j or ij.
9. Ergot stimulates and causes contraction of in-
voluntary muscle fibers, hence it is vasoconstrictor,
hemostatic, and oxytocic. It is also a cardiac sedative ;
it raises the blood pressure, it increases peristalsis,
and is an emmenagogue. The dose of the fluid extract
is thirty minims.
10. Emetine is an alkaloid of Cephaelis Ipecacuanha;
it is used as an expectorant and an emetic; the dose
(as an expectorant) is 1/100 grain; (as an emetic),
1/6 grain.
PATHOLOGY.
1. A secretion is a liquid or semi-liquid product
formed by glandular organs; as saliva.
An excretion is a product which is eliminated from
a gland (or other structure) ; as urine.
Formerly, it was held that a secretion had some fur-
ther* use in the body; and that an excretion had no
use, but that its further retention was dangerous.
344
LOUISIANA.
Another view, once held, was that in the case of an
excretion the gland merely extracted the substance
ready-made from the blood; whereas, in the case of a
secretion, the gland was supposed to produce some of
the constituents.
2. Transudates are pathological fluids of non-inflam-
matory origin, as in ascites. Exudates are patho-
logical fluids of inflammatory origin,' as in peritonitis,
Further, transudates do not coagulate spontaneously,
contain but few cells, have specific gravity below 1018,
and contain but few bacteria; exudates tend to co-
agulate on standing, have more cells and albumin, spe-
cific gravity is above 1018, and bacteria are generally
present and are often numerous.
3. Pus is the result of inflammation plus the pres-
ence of pyogenic bacteria.
4. Atrophy is a decrease in the amount of a tissue
owing to diminution either in the number (numerical
atrophy), or in the size (simple atrophy) of the his-
tological elements of which the tissue is composed.
5. An embolus is a plug in the circulation; the proc-
ess is called embolism. Causes: Thrombi, detached
pieces from the heart valves, microorganisms, oil, fat,
parasites, pieces of new growths. Results: Obstruc-
tion to the circulation; infarction: inflammation of
blood-vessel; dilatation of blood-vessel.
6. ^Gonorrheal arthritis is due to the gonococcus,
which is carried by way of the blood from the urethra,
or rarely from the conjunctiva in gonorrheal oph-
thalmia. As a rule, it appears during the subsiding
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Changes proteids into
proteoses and pep-
tones, and afterwards
decomposes them into
leucin and tyrosin ;
in an alkaline
Pancreatic ....
■*
medium.
Amylopsin.
Converts starches into
maltose.
Steapsin.
Emulsifies and saponi-
fies fats.
A curdling
Curdles the casein of
ferment.
milk.
Intestinal
Invertin.
Converts maltose into
glucose.
4. There are two normal heart sounds which follow
in quick succession, and are succeeded by a pause. The
first, or systolic, sound is dull and somewhat prolonged,
the second, or diastolic, sound is sharper and shorter.
The sounds may be expressed by the syllables lubb —
dup.
The first sound is heard best at the apex beat in the
fifth left intercostal space; the second sound is heard
best over the second right costal cartilage.
The causes producing the first sound of the heart are
not definitely ascertained; the following are supposed
to be causatory factors: (1) The vibration and closure
of the auriculo-ventricular valves, (2) the muscular
433
MEDICAL RECORD.
sound produced by the contraction of the ventricles, and
(3) the cardiac impulse against the chest wall.
The second sound is caused by the vibration due to
the closure of the semilunar valves.
5. Blood pressure is the pressure of the blood due to
the ventricular systole, the elasticity of the arterial
walls, and the resistance of the capillaries. The normal
arterial blood pressure varies; the systolic pressure be-
ing about 120 to 150 mm. of mercury, and the diastolic
from about 90 to 120 mm. of mercury. Blood pressure
is maintained by the contraction of the heart, the
peripheral resistance, and the elasticity of the arterial
walls.
Blood pressure is estimated by a syhygmomanometer.
"The individual whose blood pressure is about to be
recorded should be placed in such a position that his
heart, the artery the blood pressure of which is to be
determined, and the manometer are at the same level.
It is usual to record the pressure in the brachial artery.
The india-rubber bag of the instrument should be
wrapped round the bared arm, the metal covering of
the bag should then be adjusted, and firmly strapped
in position. The india-rubber tube leading from the
bag is then adjusted to the proximal limb of the U-
shaped manometer which contains mercury. The ex-
perimenter places the index finger of his left hand over
the radial pulse of the subject, and with his right hand
he compresses the syringe and so drives air into
the india-rubber tube and the india-rubber bag around
the individual's arm. The pressure of the air in the
bag around the arm is recorded by movement of the
mercury from the proximal to the distal limb of the
manometer. The operator keeps on pressing the syringe
until oscillatory movements are seen at the surface
of the mercury in the distal limb of the manometer;
the mean point of maximum oscillations registers the
diastolic pressure. If the pressure in the bag is still
further increased, the oscillations diminish in ampli-
tude and finally disappear, and at this point the pulse
can no longer be felt at the wrist. The height of the
mercury supported then registers the amount of systolic
pressure. It will then be noted that the mercury has
descended in the proximal limb of the manometer, and
has ascended in the distal limb of the manometer: the
difference between the two mercurial levels will be the
blood pressure of the brachial artery. The normal
systolic pressure in man is about 120 mm. Hg, and the
diastolic pressure about 100 mm. Hg. In women the
pressures are about 10 per cent. less. In children the
434
MISSISSIPPI.
systolic pressure may be as low as 90 mm. Hg, with a
diastolic pressure of about 80 mm. Hg. (R. Hutchison.)
6. The respiratory center is situated in the lowest
part of the floor of the fourth ventricle at the calamus
scriptorius.
7. Secretions : Sebum, mucus, serous fluid, tears,
saliva, gastric juice, succus entericus, pancreatic juice,
bile, milk, sweat, urine, seminal fluid, and the various
internal secretions.
Excretions: Urine, carbon dioxide, sweat.
8. Six abnormal constituents of urine: Albumin,
sugar, blood, pus, bile, and indican (in excess) .
CHEMISTRY.
1. Four elements that are gases: Hydrogen, H;
oxygen, O; chlorine, CI; nitrogen, N.
2. The molecular weight of water: H = 1, O = 16;
H 2 = 18.
3. Ammonia, NH 3 ; Ferric chloride, Fe 2 Cl s ; Hydro-
cyanic acid, HCN; Laughing gas, N 2 0; Ethyl alcohol,
C 2 H 5 OH; Benzene, C 6 H 6 .
4. HN0 3 + KOH = KN0 3 + H 2 0.
5. CaO + H 2 = Ca 2 H 2 2 .
6. Carbon, hydrogen, oxygen, nitrogen.
7. The simplest saturated hydrocarbon is methane,
CH 4 .
8. Fehling's solution is a mixture of copper sulphate,
caustic soda and potassium tartrate. It is used as a
reagent in testing urine for sugar.
MATERIA MEDICA.
1. Digitalis. Habitat, Europe; common name, fox-
glove; tincture of digitalis, dose 15 minims.
Gelsemium. Habitat, Southern United States; com-
mon name, yellow jasmine; tincture of gelsemium, dose
8 minims.
Belladonna. Habitat, Europe and Asia Minor; com-
mon name, deadly night shade; tincture of belladonna
leaves, dose 8 minims.
Aspidium. Habitat, Europe, Northern America and
Northern Asia; common name, male fern; oleoresin of
aspidium, dose 30 grains.
Physostigma. Habitat, tropical Western Africa;
common name, Calabar bean, or ordeal bean; tincture
of physostigma, does 15 minims.
Colocynth. Habitat, Southern Asia and the coun-
tries bordering the Mediterranean Sea; common name,
bitter apple; extract of colocynth, dose Y2 grain.
Veratrum viride. Habitat, North America; common
435
MEDICAL RECORD.
name, hellebore; tincture of veratrum, dose 15 minims,
2. Two derivatives of morphine: Apomorphine;
emetic dose of apomorphine hydrochloride 1/10 grain.
Heroin, dose 1/18 grain.
3. Dover's powder contains ipecac 10, powdered opium
10, and sugar of milk 80.
Seidlitz powder contains potassium and sodium tar-
trate 120 grains, sodium bicarbonate 40 grains and
tartaric acid 35 grains.
Black wash contains 30 grains of calomel in 10
ounces of lime water.
Carron oil contains equal parts of lime water and
linseed oil.
Fowler's solution contains arsenous acid 1, potassium
bicarbonate 2, compound tincture of lavender 3, and
distilled water to 100.
4. The salts of the alkaloids are, as a rule, soluble
in water, whereas the alkaloids are but slightly soluble
in water. For this reason the salts are more generally
used than the alkaloids themselves.
Five alkaloidal sulphates: Morphine sulphate, dose
1/4 grain; strychnine sulphate, dose 1/64 grain;
atropine sulphate, dose 1/160 grain; quinine sulphate,
dose 4 grains; codeine sulphate, dose 1/2 grain.
5. Ten drugs whose internal use may cause a skin
eruption: Bromine and the bromides, iodine and the
iodides, cubebs, copaiba, salicylic acid, quinine, turpen-
tine, antipyrin, belladonna, chloral.
6. Chemical antidote for arsenous acid, freshly pre-
pared solution of ferric hydroxide; for bichloride of
mercury, white of egg, or milk; for iodine, starch; for
phosphorus, no chemical antidote, but old French oil
of turpentine is recommended; for alkaloids, tannin.
To determine the proper dosage for a child: Let
x
x =: the age of the patient; then = the frac-
x + 12
tion of the adult dose which the patient should re-
ceive. Thus, a patient four years old should receive
4 4 1
= — = — of an adult dose.
4 + 12 16 4
8. One ounce == 480 grains ; a 5 per cent, solution will
contain 5/100 or 1/20 of 480 grains == 24 grains.
HYGIENE.
1. A sanitary school building. "The site of a
school building must be well drained, either by nature
or artificially; it must be convenient of access; it
436
MISSISSIPPI.
should not be near enough to railroads or noisy fac-
tories to allow the noise to interfere with work; it
should have ample playground space; it should have
some shade; the surface should be graveled or turfed;
walks must connect the school house with the street
or road and with outhouses and water supply. The
foundation must be impervious to soil-water in order
that capillarity may not dampen the walls. They
should be of non-porous natural stone, hard-burned
brick or concrete, and if of concrete must have a layer
of tarred felt, tarred paper or impervious stone or
brick interposed between the foundation and the super-
structure. If there is a basement it should rise suf-
ficiently high above the ground for light and air to
penetrate to every part of it, and should never be
allowed to become a dump for refuse of any kind. If
no basement is provided, the foundation walls should
be pierced in appropriate places and guarded with
gratings, in order to allow a circulation of air below
the floors. Cloak-rooms must always be provided in
order to avoid the stuffy and disagreeable odor of
clothing in damp weather. In the country, shelves for
dinner pails should also be provided. Toilets must be
separate for the sexes, well screened, well painted or
whitewashed, and kept clean. If water-closets are
used, a type should be selected which can easily be
scrubbed, and an automatic flush is desirable. Urinals
must be placed in the toilets allotted to boys. Wash-
rooms. — Children should be afforded an opportunity
for cleansing the hands and face after play or visits
to the toilet. For this, if piped water is available, the
ordinary porcelain basins with run-off to the sewer
connection should be installed. In case it is not avail-
able, ordinary granite or enameled basins, with a
water supply in buckets or tanks should be possible
to any school. Paper towels or individual towels
brought by the children must be used. The use of
roller towels is an abomination. Water Supply. — A
supply of water under pressure is necessary, which will
provide not only water for drinking and washing, but
for water-closets, the outflow from which can be
purified by a septic tank before its final disposal.
Space. — Not less than 225 cubic feet of space must be
allotted to each person in the schoolroom, including
the teacher. Twelve-foot ceilings are best for all pur-
poses. Ventilation. — Whatever means are used must
provide for a complete change of air in 15 to 20
minutes. This is best tested by using the "bee-smoker,"
which fills the air with light smoke from burning rags,
437
MEDICAL RECORD.
and if the air is completely clear in the time named the
ventilation may be regarded as satisfactory. What-
ever system of heating is employed should maintain
the temperature of every part of the school room
between 65° and 70° F., with a relative humidity
of at least 40 per cent. Should the temperature
fall below 60° the school must be dismissed at once.
Humidity. — Some means, even if only the placing of
pans of water on stoves or radiators, must be pro-
vided for adding to the moisture in the air. The
room should be lighted from one side only, or by prop-
erly softened sky-lights, and the lighting area should
not be less than one-sixth of the floor area. Prismatic
glass in the upper sash is an advantage, since it dif-
fuses the light to the opposite side of the room. Seats
must be adjustable to the bodies of the children. It is
nothing short of criminal to compel the child to adjust
itself to the seat. Good work cannot be done by an
uncomfortable child, and lasting eye-trouble or bodily
deformity such as spinal curvature may come from the
practice. Blackboards should be always dull-finished.
A glossy blackboard is unnecessarily hard on the eyes.
Blackboards and erasers should not be cleaned while
school is in session, and erasers should be dusted out-
side. The chalk racks should be cleaned each evening
by the janitor." — (Gardner and Simonds' Practical
Sanitation.)
2. To prevent the spread of typhoid fever: Flies
should be kept out of the house as far as possible, by
means of screens or otherwise; all discharges from the
sick person must be disinfected; all utensils, dishes,
etc., used by the patient must be thoroughly cleansed
and boiled every day; soiled linen must be soaked in a
disinfectant solution before being washed; after each
attendance on a patient physicians, nurses, and others
should wash their hands in a disinfectant; thorough
sterilization of all bedding, etc., must be performed
after the disease is over. Further, each household
should boil all water that is to be used for drinking or
for washing dishes, etc.; milk should be boiled also;
and no ice should be put in water or other drink or
food.
3. Avenues of entrance for the germs of disease:
Skin and mucous membrane, digestive tract, respiratory
tract, genital tract, conjunctiva, placenta.
4. Hygienic precautions to be taken in treating a
case of tuberculosis : "The patient's quarters should be
free from dust, and admit of his spending many hours
daily in the open air in all weathers, properly sheltered,
438
MISSISSIPPI.
and, if very ill, lying wrapped in a hammock or reclin-
ing chair. His bedroom should be well aired at night,
draughts being avoided. The room should be uncar-
peted and free from hangings. It should be often
cleaned and periodically disinfected. All sputum
should be collected in paper spit-cups, which should be
burned daily. Smoking should be forbidden. Harm is
done by any exercise which results in fatigue, and
while fever exists it should not be attempted at all.
Patients should be taught the necessity of practising
lung gymnastics and breathing only through the nose,
which should be kept clear and free from occlusion by
secretions, or an hypertrophied catarrhal mucosa.
The clothing should be woolen, but not too
heavy, or sweating is increased; and a flannel night-
gown and loosely knit leggings should be worn at night
in cool weather. The skrn should be cleansed by daily
sponge-baths of lukewarm alcohol and water."
(Thompson's Practical Medicine.)
5. Diseases transmitted through human excreta:
Actinomycosis, bubonic plague, chickenpox, cholera,
amebic dysentery, bacillary dysentery, typhoid.
Diseases specially liable to be conveyed by the in-
gestion of milk: Tuberculosis, typhoid fever, scarlet
fever, diphtheria, tonsillitis, cholera, and gastrointes-
tinal disorders.
The milk may come from a diseased cow; it may be-
come contaminated by the milker, the container, the
surroundings, the water used to wash the cans or to
adulterate the milk; or it may become contaminated
at the dealer's or purchaser's house by being left un-
covered, exposed to flies, etc., or by not being kept in
a cool place. The only way to prevent the transmission
of disease by milk is to insist on a thorough inspection
of all dairies and sources of milk supply, and to edu-
cate the public in the care of milk between the time of
its purchase and its consumption. The inspection
should include : the color, reaction, specific gravity, sedi-
ment, taste, odor, acidity, total quantity of solids and
of water ; the percentage of cream, fats, lactose, casein,
and ash ; the presence or absence of preservatives, color-
ing matter, added solids, dilution, pathogenic micro-
organism, dirt, or other foreign matter. There should
also be thorough investigation as to its source, the cows
and their environment, the method employed in caring
for, milking, storing, and transporting the milk.
Essentials for the production and preservation of
pure dairy milk: Vaughan's rules are as follows:
"(1) The cows should be healthy, and the milk of any
439
MEDICAL RECORD.
animal which seems indisposed should not be mixed
with that from the healthy animals. (2) Cows must
not be fed upon swill or the refuse from breweries or
glucose factories, or upon any other fermented food.
(3) Milch cows must not be allowed to drink from
stagnant pools, but must have access to fresh, pure
water. (4) The pasture must be freed from noxious
weeds, and the barn and yard must be kept clean. (5)
The udders should be washed and then wiped dry be-
fore each milking. (6) The milk must be at once
thoroughly cooled. This is best done in the summer by
placing the milk can in a tank of cold water or ice
water, the water being of the same depth as the milk
in the can. It would be well if the water in the tank
could be kept flowing, and this will be necessary unless
ice water is used. The tank should be thoroughly
cleaned each day to prevent bad odors. The can should
remain uncovered during the cooling, and the milk
should be gently stirred. The temperature should be
reduced to 60° F., or lower, within an hour. The
can should remain in cold water till ready for de-
livery. (7) Milk should be delivered, during the sum-
mer, in refrigerated cans or in bottles about which ice
is packed during transportation. (8) When received
by the consumer it must be kept in a clean place, and
at a temperature some degrees below 60° F."
7. "If the mother cannot nurse her infant, it must
be nourished by a wet-nurse. When none can be ob-
tained, give cow's milk one part (by measure) or two
parts of water and add milk sugar, 3 iv. to each pint
of the mixture, the proportion of milk to be increased
with age. When this food disagrees, and the child
passes lumps of undigested curd, one-third of the water
may be exchanged for lime-water. The water must be
sterilized by boiling, and the milk not by boiling, which
impairs its nutritive value, but by Pasteurization —
i. e. by keeping it continuously for thirty minutes
at a temperature of 167° F. It is of the utmost im-
portance that nipples, bottles, and vessels in which
the food is prepared should be kept aseptically clean.
They must not be used twice without being thoroughly
cleansed — the bottles and vessels scalded and the
nipples immersed in a solution of boric acid. The best
rule as to how much of the milk-mixture should be
given the child at one time, is to give it as much as it
will readily take; if it rejects any, give it less next
time." (King's Manual of Obstetrics.)
8. Soil pollution consists of the urine and droppings
of animals, the carcasses of animals that have died, and
440
MISSISSIPPI.
vegetable matters in various stages of decay, also
sewage and dead bodies.
Prophylaxis of hook-worm disease: Children and
adults should be made to wear shoes; proper toilet
facilities should be provided, and their use enforced;
bathing or wading in shallow water should be for-
bidden; a proper water supply should be available for
drinking purposes; and prompt recognition and treat-
ment of ail cases should be encouraged.
OBSTETRICS.
In extrauterine pregnancy, there v/ill be signs of
early pregnancy, hypogastric or inguinal pains, prob-
able history of a previous sterility, probable expulsion
of decidual membrane or shreds, softening of the cer-
vix, enlargement of the uterus, presence of a distended
tube, contractions of the wall of the gestation sac ; if
rupture occurs, there will be sudden, excruciating pains
over the lower abdomen and on the affected side,
shock, collapse, and symptoms of internal hemorrhage.
The treatment after rupture is — laparotomy. "After
thorough cleansing and sterilization of the abdomen
and pubes, as well as of the instruments and hands of
the operator and assistants, the bladder is emptied and
the patient anesthetized. An incision 3 inches long is
then made in the median line above the pubes down
to the peritoneum, any bleeding vessels being twisted
before opening the peritoneal cavity. The peritoneum
is then incised; the intestine kept back by pads of cot-
ton or gauze wrung out of sterilized water; the opera-
tor's fingers bring out the distended tube and ovary
at the incision after having freed them from any exist-
ing adhesions ; the pedicle is then transfixed by a double
ligature of sterilized silk, and each half of it tied
securely according to surgical rule. The pedicle is
cut, and the entire mass — the Fallopian tube, with the
cyst, fetus, ovary, and effused blood, removed, extra
care being taken, in the ruptured cases, to quickly
secure the bleeding vessels of the ruptured tube from
further hemorrhage. The pads are then withdrawn
and the abdominal incision closed and dressed in the
usual manner. In case of threatened collapse from
hemorrhage during the operation, the peritoneal cavity
may be flooded with a 1 per cent, sterilized solution of
common salt at a temperature of 100° F., a quart
of this solution having been previously prepared.
It is rapidly absorbed by the peritoneum, and acts as
a restorative — like transfusion." — (King's Obstetrics.)
2, Mastitis. Etiology: Infection, generally due to
4-11
MEDICAL RECORD.
handling; cracked or sore nipples and overactivity of
the gland with retained secretion are predisposing
causes. Treatment: This consists in resting the part;
supporting it, applying a hot boracic acid fermenta-
tion ; nursing from the affected breast should be stopped
at once.
Prophylactic measures consist in not touching the
breasts (by doctor or nurse or patient) without
thoroughly clean hands; by washing and drying the
nipple before and after nursing, and by proper atten-
tion to hygienic conditions before labor, and the nipple
and breasts being preserved from pressure.
3. Placenta pr&via is the condition in which the pla-
centa is attached in the lower uterine segment, and
may be near or over (partially or completely) the in-
ternal os. Varieties: (1) Central, when the placenta
completely covers the os. (2) Partial, when the pla-
centa overlaps the os. (3) Marginal or lateral, when
the placenta reaches the margin of the os but does not
overlap it. Symptoms: Sudden hemorrhage, accom-
panied by syncope, vertigo, restlessness, and feeble
pulse. Dangers: Hemorrhage, sepsis, death of the
mother, death of the fetus. Treatment: stop the
hemorrhage by a tampon; this must be tight and
thorough. Accouchement force is indicated; this con-
sists of dilatation of cervix, version, and immediate
extraction of the child.
4. Liquor amnii. Functions: (a) During preg-
nancy: (1) As a protection to the fetus against pres-
sure and shocks from without. (2) As a protection
to the uterus from excessive fetal movements. (3) It
distends the uterus and thus allows for the growth
and movements of the fetus. (4) It receives the excre-
tions of the fetus. (5) It surrounds the fetus with a
medium of equable temperature, and serves to prevent
loss of heat. (6) It prevents the formation of adhe-
sions between the fetus and the walls of the amniotic
sac. (7) It has been supposed, by some, to afford some
slight nutrition to the fetus, (b) During labor: It acts
as a fluid wedge, and dilates the os uteri and the cervix ;
it also slightly lubricates the parts.
5. "In mentoposterior positions, endeavor to secure
anterior rotation of the chin when it fails to take place
spontaneously. The several methods of attempting this
are: 1. Press the forehead backward and upward dur-
ing a pain, so as to make extension more complete, and
thus cause the chin to dip lower down and touch the
anterior inclined plane upon which it may glide for-
ward. 2. Put a finger in the mouth, or on the outside
442
MISSISSIPPI.
of the lower jaw, and draw the chin forward during a
pain. 3. Apply the straight forceps and twist the chin
to the pubes. 4. Apply the vectis, or one blade of the
forceps, under the most posterior cheek, and oyer the
anterior inclined plane, thus, as it were, thickening the
latter, so as to make it reach the malar bone and con-
stitute a point oVappui which the chin can touch and so
glide forward. Should these attempts to secure anterior
rotation fail, an effort may be made with the hand,
vectis, or fillet, to bring down the occiput and convert
the face into a head presentation. In order to succeed
in this maneuver the membranes should be unbroken,
the os uteri dilated, the face not so deeply engaged
that it cannot be lifted^ to or above the pelvic brim,
and an anesthetic administered. Again, failing in this
way to produce anterior rotation, the head, if it be not
too deeply engaged in the pelvis, and have not passed
through the os uteri, may be pushed back, and the child
be delivered by podalic version. Should none of these
methods be practicable and the head become impacted
in the pelvis with the chin toward the sacrum, the only
resort is craniotomy. Attempts have been made in
these cases to deliver by forceps after lateral incision
of the perineum, but they can only succeed when either
the child is small or the pelvis over-large. Usually the
child's life has been so far imperiled by delay and its
consequences that craniotomy may be done without
compunction. Possibly symphyseotomy may prove use-
ful in these cases in future. In all cases of face pres-
entation special care is necessary to avoid rupture of
the perineum" (King's Manual of Obstetrics).
6. To protect the perineum: The patient should be
restrained from bearing down unduly; extension of the
head must be retarded, and the central part of the
occiput must be allowed to be born first; pressure must
be made with the hand between the coccyx and the anus ;
when the perineum has had time to stretch, extension
and expulsion are allowed; after the birth of the head
care must be taken to see that the perineum is not torn
by the birth of the shoulders.
7. Treatment of pregnancy complicated with ne-
phritis: "Prophylaxis is of the first importance. The
urine should be examined every month in the first six
months of every pregnancy, no matter how normal it
may seem, and every fortnight in the last three months.
If albumin is present, the amount should be estimated
in an Esbach tube, and the urea in a Doremus ureo-
meter. The total quantity of urine per diem should
also be ascertained. The principles of treatment are
443
MEDICAL RECORD.
to relieve the kidneys by free elimination by the bowels
and skin, and by diminishing the nitrogenous part of
the dietary; and at the same time to prevent any fur-
ther interference with the renal functions by guarding
against cold. In mild cases where the albuminuria is
the sole symptom, the patient should be warned to rest
and guard against cold. The diet should be restricted
to milk food, with bread and butter, and a little fish
or chicken once a day, and the bowels should be made
to act freely once every day. Where there are, in addi-
tion, symptoms such as edema or headache, the patient
should be kept in bed, the diet even more rigidly re-
stricted, and nothing but milk foods given for some
days. The bowels should be briskly purged by a hydra-
gogue, such as jalap, and the kidneys flushed out with
diluent drinks. This treatment must be continued until
the symptoms have disappeared, although it is rare for
the urine to clear up altogether. A little fish and
chicken, and some light fruits and vegetables may then
be added tp the diet, but the regular free action of the
bowels must be continued. In more severe cases the
skin functions must be stimulated in addition by the
use of hot packs. The diet also should be nothing but
plain milk and diluent drinks. Hot salines per rectum
help to flush out both bowels and kidneys. If the condi-
tion grows worse in spite of treatment, it argues either
a very severe toxemia, or severely damaged kidneys.
The outlook in either case is so bad, owing to the
probable onset of eclampsia, that the pregnancy should
be terminated, particularly as the prospects of obtain-
ing a healthy living child are remote. This interference
becomes urgent if signs of drowsiness indicate ap-
proaching coma, or sickness and epigastric pain suggest
the near onset of eclampsia. The obstetric treatment
then consists in emptying the uterus. Where there
is no great urgency this should be done by Krause's
method of induction of premature labor. In urgent
cases some method of accouchement force must be em-
ployed, the choice depending upon the condition of the
cervix, and on the degree of urgency" (Johnstone's
Text-book of Midwifery) .
8. Pernicious vomiting of pregnancy . "The treatment
consists in rest in bed in a quiet, darkened room and the
administration of easily digested foods, such as milk,
broths, eggs, etc. A careful search must be made for
some local exciting cause, and if any such condition
is found, it should receive appropriate treatment.
Sexual intercourse should be interdicted. The bowels
should be kept freely open. Sodium bromide, camphor,
444
MISSISSIPPI.
cocaine, silver nitrate, cerium oxalate, hyoscine hydro-
bromide, antipyrine, etc., are among the drugs used
internally. Rectal alimentation may be necessary, and,
as a last resort, dilatation of the cervix and internal
os, or abortion may be performed (Pocket Cyclo-
pedia) .
PATHOLOGY.
1. Thrombus is a blood-clot formed within the heart
or blood vessels during life.
Embolus is a clot or other substance brought by the
blood current, and forming an obstruction where it
lodges.
Emboli are most frequently found in the following
arteries: Pulmonary, renal, splenic, cerebral, iliac,
axillary, mesenteric and coronary.
2. A physiological leucocytosis is a leucocytosis which
is found in certain physiological conditions; it is gen-
erally moderate and of brief duration. It is found in
the newborn, after parturition, after exertion, after
a cold bath or massage, during pregnancy, and during
digestion.
A pathological leucocytosis is a leucocytosis which is
found in certain pathological conditions ; it is generally
found in inflammatory, toxic, and infectious conditions.
As a rule, the polynuclears are increased.
Of the diseases mentioned there is a leucocytosis
present in: Pneumonia. It is absent in: Typhoid,
malaria, and acute miliary tuberculosis.
3. Tuberculous lesions may be diagnosed by the vari-
ous tuberculin tests, such as those of Koch, von Pirquet,
Calmette, and Moro.
4. In chronic alcoholism there may be found peri-
pheral neuritis, meningitis, catarrh of stomach, cir-
rhosis of liver, arteriosclerosis, and granular kidney.
5. Acute Lobar Pneumonia. "It is convenient to de-
scribe four stages, those, namely, of (1) hyperemia or
engorgement, (2) red hepatization, (3) gray hepatiza-
tion, and (4) resolution. First stage or splenization. —
The lung is injected, dark red, and heavy, and pits
under the finger; on pressure, there exudes a frothy
serum tinged with blood and slightly aerated. The
lung still floats in water. Second stage or red hepa-
tization. — The part involved is solid and friable, pre-
sents a granular or red granite appearance, and sinks
in water. The alveoli are filled with a coagulated exu-
dation which shows under the microscope fibrin,
leucocytes, red corpuscles, proliferated alveolar epi-
thelium, and pneumococci. Third stage or gray hepa*
445
MEDICAL RECORD.
fixation. — The lobe has now the appearance of gray
granite, the lung substance is softer and more friable;
on pressure, a dirty purulent fluid exudes. The gray
appearance is due to four factors: (1) Decolorization
of the red blood corpuscles; (2) obliteration of the
alveolar blood vessels from pressure; (3) fatty degen-
eration of the coagulated material; (4) great infiltra-
tion of leucocytes. A more advanced stage, in which the
lung tissue is bathed in purulent fluid, is known as
purulent infiltration. It is probably inconsistent with
life. Fourth stage or resolution. — Resolution of the in-
flammatory exudation is brought about principally by
absorption (autolysis), but partly by liquefaction and
expectoration. Pneumonia may affect a lobe, or the
whole of a lung, or it may attack both lungs. Double
pneumonia occurs in about 10 per cent, of cases. Differ-
ent parts of the same lung may at the same time show
different stages. There is always some degree of
pleural inflammation over the affected area. Moderate
enlargement of the spleen is very common" (Wheeler
and Jack's Practice of Medicine).
6. "In amebic dysentery the lesions are chiefly seated
in the large intestine. They present: (a) Small gela-
tinous swellings of the mucosa, with partial ulcera-
tion; (b) Necrosis and sloughing of the underlying
tissues. The ulcers of amebic dysentery thus have
undermined edges. The amebas are found in the ulcer-
ating mucosa, but more abundantly in the tissues be-
yond the ulcerated area (submucous or muscular coat),
where they set up edema and necrosis. Later, along
with the ulcers, cicatrices leading sometimes to partial
stricture, may be found. Hepatic abscess, usually sin-
gle, and hepato-pulmonary abscess, are common com-
plications. Amebae are sometimes found in the portal
capillaries. The' ameba is a rounded cell with a clear
outer ectoplasm, and a granular endoplasm. It has a
rounded or oval eccentric nucleus, and measures from
10 to 15 a* in diameter. On the warm stage it shows
active ameboid movement. In the resting stage it forms
a cyst or cysts, and in this state resists drying for a
long time. The organisms are found chiefly in the large
intestine, especially in the rectum and flexures, but
they also occur in the ileum and stomach, and in the
liver. They have the power of penetrating the tissues"
(Wheeler and Jack's Practice of Medicine).
7. In diabetes mellitus, sugar is found in the urine;
in chronic parenchymatous nephritis, the urine will con-
tain granular and hyaline casts and varying amounts
of albumin.
446
MISSISSIPPI.
8. "Since the days of Celsus, heat, redness, swell
and pain have been recognized as cardinal signs of
flammation, and to these may be added, interference
with function in the inflamed part, and general consti-
tutional disturbance. Variations in these signs and
symptoms depend upon the acuteness of the condit
the nature of the causative organism and of the
tissue attacked, the situation of the part in relatior
the surface, and other factors.
"The heat of the inflamed part is to be attributed to
the increased quantity of blood present in it, and the
more superficial the affected area the more readily is
the local increase of temperature detected by the hand,
Redness, similarly, is due to the increased afflux of
blood to the inflamed part. The shade of color varies
with the stage of the inflammation being lighter and
brighter in the early, hyperemic stages, and darker i
duskier when the blood flow is slowed or when sta
has occurred and the oxygenation of the blood is
fective. In the thrombotic stage the part may assu
a purplish hue.
"The sivelling is partly due to the increased amoi
of blood in the affected part and to the accumulat
of leucocytes and proliferated tissue cells, but chk
to the exudate in the connective tissue — inflammat<
edema. Pain is a symptom seldom absent in inflamr
tion. Tenderness — that is, pain elicited on pressure — is
one of the most valuable diagnostic signs we posse
and is often present before pain is experienced by 1
patient. That the area of tenderness corresponds
the area of inflammation, is almost an axiom
surgery. Pain and tenderness are due to the irritati
of nerve filaments of the part, rendered all the more
sensitive by the abnormal conditions of their blood
supply. In inflammatory conditions of internal orgar
for example, the abdominal viscera, the pain is fre-
quently referred to other parts, usually to an area sup
plied by branches of the same nerve as that supplyii
the inflamed part" (Thomson and Miles's Manual
Surgery) .
The terminations of inflammation are: (1) Return
the tissues to health (by resolution, by organization, oi
by new growth) ; and (2) death of tissue, or necrosis
(by suppuration, by ulceration, or by gangrene).
SURGERY.
1. Inflammation is the succession of changes occu
ring in a living tJsjrje as the result of some kind
provided tika is ii e insumeieui
diately to destroy talit
MEDICAL RECORD.
tion are: Redness, swelling, pain, heat, and disordered
function.
2. Septicemia is a condition due to microorganisms
multiplying in the blood, and is characterized by high
temperature, but not relieved by getting rid of _ the
original source of infection. Pyemia is due to particles
of blood .clot carrying microorganisms to parts distant
from the original source and there setting up meta-
static abscesses.
3. Varieties of talipes: Talipes equinus consists in
extension of the foot, with spasm or shortening of the
Achilles tendon, and usually with a loss of power in the
anterior tibial group. Talipes varus is an inversion of
the foot, associated with rotation at the midtarsal joint.
Talipes calcaneus is characterized by elongation of the
tendo Achillis and of the muscles associated therewith,
by shortening of the anterior tibial group of muscles,
and by slight flexion of the toes. Talipes valgus is a
deformity of the foot in which eversion is a prominent
feature. Talipes cavus results from bony subluxation at
the midtarsal joint and contraction of the plantar fascia,
and produces an exaggeration of the normal transverse
arch of the foot.
Talipes equinovarus is a deformity in which tl i
heel is drawn up, and the anterior part of the foot i'i
inverted and drawn inwards.
Treatment: "It may be treated in the early stages by
fixing the foot in good position by a series of plaster-of-
Paris casings, or by using a malleable metal splint.
Tenotomy of tendons which hinder reduction in some
cases is necessary, with the subsequent application of
plasters. If the ligaments on the inner side of the
ankle hinder reduction, they should be divided. In the
neglected cases, where the patient has been walking
on the outer side of the foot, tarsectomy is necessary.
A wedge of bone, with its base outwards, is removed
by a chisel or saw, irrespective of the joints, from the
tarsus in front of the peroneal groove on the cuboid.
The foot can then be brought into good position, and
maintained so by plaster-of-Paris" (Aids to Surgery).
4. Treatment of acute appendicitis: The patient
should be kept in bed; no food is to be given for the
first twenty-four hours; after this, fluid and jellies
may be given ; cooling drinks may be allowed in modera-
tion ; the pain can be relieved by hot or cold applica-
tions on the right iliac region, or morphine may be
given if necessary (and only after the diagnosis has
been made) ; an enema of olive oil or glycerine may be
given to empty the bowels (if loaded) .
448
NEW HAMPSHIRE.
The indications for operation vary according
i ws of the surgeon. Some maintain that e
I appendicitis should be operated on as soo
agnosis is made. Others would operate only in
rupture, or when suppuration occurs, or in cases
do not improve in a week or so, or in cases which
iadily getting worse. Probably all would apree
ng out every appendix that has undergone i
ne mild attack.
top the bleeding, remove foreign matter, mal
ptic as possible, coapt the edges, keep the
;.
1 dislocation of the lower jaw, the mouth is <
and -: nnot be closed, the jaw protrudes, saliva dril:
he mouth, speech and swallowing are difficult,
i is a depression in front of the ear. Treatm
urgeon wraps his thumb (for protection), t
s downward and backward on the lower m
as soon as the condyle is loosened the ja\
by pushing up the chin. A Barton bandag
d and worn for about fourteen days.
he general signs and symptoms of fracture f -
y of injury, disability, pain, swelling, deforn
nal mobility, and crepitus.
.n oblique inguinal hernia is covered by: S
icial fascia, aponeurosis of external oblique, in
lar fascia, cremasteric fascia, infundibulif
p subperitoneal tissue and peritoneum.
,TE BOARD EXAMINATION QUESTIONS.
Iampshire State Board of Medical Examin;
ANATOMY.
Classify joints and give illustration of each.
2. Give origin and complete course of the nerve t
ost to do with respiration.
low is the heart itself nourished?
4. (rive the anatomical relation of the small hitestiiM
to the other abdominal viscera.
)escribe the perinpum.
^lace and describe the nasal bones.
)escribe the internal jugular vein.
rVhat do you understand by the mesenterj 7 ?
. D lace and describe the thyroid gland.
Describe the axillary space and give its contends.
PHYSIOLOGY AND HYGIENE.
1. What is the difference between lymph and sen
449
MEDICAL RECORD.
What causes an extremity to go to sleep?
What is the result of injury to or removal
[circular canals?
What different vascular conditions may lead to a
ng of the face?
What changes are produced in milk by boi
What is the function of the pancreas?
Describe locomotor ataxia.
■ . (a) Upon what does the clotting of blood c
What is the cause of this conversion?
. (a) What do you consider the best me1
ting a dwelling, and (6) g^e the reasons f<
answer? t
10. What is the best method o:f ventilating the j
ing system?
MATERIA MEDICA, THERAPEUTICS, AND THE PRAC
MEDICINE.
.. Describe angioneurotic edema.
I. Name the principal causes of pleuritis.
3. Outline the treatment of pneumonia.
L Define bronchopneumonia and give its etiol
|>. Give a clinical description of pericardii]
usion and name some of the diseases with w
associated.
3. Give the physical signs of exophthalmic goiter
cuss its^treatment.
7. Name^the principal causes of chronic nephrkh
I. Describe diaj%tes mellitus, name its compli
I discuss its tr^atmeiiit.
9. Describe- tetany ,an9 give its etiology.
10. Name tke, exanthematous diseases and gi .
^iod of inQubatSou 6i each.
'-£***!% t'* CHEMISTRY.
1. What is aS6J^nical salt?
g. How is nitroglycerin prepared?
3. From what is phenacetine derived?
1. What areolae chemical properties of radium
5. In what is phosphorus the most readily solul
6. Urine sediments are how classified? Give ex
1. What are enzymes? Give some of their ch
aracteristics.
3. Name an efflorescent salt, a deliquescent salt
': oscopic liquid.
D. Where is sulphur found in the body, and u
• lat form? What is its function?
10, T n a ^ f ,fn W ot^ examination of stomach coi
the physical properties and normal
450
NEW HAMPSHIRE.
PATHOLOGY AND DIAGNOSIS.
1. What is the effect on the circulation of increased
pericardial pressure?
2. Describe the changes produced in the lungs by
mitral stenosis, and how these changes are produced.
3. In what way may arterial disease affect the nutri-
tion of a part?
. 4. What conditions would influence you in determin-
ing the malignity of a tumor?
5. What organ is most commonly affected in visceral
syphilis and describe the lesion found in it?
6. Differentiate diagnosis between obstruction in com-
mon and cystic biliary ducts.
7. Differentiate between lobar pneumonia and pleu-
risy with effusion.
8. Symptoms of incipient tuberculosis.
9. Symptoms (a) of aortic regurgitation; (b) mitral
regurgitation; (c) mitral stenosis.
10. Differential diagnosis in coma produced by alco-
hol, opium, uremia, and cerebral hemorrhage.
OBSTETRICS.
1. Name and describe the ligaments of the uterus.
2. How and when will you use ergot in obstetrical
practice?
3. Give indications for the use of hot vaginal douche.
4. Differentiate fibroid, pregnancy, ascites.
5. Mention three causes for retention of the placenta.
Give treatment.
6. Discuss intrauterine irrigation following complete
abortion.
7. What points should govern the duration of the ly-
ing-in period?
8. Diagnose the death of the fetus during the early
months.
9. Describe the second stage of labor.
10. Under what conditions do we most often find fail-
ure of uterine contraction?
SURGERY,
1. Enumerate suture materials in general use, and
give special value of each.
2. Give technique of first aid to the injured.
3. How would you treat organic stricture of male
urethra?
4. Describe and treat postoperative complications in
the abdominal wound.
5. What are the indications for trephining in fracture
of the skull?
451
MEDICAL RECORD.
6. Describe a modified circular amputation of the leg.
7. Give diagnosis and treatment of floating kidney.
8. Describe some one surgical procedure in the treat-
ment of hemorrhoids.
9. Give symptoms of bowel obstruction and outline a
surgical operation in the treatment of the same.
10. Describe the usual deformity in fracture of the
neck of the femur and outline method of treatment.
ANSWERS TO STATE BOARD EXAMINATION
QUESTIONS.
New Hampshire State Board Medical Examiners.
anatomy.
1. Varieties of Articulation. 1. Diarthrodial, or
freely movable; as hip and knee. 2. Amphiarthrodial,
or slightly movable; as symphysis pubis and joints be-
tween bodies of vertebrae. 3. Synarthrodial, or immov-
able; as ethmoid with vomer and parietal with frontal.
2. Pneumo gastric nerve. Superficial origin: Groove
between restiform and olivary bodies. Deep origin:
Nuclei in floor of fourth ventricle. Course: Outward
across the flocculus, to jugular foramen through which
it passes, where it is joined by the accessory portion
of the spinal accessory nerve. As it goes down the
neck, it lies in front of the rectus capitus anticus major
and longus colli muscles. It passes in the carotid
sheath behind and between the artery and vein. In
the thorax the nerve on each side runs a different
course. The right passes between the subclavian artery
and vein, by side of trachea to root of lung, behind
esophagus, through esophageal opening in diaphragm
to posterior surface of stomach. The left passes be-
tween the subclavian and carotid arteries, in front of
arch of aorta to root of lung, along anterior surface
of esophagus, through diaphragm, to anterior surface
of stomach. Distribution is shown by the names of the
branches: Meningeal, auricular, pharyngeal, superior
and inferior laryngeal, cardiac, pulmonary esophageal,
and gastric. \
3. The heart is nourished by the right and left coro-
nary arteries.
4. Relations of duodenum. First part: In front —
Liver, gall-bladder. Behind — Bile-duct, vena portae,
hepatic artery, gastroduodenal artery, Below — Head
of pancreas.
Second part: In front-— Hepatic flexure of colon. Be-
hind — Right kidney, suprarenal capsule, renal vessels,
452
NEW HAMPSHIRE.
and inferior vena cava. Left side — Head of pancreas,
common bile-duct, and pancreatic duct. Right side —
Hepatic flexure of colon.
Third part: In front — Superior mesenteric vessels
and plexus of nerves. Behind — Aorta, vena cava,
crura of diaphragm, and left psoas. Above — Pancreas.
The jejunum is in relation with the under surface of
the pancreas and the transverse mesocolon.
5. The perineum is a diamond-shaped space corre-
sponding to the inferior aperture of the pelvis. It is
bounded in front by the symphysis pubis and the sub-
pubic ligament; behind, by the coccyx; and on each side
by the rami of the pubis and ischium, the tuberosity of
the ischium, and the great sacrosciatic ligament. It is
generally divided into two parts by an arbitrary line
drawn between the ischial tuberosities, just in front of
the anus; the anterior triangle is called the urogenital
triangle, and the posterior the rectal triangle. The
floor of the perineum consists of: Skin, fascia, trian-
gular ligament, superficial perineal vessels and nerves,
accelerator urinas, transversiis perinei, sphincter ani,
erector penis, compressor urethra?.
6. The nasal bones are situated about the middle and
upper part of the face, the two together forming the^
bridge of the nose. They are small oblong bones and
articulate with the frontal, ethmoid, superior maxillary,
and^ with each other. They are generally described as
having two surfaces (an outer and an inner), and four
borders (superior, inferior, external and internal).
7. The internal jugular vein commences at the jugu-
lar foramen, and is formed by the junction of the lat-
eral and inferior petrosal sinuses; it passes vertically
down the side of the neck on the outer side of the
carotid artery, and at the root of the neck it unites
with the subclavian vein to form the innominate vein.
It collects the blood from the interior of the cranium
and from the superficial parts of the face and from
the neck. Its tributaries are the facial, lingual, pharyn-
geal, and superior and middle thyroid veins.
8. The 7nesentery is a broad fold of peritoneum
which connects the jejun-m and ileum to the posterior
abdominal wall.
9. The thyroid gland is situated on the sides and in
front of the upper part of the trachea, and extends
upward on each side of the larynx. The thyroid gland
consists of two lateral lobes and an isthmus: it is sit-
uated at the front and sides of the neck. The lobes ex-
tend from about the middle of the thyroid cartilage to
the fifth or sixth tracheal ring; the isthmus generally
453
MEDICAL RECORD.
covers the second and third tracheal rings. The lobes
measure about 2xl 1 / 4x% inches; the gland usually
weighs about one ounce. Blood supply: Superior and
inferior thyroid arteries, with thyreoidea ima; and su-
perior middle, and inferior thyroid veins. Nerve sup-
ply: Branches from the inferior laryngeal nerve, and
from the middle and inferior cervical ganglia of the
sympathetic.
10. The axillary space is bounded: Anteriorly, by the
clavicle, subclavius, pectoralis major, costocoracoid
membrane, pectoralis minor; posteriorly, by the sub-
scapulars, teres major, and latissimus dorsi; inter-
nally y by the first four ribs, first three intercostal mus-
cles, serratus magnus; externally, by the humerus,
coracobrachial, and biceps.
Contents: The axillary vessels and brachial plexus of
nerves, with their branches, some branches of the inter-
costal nerves, and a large number of lymphatic glands,
all connected together by a quantity of fat and loose
areolar tissue.
PHYSIOLOGY AND HYGIENE.
1. Blood serum is practically the same as blood
plasma, except that serum contains no fibrinogen, but
more fibrin ferment. The following figures (from
Hammarsten) show the differences between lymph and
plasma:
Lymph contains : Water 939.9
Solids 60.1
Fibrin 0.5
Albumin 42.7
Fat, cholesterin, lecithin 3.8
Extractive bodies .... 5.7
Salts 7.3
Plasma contains : Water 908.4
Solids 91.6
Total proteids 77.6
fibrin 10.1
Fat 1.2
Extractive substances.. 4.0
Soluble salts ........ 6.4
Insoluble salts 1.7
2. An extremity may go to sleep from pressure on a
nerve; as when the hand goes to sleep after pressure
on the ulnar nerve at the elbow, or the foot goes to
sleep from pressure on the sciatic nerve when the
legs are crossed. A poison circulating in the blood may
also irritate the peripheral nerves and cause a similar
sensation.
3. "The semicircular canals are, through the ves-
454
NEW HAMPSHIRE.
tibular nerve and the cerebellum, the most important
agents in the preservation of equilibrium. When in a
pigeon the horizontal canals are divided, the head
moves from left to right and from right to left, with
nystagmus and a tendency to revolve on its vertical
axis. When the inferior vertical or posterior canals
are divided, the head oscillates from front to rear; the
animal has a tendency to fall backward. A section of
the superior vertical canal causes the head to oscillate
from front to rear, with a tendency to fall forward.
A section of all the canals is followed by contortions
of the most bizarre nature. After a destruction of all
the canals the animal cannot maintain his equilibrium.
Similar phenomena have been observed in man in dis-
ease of the semicircular canals, known as Meniere's
vertigo. In the fixed position of the head there is
equilibrium, but with each movement the varying ten-
sion of the liquid in the ampulla changes and irritates
the hair-cells." — (Ott's Physiology.)
4. Paling of the face may be caused by spasm of the
arterioles, increased vasoconstriction, or defective
action of the heart.
5. When milk is boiled, a thin scum of albumin ap-
pears on the surface, it takes longer to coagulate, and
also longer to sour; the taste is changed; the color is
also changed, and various bacteria and fungi are de-
stroyed. The digestibility and rate cf absorption of
boiled milk and raw milk do not differ materially.
6. The function of the pancreas is to provide the
pancreatic juice, which changes proteids into proteoses
and peptones, and afterward decomposes them into
leucin and tyrosin; converts starches into maltose;
emulsifies and saponifies fats; causes milk to curdle.
It also supplies an internal secretion.
7. Locomotor ataxia is a disease of the spinal cord,
characterized by loss of coordination, characteristic
and unsteady gait, a tendency to stagger when stand-
ing up with the feet together and the eyes closed, sharp
and paroxysmal pains called crises, girdle sensation,
Argyll-Robertson pupils, and loss of knee-jerk and
other reflexes. In locomotor ataxia the posterior col-
umns of the spinal cord and the posterior nerve roots
are involved. The process is destructive and progressive ;
it is not a simple wasting, although the nerve fibers
are atrophied, but it is characterized by irritation,
changes in the axis cylinders, overgrowth of the con-
nective tissue, and sometimes congestion. The spinal
ganglia may also be affected, and the membranes over
the affected parts are adherent and opaque.
455
MEDICAL RECORD.
8. In the plasma a proteid substance exists, called
fibrinogen. From the colorless corpuscles a nucleo-
proteid is shed out, called prothrombin. By the action
of calcium salts prothrombin is converted into fibrin
ferment, or thrombin. Thrombin acts on fibrinogen in
such a way that two new substances are formed: one
of these is unimportant and remains in solution; the
other is important, viz., fibrin, which entangles the
corpuscles and so forms the clot.
9. "Hot-water heating. — This is regarded as the best
form of central heating for small dwellings. Instead
of an air jacket over the combustion chamber, there is
provided a water receptacle, from which a continuous
pipe ascends through the house to its uppermost part,
whence it returns by a continuous descending pipe and
connects with same water receptacle. The water being
heated, circulates freely throughout the system of pipes
and the radiators attached thereto, and by heating of
pipes and radiators warms the air of the rooms. Be-
tween the ascending and descending pipes there is
usually placed an expansion tank to allow for the ex-
pansion of the water by heat. This system of heating
is simple, needs little attention, produces a pleasant
and not too high temperature, is not subject to sudden
variations, and consumes a relatively small amount of
coal.
"Steam Heating. — In this system the pipes are filled
with steam instead of with hot water, and the water
in the boiler is converted into steam. The temperature
of the pipes and radiators is higher, their size corre-
spondingly smaller, more fuel is needed to convert the
water into steam, a higher pressure gained, more ex-
pert attention necessary, a greater degree as well as
variation of heat reached. This system is especially
suitable to large houses. Steam-heating plants may be
located outside of the house and convey the heat by
means of underground steam pipes." — (Price's Essen-
tials of Hygiene).
10. "The whole plumbing system is ventilated by ver-
tical pipes led through the roof and left open to the out-
side air, while air from the outside is provided by means
of the 'fresh-air inlet,' which, beginning with an air
box in the sidewalk, runs into the house drain, inside
of the main trap, and by a 4-inch iron pipe. The vent
pipes also aid the ventilation within the pipes."
— (Price's Essentials of Hygiene.)
MATERIA MEDICA, THERAPEUTICS, AND THE PRACTICE OF
MEDICINE.
1. "Angioneurotic edema is a neurotic condition in
456
NEW HAMPSHIRE.
which transient circumscribed, edematous swellings ap-
pear on the skin, and sometimes on the mucous mem-
branes, and disappear after a variable period without
leaving behind any structural alterations. It arises
usually without obvious cause and is in all probability
a vasomotor neurosis. Certain drugs in susceptible
individuals may induce it. Recurrences are frequent,
and when the larynx is involved the affection assumes
a grave aspect." — (Hughes' Practice of Medicine).
2. The Principal Causes of Pleuritis are: Exposure
to cold or damp, tuberculosis, pneumonia, pulmonary
abscess, bronchitis, nephritis, cancer, various specific
fevers, traumatism of the chest; the microorganisms
usually found are the pneumococcus, tubercle bacillus,
and streptococcus.
3. The treatment of pneumonia "consists in fresh air,
good nursing, rest in bed, milk diet, and the adminis-
tration of fractional doses of calomel followed by a
saline in the early stage. The nervous symptoms and
temperature may be controlled by applying ice-bags
or compresses wrung out of cold water (60°-70° F.) to
the chest or by the use of the warm or cold wet-pack.
The heart and pulse should be sustained by the admin-
istration of alcohol, strychnine (gr. 1/60-1/20), atro-
pine, caffeine, strophanthus, and nitroglycerin. Digi-
talis may also be employed. Inhalations of oxygen
afford temporary relief when the dyspnea and cyanosis
are extreme. In young, vigorous, and plethoric adults,
with hyperpyrexia and a high-tension pulse, bleeding
may be beneficial in the first 48 hours. Convalescence
should be guarded, and tonics, stimulants, etc., will be
found very useful in this period of the disease." —
{Pocket Cyclopedia.)
4. Bronchopneumonia is an acute inflammation of the
bronchioles and the alveoli of the lungs. It may be
due to a bronchial catarrh, one of the infectious fevers,
influenza, heart disease, uremia, nephritis, diabetes;
the microorganisms generally present are the Micro-
coccus lanceolatus, Streptococcus pyogenes, Staphylo-
coccus aureus and albus, Friedlander's bacillus, and
occasionally the colon bacillus, typhoid bacillus, Klebs-
Loeffler bacillus, or bacillus of pneumonia.
5. Pericarditis ivith effusion. — "The symptoms are
somewhat obscure and may be masked by previously
existing disease. Taking a typical case as it occurs
in the course of rheumatic fever, we usually find pre-
cordial distress; sharp pain is rare, but w T hen present
it is most marked at the lower end of the sternum.
Moderate fever, or exacerbation of already existing
457
MEDICAL RECORD.
fever, at the onset; dyspnea, and dusky appearance of
the face; rapid action of the heart, sometimes with
feeble pulse; symptoms due to pressure by the fluid on
the neighboring organs (trachea and esophagus, etc.) ;
great restlessness. The physical signs are: Marked
increase of the cardiac dulness; displacement of the
apex beat; muffling of the heart sounds; displacement
of other organs (if effusion is great). The shape of
the dulness is characteristic. It is conical, the apex
of the cone being truncated, and situated at the level
of the second rib, owing to the close attachment of the
pericardium to the great vessels at this point. The
apex beat is generally pushed upwards and to the left.
It lies, when it is palpable at all, distinctly within the
left border of cardiac dulness, not, as in enlargement
due to valvular disease, in close relationship to it.
The marked distention of the pericardial sac surrounds
the heart limits of the organ itself. The amount of
bulging and displacement of organs will, of course,
vary with the amount of fluid present. As resolution
takes place the friction returns, and may be very coarse
in character. Muffling of the heart sounds is not al-
ways present, and is not entirely due to the presence
of fluid. The muffling is therefore due mainly to weak-
ness of the cardiac muscle from accompanying myocar-
ditis, although where the quantity of fluid is very
great, in serous and chronic pericarditis, this may in
part account for it." — (Wheeler and Jack's Handbook
of Medicine).
6. The physical signs of exophthalmic goiter are:
Exophthalmos, goiter, tachycardia, and muscular tre-
mor; anemia, hemic murmurs, cardiac hypertrophy or
dilatation, palpitation of the heart; there may be a
systolic thrill over the goiter. The treatment demands
rest, fresh air, and light but nutritious diet; digitalis,
bromides, iodides, arsenic, and electricity have all been
recommended ; partial thyroidectomy, section of the cer-
vical . sympathetic, and ligature of the thyroid arteries
have been advocated; the newest remedy is probably
antithyroidin.
7. The principal causes of chronic nephritis are:
Arteriosclerosis, alcoholism, gout, lead poisoning, syph-
ilis, acute nephritis, malaria, excess of nitrogeneous
diet.
8. Diabetes mellitus is a constitutional disease, char-
acterized by polyuria, excess of sugar in the blood and
excretion of the same in the urine, and accompanied
by severe emaciation. It generally occurs after the
fortieth year, but may come on at any age; it is more
458
NEW HAMPSHIRE.
common in males, among Hebrews, and in the well-to-
do classes. The direct cause is not known. Complica-
tions are: Pruritus, eczema, boils, cataract, retinitis,
neuritis, albuminuria, cirrhosis of kidney, acidosis, and
tabes. Treatment consists in a quiet, regular mode of
living, without worry; gentle exercise; daily bathing
in lukewarm water; flannel underwear; the carbo-
hydrates in the food should be cut down until there
is no sugar in the urine or a non-carbohydrate diet is
reached. Codeine, morphine, antipyrin, arsenic, and
strychnine have been recommended.
9. Tetany is a condition characterized by tonic mus-
cular spasms of the extremities, which occur at inter-
vals, are painful, and usually bilateral. The cause is
unknown; toxins acting on the peripheral motor neu-
rons, removal of the thyroid gland, rickets and hys-
teria are said to be etiological factors.
10. Exanthematous diseases. — Cerebrospinal menin-
gitis, incubation period is unknown; erysipelas, a few
hours to 3 or 4 days; measles, 10 to 12 days; rotheln, 8
to 16 days; scarlatina, 1 to 21 days; typhoid, 5 to 30
days; typhus, 4 to 12 days; varicella, 4 to 14 days;
variola, 7 to 14 days. The figures are approximate.
CHEMISTRY.
1. A Salt is a substance derived from an acid by
substituting a metal (or its equivalent) for part
or all of the replaceable hydrogen of the acid.
2. Nitroglycerin is prepared by the action of a mix-
ture of sulphuric and nitric acids upon glycerin.
3. Phenacetine is derived from para-phenetidin,
which is derived from phenol.
4. Chemical properties of radium. — "The emitted
rays convert oxygen into ozone and change yellow
phosphorus to red. The alpha rays immediately coag-
ulate a sensitive solution of globulin. The beta and
gamma rays liberate iodine from iodoform in the
presence of oxygen." — (Holland's Chemistry.)
5. Phosphorus is soluble in carbon disulphide, and
in the fixed and volatile oils.
6. Sediments in the urine may be classified according
to their presence in acid urine, and in alkaline urine.
In acid urine, are found: Uric acid, urates, calcium
oxalate, cystin, and calcium phosphate. In alkaline
urine are found : Phosphates, calcium carbonate, and
ammonium urates.
7. Enzymes are organized ferments produced by liv-
ing cells; they cause definite chemical changes in cer-
tain substances. They are capable of causing change
459
MEDICAL RECORD.
in a large amount of material, and they themselves
remain unaltered; they only act in a medium of cer-
tain reaction, some in an acid medium, some in an
alkaline; for each enzyme there is a certain tempera-
ture at which its action is the most energetic; the
products of their activity must be removed, or the
accumulation of these products will hinder further
activity.
8. An efflorescent salt, sodium carbonate; a delique-
scent salt, calcium chloride; a hygroscopic liquid, alco-
hol.
9. Sulphur occurs in the body chiefly in the hair, nails
and epithelium, but it is a constituent of most proteids.
It is found as hydrogen sulphide and as sulphates.
10. Gastric juice is a liquid, slightly cloudy, almost
colorless, acid, with specific gravity of 1001 to 1Q10; it
deposits a sediment which may contain food particles,
gland cells, nuclei, epithelium, and mucus. It consists
of water and solids, and free hydrochloric acid; pep-
sin, chlorides of sodium, potassium, and calcium; phos-
phates of calcium, magnesium, and iron; mucin, a
thiocyanate, and nucleo-proteid.
PATHOLOGY AND DIAGNOSIS.
1. Increased pericardial pressure causes embarrass-
ment of the circulation, through pressure on the auri-
cles and great veins. Less blood goes into the right
auricle, right ventricle, and pulmonary artery; the
blood pressure in the pulmonary artery falls ; less
blood reaches the left side of the heart and the aorta,
and the aortic blood pressure falls. The venous blood
pressure rises.
2. In mitral stenosis the lungs may be congested and
edematous, and hemorrhage may occur. These condi-
tions may be due to back pressure or to embolic infarc-
tion, the emboli coming from the dilated right side of
the heart.
3. Arterial disease, such as narrowing, pressure by
tumors, sclerosis, aneurysms, and blood clots may hin-
der the flow of blood to a part and so affect its nutri-
tion.
4. Malignant tumors interfere with the general health
of the patient, produce a cachexia, tend to spread into
the neighboring tissues, are apt to recur after removal,
and show a tendency to metastasis.
5. The organ most commonly affected in visceral
syphilis, is the liver,
"Syphilis is met with in the form of diffuse infiltra-
tion and cirrhosis, or in the form of gummata. Either
460
NEW HAMPSHIRE.
of these varieties may be found as a result of acquired
or of hereditary syphilis. In the diffuse form the liver
presents much the same appearances as in atrophic cir-
rhosis, but the connective-tissue bands are much more
pronounced and the liver is prone to be irregularly con-
tracted and lobulated. Gummata may occur in any part
of the organ, and may be single or multiple, presenting
themselves as rounded, yellowish, or grayish masses,
ofttimes showing central necrosis and surrounded by
connective-tissue hyperplasia. Complete cicatrization
may lead to decided scar-formation. In addition to these
forms, congenital syphilis may manifest itself in the
form of a uniform, diffuse connective-tissue hyperplasia
and round-cell infiltration. The liver-cells are pushed
apart and are ill-developed or atrophic." — (Stengel's
Pathology.)
6. If the obstruction is in the cystic duct there is
usually no jaundice; if the obstruction is in the common
bile duct there is usually intense jaundice.
PLEURISY WITH EFFUSION
Onset marked by chilliness
persisting for a few
days.
Cough is irritating ; no ex-
pectoration, or, if pres-
ent, catarrhal in char-
acter.
Sputum negative; tubercle
bacilli rare.
Moderate fever of continu-
ous type; declines by
lysis.
Prostration moderate.
Unilateral distention of
the thorax.
Countenance pale and
anxious.
Limited expansion at base
of chest on the affected
side.
Tactile fremitus dimin-
ished or absent.
Interspaces bulging at
base of chest.
Percussion shows flatness,
with great resistance to
the pleximeter finger.
LOBAR PNEUMONIA
Onset acute, with rigor,
lasting one hour or
longer.
Cough more marked, and
accompanied by rusty
or bloody, tenacious ex-
pectoration.
Dense aggregations of
pneumococci present.
Fever, 102° to 104° F.;
falls by crisis.
Prostration extreme.
Absent.
Mahogany-colored flush
of cheeks.
Degree of expansion
slightly, if at all, in-
hibited.
Increased over area of
consolidation.
Absent.
Dullness with less resist-
ance, and sometimes a
tympanitic note.
461
MEDICAL RECORD.
PLEURISY WITH EFFUSION
Diminished or absent
breath-sounds over effu-
sion the rule. Respira-
tion murmur diffuse,
distant, and generally
unaccompanied by rales.
Bronchial breathing may
be present over the en-
tire affected side.
Friction sound heard in
early a nd late stages.
LOBAR PNEUMONIA
Harsh bronchial breathing
and presence of rales
in first and third stages,
unless a bronchus is
plugged.
No friction murmur; rales
present.
— (From. Anders and Boston's Medical Diagnosis) .
8. The early manifestations of pulmonary tuber-
culosis are: (1) Physical signs: Deficient chest expan-
sion, the phthisical chest, slight dullness or impaired
resonance over one apex, fine moist rales at end of in-
spiration, expiration prolonged or high pitched, breath-
ing interrupted. (2) Symptoms: General weakness,
lassitude, dyspnea on exertion, pallor, anorexia, loss of
weight, slight fever, and night sweats, hemoptysis.
9. In aortic regurgitation, there is a diastolic mur-
mur, heard loudest at the midsternum opposite the
upper border of the third costal cartilage, and trans-
mitted down the sternum; the murmur is soft, blow-
ing, sometimes rough.
In mitral regurgitation, there is a systolic murmur,
heard loudest over the apex, and transmitted round
to the left axilla and under the left scapula; the mur-
mur is soft and blowing.
In mitral stenosis, there is a presystolic murmur,
heard loudest over the apex, and not transmitted; the
murmur is generally low-pitched, and rough.
10. The following table (from Eisendrath's "Surgical
Diagnosis") gives the diagnosis: (See table page 463).
OBSTETRICS.
1. The ligaments of the uterus are: (1) Broad
ligaments, which extend outward on each side from the
side of the uterus to the side of pelvis. (2) Rectouterine
ligaments, which extend backward from the intraperi-
toneal portion of the cervix uteri to the peritoneal in-
vestment of the rectum. (3) Round ligaments, which
extend from the uterus just below the Fallopian tubes,
through the inguinal canal to the labia majora. (4)
The ovarian ligaments, which extend from the superior
part of the uterus, behind the Fallopian tubes, to the
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MEDICAL RECORD.
inner end of the ovary. (5) The uterosacral ligaments,
which extend from the highest part of the cervix uteri
to the sides of the sacrum opposite the lower border of
the sacroiliac synchondrosis.
2. "The use of ergot favors uterine contraction and
retraction. Ergot may be given hourly as a routine, in
half dram doses of the fluid extract, until three doses
have been taken, or used only when there are signs of
relaxation, as a prophylactic against postpartum
hemorrhage. Postpartum inertia is not uncommon
when the patient has been the subject of hydramnios,
twins, etc., or has been subjected to a long general
anesthesia, or is exhausted, with a rapid pulse and
low blood pressure. Ergot is best used hypoder-
matically in the form of ergone (25 min.), or ergotole
(25 min.), combined with pituitrin (1 ampoule). The
generous use of ergot in the puerperium is of value
also as a prophylactic against puerperal infection,
since it tends to prevent the formation and the pro-
longed retention of blood clots within the uterus, and
by its action on the muscular fibers tends to close the
lymphatics and blood vessels against absorption. More-
over, by thus limiting the blood supply it promotes in-
volution." — (Polak's Obstetrics) .
3. Indications for hot vaginal douche. — Before
labor: 1. To induce premature labor. 2. As a pro-
phylactic in cases of suspicious or undoubtedly infect-
ive vaginal discharge. During labor: As preliminary
to version, forceps, or embryotomy. After labor:
1. Many obstetricians give a routine douche for the
sake of cleanliness. 2. In case of foul lochia. 3. After
repair of perineal lacerations. 4. As an element of
treatment of puerperal sepsis. — (From Scott's State
Board Obstetrics) .
4. Pregnancy: The tumor is hard and does not fluc-
tuate, is situated in the median line, and may give fetal
heart sounds and movements; the cervix is soft, and
the other signs of pregnancy are present. The rate of
growth of the tumor and the general condition of the
patient's health may also help in arriving at a diag-
nosis.
Uterine fibroid: Menstruation is irregular and some-
times very profuse; absence of the signs of pregnancy;
the tumor is nodular, firm, irregular in outline, and
while generally placed somewhat centrally is not in the
median line, and is not symmetrical ; the rate of growth
is irregular, being, as a rule, slow, and sometimes ex-
tending over years.
Ascites: Absence of the signs of pregnancy; the abdo-
464
NEW HAMPSHIRE.
men is distended, but the shape varies with the position
of the patient; on lying down there is bulging at the
sides, the tumor fluctuates, and percussion shows dull-
ness in the flanks, with resonance in the median line,
but the dullness varies according to the position of the
patient.
5. Retained placenta — Three causes: Inertia uteri,
endometritis, or morbid adhesion of the placenta to the
wall of the uterus. Treatment: "A finger— one or two
— must be insinuated between the uterus and placenta
at some point already partially separated, or, if no par-
tial separation exists, at a point where the placental
border is thick, and then passed to and fro, trans-
versely, through the uteroplacental junction, acting
like a sort of blunt paper knife, until separation be
complete. Another mode is to find or make a margin
of separation as before, and then peel up the placenta
with the finger-ends, rolling the separated portion to-
ward the palm of the hand upon the surface of the still
adherent part. Great care is necessary to avoid peel-
ing up an oblique layer of uterine muscular fiber, which
might split deeper and deeper until leading the finger-
ends through the uterine wall into the peritoneal cavity.
Should such a splitting begin, leave it alone and
recommence the separation at some other point on the
placental margin. It is sometimes only possible to get
the placenta away in pieces. These should be after-
ward put together and examined to indicate what rem-
nants are left behind. It may be quite impracticable
to get out every bit, but small remnants or thin layers
too firmly adherent for removal do not distend the
womb enough to create hemorrhage from their bulk,
and the subsequent danger of septicemia from their
decomposition may be obviated by injecting warm (2
per cent.) creolin water into the uterus twice daily,
until everything has come away." — (King's Obstetrics.)
6. If the abortion is complete, and there is no septic
or other pathological condition present there is no need
for an intrauterine douche.
7. Points which should govern the duration of the
lying-in period, are the character and duration of the
labor, the presence or absence of complications, the
condition of the uterus, and the strength of the woman.
8. Diagnosis of the death of the fetus during the
early months is difficult. The chief signs are that
the uterus ceases to grow, the abdomen does not en-
large, the breasts either cease enlarging or become
smaller again, the temperature of the cervix ceases
to be higher than that of the vagina. The mother ex-
465
MEDICAL RECORD.
periences vague symptoms of malaise, languor, heavi-
ness, depression, chilly sensations and anorexia.
9. During the second stage of labor, examinations
should be made only when necessary. In multiparas the
membranes may be ruptured with the finger or with
some aseptic instrument. Care should be taken not to
injure the child's scalp or the lower uterine segment.
The pain may require the administration of chloro-
form or ether, but not to the extent of complete anes-
thesia. The expulsive force of the abdominal walls
may be increased by directing the patient to pull upon
a sheet firmly secured to the foot of the bed. Attempts
may be made to prevent laceration of the perineum by
making firm backward and upward pressure against
the occiput during the pains; by restraining voluntary
expulsive efforts during the pains; and by securing ex-
pulsion of the head between the pains. The head
should be supported when born; the eyes should be
cleansed with sterile water; and if the cord is coiled
about the neck, it should be loosened or slipped over the
head. Delay in delivery of the shoulders may be over-
come by stimulating the uterus by friction through the
abdominal wall or traction. The cord is ligated and
cut when pulsation has ceased, and the child is placed
by the mother's side with its face turned away from
the maternal discharges. — (Pocket Cyclopedia,)
10. Failure of uterine contraction may be caused by:
"Overdistention of the uterus from plural pregnancy or
polyhydramnios; distention of the bladder or rectum;
obliquities and displacements of the uterus; thinning of
the uterine walls resulting from frequent and quickly
repeated labors, or from degeneration of the uterine
tissues; precocious or advanced age; general debility
or feebleness of the woman from previous diseases,
enervating habits, heat of climate, or of season, or the
air of a superheated room; exhaustion of the woman
from hemorrhage or from lack of sleep or food. Uter-
ine action is sometimes inefficient from uremia, and
when there is morbid adhesion between the fetal mem-
branes and uterine wall. Mental emotions: fear, grief,
surprise, anxiety, disappointment, and the presence of
offensive persons or things will produce it. These last
named causes may depend upon idiosyncrasy or unac-
countable personal antipathies." — (King's Manual of
Obstetrics.)
SURGERY.
1. Suture materials: (1) Silkworm gut, used only
on surfaces, from which it may subsequently be re-
moved. (2) Silk, used in abdominal surgery, for sutur-
466
NEW HAMPSHIRE.
ing intestines and tying pedicles. (3) Catgut, used
for buried sutures. (4) Kangaroo tendon, used for
bone, and as an absorbable suture which will last a
long time. (5) Silver wire, used for bone.
2. The nature of first aid to the injured will depend
upon the injury. If a layman is rendering first aid,
his first duty is to keep the crowd away, allow the in-
jured one to get fresh air, see that the injury is not
made worse, combat shock, check hemorrhage, place
the patient in the most comfortable and safe position,
and keep him warm and sheltered.
3. Organic stricture of the male urethra may be
treated by: Gradual dilatation, continuous dilatation,
excision of the stricture, external or internal urethrot-
omy, urethrectomy, or the operation of Wheelhouse or
Cock.
4. Post-operative complications in an abdominal
wound, are: (1) Stitch-hole abscess; the infected
sutures should be removed, and their tracts syringed
with hydrogen peroxide; this should be done daily; a
thick gauze compress soaked with a 1:1000 solution
of mercury bichloride is then applied, and covered with
the usual dressings. (2) Suppuration in the wound;
open the abscess, with all blind pouches or cul-de-sacs,
irrigate the wound with hydrogen peroxide, and dress
as in case of stitch-hole abscess. (3) Ventral hernia;
this requires either a support or binder, which is mere-
ly palliative; or another operation.
5. Trephining, in cases of fracture of the skull, is
indicated in: Simple fractures with pronounced de-
pression; compound fractures with much depression;
punctured frac 1 res; any fracture where there are dis-
tinct cerebral symptoms.
6. "Modified circular amputation of the leg. — Cut
semilunar skin-flaps, lay them back, and cut circularly
to the bone at the edge of the turned-up flap. Another
method of modified circular amputation is by adding to
the circular cut a vertical incision down the front of
the leg. In sawing the bones of the leg the surgeon,
who stands to the outer side of the right leg or to the
inner side of the left leg, divides the fibula first, and
at a higher level than the tibia, and bevels the anterior
surface of the tibia. In sawing the left fibula the saw
points to the floor; in sawing the right fibula it points
to the ceiling." — (Da Costa's Modern Surgery.)
7. In floating kidney the symptoms may be entirely
absent in some cases. They consist of aching pain in
the loin, nausea, vomiting, and constipation. Attacks
of renal colic and intermittent hydronephrosis may oc-
467
MEDICAL RECORD.
cur from kinking of the ureter. A movable tumor can
be felt in the region of the kidney.
Treatment consists in improving the general health
and wearing an abdominal belt with a pad. When this
fails, or there are attacks of colic or hydronephrosis,
nephrorrhaphy should be done.
8. "The application of the ligature is an easy and
useful method. It is not so rapid as the cautery, is
followed by more pain, healing requires a longer time,
and stricture is more common. In this operation, after
anesthetizing, stretch the sphincter and treat each
hemorrhoid separately. Catch a pile with a pair of
forceps or a volsellum, pull it down, and cut a gutter
through the skin-margin if the pile is of the mixed
variety; tie the small piles without transfixing, but
transfix the large piles; tie with silk (coarse silk for
the large piles, finer silk for the small piles) ; cut off
each tumor beyond the thread, and cut the ligatures
short. Treat the other piles in the same manner. Ir-
rigate with hot normal salt solution. Do not insert
packing. Apply a gauze pad and a T-bandage. Give
some morphine to lock up the bowels, and keep the pa-
tient on a light diet for three days, at the end of which
time a saline may be given. Just before the bowels act
remove the dressings and give an enema of warm water
or of glycerin. After the movement wash out the rec-
tum first with dilute peroxide of hydrogen and next
with hot salt solution, dust with iodoform, and apply a
gauze pad over the anus. Irrigate daily until healing
is complete. After the tenth day examine with a spec-
ulum to see that the ligatures have come away; if any
are found in place, remove them." — (Da Costa's Modern
Surgery.)
9. Symptoms of acute intestinal obstruction: "Sudden
severe pain referred to the umbilicus comes on, per-
haps, after an effort. Shock, evidenced by a weak pulse,
a cold, clammy skin, and a subnormal temperature,
accompanies the pain. The pain, intermittent at first,
becomes continuous. Vomiting is persistent, and soon
becomes fecal smelling. The patient becomes exhausted
by the vomiting and inability to take food. The ab-
domen becomes distended, and if the obstruction is not
relieved, perforative peritonitis follows, so that the
patient dies in about seven to ten days from the onset.
Constipation is usually absolute, though the lower bowel
may empty itself at first."
Treatment: — "The only thing that can give the pa-
tient the chance he ought to have is immediate opera-
tion. It is advisable to wash out the stomach before the
468
NEW HAMPSHIRE.
operation, so that intestinal contents may not be vom-
ited and inhaled during the operation. Three objects
are aimed at: (1) To empty the distended bowel above
the obstruction; (2) to relieve the obstruction; (3) to
treat the strangulated intestine. In cases that are
almost moribund, the abdomen should be opened with
cocaine or eucaine anesthesia; a distended coil is pulled
out and tapped, a PauPs tube being subsequently tied
in. The peritoneal cavity is protected with gauze pack-
ing during these manipulations. The bow r el is stitched
to the abdominal wound after the feces and flatus have
drained away. No attempt at relief of the obstruction
can be made in these cases till a later date, and, of
course, under the circumstances a high death-rate must
be expected.
In less severe cases the abdomen should be opened in
the midline below the umbilicus, and a systematic
search made for the cause of the obstruction. The
hernial orifices are first examined, then the cecum. If
the cecum is distended, the obstruction lies below it; if
collapsed, above it. In the former case the sigmoid
should next be examined. If collapsed, the colon must
then be traced backwards till the obstruction is found.
If the cecum is collapsed, the intestine must be pulled
out a foot at a time and examined, beginning with the
ileum, and replacing it as each part is done with. If
the intestine is much distended, several coils may be
tapped and emptied, to facilitate the search." — (Aids
to Surgery.)
10. If the fracture of the neck of the femur is intra-
capsular, there is very apt to be fibrous union with
false joint; if the fracture is extracapsular ', shorten-
ing is very common.
Treatment of intracapsular fracture : "Fibrous union
nearly always occurs in old people, as the blood supply
of the upper fragment depends solely on the obturator
branch running in the ligamentum teres. Then, old
people often die of hypostatic pneumonia if kept lying
long upon the back. If the patient be young, he should
be put upon a long Liston splint, with extension, for
six weeks. The same should be tried with old people,
but the moment the respirations begin to increase the
patient must be got up, wearing a Thomas' hip splint.
Impaction favors bony union, and so should not be
broken down."
Treatment of extracapsular fracture: "Unless there
is great deformity, it is not advisable to break up im-
paction. Bony union always occurs. The patient
should be anesthetized, and traction kept upon the leg
469
MEDICAL RECORD.
during fixation. A stirrup extension is first put on,
and then the leg is firmly bandaged to a long Liston
splint, with the eversion corrected. The chest is fixed
to the splint by a binder; the foot of the bed is raised,
and a weight of eight or ten pounds is put on to the
cord of the stirrup extension. Hodgen's splint may also
be used. Union occurs in six weeks." — (Aids to
Surgery.)
STATE BOARD EXAMINATION QUESTIONS.
State Board of Medical Examiners of New Jersey.
ANATOMY.
1. Describe the structure of the arteries and give
their nerve and blood supply.
2. What arteries, muscles, and nerves would be sev-
ered in a cross-section at the middle of the humerus?
3. What are the lymphatic glands?
4. Give the situation of the lymphatic glands of the
chest.
5. Locate and describe Peyer's glands.
6. Give the deep and superficial origin, course, and
distribution of the pneumogastric nerve.
7. Bound Scarpa's triangle and mention the vessels
and nerve in it.
8. What bones enter into the formation of the nasal
fossae?
9. Name the bones that form the ankle-joint and give
their relations.
10. Name the abdominal viscera wholly covered with
peritoneum; those partially covered.
PHYSIOLOGY.
1. Define physiology.
2. Trace the circulation of the blood beginning at the
left ventricle.
3. How does the fetal circulation differ from that of
the adult?
4. Give the physical and chemical composition of
blood.
5. What are the functions of blood?
6. What is the portal system? Name the enzymes
manufactured from its blood.
7. Name the organs of excretion in order of impor-
tance.
470
NEW JERSEY.
8. What is the function of the red blood cells? Of
the leucocytes?
-9. What is glycogen? What is its use?
10. What changes occur in a muscle in exercise?
CHEMISTRY.
1. What is chemistry?
2. What are the three laws of chemical combination?
3. Name three strong mineral acids and which is the
strongest?
4. What are alkaloids, and how are they divided?
5. What is the chemical composition of the blood?
6. Give the antidote for poisoning by carbolic acid.
7. What are physical and what are chemical changes?
8. Define organic and inorganic chemistry.
9. Define specific gravity. What relation does the
amount of solid matter in urine bear to the specific
gravity of the urine?
10. What is the formula of hydrogen dioxide and by
what other name is it known?
MATERIA MEDICA AND THERAPEUTICS.
1. Name three drugs that will liquefy and increase
bronchial secretion. Give official name, dose of each.
Write a prescription containing one.
2. Define a diuretic; name three vegetable diuretics.
Give dose and official name of each. Write a prescrip-
tion containing one.
3. Name two drugs that will lower blood pressure.
Give official name and dose of each.
4. Name two official drugs that will change the color
of the urine; also name two that will change the color
of the feces.
5. What is epinephrin? Give official name, dose,
properties, and uses.
6. Name three drugs that may cause irritation or
skin eruption. Give official name, dose, and properties
of each.
7. Oil of santal; give dose, properties, and uses; offi-
cial name.
8. Elaterin; give official name, dose, properties, and
uses.
9. What drugs would you use in the early stages of
a case of pneumonia? Give official name; dose of each.
Write a prescription containing one.
10. Name five official tinctures and give dosage of
each.
HISTOLOGY.
1. Describe the suprarenal capsule, macroscopically
and microscopically.
471
MEDICAL RECORD.
2. What do you mean by the reconstruction of ana-
tomical structure? Give technique.
3. Describe epithelial tissue ; give varieties and where
found.
4. Describe motor nerve endings in voluntary muscle
tissue.
PATHOLOGY.
1. What is the difference between hypertrophy and
enlargement?
2. Give theory of diabetes mellitus.
3. Describe gout; give theory.
BACTERIOLOGY.
1. Name the pathogenic spirilla and diseases caused
by them.
2. Describe mycetoma.
3. Name the pathogenic protozoa and give life his-
tory of the dysentery ameba.
HYGIENE.
1. What is a water shed?
2. How can it be properly safeguarded, and why?
3. Name the water-borne diseases.
4. What is the best general method of purifying
drinking water?
5. How may ground water injuriously affect the pub-
lic health?
MEDICAL JURISPRUDENCE.
1. What is the difference between molecular and
somatic death?
2. What are the signs of, and how can you determine
between, real and apparent death?
3. How would you conduct an autopsy?
4. Name most of the causes of violent death, and tell
how you would differentiate them.
5. What is the object of a coroner's inquest?
PRACTICE OF MEDICINE.
1. Differentiate rachitis and scurvy.
2. Describe the several kinds of arterial pulse.
3. Differentiate catalepsy, epilepsy, and hysteria.
4. What diseases may cause occlusion of the common
bile-duct?
5. Describe the varieties of stomatitis, giving the
causes of each.
6. Describe vocal fremitus and name the conditions
causing its increase or decrease.
7. Describe the urinary casts; where formed and the
disease each indicates.
472
NEW JERSEY.
8. Describe the eruption only, in its different stages,
of measles, scarlet fever, and smallpox.
9. Describe the pathological pulmonary sounds heard
on auscultation of the lungs and name the conditions
causing them.
10. Describe the normal heart sounds and state the
points on the chest where each is heard with the great-
est distinctness.
OBSTETRICS.
1. Give average normal pelvic measurements which
you would take at examination of a woman in her first
pregnancy. Give smallest measurements which would
permit natural delivery.
2. Give mechanism of second stage of labor in
L. O. A.
3. Give treatment of different degrees of uterine in-
ertia.
4. Give three causes for postpartum hemorrhage, and
treatment for each.
5. Give management of shoulder presentation.
6. Give causes for non-engagement of head at brim,
and give management of each condition.
GYNECOLOGY.
1. Name two conditions in which cystoscopy would
aid in diagnosis, and give cystoscopic findings in each.
2. Differentiate subinvolution of uterus, chronic me-
tritis, and uterine fibroid.
3. Give history and symptoms of tubal pregnancy in
third month, and its possible terminations.
4. Give blood supply of the uterus and ovaries.
SURGERY.
1. Define a compound, comminuted, and complicated
fracture. Give treatment.
2. Give diagnostic symptoms and treatment of acute
epididymitis.
3. Give diagnostic symptoms of stone in ureter.
4. Describe the deformity and the method of reduc-
tion of the same in Pott's fracture.
5. Describe congenital dislocation of the hip.
6. What conditions may give rise to symptoms simu-
lating those of appendicitis?
7. What is the clinical aspect of a beginning car-
cinoma of the female breast?
8. Define hernia; give different varieties of abdomi-
nal hernia.
9. What are the symptoms produced by gallstones?
10. Define and give symptoms of hypothyroidism.
473
MEDICAL RECORD.
ANSWERS TO STATE BOARD EXAMINATION
QUESTIONS.
State Board of Medical Examiners of New Jersey.
ANATOMY.
1. An artery consists of three coats: The tunica in-
terna, or internal coat; the tunica media, or middle
coat, and the tunica adventitia, or external coat. The
internal coat consists of a basement membrane, on
which is a layer of endothelial cells. The middle coat
consists of involuntary muscle fibers, between the layers
of which are some elastic fibers. The external coat con-
sists of connective tissue (white fibrous and yellow elas-
tic). Between the two outer coats is an elastic mem-
brane.
The nerve supply is by the vasomotor nerves. The
blood supply is by the vasa vasorum.
2. Brachial, superior profunda and inferior profunda
arteries; biceps, triceps, and brachialis anticus mus-
cles; median, ulnar, internal cutaneous, musculospiral,
and musculocutaneous nerves.
3. Lymphatic glands are solid bodies, of variable
size, situated in the course of the lymphatic and lacteal
vessels; they are surrounded by a capsule, and are fil-
ters through which lymph and chyle flow.
4. Lymphatics of the thorax. The intercostal lym-
phatic vessels, derived from the side of the abdomen and
thorax, pleurss, diaphragm, spinal canal, muscles of the
back, etc., follow the course of the veins, traverse fif-
teen to twenty intercostal glands near the heads of the
ribs, and terminate in the thoracic duct. The posterior
mediastinal glands are between the intercostal glands,
and communicate with them. They receive vessels from
the pericardium, esophagus, and diaphragm. Some of
the efferent vessels end in the bronchial glands, others
in the thoracic duct. The anterior mediastinal lym-
phatic vessels are derived from the anterior wall of the
abdomen and thorax, the diaphragm, pericardium, up-
per surface of the liver, heart, and thymus gland. They
traverse about eighteen to twenty anterior mediastinal
glands, situated in the course of the internal mammary
vein, pericardium, and great vessels of the heart, and
terminate in thoracic and right lymphatic ducts. The
pulmonary lymphatic vessels consist of a superficial and
deep set, traversing in the last part of their course the
pulmonary glands. The bronchial glands are twenty or
more- glands at the bifurcation of the trachea and root
of the lungs, and receive the lymphatic vessels of the
474
NEW JERSEY.
lungs and bronchi. They become pigmented, and are
often the seat of disease. Their efferent vessels ter-
minate on the right side in the right lymphatic duct,
either directly or by forming the broncho-mediastinal
trunk, and on the left side in the thoracic duct.
— (Young's Anatomy,)
5. Peyer's glands are large, oval groups of lymph
follicles; practically they are groups of solitary fol-
licles; they are from half an inch to four inches in
length, and are situated throughout the small intestine
but are largest and most numerous in the ileum.
6. Pneumo gastric nerve. Superficial origin: Groove
between restiform and olivary bodies. Deep origin:
Nuclei in floor of fourth ventricle. Course: Outward
across the flocculus, to jugular foramen through which
it passes, here it is joined by the accessory portion of
the spinal accessory nerve. As it goes down the neck
it lies in front of the rectus capitis anticus major and
longus colli muscles. It passes in the carotid sheath
behind and between the artery and vein. In the thorax
the nerve on each side runs a different course. The
right passes between the subclavian artery and vein,
by side of trachea to root of lung, behind esophagus,
through esophageal opening in diaphragm to posterior
surface of stomach. The left passes between the sub-
clavian and carotid arteries, in front of arch of aorta
to root of lung, along anterior surface of esophagus,
through diaphragm, to anterior surface of stomach.
Distribution is shown by the various names of the
branches of the nerve: Meningeal, auricular, pharyn-
geal, superior and inferior laryngeal, cardiac, pulmo-
nary esophageal, and gastric.
7. Scarpa's triangle is a triangular area or depres-
sion situated just below the fold of the groin. It is
bounded above by Poupart's ligament, externally by the
Sartorius, and internally by the inner margin of the
Adductor longus; its apex is formed by the junction of
the Adductor longus and Sartorious. The floor is
formed, from without inward, by the Iliacus, Psoas,
Pectineus, Adductor brevis, and Adductor longus. Con-
tents : The femoral vessels pass from about the center
of the base to the apex, the artery being on the outer
side of the vein ; the artery gives off the superficial and
profunda branches, and the vein receives the deep
femoral and internal saphenous; the anterior crural
nerve lies to the outer side of the femoral artery; the
external cutaneous nerve is still further external, lying
in the outer corner of the space; just to the outer side
of the femoral artery, and in the sheath with it is the
475
MEDICAL RECORD.
crural branch of the genitocrural nerve. At the apex,
the vein (which at the base was internal to the artery)
lies behind the artery. The triangle also contains fat
and lymphatics.
8. Bones entering into formation of nasal fossse:
Nasal, frontal, ethmoid, sphenoid, vomer, palate,
superior maxillary, lacrimal, and inferior turbinated.
9. Bones entering into the formation of the ankle
joint, are: The lower end of the tibia above the in-
ternal malleolus (of tibia) internally, the external mal-
leolus (of fibula) externally, and the upper surface of
the astragalus below.
10. Viscera covered by peritoneum: Liver, stomach,
spleen, first part of duodenum, jejunum, ileum, cecum,
transverse colon, sigmoid flexure, upper half of rectum,
ovaries.
Viscera partially covered by peritoneum: Second and
third parts of duodenum, ascending and descending
colon, bladder, middle part of rectum.
PHYSIOLOGY.
1. Physiology is that branch of science which treats
of the functions of the body in a state of health.
2. "The left ventricle pumps the arterial blood
through the large arteries, the small arteries, and the
arterioles into the systemic capillaries. For the most
part between the capillaries and the tissues is the tissue
fluid, and across this the tissues acquire the oxygen
from the arterial blood, and return carbon dioxide to
the blood in the capillaries. The blood which leaves the
tissues is venous. The venous blood returns from the
capillaries through the small veins into the larger
veins, and the largest veins pour the blood back into
the right auricle. It will thus be seen that the right
side of the heart is occupied with the pulmonary cir-
culation, and the left side of the heart with the sys-
temic circulation. The righ* auricle receives the ven-
ous blood as it returns from the tissues, and transmits
it to the right ventricle. The function of the right ven-
tricle is to pump the venous blood through the pulmon-
ary arteries into the lung capillaries, where the venous
blood becomes oxygenated. The oxygenated blood re-
turns by the pulmonary veins to the left auricle, and
the arterial blood is then received into the left ven-
tricle." — (Lyle's Physiology.)
3. Differences between the fetal circulation and that
ef the adult: In the fetus there is direct communica-
tion from the right auricle to the left auricle by the
foramen ovule; the Eustachian valves are larger, the
heart is relatively larger; there is communication be-
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NEW JERSEY.
tween the pulmonary artery and the descending aorta
by means of the ductus arteriosus; there is communica-
tion between the internal iliac arteries and the placenta
by means of the umbilical or hypogastric arteries; and
the presence of the ductus venosus which unites the um-
bilical vein and the inferior vena cava.
4. Physical composition of the blood:
1. Plasma.
( Colored
2. Corpuscles \ Colorless
I Platelets.
Chemical composition of the blood: Plasma consists
of water and solids (proteids, extractives, fats, and
salts of sodium, potassium, and calcium). Corpuscles
consist of water and solids (hemoglobin, globulin, leci-
thin, cholesterin, iron, and salts of sodium, potassium,
magnesium, and calcium.
5. Functions of the Blood: The red blood cells
carry oxygen from the lungs to the tissues. The ivhite
blood cells: (1) Serve as a protection to the body from
the incursions of pathogenic microorganisms; (2) take
some part in the process of the coagulation of the
blood; (3) aid in the absorption of fats and peptones
from the intestine, and (4) help to maintain the proper
proteid content of the plood plasma. The function of
the platelets is not determiner!; it is possible that they
take some part in the coagulation of the blood. The
plasma conveys nutriment to the tissues; it holds in
solution the carbon dioxide and water which it receives
from the tissues, and takes them to be eliminated by
the lungs, kidneys, and skin; it also holds in solution
urea and other nitrogenous substances that are taken to
and excreted by the liver or kidneys.
6. The portal system is composed of four veins
(superior mesenteric, inferior mesenteric, splenic, and
gastric), which collect the venous blood from the
stomach, intestine, pancreas, and spleen, and conduct
it to the liver.
The enzymes manufactured from its blood: "No
fewer than eleven ferments have been stated to be pres-
ent and active in the liver alone — viz., a proteolytic and
a nuclein-splitting ferment, a ferment which splits off
ammonia from amino-acids, a milk-curdling ferment, a
fibrin ferment, a bactericidal ferment, an oxydase, a
lipase, a maltase, a ferment called glyeogenase, which
changes glycogen into dextrose, and an autolytic fer-
ment." — (Stewart's Physiology.)
7. The chiefs organs of excretion are: The kidneys,
skin, lungs, alimentary canal, and liver.
477
MEDICAL RECORD.
8. See Question 5.
9. Glycogen, or animal starch, is a polysaccharide,
found in the liver, muscles, placenta, leucocytes, carti-
lage, and other tissues. Glycogen is a source of energy
and heat for the body, is a convenient method for the
storage of sugar in the body, and is a possible source
of fats and proteins.
10. When a muscle is in a state of activity: (1) It
becomes shorter and thicker, but (2) there is no change
in volume; (3) there is an increased consumption of
oxygen; (4) more carbon dioxide is set free; (5) sarco-
lactic acid is produced; and hence (6) the muscle be-
comes acid in reaction; (7) it becomes more extensible,
and (8) less elastic; (9) there is an increase in heat
production and consequently a rise of temperature;
(10) the electrical reaction becomes relatively negative;
and (11) a sound is produced.
CHEMISTRY.
1. Chemistry is that branch of science which treats
of the composition of substances, their changes in com-
position, and the laws governing such changes.
2. (1) Law of definite proportions: A compound al-
ways consists of the same elements, and in the same
proportions.
(2) Law of multiple proportions: When two elements
unite with each other to form more than one compound,
the resulting compounds contain simple multiple pro-
portions of one element and a fixed quantity of the
other element.
(3) Law of reciprocal proportions: The ponderable
quantities in which substances unite with the same sub-
stance express the relation, or a simple multiple thereof,
in which they unite with each other.
3. Three strong mineral acids : Sulphuric acid, hydro-
chloric acid, nitric acid; of these, sulphuric acid is the
strongest.
4. Alkaloids are organic, nitrogenized, basic sub-
stances^ alkaline in reaction, and capable of combining
with acids to form salts in the same way that ammonia
does.
They are divided into volatile and fixed alkaloids.
5. See above, Physiology, Question 4.
6. Antidote for poisoning by carbolic acid is sodium
sulphate, also alcohol.
7. A physical change does not alter the composition
of the substance; a chemical change does alter its
composition.
8. Organic chemistry is the chemistry of the carbon
compounds.
478
NEW JERSEY.
Inorganic chemistry is the chemistry of substances
which do not contain carbon.
9. Specific gravity is the weight of a given volume of
a substance as compared with the weight of the same
volume of some other substance taken as a standard,
under like conditions of temperature and pressure.
The amount of solid matter in the urine may be esti-
mated by multiplying the last two figures of the specific
gravity of the urine by 2.33 (Haeser's coefficient) ; the
product gives the amount of solid matter in one liter
of urine.
10. The formula of hydrogen dioxide is EUO*; it is
also known as hydrogen peroxide, and as oxygenated
water.
MATERIA MEDICA AND THERAPEUTICS.
1. Three drugs that will liquefy and increase bron-
chial secretion: Ammonii chloridum, gr. vijss; ammonii
carbonas, gr. vijss; fluidextractum senegas, n#xv.
Ammonii carbonatis, gr. xxxij.
Fluidextracti senegas.
Fluidextracti scillae, aa 3j.
Tincturae opii camphor atae, 3vj.
Aquae, 3iv.
Syrupi Tolutani q. s. ad Jiv. Misce.
Signa: One teaspoonful every three hours.
2. A diuretic is an agent which promotes the secre-
tion of urine.
Three vegetable diuretics: Tinctura digitalis, ff^xv;
tinctura strophanthi, mviij ; fluidextractum cimicif ugaa,
11£XV.
5.
Tincturae digitalis, 3j.
Spiritus aetheris nitrosi, 3iij.
Liquoris ammonii acetatis, Jss.
Aquae, q. s. ad 3 V J- Misce.
Signa: One ounce every three hours.
3. Two di~ugs that will lower blood pressure: Amylis
nitris, TTgii j ; spiritus glycerylis nitratis, tt£j.
4. Two official drugs that tvill change the color of the
urine: Phenol and santoninum.
Two that will change the color of the feces: Ferrum
and bismuthi subnitras.
5. Epinephrin is a substance obtained from the me-
dullary portion of the suprarenal glands of the sheep
(or other animal). It is official under the name of
Glandulae suprarenales siccae; dose 4 grains; proper-
ties: "it is a strong cardiac stimulant, slowing the
pulse-rate and affecting the heart muscle in the same
479
MEDICAL RECORD.
way as digitalis; it is a powerful vasoconstrictor and
raises blood-pressure more than any other know sub-
stance ; it increases the tone of all muscular tissue ; it
causes diminution of peristalsis and a depression of the
respiratory center, which may result in respiratory
failure and death. Uses: In minor surgery as a local
vasoconstrictor; hay fever (both internally and
locally); bronchitis; bronchial asthma; congestion and
edema of the lungs; cardiac diseases (here it should
be employed with caution) ; Addison's disease; shock."
— (Wilcox's Materia Medica.)
6. Three drugs that may cause irritation or skin
eruption: Belladonnae folia, gr. j; belladonnas radix,
gr. % ; properties : Anodyne, mydriatic, inhibits secre-
tions, depressant of terminations of nerves, accelerates
the heart beat, causes rise in blood pressure, but toxic
doses cause the blood pressure to fall, stimulates the
respiratory center, but large doses depress the same; it
may cause vertigo, restlessness, excitement, delirium,
or mania.
Copaiba, rrgxv; properties: "In small doses it is
stomachic, in large ones a gastrointestinal irritant; in
the process of excretion it stimulates and disinfects
mucous membranes, especially those of the genito-
urinary tract, and on the skin it may give rise to erup-
tions and annoying itching. It is also diuretic, and in
large amounts irritates the kidneys."- — (Wilcox's
Materia Medica.)
Cubeba, gr. xv; properties: "Rubefacient; irritant to
the stomach; diuretic; like other volatile oils, it causes
some cardiac stimulation and also stimulates the func-
tions of the organs by which it is excreted; sometimes
produces a papular or erythematous rash. Its chief
action is on the mucous membrane of the genitourinary
tract, which is both stimulated and disinfected by it.
Its resinous acid is believed to aid the effects of the oil
in its action upon the renal epithelium, as well as the
bronchial mucous membrane."— (Wilcox's Materia
Medica.)
7. Oil of santal: dose 9 8 minims; properties: "Closely
resembles that of copaiba and cubebs, but oil of santal
is less irritant and more palatable. Uses: gonorrhea,
gleet, cystitis, urethral hemorrhage, bronchitis."—
(Wilcox's Materia Medica.) Official name is oleum
santali.
8. Elaterin: Official name, elaterinum; dose, 1/10
grain; properties: "Closely resembling that of colocynth,
but much more energetic, elaterin being regarded as the
most powerful hydragogue cathartic known. In prop-
480
NEW JERSEY.
erly regulated doses, however, it causes comparatively
little pain or irritation, notwithstanding the free
catharsis produced. Uses: It is the most efficient of
the hydragogue cathartics in general dropsy and in
ascites; also used with advantage in uremia." — (Wil-
cox's Materia Medica.)
9. In lobar pneumonia routine treatment is to be con-
demned. In the first stage the following drugs may be
required, under certain conditions: Alcohol, ammonii
carbonas, 4 grains; quininaa hydrochloridum, gr. iv;
tinctura veratri, 15 minims; digitalis, 1 grain; strych-
nine sulphas, 1/60 grain.
*.
Tincturae veratri, p#. xl.
Spiritus aetheris nitrosi, 3vj.
Liquoris potassii citratis, 3ivss.
Syrupi zingiberis qs. ad 5vj. Misce.
Signa: One tablespoonful q. 3. h.
10. Five official tinctures: Tinctura aconiti, 10 min-
ims; tincture aloes, 30 minims; tinctura capsici, 8
minims; tinctura, digitalis, 15 minims; tinctura opii,
8 minims.
HISTOLOGY.
1. The suprarenal capsules "are two triangular flat-
tened organs covered with fat that lie one on either side
of the spine, in close proximity to the upper kidney
border. Each suprarenal is invested in a fibrous cap-
sule and a liberal supply of fat. The capsule contains
many elastic fibers and some smooth muscle cells. The
cortex shows a radial structure and has been divided
into three zones, which are not very well defined. (1)
The zona glomerulosa, next to the capsule, consists of
a row of columnar epithelial cells folded in such a way
as to form oval bodies or elongated heads separated
by strands of connective tissue from the capsule. The
oval nuclei are in the middle of the cells. (2) The
zona fasciculata makes up the larger portion of the cor-
tex and consists of anastomosing columns of epithelial
cells, a continuation of the zona glomerulosa. Each
column has two rows of polygonal cells that are
smaller than those of the glomeruli. (3) The zona
reticularis borders on the medulla. Here the columns
anastomose and freely interlace. The cells resemble
those of the fasciculata. Connective tissue cells ramify
between the columns, hence the radial appearance of
the cortex. The medulla is coarsely vascular. The
cells are smaller than those of the cortex and are
grouped in round or oval masses. These cells are finely
481
MEDICAL RECORD.
granular, often pigmented, and stain a brown color.
Numerous ganglion cells are present and many nerve
fibers." — (Hill's Histology and Organography.)
2. "Graphic reconstructions, — Making reconstruc-
tions of this kind consists of plotting out on paper
magnified representations of structures from a series
of sections. Serial sections are, of course, necessary,
and the thickness of the sections must be known. A
camera lucida must be used and some given magnifica-
tion chosen and adhered to for a particular reconstruc-
tion. Suppose, for a simple example, that a reconstruc-
tion of the stomach of an embryo is to be made. First
determine the desired magnification. Then, with a
camera lucida, draw on a sheet of paper an outline of
a section of the stomach at its cephalic end, and, still
keeping the paper in exactly the same position, draw a
line to represent the median line of the section. On a
sheet of drawing paper, upon which a straight line has
been drawn to represent the median line of the section
(sagittal plane of the embryo), measure off the dis-
tance as indicated in the camera lucida sketch, of each
edge of the stomach from the median line and mark
with a dot. Make the same kind of a camera lucida
sketch from the next succeeding section. Plot this on
the drawing paper as in the preceding case, putting
the dots below, or, so to speak, caudal to the first dots
at a distance equal to the thickness of the section
multiplied by the magnification. Pursue the same
method with successive sections, and then connect the
dots that represent the edge of the stomach in the sec-
tions with a continuous line. The line, of course, rep-
resents the outline of the stomach, and, if the plotting
has been properly done, it will show the relative posi-
tion and general shape of the organ as seen from the
dorsal or ventral side. If desired, the sketch can be
shaded to represent the stomach in perspective. Draw-
ings of two or three different structures to show their
interrelation can be made in this way, so long as the
structures do not become too complicated. Sometimes
it is necessary to draw only from every third or fourth
section." — (Bailey and Miller's Embryology.)
3. Epithelial tissue consists mainly of cells, with a
small amount of intercellular substance; the cells are
usually prominent and granular. The kinds of epi-
thelium are: (1) Pavement or Squamous: A single
layer of flat, nucleated cells, cemented together at their
edges; found in descending limb of Henie's loop, Bow-
man's capsule of kidney, alveoli of lungs. (2) Strati-
fied squamous: In layers of cells that are unlike in
482
NEW JERSEY.
form, found in the epidermis, tongue, pharynx, vocal
cords, vagina, anus. (3) Columnar: Tall, cylindrical
cells arranged in a single layer; found in penile part of
urethra, stomach, intestines, gall bladder, and ducts of
glands. (4) Cuboidal: Similar to columnar, but the
cells are shorter; found in thyroid gland. (5) Ciliated:
Columnar cells with hair-like processes (cilia) on their
free surface; found in Fallopian tubes, ventricles of
brain, spinal canal. (6) Transitional: When the cells
are neither arranged in a single layer like squamous,
nor yet in many superimposed layers like stratified, but
in two or three layers; found in pelvis of ureter, blad-
der, urethra.
4. "The motor endings of the voluntary muscles are
chiefly from myelinated fibers. After piercing the epi-
mysium the nerve follows the septa to the primary
bundles and breaks up into fibers of which each muscle
receives one; no doubt one nerve fiber supplies many
muscle fibers. The neurilemma and myelin sheath of
the nerve fibers upon passing through the sarcolemma
blend with it and the axis cylinder breaks into fibrillar,
each of which forms a number of bulbous enlargements
that pass to a sole-plate. This sole-plate consists of a
mass of nucleated, granular protoplasm, and with the
bulbous nerve masses constitutes the end-plate." —
(Radasch's Histology.)
PATHOLOGY.
1. In hypertrophy, all of the tissues or constituents
of an organ are increased in size or weight or number,
In enlargement, only one tissue of the organ is in-
creased.
2. Theory of diabetes: "The theoretic interpretation
of diabetes varies with the view which may happen to
be held of the glycogenic function of the liver. Nor-
mally about 0.1 per cent, of sugar is present in the
blood, and a minute trace, w r hich the clinical tests can-
not detect, in the urine. When the amount in the blood
is more than 0.2 per cent, an appreciable glycosuria oc-
curs, and even in health a temporary glycosuria may
be produced by an ingestion of sugar beyond the physio-
logical limit. The appearance of sugar in the urine is
thus due to an excess of sugar in the blood. The usual
view of the glycogenic function is that the liver con-
verts the carbohydrates brought to it from the intes-
tines into glycogen, which it stores up as a reserve, and
gradually reconverts into sugar and delivers via the
blood to the tissues according to their needs. On this
view the excess of sugar in the blood is due either to
483
MEDICAL RECORD.
excessive production of sugar in the liver, or to dimin-
ished oxidation by the tissues. On the other hand,
Pavy holds that part of the ingested carbohydrates is
converted by the intestinal villi into fat, and another
part is synthetically built up into proteids, in which
forms it reaches the blood, and that only a portion
reaches the liver, where it is stored up as glycogen, and
prevented from entering the general circulation except
in synthetic combination with proteid bodies. A tem-
porary glycosuria would therefore be due to a defect in
the sugar-transforming mechanism, and diabetes to its
arrest, permitting the passage of unaltered glucose. In
mild forms of the disease, a diet free from carbohy-
drates stops the glycosuria, the excess of sugar being
thus derived from the carbohydrates of the food; but
in severer cases, glycosuria persists though carbohy-
drates are withheld, and sometimes even though no food
is taken. In these instances, sugar is formed by disin-
tegration of the proteids of the food, and in the gravest
cases by disintegration of the body proteids. It re-
mains to explain why the excess of sugar is not utilized
by the tissues, is not, that is, oxidized in the ordinary
manner by the muscles. It has been conjectured that
it may require previous elaboration in other organs, and
as the pancreas is in many instances diseased attention
has been directed to that gland. The recent researches
of the younger Cohnheim are suggestive in this regard.
He finds that neither pancreatic juice nor muscle juice
has singly any action upon sugar, but that when the
two are combined the sugar is rapidly broken up. He
holds, therefore, that the proenzyme produced in the
muscles is only activated by a glycolytic substance con-
tained in the pancreatic juice, and probably derived
from the internal secretion of the islands of Langer-
hans. Extensive disease of the pancreas would destroy
this substance, and render the sugar unavailable for
combustion in the muscles. It must be added that, in
some cases, no disease of the pancreas or liver has been
found. In some of these there has been disease in the
region of the "diabetic puncture" (floor of the fourth
ventricle)." — (Wheeler and Jack's Handbook of Medi-
cine.)
3. "Gout is a condition characterized by attacks of
acute arthritis and other constitutional symptoms, clini-
cally, by the excess of uric acid in the blood, and ana-
tomically, by the deposit of sodium biurate in the car-
tilages and elsewhere. It must not be imagined that
this excess of uric acid in the blood is the cause of the
disease, for uric acid in excess exists in the blood in a
484
NEW JERSEY.
number of different states without gout being present.
The urates are inert bodies, and the most that can be
said is that they are an indicator; that is, the faulty
metabolism which produces them produces also sub-
stances that are toxic. These substances we do not
know with any exactness. . . . It is necessary to
know, more fully than we do, the toxic effects of the
purin bases, for they are toxic, and it is perhaps the
purin bases that are responsible for gout. Gout, there-
fore, is probably the outcome of insufficient oxidation,
whereby the precursors of the uric acid, and similar
bodies, are not fully oxidized, and by their accumula-
tion and their toxicity, set up morbid changes; and the
uric acid formed is in its turn imperfectly oxidized, and
accumulates; this diminished oxidation is due to a
constitutional deficiency of oxidases, inherited or ac-
quired." — (Adami and McCrae's Textbook of Pathol-
ogy-)
BACTERIOLOGY.
1. Pathogenic spirilla. Spirillum cholera found in
Asiatic cholera; Spirochseta recurrentis, in relapsing
fever ; another variety of the same, in Congo tick fever ;
Spirochseta pallida, in syphilis; Spirochseta refringens,
in syphilis; Spirochseta fusiformis, in Vincent's angina.
2. "Mycetoma, or Madura foot, is a localized chronic
inflammation, almost painless, and usually involving
the foot, the hand, or some exposed portion of the body.
The disease involves the tissues by direct extension,
attacking the bones as well as the soft tissues. It
usually remains localized to one extremity. It is due to
the Streptothrix madurse. The black variety of Madura
foot is due to a different organism, the threads of which
are 3 to 8m in thickness. This organism seems to be an
aspergillus, and has been named Madurella mycetori."
— (MacNeal's Pathogenic Microorganisms.)
3. Pathogenic protozoa: The ameba of dysentery
(entamoeba histolytica), Trypanosoma lewisi, Trypa-
nosoma evansi, Trypanosoma b?~ucei, Trypanosoma
gambiense, a trypanosoma probably causing kala-azar,
Plasmodium vivax, Plasmodium malarise, Plasmodium
falciparum, Piroplasma (various species pathogenic for
animals), and Balantidium coli.
"The ameba is a rounded cell with a clear outer
ectoplasm, and a granular endoplasm. It has a rounded
or oval excentric nucleus, and measures from 10 to 15/x
in diameter. On the warm stage it shows active ame-
boid movement. In the resting stage it forms a cyst
or cysts, and in this state resists drying for a long time.
The organisms are found chiefly in the large intestine,
485
MEDICAL RECORD.
especially in the rectum and flexures, but they also
occur in the ileum and stomach, and in the liver. They
have the power of penetrating the tissues." — (Wheeler
and Jack's Handbook of Medicine.)
HYGIENE.
1. A watershed is the region from which a water
supply is derived.
2. It can be properly safeguarded by preventing the
discharge of sewage or waste into the source of water
supply; also by purification.
3. The water borne diseases are: Typhoid, cholera,
gastric and intestinal irritation, parasites, and diseases,
diarrhea, dysentery, and (according to some) goiter.
4. Drinking water may be purified by distillation,
or by filtration, and boiling.
5. Ground water may become polluted in its course
through the soil, or after it has passed through the
surface soil.
MEDICAL JURISPRUDENCE.
1. By molecular death is "understood the incessant
disintegration of tissue which is going on in the body
during the active processes of life; the waste of ma-
terial thus produced being compensated by the repara-
tion. In youth, the supply is in excess of the waste,
and growth is the result; in advanced age, the reverse
is the case. Somatic death is the cessation of all the
vital functions of the body, or the death of the whole
body. The latter is the popular idea of death, and the
time when it takes place is generally recognizable.
The precise period when universal molecular death
occurs cannot be accurately determined. No doubt,
molecular life may continue some time after somatic
death, as is evidenced by postmortem temperature and
muscular irritability, by the postmortem beating of the
heart, and by certain acts of nutrition and secretion."
— (Reese's Medical Jurisprudence.)
2. Signs of death: Complete and continuous cessa-
tion of circulation and respiration ; loss of body heat ;
pallor; rigor mortis; cadaveric lividity; putrefaction;
adipocere formation; and, occasionally, mummification.
The presence of some of these signs of death marks
the difference between real and apparent death.
3. For a complete answer to this question the reader
must consult one of the standard works on pathology
or medical jurisprudence.
4. Causes of violent death: Wounds, burns, and
scalds, suffocation, hanging, strangulation, electricity,
drowning, excessive heat or cold, starvation, and
poisoning.
486
NEW JERSEY.
5. The object of a coroner's inquest is to discover the
cause of death when the latter is unknown, or inex-
plicably sudden.
PRACTICE OF MEDICINE.
1. In scurvy, the cardinal symptom is the extravasa-
tion of blood beneath the periosteum, with resulting
thickening and tenderness of the shaft of the bone.
The pain in the legs, their position, and the spongy and
bleeding gums are symptoms of nearly equal impor-
tance. The disease may be suspected in any child who
has difficulty or pain- in moving the legs, or in whom
paralysis is suspected.
In rachitis, although the early stages may be indis-
tinguishable, there soon develops the rachitic rosary
and the enlargement of the ends of the long bones;
pain is, as a rule, absent; and ecchymoses, petechia?,
and spongy gums are not observed. Both may coexist.
— (Butler's Diagnostics of Internal Medicine.)
2. Kinds of arterial pulse. The normal pulse; the
pulse of increased frequency, or tachycardia; the pulse
of decreased frequency, or bradycardia; the intermit-
tent or irregular pulse; the high tension pulse; the
pulse with a wave of great volume; the slow, or tardy
pulse; the dicrotic pulse.
3. Catalepsy is a condition characterized by mus-
cular rigidity of the limbs ; the affected limb will stay
for a long time in the position in which it is placed;
the patient is insensible.
epilepsy.
1. No apparent cause.
2. Sudden and rapid on-
set.
3. Aura generally present.
4. Consciousness lost.
5. Pupils generally di-
lated.
6. Tongue often bitten.
7. Patient very liable to
hurt himself.
8. May be involuntary
bladder and bowel dis-
charges.
9. Of short duration.
HYSTERIA.
1. Cause, emotional.
2. Onset gradual, usually
after some mental ex-
citement.
3. Globus hystericus or
palpitation.
4. Consciousness general-
ly preserved.
5. Pupils normal.
6. Tongue never bitten.
7. Patient not liable to
hurt himself; may in-
jure others.
8. Never.
9. Duration longer.
487
MEDICAL RECORD.
4. The common bile duct may be occluded by: Gall-
stones; ulceration; parasites; foreign bodies; pressure
from outside by tumor of pylorus or pancreas, ab-
dominal tumors, aneurysm, or enlarged glands; cica-
tricial contraction following duodenal ulcer or syphilis
of the liver.
5. Varieties of stomatitis, with causes. Catarrhal
stomatitis, due to dentition or gastrointestinal disturb-
ances in children, irritating or too hot food, and the
acute infectious diseases. Aphthous or follicular
stomatitis; canker, sore mouth is. most common in in-
fants and young children, either as an idiopathic af-
fection or as a result of indigestion or a febrile attack;
and occurs in adults when the general health is im-
paired. Ulcerative or fetid stomatitis; putrid sore
mouth occurs most commonly in children during the
first dentition, and may be epidemic, even in adults, in
asylums, jails, and camps, where the hygienic condi-
tions are poor. Parasitic or mycotic stomatitis; this
affection (thrush, soor, muguet) is dependent upon the
Saccharomyces (or Oidium) albicans. It occurs mainly
in bottle-fed infants. Predisposing conditions are un-
cleanliness of the mouth and of feeding utensils, and
cachectic or diseased states in general, in adults as
well as children. Gangrenous stomatitis; cancrum
oris or noma is a rare disease, affecting children of
from 2 to 5 years of age, and occurring usually during
convalescence from the acute fevers. More than fifty
per cent, of the cases follow measles; less frequently
it occurs after typhoid fever, scarlet fever, variola,
and whooping-cough. Debilitated and cachectic states
also predispose. The exciting cause is probably a yet
unknown microorganism. Mercurial stomatitis; due
to personal idiosyncrasies this may follow the use of
repeated minute doses of a mercurial; or it may be an
occupation poisoning. Subvarieties of stomatitis; in
the newborn there may be small ulcers of the hard
palate, symmetrically placed on either side of the
median line, which may involve the bone (Parrot).
Similar ulcers on the hard palate may be caused in
marasmic children by the irritation of a rubber nipple
(Bednar). Jacobi has described a chronic recurring
herpetic eruption of the buccal cavity in neurotic per-
sons, sometimes coexisting with erythema multiforme."
— (Butler's Diagnostics of Internal Medicine.)
6. Vocal fremitus is the vibration of the chest com-
municated to the hands of the physician while the pa-
tient is speaking. It is increased in lobar pneumonia,
tuberculosis of the lungs, and bronchopneumonia; it is
488
NEW JERSEY.
decreased in pleural effusions, emphysema, collapse of
the lung, tumors of the lung, and pulmonary edema.
7. Urinaiy casts are moulds of the uriniferous
tubules of the kidney. Epithelial tube casts are found
in desquamative nephritis. Blood casts are found in
acute renal hyperemia, acute nephritis, hemorrhagic
infarction, and renal hematuria. Pus casts are found
in suppurative nephritis and pyelitis. Bacterial casts
are found in pyelonephritis and suppurative nephritis.
Granular casts are found in chronic degenerative
processes of the kidneys. Fatty casts are found in sub-
acute or chronic nephritis with fatty degeneration, espe-
cially large white kidney. Hyaline casts are found in
all inflammations, acute or chronic, of the renal tubules.
Waxy casts are found in subacute or chronic nephritis.
— (From Butler's Diagnostics of Internal Medicine,)
8. Smallpox: The eruption usually appears first on
the forehead and wrists, and on the third or fourth day ;
it is first macular, then papular, then vesicular, and
finally pustular; it does not appear in successive crops;
the spots are multilobular, and do not collapse on being
punctured; the papule is hard and shotty, and does not
disappear on stretching the skin.
Scarlet fever: Character of eruption, a scarlet
punctate rash, beginning on neck and chest, then cov-
ering face and body; desquamation is scaly or in flakes.
As compared with smallpox and measles, the eruption
is brighter, is on a red background, punctiform, and is
more uniform; the temperature is higher, the pulse
quicker; the tongue is of the "strawberry" type, the
lymphatics in the neck may be swollen, and there is
sore throat; Koplik's spots are absent. Measles: Char-
acter of eruption, small, dark red papules with cres-
centic borders, beginning on face and rapidly spreading
over the entire body; desquamation is branny. As
compared with scarlet fever, the eruption is darker, less
uniform, more shotty; Koplik's spots are present.
9. Pathological sounds heard on auscultation of the
lungs: "Bronchial breathing occurs in lobar pneumonia,
phthisis, compensatory emphysema, tumor, syphilis, and
infarct. Both inspiration and expiration are harsh
and have a high-pitched (tubular) character. Cavern-
ous breathing is low-pitched and blowing in character
and is heard over cavities. Amphoric breathing is sim-
ilar to the sound produced by blowing gently over the
mouth of an empty jar. It is present in phthisical
cavities, pneumothorax with patulous opening, f the Testes. — "In early fetal life the
testes are placed at the back part of the abdomen,
below and in front of the kidneys, and behind the
peritoneum. About the third month a peculiar struc-
ture, the gubernaculum testis, appears, attached to
the lower end of the epididymis, and extending as a
cord to the bottom of the scrotum. It is supposed to
cause the descent of the testicle. It reaches its full
development between the fifth and sixth month, at
which time the testicle reaches the iliac fossa. It
enters the internal abdominal ring by the seventh
month, and the scrotum by the eighth month, carrying
536
NORTH CAROLINA.
before it a fold of peritoneum, which is afterward
shut off, forming the tunica vaginalis testis. Other
coverings of the testicle are also derived in this man-
ner. In the female a structure similar to the guber-
naculum forms the round ligament.". (Young's Hand-
book of Anatomy.)
9. The following table (from Thayer's "Pathology")
will assist in distinguishing the two varieties of cir-
rhosis of the liver:
Synonyms. Charcot's, Hy-
pertrophic, Unilobular,
Hepatogenous, Biliary.
Jaundice. Early and
marked, bile often absent
from feces.
Ascites. Late and unim-
portant.
Spleen. Enlarged early
and markedly.
Alimentary hemorrhage,
piles. Not common.
Liver. Large, smooth,
mottled, green.
Neiv fibrous tissue. In fine
lines and strands be-
tween acini and cells, in-
volving ail parts equally.
Laennec's, Atrophic, Mul-
tilobular, Hematogenous,
Hob-nail liver.
Late and slight, bile usu-
ally present.
May be early; often enor-
mous.
Late and less.
Common.
Small, rough, pale or yel-
low.
In broad bands, making
prominent islands in
which the single acinus
may appear nearly nor-
mal; distributed irregu-
larly.
10. In amebic dysentery : "The lesions are chiefly
seated in the intestine. They present: (a) Small
gelatinous swellings of the mucosa, with partial ulcera-
tion; (6) Necrosis and sloughing of the underlying
tissues. The ulcers of amebic dysentery thus have un-
dermined edges. The axnebae are found in the ulcerating
mucosa, but more abundantly in the tissues beyond the
ulcerated area (submucous or muscular coat), where
they set up edema and necrosis. Later, along with the
ulcers, cicatrices, leading sometimes to partial stricture,
may be found. Hepatic abscess, usually single, and
hepatopulmonary abscess are common complications.
Amebse are sometimes found in the portal capillaries.
"The ameba is a rounded cell with a clear outer ecto-
plasm, and a granular endoplasm. It has a rounded
or oval eccentric nucleus, and measures from 10 to
15 n in diameter. In the warm stage it shows active
ameboid movement. In the resting stage it forms a cyst
537
MEDICAL RECORD.
or cysts, and in this state resists drying for a long time.
The organisms are found chiefly in the large intestine,
especially in the rectum and flexures^ but they also
occur in the ileum and stomach, and in the liver. They
have the power of penetrating the tissues." — (Wheeler
and Jack's Handbook of Medicine.)
PHYSIOLOGY AND HYGIENE.
1. The functions of epithelium are: Protection, se-
cretion, absorption, special sensation, and ciliary mo-
tion.
The functions of connective tissues are: Support,
connection, and protection.
2. Foods are classified as follows:
• (Salts
Inorganic \
[ Water
f Nitrogenous— Proteins
Organic
( Non-nitrogenous
(a) Proteins.
(6) Nitrogen.
(c) About 15 to 18 per cent.
(d) Urea.
(e) In the liver.
f Carbohydrates
I Fats
ENZYMES.
ORIGIN.
I FUNCTIONS.
Ptyalin.
Saliva.
Changes starches
into dextrin
and sugar.
Pepsin.
Gastric juice.
Changes proteids
into proteoses
and peptones in
an acid me-
dium.
A curdling fer-
Gastric juice.
Curdles the
ment.
casein of milk.
Trypsin.
Pancreatic juice.
Changes proteids
into proteoses
and peptones,
and afterward
d e c o m poses
them into leu-
cin and tyrosin
in an alkaline
medium.
538
NORTH CAROLINA.
ENZYMES.
QRIGIN.
FUNCTIONS.
Amy lop sin.
Pancreatic juice.
Converts starches
into maltose.
Steapsin.
Pancreatic juice
Emulsifies and
saponifies fats.
A curdling fer-
Pancreatic juice.
Curdles the
ment.
casein of milk.
Invertin.
Succus entericus.
Converts maltose
into glucose.
4. White blood corpuscles are classified as follows:
(a) Small mononuclear leucocytes or lymphocytes,
about 25 per cent, of the white blood corpuscles; (b)
large mononuclear leucocytes, about 1 per cent.; (c)
transitionals, about 2 to 4 per cent.; (d) polynuclears,
about 70 per cent.; (e) eosinophiles, about 2 per cent.;
(/) and mast-cells, about 0.1 to 0.5 per cent.
5. The fluid in muscle tissue is called muscle-plasma.
(a) Alkaline.
(b) Acid, due to development of sarcolactic acid.
(c) Acid, due to development of sarcolactic acid.
6. Renal circulation. "The renal artery, on entering
the kidney, breaks up into numerous primary branches,
which travel along the columns of Bertini, and are
called the arteriae propriae renales. These divide at
the base of the pyramids and form arches with their
neighbors; these arches give off (1) branches into the
cortex termed the interlobular arteries, from which
the afferent vessels to the Malpighian tuft arise; the
efferent vein from the glomerulus breaks up into a
capillary network which ramifies on the urinary
tubules in the cortex, and after an extended course
joins the interlobular veins; the efferent vessels of the
lowermost glomeruli break up into and surround the
straight tubules; (2) branches downward into the
pyramids running between the bundles of collecting
tubes, and termed the vasa recta or arteriae rectae.
The interlobular veins correspond with the arteries,
and receive some veins termed stellate from beneath
the capsule, and also the small veins which receive the
blood from the minute plexus surrounding the con-
voluted tubes. The venae rectae run along the pyramids
accompanying the corresponding arteries. The venae
propriae renales pass along the columns of Bertini
after having been joined by the interlobular veins and
venae rectae." — (Ashby's Notes on Physiology.)
7. Wallerian degeneration: "When a nerve is divided
the first result is a loss of its function. Inasmuch as
539
MEDICAL RECORD.
each nerve-fiber develops from a cell which later nour-
ishes it, if the connection between the two is severed
the nerve-fiber undergoes Wallerian degeneration, and
in the case of a nerve which is made up of nerve-fibers
the whole nerve undergoes this change. This degener-
ation consists, in the case of medullated nerves, in the
death of the axis-cylinder, the breaking up of the me-
dullary sheath into drops of myelin, which are later ab-
sorbed, and the multiplication of the nuclei of the prim-
itive sheath. In non-medullated nerves the only result
is the death of the axis-cylinder. Degeneration begins
very soon after the section — within a day or two —
and throughout the entire severed portion of the nerve
at the same time. Thus the course of a nerve, or a
collection of nerves, may be traced throughout its en-
tire extent^ These changes are believed to be due to
the severance of the nerve from its trophic center. If
an anterior root of a spinal nerve is divided, the distal
end, being separated from the gray matter of the cord
which is its center of nutrition, undergoes degenera-
tion, while the end which remains connected with the
cord retains its integrity. If a posterior root is divided
between the cord and the ganglion, the degeneration
takes place between the cord and the ganglion; while
if divided below the ganglion, the degeneration takes
place in that portion separated from the ganglion,
showing that the ganglion is the nutritive center for
the posterior root." (Raymond's Physiology.)
8. Distribution of pneumo gastric nerve: To dura,
external ear, pharynx, heart, lungs, esophagus, and
stomach. Functions: "Throughout its whole course
the pneumogastric contains both sensory and motor
fibers. To summarize the many functions of this nerve
* * * it may be said that it supplies (1) motor in-
fluence to the pharynx and esophagus, stomach, and
intestines, to the larynx, trachea, bronchi, and lungs;
(2) sensory and, in part, (3) vasomotor influence, to
the same regions; (4) inhibitory influence to the heart;
(5) inhibitory afferent impulses to the vasomotor cen-
ter; (6) excitosecretory to the salivary glands; (7)
excitomotor in coughing, vomiting, etc." (Kirkes* Phy-
siology.)
9. The presence of colon bacilli in drinking water is
an indication that the water is polluted with sewage.
MATERIA MEDICA AND THERAPEUTICS.
1. Conditions which affect the dosage of medicines:
Age, sex, weight, habit, idiosyncrasy, method of admin-
istration, mental emotion, preparation of the drug, cu-
540
NORTH CAROLINA.
irwilative action of the drug, and the presence of disease.
Methods of introducing medicine into the circulation:
By mouth or stomach, hypodermatically, by inhalation,
by the rectum, by inunction, by fumigation, intra-
venously, and intramuscularly.
2. Salines stimulate the intestinal glands to increased
secretion, and by their low diffusibility impede reab-
sorption ; this results in an accumulation of fluid in the
intestinal tract, which partly from the effect of gravity
and partly by stimulating peristalsis, causes a copious
evacuation.
Salines are indicated in constipation, intestinal pu-
trefaction, dropsy and to lessen the secretion of milk in
nursing mothers.
3. Tincture of opium, 1(T minims equals one grain of
opium; camphorated tincture of opium, about half an
ounce contains one grain of opium ; Dover's powder, 10
grains contains one grain of opium.
4. Antidote for arsenic, freshly prepared solution of
ferric hydroxide (chemical) ; for opium, potassium
permanganate (chemical) ; for copper, potassium ferro-
cyanide (chemical) ; for strychnine, potassium perman-
ganate (chemical).
5. The following table (from Potter's "Materia
Medica") gives the chief antipyretics with their man-
ner of action. Temperature depression may be done
by five different actions working upon two principal
lines, viz., by:
f (1) diminishing tis-
(a) Lessening heat production, by\ ^ ue ^educmg the
t circulation.
(3) dilating cutaneous
vessels, thus increasing
heat radiation.
(4) promoting perspira-
tion — its evaporation
lowering the tempera-
ture.
(5) abstracting heat from
the body.
The following list of antipyretics include a few for
each of the above-named actions, to which the numbers
refer in each case, viz.:
Quinine, 1. Aconite, 2. Antipyrin, 1, 4.
Phenol, 1. Alcohol, 1, 3. Antimony, 2, 4.
Salicin, 1. Nitrous ether, 3, 4, Cold Bath, 5.
Digitalis, 2, Acetanilid, 1, 4. Cold drinks, 5.
Phenacetin, 1, 4. Wet-pack, 5.
541
(b) Promoting heat loss, by
MEDICAL RECORD.
6. To stimulate the heart 9 s action: Alcohol 3ss; aro-
matic spirit of ammonia, 3j; nitroglycerin, gr. 1/20;
ether, 3j; heat, applied over the heart; digitalis, extr.
gr. j; citrated caffeine, gr. v; tincture of strophanthus,
n#v; strychnine sulphate, gr. 1/20.
To produce emesis: Ipecac, gr. xx; apomorphine hy-
drochloride, gr. 1/10; tartar emetic, gr. %; zinc sul-
phate, gr. xv ; copper sulphate, gr. iv; mustard and
water.
To control hemorrhage : Wine of ergot, 3ij ; adrenalin
chloride, n#v of the solution ; fluid extract of hamamelis,
n#xxx.
To produce sleep: Opium, gr. ss; tincture of Can-
nabis indica, trgx; alcohol, 5J; chloral hydrate, gr. xv;
sulphonal, gr. xv; trional, gr. xv; veronal, gr. vij.
To relieve pain: Opium, gr. jss to ij.
7. The salts of potassium, lithium, and sodium render
the urine alkaline. Lithium bromide, gr. xv; lithium
citrate, gr. vij; potassium acetate, gr. xxx; potassium
bicarbonate, gr. xxx; potassium citrate, gr. xv; potas-
sium bitartrate, gr. xxx; potassium and sodium tar-
trate, 5ij; .sodium acetate, gr. xv; sodium bicarbonate,
gr. xv ; sodium, gr. xv.
To acidify the urine: Vegetable acids, in excess, acid
sodium phosphate, or benzoic or salicylic acids.
Linimentum Calcis contains equal parts of lime water
and linseed oil. It is used locally for burns.
8. Incompatibility is that relation between medicines
which renders their admixture unsuitable. Incompati-
bility may be chemical, pharmaceutical, or therapeutic.
Chemical incompatibility is seen in compounding an
acid with a base, and forming a salt. Pharmaceutical
incompatibility is seen in compounding a resinous tinc-
ture with an aqueous solution. Therapeutic incompati-
bility is seen when two agents are administered to-
gether which have an opposite action, such as bella-
donna and physostigma.
CHEMISTRY AND DISEASES OF CHILDREN.
1. Chloroform can be obtained by heating chloral
hydrate with an alkali:
C 2 HC1 3 (OH) 2 + KHO = CHCla + H.COOK + H 2
Ether is made by the action of sulphuric acid on al-
cohol :
H 2 S04 + C.H 5 OH = H 2 + C 2 H 5 HS04
C 2 H 5 HS0 4 + C 2 H 5 OH = H 2 S0 4 + (C 2 H 5 ) 2
Nitrous oxide is made by heating ammonium nitrate :
NH 4 N0 3 = N 2 + 2H 2
2. Electrolysis and Electrical Dissociation. — "The
molecules of many simple chemical substances, on be-
542
NORTH CAROLINA.
ing dissolved in water, are more or less completely split
up or dissociated into two or more (generally two)
parts called ions. This behavior of substances, on go-
ing into solution, is known as electrolytic dissociation
or ionization. The substances which dissociate in this
manner are all conductors of electricity, and are called
electrolytes; those substances which do not dissociate
are non-conductors. When a current of electricity
passes through an electrolyte or its solution, the latter
undergoes certain changes, which we group under the
term electrolysis. The electrodes are the conductors
by which the current enters or leaves the electrolyte.
Under the influence of an electrical current the ions
of the electrolyte migrate in two directions. Those ions
which migrate toward and concentrate about the anode
(or positive electrode) are called anions. Those which
migrate toward and accumulate about the cathode (or
negative electrode) are called cathions. Certain gases
undergo ionization under the action of the ultraviolet
light, Rontgen rays, radium rays or heat." — (Bartley's
Medical Chemistry).
3. Acid conditions of the urine are caused by animal
food, restricted fluids Basic conditions are caused by
vegetable food, milk diet, and a large amount of fluids.
4. The two sugars are cane sugar and lactose. They
are converted into glucose in the liver. When sugar is
not assimilated, the excess appears in the urine.
5. Chemically, fats are esters of glycerol with a fatty
acid; most of them are mixtures of glyceryl tripal-
mitate, glyceryl tristearate, and glyceryl trioleate.
Fats are formed in the body from the food ingested,
chiefly (1) the fats and (2) the carbohydrates.
In the alimentary canal the fat is split up into
glycerol and fatty acid, these are absorbed by the cells
covering the villi of the intestine and are here again
converted into fat.
Excessive fat in the feces is an indication that more
fat has been taken in than could be absorbed.
The fats are utilized in the body for the production
of force or to be stored as adipose tissue to be used
later; they therefore serve for the production or
maintenance of heat and for the performance of work.
The products of combustion of fat are C0 2 and H 2 0.
6. During digestion the proteids are split up into
proteoses, peptones, polypeptides and amino-acids. The
amino-acids are believed to be taken as such by the
epithelial cells and carried to the blood of the portal
capillaries. Another view is that in the intestinal
epithelium the amino-acids are built-up again into
543
MEDICAL RECORD.
proteins such as are found in the blood. There are
three theories of the further history of the proteids.
According to one of them (the theory of Voit), "the
protein of the tissues, living or organized protein, is
to be differentiated from the absorbed circulating pro-
tein. It is only in this circulating protein, which is
assumed to be present in the fluids of the body, the
blood and lymph, that catabolic changes take place.
These changes take place under the influence of the
living cells. The more resistant organized protein is
not supposed to undergo catabolic changes. If any of
it does, it is cast off into the fluids of the body, and
thus becomes circulating protein, undergoing catabolic
changes in precisely the same manner. It is obvious
that a small part of the absorbed protein must be
utilized to replace the waste of the organized protein
and to subserve the process of growth. This portion
is termed tissue protein." — (Lyle's Physiology.)
7. The various carbohydrates used in infant feeding-
are sugars and starches. Sugars, particularly lactose,
are useful; but starches should not be given before the
period of teething, as the infant is not capable of
digesting starches until that time.
8. Kernig's sign. The patient lies on his back with
the thigh at right angles to the body; he then tries to
extend his leg and so bring it into a line with the thigh.
In case of cerebrospinal meningitis this is nearly al-
ways impossible.
Babinski's sign. If the skin of the sole of the foot
is irritated, there will be noticed extension of the toes
instead of flexion. It is found in lesions of the pyra-
midal tract.
9. Congenital atelectasis. "This is a condition
in which the alveoli of the lungs have not become filled
with air at birth, but remain empty and collapsed. The
child makes only faint efforts at breathing, the skin
feels cold, and the temperature is only 97° F. The
fingers and toes are blue, and the cry is faint; the
child is unable to suckle; the pulse is hardly percept-
ible, and the fontanelle is deeply depressed. Ausculta-
tion reveals little air entering the chest, and at the
bases and along the borders of the lungs vesicular
sounds may be entirely absent. Percussion will give
some dullness at the bases and along the borders of the
lungs close to the spine. Cases of this severity live
but a few hours, but many others, not so extensive,
may, by energetic treatment, recover."
Treatment. "Artificial respiration; the warm bath;
rubbing the back with whisky; dashing cold water on
544
NORTH CAROLINA.
the chest, are the means used when the child is born
apparently lifeless. It is very necessary that the body-
heat be maintained, therefore keep the child in a warm
room, and roll it in cottonwool. If unable to suckle,
it must be spoon-fed, and it should get 5 drops of
brandy in a spoonful of hot milk every hour. Stimulat-
ing liniments and the mustard-bath are also service-
able, and the inhalation of oxygen may be tried. " —
(McCaw's Aids to Diseases of Children).
PRACTICE OF MEDICINE.
1. Aphasia is partial or complete loss of the power
of expressing or of understanding spoken or written
language; it is due to a cortical lesion and not to
peripheral lesions. Loss of power to produce the va-
rious movements necessary to speech is called Motor
aphasia; loss of memory for words, or inability to per-
ceive and interpret words is called Sensory aphasia.
In motor aphasia the central lesion is located in Bro-
ca's convolution (on the left side in right-handed
people) .
2. Multiple neuritis is an inflammation of a number
of nerves either simultaneously or in rapid succession.
It may be due to poisons (alcohol, lead, arsenic), or
diseases (syphilis, sepsis, gout, diabetes, malaria, diph-
theria), or general malnutrition. It may begin in-
sidiously, and is generally characterized by numbness
or tingling in hands and feet, cramps, disturbances of
sensation and motion, wasting and paralysis; the dis-
tinctive feature is the symmetrical location of the symp-
toms. Treatment consists in removal of the cause (if
possible), general tonics, morphine for the pain,
bromides or chloral for the insomnia, strychnine for
the paralysis; massage and electricity are useful.
3. Diabetes (mellitus) is a constitutional disease
characterized by polyuria, excess of sugar in the blood
and excretion of the same in the urine, and accom-
panied by severe emaciation.
Etiological factors are said to be: — -Age between 40
and 60, Jewish race, worry, nervous strain, and lesions
of the pancreas. In the treatment, carbohydrates
should be gradually removed from the diet until either
the urine is free from sugar or the diet is free from
carbohydrates. When the urine is free from sugar,
carbohydrates may be gradually resumed, but must be
reduced or stopped on the re-appearance of sugar in
the urine.
4. In gastralgia, the pain is sudden, and burning,
boring, tearing or lancinating, originating in the epi-
gastrium and radiating in various directions.
545
MEDICAL RECORD.
In ulcer of the stomachy the pain varies from a gnaw-
ing sensation to a feeling of soreness in the epigas-
trium or a painful sense of lump or oppression. It is
usually located in the epigastrium, more rarely in one
or the other hypochondriac region, with a tendency to
run to the back. The pain may occur within fifteen to
twenty minutes after the ingestion of food, or it may
be deferred until one or two hours after eating.
In lead colic, there is a violent outbreak of spasmodic
abdominal pain. It may be chiefly umbilical, or epi-
gastric, or diffuse over the entire abdomen.
In appendicitis, the pain may occur two or three
hours after eating and may be relieved by eating.
The location of the pain, roughly speaking, is epi-
gastric, but lacks the accurate localization that is seen
in ulcer. In many cases the pain is felt lower down
in the abdomen below or to the right of the navel, and
even though the pain may originate in the epigastrium
radiation downward toward the umbilicus or lower ab-
domen may occur.
In gallstone colic, the pain is immediate, severe, and
lancinating, appearing suddenly in the epigastrium
and radiating to the right and upward or to the right
side of the back. The pain is continuous, with periods
of intense exacerbation, and is uninfluenced by food,
fluids, or alkalies. — (From Lockwood's Diseases of the
Stomach.)
In peritonitis, the pain is at first local and corre-
sponds to the seat of the primary lesion, but soon be-
comes diffused and general. Except when due to per-
foration of a gastric ulcer, when it is referred to the
chest, back, or shoulder, the greatest pain is below the
navel. The pain is increased by pressure or movement
In renal colic, the pain is sudden and agonizing, hav-
ing its origin in the lumbar region, and following along
the course of the ureter. It is felt also in the testicle
and down the inner side of the thigh, and is at times
referred to the glans penis. It may last only a few
minutes or for hours. — (From Butler's Diagnostics of
Internal Medicine) .
5. Cause of secondary anemia: Hemorrhages, ne-
phritis, cancer, suppuration, tuberculosis, malaria,
poisons (such as mercury), syphilis, and very high
fevers.
Secondary anemia has an ascertainable cause; and
a blood examination shows the red cells reduced to
about 1,000,000 to the cubic millimeter, a relatively
low hemoglobin estimate, a few normoblasts and
546
NORTH CAROLINA.
megaloblasts, and the white cells generally increased
in number.
Primary pernicious anemia has no ascertainable
cause; and a blood examination shows a marked re-
duction in the number of red cells, but a relatively high
hemoglobin estimate; nucleated red cells are quite com-
mon; and the white cells are generally decreased.
6. An aneurysm is a pulsating sac containing blood,
and communicating with the lumen of an artery. Aneu-
rysms may be classified as: — true, false, and dissect-
ing; also fusiform, and sacculated.
ANEURYSM OF ASCENDING
AORTA.
Physical signs. Pulsa-
tion often expansile, in
second and third inter-
spaces.
On palpation, systolic
thrill and diastolic shock
to right of sternum.
Dullness to right of ster-
num, above cardiac area.
Rough systolic murmur,
loud clanging second
sound. May have diastolic
murmur from implication
of aortic valve.
Parts liable to pressure
and results of pressure.
Vena cava superior; di-
lated superficial veins,
edema of head and neck.
Innominate artery;
weakness of right radial
pulse.
Heart; downward dis-
placements of apex.
Ribs to right of ster-
num; pain.
Right bronchus; defec-
tive respiration on right
side.
Right recurrent laryn-
geal (rarely) ; paralysis
of right vocal cord.
ANEURYSM OF TRANSVERSE
AORTA.
Pulsation in episternal
notch.
Systolic thrill in epi-
sternal notch.
Dullness over manu-
brium sterni.
Murmur more distinct
over manubrium. Dias-
tolic murmur rare.
Left innominate vein ;
edema of left side of head
and neck.
Any branch of the
arch; weakness of right
or left radial pulse.
Ma n u b r i u m sterni ;
pain.
Trachea or left bron-
chus ; paroxysmal dysp-
nea, altered cough, de-
fective respiration on left
side.
Left recurrent laryn-
geal; paralysis of left
vocal cord.
-(Wheeler and Jack's Handbook of Medicine.)
547
MEDICAL RECORD.
7. Obstruction of the common bile duct produces
jaundice because the bile being unable to pass from the
liver into the intestine is absorbed into the hepatic
vein, and carried into the general circulation. The
causes of jaundice from mechanical obstruction of the
bile-duct, are given by Murchison as follows:—
(a) Obstruction by foreign bodies within the duct:
Gallstones and inspissated bile; hydatids and disto-
mata; foreign bodies from the intestines.
(b) Obstruction by inflammatory tumefaction of the
duodenum, or of the lining membrane of the duct,
with exudation into its interior.
(c) Obstruction by stricture or obliteration of the
duct: Congenital deficiency of the duct; stricture
from perihepatitis; closure of the orifice of the duct in
consequence of an ulcer in the duodenum; stricture
from cicatrization of ulcers in the bile ducts; spas-
modic stricture.
(d) Obstruction by tumors closing the orifice of the
duct, or growing in its interior.
(e) Obstruction by pressure on the duct from with-
out, by: Tumors projecting from the liver itself; en-
larged glands in the fissure of the liver; tumors of the
stomach, duodenum, pancreas, kidney, or omentum;
abdominal aneurysm; accumulation of feces in the
bowels; pregnant uterus; ovarian and uterine tumors.
The clinical manifestations ^ are : Jaundice or dis-
colored skin, some of the secretions are tinged with bile
or contain bile pigment, there may be a bitter taste in
the mouth, the digestion is disturbed, pruritus is gen-
erally present, there may be skin eruptions, xanthopsia
is present, and there may be some cerebral symptoms ;
in addition to these, the inability of the pancreatic
juice to reach the intestine will cause fatty stools,
emaciation, and glyscosuria.
8. Pellagra is a chronic specific disease, probably m-
fectious, characterized locally by erythema involving
usually the exposed portions of the body surface and
recurring from year to year during the summer
months; characterized constitutionally by symptoms
involving the gastrointestinal tract and the mental
and nervous systems. Languor and debility are fre-
quent prodromata. Bacteria, maize, metazoa and pro-
tozoa have all been supposed to be the main etiological
factor. The skin symptoms are the most striking, most
constant, most characteristic and most important from
a diagnostic standpoint. In their absence, a diagnosis
of pellagra is unwarranted. The eruption usually ap-
pears suddenly as an erythema, irregular in outline, in-
548
NORTH CAROLINA.
volying most frequently the dorsal aspect of the hands.
It is symmetrical, and may encircle the wrists or ap-
pear on the face. The skin becomes pigmented and
thickened. Digestive disorders and dysentery often ap-
pear; and mental depression, insomnia, headache, ver-
tigo, and tremors may be present. Treatment is chiefly
symptomatic; arsenic (Fowler's solution or atoxyl) has
been recommended. — (Pocket Cyclopedia.) The most
recent methods of treatment are: "Organo-polymin-
eralized serum"; salvarsan (intravenous injection) ;
and direct transfusion of blood.
GYNECOLOGY AND OBSTETRICS.
1. The liquor amnii consists chiefly of water, but
contains small amounts of albumin, epithelial cells,
urea, phosphates, chlorides, etc. Its specific gravity is
about 1.001 to 1.008. Its source is unknown; it is
probably derived from the amnion, by transudation
from the maternal vessels of the placenta.
2. "Mendel's formula may be set down as follows: if
D represent a plant with the dominant red and its
germplasm, and R one with the recessive white and its
germplasm, then the first generation of crosses of D
and R will all be DR, and if these DR individuals be
crossed the result will be x (DR + DR) = x (DD +
2DR -f- RR) , or in other words, a dominant crossed
with a recessive gives in the second generation, as re-
gards this one particular feature, one dominant, two
hybrids, and one recessive, and of these, each dominant
will give nothing but dominants, each recessive noth-
ing but recessives, and each hybrid the same proportion
of dominant, hybrid, and recessive." — (Adami and
McCrae's Text-Book of Pathology) .
3. The pelvic floor is composed of skin, connective
tissue, pelvic fascia, perineal fascia, levator ani, coccy-
geus, sphincter ani, transversus perinei, constrictor
vaginse, and triangular ligament.
4. Some of the indications for producing sterility in
a woman are: Excessive pelvic deformity rendering
delivery of a living child either impossible or decidedly
dangerous to the mother; advanced tuberculosis.
The operation may be a ligature and division of the
two Fallopian tubes.
5.
INVERSION OF UTERUS.
1. No pedunculated at-
tachment to uterus.
UTERINE POLYPUS.
1. Attached to uterine
wall by broad surface or
by narrow pedicle.
549
MEDICAL RECORD.
INVERSION OF UTERUS.
2. Uterine cavity being
obliterated, sound can be
passed but short distance,
m incomplete and not at
all in complete inversion.
3. Vaginal or rectal
conjoined examination
shows a ring or depres-
sion where the uterus
should be, and fails to
show the uterus above the
vagina.
4. The inverted uterus
is a symmetrical pyriform
body.
5. Orifices of the Fallo-
pian tubes usually de-
monstrable.
6. Muciparous glands
of the uterus present and
microscopially demon-
strable.
UTERINE POLYPUS.
2. Sound passes by the
side of the mass through
external os far into
uterine cavity.
3. Uterus
vagina.
felt above
4. Not usually sym-
metrical and may be very
asymmetrical.
5. Not present.
6. Not present, or if
present less perfectly de-
veloped.
— (Dudley's Gynecology) .
In chronic inversion of the uterus, the patient is
anesthetized and the uterus is reduced and kept in
place by means of a repositor. Sometimes a celiotomy
must be performed to allow of the reduction; and
sometimes amputation of the uterus is expedient.
Uterine polypus will require dilatation of the cervix
and removal of the polypus by cutting through the
pedicle.
6. The normal course of delivery in occipito-posterior
positions, is the same as in occipito-anterior positions
except that the head must rotate to the front through
three-eighths of a circle; of course this takes longer
and is more tedious.
In abnormal cases, the management is as follows:
"(a) When diagnosed while the head is at the brim.
(1) Leave it alone. The occiput will probably rotate
to the front all right if it is given plenty of time. (2)
If flexion appears to be deficient, try to increase it by
pushing up the sinciput with the fingers in the vagina
during a pain, at the same time pressing down upon
the fundus with the other hand. (3) The head may be
rotated by passing the hand into the vagina and grasp-
ing it between the fingers and thumb. At the same
550
x\ T ORTH CAROLINA.
time the shoulders must be rotated by abdominal palpa-
tion, or else the head will at once go back to its original
position. This maneuver requires an anesthetic.
"(6) When diagnosed after the head has entered the
pelvis. (1) Leave it alone. After exercising the pa-
tience of all concerned, it will probably rotate spon-
taneously. Only about one case out of twenty fails to
do so. (2) An attempt may be made to increase flexion
as before. (3) Manual rotation may be attempted as
before, but the head must first be flexed and gently
pushed back out of the pelvis. (4) If the pains are
weak, forceps should be applied well back on the head,
so that when traction is applied, flexion will be pro-
moted. The head should then be pulled well down on
to the pelvic floor. If it begins to rotate, take off the
forceps and leave the rotation to nature, merely keep-
ing the head on the pelvic floor by pressure on the
fundus. After rotation the forceps may, if necessary,
be reapplied and delivery completed.
"(c) When the occiput has definitely rotated into
the hollow of the sacrum, and the case has become a
persistent occipitoposterior, forceps should be applied
and the head delivered with the occiput posterior. The
perineum should be guarded as much as possible, and
any tears stitched up at once. In extreme cases crani-
otomy and pubiotomy may require to be considered."
— (Johnstone's Textbook of Midwifery.)
In the latter case, the maternal mortality is nil; the
fetal mortality is about 12 to 15 per cent.
7. Diseases of the breast liable to occur during the
puerperium are: Engorgement, inflammation, abscess,
and cracked nipple,
Engorgement is treated by giving the patient salines,
limiting the amount of fluid ingested, and compressing
the breasts with a binder. Inflammation is treated by
resting the part, supporting it, applying a hot boracic
acid fomentation, nursing from the affected breast
should be stopped at once. Abscess is treated by mak-
ing an incision radiating from the nipple, and drainage ;
thorough antiseptic and aseptic precautions must be
observed; the breast should be put at rest for a couple
of days; saline cathartics may be necessary, also sup-
portive measures. Cracked nipples require to be kept
clean and dry ; they may be protected by a nipple shield
while the infant is nursing; an application of tannic
acid, or nitrate of silver may be used.
Prophylactic measures consist in not touching the
breasts (by doctor or nurse or patient) without thor-
oughly clean hands; by washing and drying the nipple
551
MEDICAL RECORD.
before and after nursing, and by proper attention to
hygienic conditions before labor, and the nipple and
breasts being preserved from pressure.
8. The indications for emptying the uterus are:
"Intractable toxemia of pregnancy, chronic nephritis,
extensive vascular degeneration of the chorion, irre-
ducible retroversion of the pregnant uterus, absolute
contraction of the pelvis, death of the fetus, chorea,
pernicious anemia or leucemia.
"At two months, the operation can be carried out at
one sitting by the method of dilatation by graduated
bougies. This is carried out exactly as for a curettage.
The genitals are cleansed and shaved, the vagina
washed out, and the cervix fixed and drawn down by
vulsella. The dilators are then passed in one after
the other until the cervix admits one or even two
fingers. The ovum is then separated, and extracted by
the fingers or an ovum forceps.
"At six months the patient is anesthetized and placed
in the lithotomy position. After the external parts
have been scrubbed, the operator puts on boiled gloves
and washes out the vagina. The cervix is then exposed
by the speculum and drawn down by the vulsella. If
necessary the os may be dilated by one or two Hegar's
dilators sufficiently to admit the finger, which is then
swept round the lower uterine segment and the mem-
branes separated. One bougie is then gently intro-
duced between the membranes and the uterine wall,
great care being taken not to rupture the membranes.
If difficulty is met with in passing the bougie, force
must not be used, as the obstruction is probably due to
the edge of the placenta. The bougie must be with-
drawn and inserted in another direction. If
no obstruction is encountered, the bougie should
be passed in as far as it will go, which
usually leaves about an inch or so projecting outside
the cervix. A second and even a third bougie may be
introduced in like manner. The ends of the bougies are
then wrapped in sterile gauze and left in the vagina,
which is lightly packed. The patient is kept in bed
afterwards. Labor may be expected in about twelve
hours, although it may start within half an hour, or be
postponed for thirty-six hours, or even a day or two.
Hot vaginal douches may be given every few hours in
the meantime. If labor has not ensued after forty-
eight hours, the bougies should be withdrawn, the
vagina well douched, and either a fresh set of bougies
introduced or the cervix tamponed with sterile gauze
soaked in glycerin. If labor ensues after the introduc-
552
NORTH CAROLINA.
tion of the bougies they should be left in situ until ex-
pelled by the uterus. If removed too soon the labor
may stop and the pains pass off again." — (Johnstone.)
SURGERY.
1. Hematuria may be produced by: — Inflammation,
congestion, contusion of kidney, ureter, or bladder;
stone in kidney, ureter or bladder, catheterization;
tumors of bladder or kidney; urethritis; traumatism;
purpura; hemophilia; scurvy; metallic poisons; the
Bilh arzia hsemato b ia :
2. Resection of the elboiv-joint : — "The patient is su-
pine, but inclining to the sound side, the affected arm
being held almost vertical, with the forearm flexed and
nearly horizontal. The incision is made on the pos-
terior surface of the joint. A single posterior incision
is usually employed. An incision is made a little in-
ternal to the long axis of the olecranon, beginning two
inches above and terminating two inches below the tip
of the olecranon. This incision goes down to the bone,
and throughout the entire operation the surgeon must
guard and shield the ulnar nerve. The periosteum and
soft parts are well separated; the olecranon is sawn
off; forced flexion exposes the joint cavity freely, and
enables the surgeon to lift the periosteum and soft parts
from the humerus; the humerus is sawn through at
the beginning of its condyloid processes; the radius and
ulna are cleared and are sawn at a level below that of
the base of the coronoid process of the ulna. Diseased
tissues are cut and scraped away; the wound is irri-
gated, sutured, drained, and dressed. In some cases an
H-shaped incision is employed, but the cicatrix of a
transverse cut will limit flexion of the limb." (Da
Costa's Surgery.) The ulnar and posterior interosse-
ous nerves are to be specially guarded.
3. The various dislocations of the shoulder- joint are:
(1) Subcoracoid — forward, inward, and downward.
(2) Subglenoid — downward, forward and inward. (3)
Subspinous — backward, inward, and downward. (4)
Subclavicular — forward, inward, and upward.
"In subcoracoid dislocation, the head of the bone lies
below the coracoid process upon the neck of the scapula.
The tendon of the subscapularis is torn or stretched
over the neck of the humerus. The supraspinatus, in-
fraspinatus, and teres minor are either tightly
stretched, producing external rotation, or torn (some-
times with great tuberosity), with internal rotation.
There will be found : Local contusion ; restricted mobil-
ity; flattened outer border of shoulder; head of the bone
553
MEDICAL RECORD.
is felt below outer end of clavicle; elbow is displaced
from the side outward and backward, and cannot touch
the chest wall when the hand is placed on the opposite
shoulder ; there is little or no shortening. Treatment : —
Kocher's method: Anesthetize. Elbow is held to the
side. Hand is brought forward and outward, so as to
externally rotate the humerus and relax the external
rotators. Elbow is adducted to the mid-line — this
makes the margins of the gap in the capsule tense.
Elbow is raised, so as to slacken upper margin of the
rent and keep lower tense. Hand is placed on the
opposite shoulder, i.e. arm is rotated inward, to make
the head of the humerus slip into capsule. Elbow low-
ered." — (Groves' Synopsis of Surgery.)
4. In ligation of the lingual artery: "The incision
is a curved one two inches long, its concavity directed
upward from the anterior edge of the sternocleido-
mastoid muscle, half an inch above the great horn of
the hyoid bone, to a point one inch within the median
line of the neck. Divide the skin and platysma, dis-
placing the superficial veins, and open the deep fascia,
when the submaxillary gland will be exposed; this is
displaced upward with the handle of the knife, when
the tendon of the digastric muscle attached to the
hyoid bone, and the hypoglossal nerve will be exposed;
next divide the fibers of the hyoglossus muscle mid-
way between the hypoglossal nerve and the hyoid bone,
and the lingual artery will be exposed. The needle
should be passed around the vessel from above down-
ward, in order to avoid the nerve."— (Wharton.)
5. "In the treatment of compound fractures the main
object is to render the wound aseptic and to give effi-
cient exit to the discharges. For this purpose the
patient should in all cases be anesthetized, the limb
shaved, and thoroughly purified, and the wound en-
larged and thoroughly washed out with some reliable
antiseptic. It may be advisable to excise torn and
dirty fragments of skin, muscle, and tendon, especially
when dirt has been ground into them. Loose frag-
ments of bone are removed and portions denuded of
their periosteum may be taken away lest necrosis
should ensue; where fragments retain any considerable
connection with the soft parts they may be left with-
out fear. When a sharp end of one of the fragments
is protruding through a small opening in the skin it
is first purified thoroughly before attempting its reduc-
tion and then replaced after enlarging the wound in
the skin, or a portion sawn off. Hemorrhage is dealt
with in the usual way, and the fragments are placed
554
NORTH CAROLINA.
as nearly as possible in their normal position. If the
fragments can be brought accurately into position it is
well to fix them by some mechanical appliance; but
where the ends of the bone are much comminuted the
small portions must be arranged in position as well as
possible, and no attempt made to wire them. A good-
sized drainage tube is inserted, and, if need be, counter-
openings are made ; the external wound is closed or not,
according to circumstances, and dressed, and suitable
splints are then applied." — (Rose and Carless.)
6. Acute infective osteomyelitis. "Symptoms. —
The disease begins with a rigor, high temperature, and
severe pain. The part becomes swollen, infiltrated, and
congested, with distended veins over it. The pulse is
rapid and small and the tongue dry, and delirium soon
comes on. It should be distinguished from acute rheu-
matism by the fact that the interarticular and not the
articular region is affected. Fluctuation can be de-
tected if the bone be superficial, or the abscess may
burst on the surface. The bone is then found to be
bare over the extent of the abscess cavity. When the
bone is deeply seated or the disease confined to the
medulla, the swelling is later in evidence, but the pain
and toxemia are very severe, and the patient may die
from this before local signs show themselves. When
the epiphysis is attacked, septic arthritis often quickly
follows,, and a loose flail joint may result.
"Treatment must be very prompt. A free incision
must be made through the periosteum and the pus
evacuated. In any case, whether pus is found or not,
the surface of bone must be gouged away to expose the
medulla freely, and any gangrenous tissue scraped out.
The cavity must then be washed out and freely
drained. The wound in the soft structures is not
closed in any part. If symptoms of pyemia occur, it
may be necessary to amputate the limb through the
joint or bone above, so as to cut off the source of em-
boli. When a large portion of, or the whole diaphysis
is necrosed, there are two courses; either to cut short
the disease by removing the dead portion at once, or
to leave the sequestrum to stimulate the formation of
an involucrum. Where there is a single bone, as in the
arm and thigh, the sequestrum is left; where there is
a double set of bones, as in the forearm and leg, the
sequestrum is removed at once. Celluloid, zinc, and
ivory rods have been inserted to stimulate osteogenesis.
In most cases it is doubtful how much bone is actually
dead, so that it is better to open up the cloacae in the
newly formed involucrum to remove the sequestrum.
555
MEDICAL RECORD.
The cavity heals by granulation." — (Aids to Surgery.)
7. A chancroid is an ulcer, usually of venereal origin,
due to infection with the bacillus of Ducrey.
Chancroid of the penis may be treated by being
sprayed with peroxide of hydrogen, dried with cotton,
then touched with pure carbolic acid and then with
pure nitric acid; afterwards a dressing soaked with
black wash may be applied. The penis should be soaked
in hot salt water every few hours, the above treatment
being repeated.
The incubation period is about five to ten days.
8. Tracheotomy: — "The patient is placed on the
back with a narrow pillow under the neck. Chloroform
or cocaine can be used as anesthetics. An incision, one
and a half inches long, is made downward from the
cricoid cartilage, keeping strictly in the mid-line. The
incision is deepened till the tracheal rings and isthmus
are exposed. Enlarged veins give trouble during this
stage if there is dyspnea. A director-hood is thrust
into the trachea, and the point of a knife is slid along
the groove to open the trachea from below upward.
The patient is allowed to cough for a few minutes while
the wound is kept open with dilating forceps; then the
tube is tied in." — (Aids to Surgery.)
STATE BOARD EXAMINATION QUESTIONS.
Ohio State Board of Medical Examiners.
ANATOMY.
1. Name the subdivisions of the abdominal cavity.
2. Give a description of the knee joint.
3. Name the carpal bones.
4. Describe the prostate gland.
5. What is the length of the intestine and its divi-
sions?
PHYSIOLOGY.
1. Describe the functions of visceral muscle.
2. What is the nature of the nerve impulse? Discuss
nerve fatigue.
3. What are the advantages of a mixed diet? How
does a purely protein diet affect metabolism?
4. What is the mode of secretion and discharge of
the bile?
5. Give histology of blood plates.
6. Discuss intravascular coagulation. What patho-
logical conditions of the vessels favor its development?
7. Locate the cardio-accelerator center. How is the
heart rate affected through the vagus nerve?
556
OHIO.
8. Describe Cheyne-Stokes respiration. With what
pathological states is it usually associated?
9. Describe effects of removal of parathyroid tissue.
10. What is the origin, distribution, and function of
the third nerve?
CHEMISTRY.
1. Give the chemical formula for mercurous chloride,
mercuric chloride, and mercurous nitrate. Give one
characteristic of each.
2. State the difference between a physiological and
chemical antidote for poison, and give an example of
each.
3. What is organic chemistry? State the general
properties of organic compounds.
4. Differentiate between fermentation and putrefac-
tion.
5. What is methyl alcohol? Give formula, proper-
ties, and uses.
MATERIA MEDICA AND THERAPEUTICS.
1. Name the three principal serums. Give mode of
administration and indication for use of each.
2. Name the different preparations of digitalis and
aconite. Give dose and cumulative action of each.
3. Cocaine hydrochloride — its physiological action
and principal uses. Give symptoms and treatment of
an habitue.
4. For what purposes are diuretics employed. Name
the principal ones. How are they usually classified?
5. Give the physiological action, use, and dose of
salicylate of sodium.
6. Potassium salts — name the principal ones and give,
dose and use of each.
7. Name three external antiseptic remedies. Give
indications, and state how each may be used.
8. Nux vomica — its therapeutic uses, important prep-
arations — dose of each.
9. Give the indications for internal use of corrosive
sublimate; state dose.
10. Give the therapeutic uses and state the dose of
opium and its alkaloids.
DIAGNOSIS.
1. Give symptomatology of incipient pulmonary tuber-
culosis.
2. Give etiology and physical signs of myocarditis.
3. Describe difference in symptomatology of acute
dilatation of heart and hypertrophy of heart.
4. How can the functional competency of each kidney
be demonstrated?
557
MEDICAL RECORD.
5. Give differential diagnosis: ulcer of stomach,
ulcer of duodenum, and cholecystitis.
6. Give early signs of hyperthyroidism.
7. Differentiate enlarged gall bladder and ptosed
right kidney.
8. Describe physical signs of effusion in acute
pleuritis.
9. What is the most important sign of leukemia?
10. What are the early signs of acute poliomyelitis?
PATHOLOGY.
1. What is the blood picture in myelogenous leu-
kemia; give source of abnormal cells found.
2. What is a hemorrhagic infarct; what would be
the course of such a condition — for example, in the
kidney?
3. Describe tubercle formation, and the various path-
ological results in pulmonary tuberculosis.
4. Give method of preparing a vaccine for furuncu-
losis.
5. Describe your precautions in treating a case of
diphtheria: (a) for the physician; (b) for the pa-
tient's family; (c) for the general community.
PRACTICE.
1. Describe the symptom complex of uremia; tell
how you might suspect it to be impending in a given
case, and what treatment you would employ in an
effort to avert it.
2. In what diseases should one be on the lookout for
acute endocarditis, and how would you recognize its
occurrence?
3. Give symptoms of cancer of the liver involving the
neighborhood of the hepatic duct.
4. Given a case of a man of sixty-five of alcoholic
history, with edematous ankles, dyspnea, and cough
with occasional bloody expectoration, albuminuria, and
blood pressure of 150 (sys.) ; what would be your pre-
sumptive diagnosis?
(b) Trace the prognosis of the case from the primary
condition.
5. In an instance of alleged hematemesis, give other
possible sources of the blood, and tell how you would
recognize the origin in a given case.
6. Describe your treatment of a case of pulmonary
tuberculosis, moderately advanced, involving chiefly
one side, with a temperature of 101° Fahrenheit, and
subject to occasional hemorrhage.
7. Give symptoms and treatment of a case of in-
fluenzal pneumonia.
558
OHIO.
8. Give symptoms of acute myelitis, differentiating
it from multiple neuritis.
9. Mention some indications of cerebral syphilis.
How would you make a positive diagnosis? Briefly
outline the treatment.
10. How would you treat a case of acute articular
rheumatism?
DERMATOLOGY, SYPHILOLOGY, AND DISEASES OF EYE, EAR,
NOSE, AND THROAT.
1. Describe psoriasis. Give treatment.
2. Of what disease is the occurrence of pruritus ani
a frequent sign?
3. Upon what evidence would you base a belief that
a patient is cured of gonorrhea?
4. Describe signs and symptoms of congenital syph-
ilis.
5. Outline an approved treatment of syphilis.
6. What are the dangers of acute suppurative in-
flammation of the middle ear?
7. Describe trachoma. Give treatment.
8. Describe tuberculous laryngitis.
9. Give treatment of acute suppurative inflammation
of frontal sinus.
10. Give treatment of nasal polypi.
OBSTETRICS.
1. When would you be justified in inducing prema-
ture labor?
2. How would you diagnose the existence of preg-
nancy?
3. What are the symptoms of fetal death?
4. State the indications and contraindications for the
use of the curette and describe the technique of this
operation.
5. Name the stages of labor and describe the man-
agement of the third stage in detail.
SURGERY.
1. Shock: (a) Cause; (6) Symptoms; (c) Outline
treatment.
2. Acute Suppurative Appendicitis, (a) Diagnosis:
(1) Subjective and objective symptoms; (2) Differen-
tiate between this and similar abdominal disorders;
(3) Preliminary treatment. (6) Operation: (1) Sur-
gical technique; (2) After treatment; (3) Prognosis.
3. Colles' Fracture: (a) Diagnosis; (b) Pathology;
(c) Treatment.
4. Hip- Joint Disease: (a) Diagnosis; (6) Treat-
ment — surgical, mechanical; (c) Prognosis.
559
MEDICAL RECORD.
5. Gunshot Wounds: (a) Give rule regarding prob-
ing; (6) Give rule regarding immediate operation; (c)
In a gunshot wound of the knee what would be your
course of pursuance?
ANSWERS TO STATE BOARD EXAMINATION
QUESTIONS.
Ohio State Board op Medical Examiners.
anatomy.
1. The abdominal cavity is divided into the abdomen
proper and the pelvis.
2. The knee joint is a ginglymus, and is formed by
the condyles of the femur, the head of the tibia, and
the patella. "The external ligaments: the anterior
or ligamenturm patellae is the continuation of the ten-
don of the triceps extensor. Above it occupies the apex
and rough marking on the lower and posterior surface
of the patella ; below it is attached to the lower part of
the tubercle of the tibia. There is a bursa between the
upper part of the tubercle and the ligament. The poste-
rior ligament (lig amentum posticum Winslowii), broad
and thin, covers the back of the joint. It consists of a
central and two lateral parts. The lateral parts spring
above from the femur above the condyles and are at-
tached below to the head of the tibia. The central part
is derived from an expansion of the semi-membranosus
tendon, and passes from the inner tuberosity of the
tibia to the inner side of the upper part of the outer
condyle of the femur. The internal lateral ligament,
broad and flat, is attached above to the inner condyle
of the femur; below, to the margin of the inner tuber-
osity, to the internal fibrocartilage, and to the inner sur-
face of the shaft of the tibia for 1% inches. The long
external lateral ligament, a rounded cord, is attached
above to the external condyle of the femur, and below
to the external part of the head of the fibula, dividing
the biceps tendon into two parts, a bursa intervening.
The short external lateral ligament, very indistinct, lies
parallel and behind the preceding, attached above to the
outer condyle of the femur, and below to the styloid
process of the fibula. The capsular ligament, thin, fills
up the intervals between the special ligaments; it is at-
tached to the margins of the articular surfaces of the
bones, and blends with the fascia lata of the thigh:
above it receives expansions from the vasti (lateral
patellar ligaments) .
"The Internal Ligaments: The anterior or exter-
560
OHIO.
nal crucial ligament is attached to the depression in
front of the spine of the tibia and to the external semi-
lunar fibrocartilage ; it passes upwards, backwards,
and outwards to the posterior part of the inner side of
the external condyle of the femur. The posterior or in-
ternal crucial ligament is attached to a depression be-
hind the spine of the tibia, to the popliteal notch, and
the posterior border of external semilunar fibrocarti-
lage, this latter slip being sometimes called the ligament
of Wrisberg; it passes upwards, forwards, and inwards,
the posterior fibers attached by side of oblique curve of
inner condyle, the anterior ones to the fore part of inter-
condylar fossa and to the anterior part of the outer
surface of the inner condyle. The semilunar cartilages
are thicker at the circumferences than at the central
margins and serve to deepen the cavities for the head
of the femur. The internal semilunar cartilage is oval
in shape, the anteroposterior diameter being the longer.
Its anterior extremity is attached to the tibia in front
of the anterior crucial ligament, and the posterior ex-
tremity in front of the posterior crucial ligament. The
external semilunar cartilage is nearly circular; its an-
terior extremity is attached to the tibia in front of the
spine, the posterior extremity to the back of the spine."
(Aids to Anatomy.)
3. The carpal bones, from radial to ulnar side, are
(in the first row) scaphoid, semilunar, cuneiform, and
pisiform; (in the second row) trapezium, trapezoid,
os magnum, and unciform.
4. The prostate gland is about the size and shape of
a horse-chestnut, and surrounds the neck of the blad-
der and first part of the urethra in the male. It is sur-
rounded by a dense capsule, and consists of three lobes
(two lateral and one middle) ; it is pierced by the
ejaculatory ducts and by the urethra. Its base is at-
tached to the base of the bladder, and its apex is in
relation with the posterior layer of the triangular liga-
ment and the compressor urethrse muscle. The pos-
terior surface is in relation with the rectum and is
about an inch and a half from the anus.
5. The small intestine is about twenty-one feet in
length, the duodenum, being about ten inches, the
jejunum about eight feet, and the ileum about twelve
feet. The large intestine is about five or six feet in
length, the cecum being about two and a half inches,
the ascending colon about five inches, the transverse
colon about twenty inches, the descending colon about
eight and a half inches, the sigmoid colon about seven
teen inches, the rectum about five inches, and the anal
561
MEDICAL RECORD.
canal about one and a half inches. All these measure-
ments are liable to variation, particularly those of the
large intestine.
PHYSIOLOGY.
1. The function of visceral muscle. "In a general
way is may be said that the visceral muscle determines
and regulates the passage through the viscus or organ
of the material contained within it. The food in the
stomach and intestines is subjected to a churning proc-
ess by the muscles, in consequence of which the digest-
ive fluids are more thoroughly incorporated and their
characteristic action increased. At the same time the
food is carried through the canal, the absorption of
the nutritive material promoted, and the indigestible
residue removed from the body. The blood is delivered
in larger or smaller volumes according to the needs
of the tissues through a relaxation or contraction of
the muscle fibers of the blood-vessels. The urine is
forced through the ureters and from the bladder by the
contraction of their respective muscles." (Brubaker's
Textbook of Physiology.) During labor the uterus ex-
pels the fetus, followed by the placenta and membranes.
2. The nature of the nerve impulse. "As to the
nature of the nerve impulse but little is known. It has
been supposed to partake of the nature of a molecular
disturbance, a combination of physical and chemical
processes attended by the liberation of energy, which
propagates itself from molecule to molecule. The
passage of the nerve impulse is accompanied by changes
of electric tension, the extent of which is an indication
of the intensity of the molecular disturbance. Judging
from the deflections of the galvanometer needle it is
probable that when the nerve impulse makes its appear-
ance at any given point it is at first feeble, but soon
reaches a maximum development, after which it speedily
declines and disappears. It may, therefore, be graphi-
cally represented as a wave-like movement with a defi-
nite length and time duration. Under strictly physio-
logical conditions the nerve impulse passes in one
direction only; in efferent nerves from the center to the
periphery, in afferent nerves from the periphery to the
center. Experimentally, however, it can be demon-
strated that when a nerve impulse is aroused in the
course of a nerve by an adequate stimulus it travels
equally well in both directions from the point of stimula-
tion. When once started, the impulse is confined to the
single fiber and does not diffuse itself to the fibers ad-
jacent to it in the same nerve trunk." (Brubaker's
Textbook of Physiology.)
562
OHIO.
Nerve Fatigue. "Inasmuch as nerves are parts of
living cells, the seat of nutritive changes, it might be
supposed that the passage of nerve impulses would be
attended by the disruption of energy-holding com-
pounds, the production of waste-products, the liberation
of heat, and in time by the phenomena of fatigue.
Though it is probable that changes of this character
occur, yet no reliable experimental data have been ob-
tained which afford a clue as to the nature or extent
of any such changes. Stimulation of motor nerves with
the induced electric current for hours appears to be
without influence either on the intensity of the nerve
impulse or the rate of its conduction." (Brubaker's
Textbook of Physiology.)
3. Mixed Diet. "The chemical composition of the
tissues, taken in connection with their metabolism dur-
ing starvation, implies that no one article of food is
sufficient for tissue repair and heat production; but
that all classes of food — in other words, a mixed diet —
are essential to the maintenance of a normal nutrition.
Experimental investigation has also conclusively estab-
lished this fact. Moreover, the amounts of nitrogen and
carbon eliminated daily, and the ratio existing between
them, indicate the amounts of proteid, fat, and car-
bohydrate which are required to cover the loss." (Bru-
baker's Textbook of Physiology.)
Metabolism on a purely protein diet. "Notwithstand-
ing the chemical composition of the proteins and the
possibility of their giving rise to both fat and carbo-
hydrate during their metabolism, it has been found
extremely difficult to maintain the normal nutrition for
any length of time on a pure proteid or fat-free diet.
This, however, has been accomplished with dogs. It
was found, however, that, in order to maintain the equi-
librium, it was necessary to increase the proteins from
two to three times the usual amount. Thus a dog
weighing 30 to 35 kilograms required from 1500 to
1800 grams of flesh daily in order to get the requisite
amount of carbon to prevent consumption of its own
adipose tissue. Under similar circumstances, a human
being weighing 70 kilograms would require more than
2000 grams of lean beef — an amount which, from the
nature of the digestive apparatus, it would be practi-
cally impossible to digest and assimilate for any length
of time. Even the slight habitual excess beyond the
amount normally required is imperfectly assimilated
and gives rise to the production of nitrogen-holding
compounds which, on account of the difficulty with
which they are eliminated by the kidneys, accumulate
563
MEDICAL RECORD.
within the body and develop the gouty diathesis, with
all its protean manifestations." (Brubaker's Textbook
of Physiology.)
4. Mode of secretion and discharge of bile. "Al-
though the liver presents some physiological peculiar-
ities there is no reason to believe that the condi-
tions of secretion therein are different from those
in any other secretory organ, or that any other struct-
ure than the cell is engaged in this process. As shown
by chemical analysis, the bile consists of compounds,
some of which, like the bile salts, are formed in the
liver cells, out of material furnished by the blood by
a true act of secretion, while others, such as cholesterin
and lecithin, principles of waste, are merely excreted
from the blood to be finally eliminated from the body.
The bile is thus a compound of both secretory and ex-
cretory principles. The flow of bile from the liver is
continuous, but subject to considerable variation dur-
ing the twenty-four hours. The introduction of food
into the stomach at once causes a slight increase in the
flow, but it is not until about two hours later that the
amount discharged reaches its maximum. After this
period it gradually decreases up to the eighth hour, but
never entirely ceases. During the intervals of diges-
tion, though a small quantity passes into the intestine,
the main portion is diverted into the gall bladder, be-
cause of the closure of the common bile duct by the
sphincter muscle near its termination, where it is re-
tained until required for digestive purposes. When
acidulated food passes over the surface of the duo-
denum, there is an increase in the secretion, or at least
the discharge of bile, and as this takes place after the
nerves distributed to the liver are divided, the assump-
tion is that an agent, possibly secretin, is developed in
the duodenal mucous membrane, which, absorbed into
the blood, is ultimately distributed to the liver cells
and by which they are excited to activity. At the
same time there is excited, through reflex action, a
contraction of the muscle walls of the gall bladder and
ducts, a relaxation of the sphincter, and a gush of bile
into the intestine, the discharge continuing intermit-
tently until digestion ceases and the intestine is emptied
of its contents." (Brubaker's Textbook of Physiology.)
5. The blood platerlets are small granular or homo-
geneous discs, about 1.5 to 3.5 a* in diameter. The
edges are rounded and well defined ; they have no
nucleus; they have been estimated at about 250,000
to 300,000 to the cubic millimeter of blood.
6. Intravascular coagulation. "So long as the rela-
564
OHIO.
tions of the blood and the vascular apparatus remain
physiological, no coagulation occurs in the vessels. The
reasons assigned for this are: (1) the absence of
thrombo-kinase in sufficient amounts; (2) the presence
of an antithrombin. On either assumption the reaction
between prothrombin and calcium with the formation
of thrombin does not take place. If the vessels are in-
jured as they are when ligated or torn or in any way
impaired, coagulation promptly takes place with the
subsequent occlusion of the vessel. As to whether the
injured tissues or the blood cells now generate an agent,
thrombo-kinase, which activates the prothrombin and
calcium, or whether they generate an agent thrombo-
plastin, which neutralizes an antithrombin, is a sub-
ject of discussion." (Brubaker's Textbook of Physi-
ology.)
7. The car olio-accelerator center is in the medulla.
The vagus nerve is the inhibitory nerve of the heart; it
slows the heart. Section of one vagus produces slight
acceleration of the heart. A more marked effect occurs
when both vagi are divided. The inhibitory action of
the vagus is continuous.
8. Cheyne-Stokes respiration "is a condition in which
the respirations gradually increase in volume and rapid-
ity until they reach a climax, when they gradually sub-
side, and finally cease for from ten to forty seconds,
when the same cycle begins again. It may occur in
tuberculous meningitis, cerebral hemorrhages, em-
bolism, thrombosis, aneurysm of basilar artery, uremia,
heart disease, etc." (Hughes' Practice of Medicine.)
9. Removal of the parathyroids is followed by twitch-
ing and spasms of the voluntary muscles, paralysis of
the legs, increased frequency of respiration, and death.
10. The third cranial nerve (motor oculi) arises from
the inner side of the crus cerebri, in front of the pons,
and from the floor of the aqueduct of Sylvius. It enters
the cavernous sinus and then passes forward to enter
the orbit through the sphenoidal fissure. While in the
sphenoidal fissure it divides into two branches. It is
the motor nerve for the following five muscles of the
eyeball, and is distributed to these muscles: the
superior rectus, levator palpebrae superioris, internal
rectus, inferior rectus, and inferior oblique muscles.
CHEMISTRY.
1. Mercurous chloride, Hg 2 Cl 2 , insoluble in water.
Mercuric chloride, HgCl 2 , soluble in water.
Mercurous nitrate, Hg 2 (N0 3 ) 2 , is efflorescent.
2. Physiological antidotes act as such by combating
565
MEDICAL RECORD.
one or more of the physiological actions of the poison,
such as opium for belladonna.
Chemical antidotes act as such by uniting chemically
with the poison and thus converting it into a harmless
or insoluble compound, such as magnesium sulphate for
lead poisoning.
3. Organic chemistry is the chemistry of the carbon
compounds.
General properties of organic compounds: They may
be solids, liquids, or gases; if solid, may be crystalline
or amorphous ; they may be volatile or non-volatile, and
they are very liable to undergo change when acted upon
by heat or reagents The more complex they are, the
more readily they undergo change.
4. Fermentation is a form of decomposition of or-
ganic matter containing only carbon, hydrogen, and
oxygen.
Putrefaction is a form of decomposition of organic
matter which contains nitrogen in addition to carbon,
hydrogen, and oxygen.
5. Methyl alcohol is the hydroxyl of methyl, CH 3 OH.
It is a colorless liquid having an ethereal and alcoholic
odor and a sharp, burning taste. It burns with a pale
flame, giving less heat than that of ethyl alcohol. It
mixes readily with water, alcohol and ether, and is a
solvent for sulphur, phosphorus, potash, soda, and resin-
ous substances.
MATERIA MEDICA AND THERAPEUTICS.
1. Antidiphtheritic serum should be given to patients
suffering from diphtheria, or even suspected to be suf-
fering from that disease. It is given subcutaneously.
Antimeningococcic serum is injected into the spinal
canal after the withdrawal of about 30 cc. of cerebro-
spinal fluid. It is administered to patients suffering
from cerebrospinal meningitis.
Antistreptococcic serum is given in various diseases
due to streptococcus infection (erysipelas, puerperal
fever, septicemia, ulcerative endocarditis). It is given
subcutaneously.
2. Digitalis. Fluidextract, tt#j; extract, gr. i-v; in-
fusion, 3ij; tincture, ii#xv.
Symptoms of cumulative effect of digitalis: Weak,
dicrotic pulse, perspiration, nausea, vomiting, lowered
reflexes, lowered body temperature, vertigo, muscular
tremors, lassitude, delirium, stupor.
Aconite. Fluidextract, irgj; tincture, ti#x.
Symptoms of aconite poisoning usually manifest
themselves witnin a few minutes; sometimes are de-
566
OHIO.
layed for an hour. There is numbness and tingling,
first of the mouth and fauces, later becoming general.
There is a sense of dryness and of constriction in the
throat. Persistent vomiting usually occurs, but is ab-
sent in some cases. There is diminished sensibility, with
numbness, great muscular feebleness, giddiness, loss of
speech, irregularity and failure of the heart's action.
Death may result from shock if a large dose of the
alkaloid be taken, but more usually it is by syncope.
3. Cocaine hydrochloride. Physiological action:
Local anesthetic (externally) ; internally it is a muscu-
lar, cerebral, circulatory, and respiratory stimulant,
also a mydriatic. Its jnnncipal uses are: As a local
anesthetic; also in paralysis agitans, chorea, and alco-
holic tremors.
The chief symptoms of an habitue, are: — "Emotional
excitement, physical unrest, mental impairment, moral
turpitude, hallucinations, mild epileptiform attacks,
dilatation of the pupils, a rapid and feeble pulse, severe
gastric disturbance, wasting and anemia. Treatment:
The drug should be withdrawn rapidly but not sud-
denly. Treatment in a sanatorium is always advisable,
Stimulants like strychnine are often useful. Hygienic
and dietetic measures calculated to improve general nu-
trition are indicated." (Stevens' Materia Medica.)
4. Diuretics are used: To dilute the urine, to increase
the flow of the urine, to remove liquids from the body
(as in dropsy), to remove toxic substances from the
body, and to stimulate atonic kidneys.
Diuretics are classified, as (1) Those that act as such
by increasing the arterial pressure, digitalis, squills, and
strophanthus are examples; (2) those that act by dilat-
ing the renal vessels, such as caffeine; (3) those that
act as stimulants to the renal epithelium, such as caf-
feine, theobromine, scoparius, calomel; and (4) various
salines which act by increasing the water in the blood,
such as several of the salts of lithium and of potassium.
5. Sodium Salicylate. Dose, 15 grains. Physiologi-
cal action: — Antiseptic; irritant; strongly cholagogue;
antipyretic; diaphoretic; diuretic (markedly increasing
the excretion of uric acid). In exceptional instances
skin eruptions are caused, and in some individuals a
train of symptoms analogous to those of cinchonism,
and designated as salicylism, results from the use of
salicylic preparations.
Uses:- — Externally, as antiseptic and stimulating ap-
plications and for the checking of abnormal perspira-
tion; also in parasitic and other skin diseases. Inter-
nally, rheumatic fever (in which it seems to act as a
567
MEDICAL RECORD.
specific); gout; migraine; sciatica; diabetes; chole-
lithiasis. (Wilcox's Materia Medica.)
6. Potassium salts: Carbonate, gr. xv; bicarbonate,
gr. xxx ; acetate, gr. xxx; citrate, gr. xv; sulphate, gr.
xxx ; bitartrate, gr. xxx; nitrate, gr. vij; chlorate, gr.
iv ; permanganate, gr. j ; iodide, gr. vij ; bromide, gr. xv ;
cyanide, gr. 1/5.
The carbonate and bicarbonate are used for itching
and for skin diseases; the latter is also used for dys-
pepsia, rheumatism, gout, jaundice, and gall stones.
The acetate and citrate are used for gout, rheumatism,
in dropsy, renal diseases, cardiac diseases, and in gen-
eral as diuretics. The sulphate and bitartrate are used
as cathartics, the latter also as a diuretic. The nitrate
is used (by inhalations of its fumes) in asthma. The
chlorate is used for inflammatory conditions of mouth
and throat. The permanganate is used for wounds,
sores, ulcers, erysipelas, and as a douche in gonorrhea,
gleet, etc.; also as an antidote to morphine poisoning.
The bromide is used in epilepsy, insomnia, neuralgia,
migraine, delirium tremens, convulsions, nymphomania.
The iodide is used in syphilis, asthma, chronic rheu-
matism. The cyanide is used to relieve vomiting, gas-
trointestinal pain, and cough.
7. Three external antiseptics :— For rooms and furni-
ture, sulphur dioxide, generated by burning three
pounds of sulphur for each 1000 cubic feet of space; for
hands of surgeon, mercuric chloride, in solution of
1:1000; for glassware, dry heat at about 150° C, con-
tinued for an hour.
8. Nux Vomica. Preparations and Doses Extract-
um nucis vomicae, gr. % ; fluidextractum nucis vomicae,
Ti#j; tinctura nucis vomicae, n#x; strychnine, gr. 1/64;
strychinae sulphas, gr. 1/64; strychinae nitras, gr. 1/64.
Therapeutic indications: As a general tonic or bitter;
in indigestion, cardiac depression, impaired peristalsis,
pneumonia, phthisis, amenorrhea, dysmenorrhea, im-
potence, some forms of paralysis, chorea, epilepsy, neu-
ralgia, alcoholism, and urinary incontinence.
9. Corrosive sublimate is used internally in the treat-
ment of diphtheria, syphilis, and as a tonic. Dose, gr.
1/100 to 1/20.
10. Opium. Therapeutic uses: As an anodyne, a
hemostatic, in inflammations, as an expectorant, in
diarrhea, in alcoholism, manias and diabetes, as an
antispasmodic, in insomnia, and as a diaphoretic.
Dose: Of powdered opium, gr. j; morphine, gr. 1/5;
morphine sulphate, acetate, and hydrochloride, each gr.
% ; codeine, gr. % ; codeine sulphate and phosphate,
each, gr. %.
568
OHIO.
DIAGNOSIS.
1. The early manifestations of pulmonary tubercu-
losis are: (1) Physical signs: Deficient chest expansion,
the phthisical chest, slight dullness or impaired reson-
ance over one apex, fine moist rales at end of inspira-
tion, expiration prolonged or high pitched, breathing
interrupted. (2) Symptoms: General weakness, lassi-
tude, dyspnea on exertion, pallor, anorexia, loss of
weight, slight fever, and night sweats, hemoptysis.
2. "Acute myocarditis may be incident to rheumatism,
pneumonia, septicemia, tuberculosis, typhoid fever, etc.,
and accompanies acute pericarditis and acute endo-
carditis. Subjective symptoms are generally absent,
but the condition may be suspected when the heart be-
gins to dilate rapidly, when the pulse becomes ex-
tremely rapid, thready, and irregular, or when the tem-
perature suddenly rises. A systolic murmur may be
heard at the apex."
"Chronic myocarditis results from sclerosis of the
coronary arteries, but may follow acute myocarditis.
The symptoms appear insidiously, and include dyspnea,
palpitation, weak, rapid, and irregular pulse, anginoid
pains, maniacal attacks, vomiting, etc. The area of
dullness is increased. The pulmonary second sound
may be accentuated if the right heart is hypertrophied,
and a murmur may be heard at the apex." (Pocket
Cyclopedia of Medicine and Surgery.)
3. In cardiac hypertrophy "the symptoms depend
upon the amount of hypertrophy. If only sufficient to
compensate for valvular defects or other circulatory
disturbances there will be no symptoms. When the
enlargement is disproportionate to the obstruction, it
is manifested by increased and forcible cardiac action,
precordial discomfort, headache, dizziness, ringing in
the ears, flushes or flashes of light, dyspnea on exertion,
congestion of the face and eyes, dry cough, epistaxis,
and restless nights, with more or less jerking of the
limbs. The arteries become full and the pulse is firm
and bounding. The carotids and superficial arteries
pulsate markedly, the patient frequently complaining
of throbbing sensations. A sphygmographic tracing
shows the line of ascent vertical and abrupt, but the
apex is rounded, and the line of descent is oblique, un-
less there is more or less insufficiency of the valves."
In cardiac dilatation "the manifestations are refer-
able to the enfeebled circulation and include feeble
pulse, headache aggravated by the upright position, at-
tacks of syncope, cough, dyspnea, jaundice, dyspepsia,
constipation, scanty, often albuminous urine, mental
569
MEDICAL RECORD.
dullness, vertigo, often relieved by a copious epistaxis,
and finally dropsy beginning in the lower extremities.
The condition terminates in death by exhaustion."
(Hughes' Practice of Medicine.)
4. The functional activity of each kidney may be "de-
termined by the intramuscular injection of 1 cc. of a 5
per cent, acqueous solution of methylene blue; the col-
lection of the urine (from each kidney) after the lapse
of one-half hour, one hour, and hourly thereafter; and
noting the time of the appearance of a bluish tint to
the urine, the time of maximum coloration, and the
time of disappearance of the coloring. Normally a
slight tint may be observed in the first specimen, cer-
tainly at the end of one hour. The maximum coloration
occurs at the end of three or four hours, and the urine
is free of coloring at the end of thirty-six to forty-
eight or sixty hours. Delay of beginning excretion
beyond one hour, and of maximum coloration beyond
the fourth hour, and continuation of excretion, as may
occur for five or six days, is indicative of deficient func-
tional activity." (Kelly's Practice of Medicine.)
5. Gastric ulcer is generally caused by injury or bac-
teria, is most apt to occur between the ages of twenty
and forty-five. After eating there is pain localized in
the stomach, vomiting occurs soon after eating, hema-
temsis is common, there is localized tenderness over the
stomach, and examination of the gastric contents shows
an excess of free HC1.
In duodenal ulcer the pain is apt to be more to the
right, and to occur at an interval of two or three hours
after meals; the hemorrhages will be intestinal, and
the blood will be passed by way of the bowels, and not
vomited. In many cases the symptoms are identical
with those of gastric ulcer.
Cholecystitis: The pain is further to the right, and
with tenderness and muscular rigidity, is referred to
the region of the gall bladder; there are rise of tem-
perature, increased pulse rate, leucocytosis, and vom-
iting.
6. Hyperthyroidism is exophthalmic goiter; the cardi-
nal symptoms are tachycardia, exophthalmos, goiter,
and tremor.
7. In enlarged gall bladder pain is located in the
region of the liver and may radiate to the right shoul-
der; there may be jaundice.
In ptosis of the right kidney the kidney may be pal-
pated and often replaced; the pain radiates down the
ureter ; chill, nausea and vomiting may be noticed ; blood
may be found in the urine ; when the kidney is replaced
all the symptoms cease.
570
OHIO.
8. Physical signs of effusion in acute pleuritis: There
is fullness or bulging of the affected side, with oblitera-
tion of the intercostal spaces and displacement of the
cardiac impulse; over the effusion there is little or no
vocal fremitus, while above the effusion it is exag-
gerated; over the effusion the percussion note is dull,
above the effusion it is tympanitic; the fluid changes
its level with different positions of the body; on ausculta-
tion there will be heard a feeble vesicular murmur;
vocal resonance is diminished or absent over the fluid
and increased above the effusion.
9. The most important sign of leucemia is a persistent
increase in the total number of leucocytes.
10. Early signs of acute poliomyelitis: Fever;
malaise; chilliness; tonsilitis, coryza, diarrhea; convul-
sions; profuse sweating; rigidity of head, neck and
limbs; pain in neck and back. There may be no early
signs.
PATHOLOGY.
1. In myelogenous leucemia the white cells are
enormously increased, the red cells are decreased; the
chief feature of the blood is the large number of
myelocytes which it contains; the eosinophiles are also
increased; so, too, are the basophiles or mast cells;
the polymorphonuclears are absolutely increased, but
relatively diminished as the myelocytes increase; the
lymphocytes are not very numerous. The myelocytes
are derived from the bone marrow.
2. A hemorrhage infarct is an infarct where the ob-
structed area is full of blood. Sooner or later the
infarct becomes decolorized, owing to diffusion of the
dissolved hemoglobin; the involved tissues degenerate
and become absorbed; and scar tissue, more or less
pigmented, may remain at the site of the lesion. In-
farction is always accompanied by necrosis and fatty
degeneration. Hemorrhagic infarct occurs but rarely
in the kidney.
3. Tubercle formation. — "Miliary tubercles are tiny
grayish nodules, and each consists of a collection of
cells. The bacillus is brought to the tissues by a blood
vessel. The bacilli set up changes in the tunica intima
and the connective tissue around the vessel, which re-
sult in the formation of a collection of cells which are
bigger than leucocytes. They are derived from connect-
ive-tissue cells and endothelial cells. One or more of
these in each tubercle increase in size or coalesce to form
a giant cell. The giant cell forms the center of the
tubercle ; it has many nuclei arranged around its periph-
571
MEDICAL RECORD.
ery, and contains bacilli. Around it are arranged lay-
ers of epithelioid cells. Beyond these are collected
many leucocytes, which merge through granulation
tissue into the normal structures. The structure is not
so typical in ail cases, as giant cells may be absent.
No blood vessels are present in tubercles, and the sur-
rounding vessels are narrowed or obliterated by en-
darteritis."
Results.— "(1) Caseation is a result of progressive
action of the bacilli. Two factors contribute to this:
(1) The destructive action of the bacillus; (2) the de-
fective blood supply from endarteritis. The center of
each tubercle softens and becomes yellow or caseous.
Neighboring . tubercles after caseating coalesce, and a
tuberculous abscess is formed and in its walls further
miliary tubercles are found. (2) Retrogressive changes.
— The resistance of the tissues is considerable, and if
circumstances are favorable the bacilli are destroyed or
their growth inhibited and retrogressive changes occur.
The tubercle may be converted into fibrous tissue, and
only a cicatrix remains; or the caseous matter may be-
come encapsuled, and perhaps resume activity at some
later date, if the capsule is ruptured by some injury.
Sometimes calcification occurs. (3) Diffusion is a
marked feature. This may be (1) local, by direct ex-
tension; (2) to distant viscera, by minute emboli; (3)
acute general tuberculosis may occur in any case. Tu-
bercles are scattered throughout the body, and the dis-
ease is fatal in a few weeks." — (Aids to Surgery.)
4. Method of preparing vaccine. — "(1) The causal
organism (in this case the Staphylococcus pyogenes) is
obtained from the seat of the lesion and isolated in
pure culture at 37° C. on a suitable medium such as
agar. (2) The culture growth is emulsified in about
5 c.c. of a 0.9 to 1.0 sodium chloride solution. (3) The
bacterial emulsion is transferred to a water bath or
incubator, and kept at 60° C. for from thirty to sixty
minutes. (4) The number of bacteria in the emulsion
is estimated. (5) The vaccine is diluted with normal
saline solution until each cubic centimeter contains an
appropriate number of organisms for the dose, e.g. 10
millions, 100 millions, 1,000 millions, etc. (6) The
sterility of the emulsion is proved and a small amount
of antiseptic, e.g. phenol 0.5 per cent, or tricresol 0.25
per cent., is added, and the vaccine is filled into sterile
bulbs for use. In practice the bulb is opened, the con-
tents are filled into a sterile syringe, preferably all
glass, and the vaccine is injected subcutaneously under
strict aseptic precautions." — (Bruce's Materia Medica
and Therapeutics.)
572
OHIO.
5. The physician should wear a gown while with the
patient, snould inspect the patient's eyes, nose, and
throat through a pane of glass so that the patient may
not cough in his face, and should carefully wash his
hands in an antiseptic solution before leaving. The
patient should be isolated, and the nose, throat, and
mouth should be washed with an antiseptic solution;
diphtheria antitoxin should be administered as early as
possible. The family should be kept away from the
patient, and all infected articles should be soaked in a
solution of corrosive sublimate or carbolic acid. The
community is protected by the above procedure; but, in
addition, the disease should be reported to the proper
health authorities, other children from the family should
not be allowed to go to school or church or other public
places, strict quarantine must be observed, and there
must be a thorough disinfection at the close of the case.
PRACTICE.
1. Symptoms of uremia. — Headache, insomnia, con-
vulsions, vomiting, delirium, dyspnea, amaurosis, and
coma. Uremia may be suspected from the presence of
nephritis, a urinous odor of the breath, scanty urine,
and increased arterial tension.
The patient should be put to bed; croton oil (1 minim)
may be administered; vensection and dry cupping over
the kidneys may be tried ; diaphoretics are useful.
2. Endocarditis is apt to occur during or following
rheumatism and scarlet fever. The signs and symptoms
may be negative; but there is generally some alteration
in the character of the heart sounds, and dilatation of
the heart may be present; the pulse rate is often in-
creased. The sounds heard depend upon the valve af-
fected, and since the mitral valve is the one most com-
monly involved there is apt to be a systolic murmur
heard best at the apex and transmitted to the left axilla.
3. Symptoms of cancer of liver. — Pain, tenderness,
and a sense of weight in the hepatic region ; emaciation
and weakness; cachexia; jaundice, vomiting, and fever.
4. The case is one of cardiac decompensation, follow-
ing endocarditis (which may have been due to rheuma-
tism, scarlet fever, or some other infection). The
prognosis of endocarditis is good so long as compensa-
tion is maintained; but is unfavorable when compensa-
tion is ruptured.
5. In a case of alleged hematemesis other possible
sources of the blood are: The blood may have been
swallowed (as in epistaxis, after tonsillectomy, pul-
monary hemorrhage). The main question is to dif-
ferentiate between hemoJemesis and hemoptysis:
573
MEDICAL RECORD.
Hematemesis.
1. Previous history of gas-
tric, hepatic, or splenic
disease.
2. Blood is vomited.
3. Blood is dark colored
and not frothy.
4. Blood may be mixed
with food.
5. Giddiness or faintness
usually precedes vomit-
ing.
6. Nausea and weight in
epigastrium.
7. Often followed by mel-
ena (black, tarry
stools).
Hemoptysis.
1. Previous history of pul-
monary troubles.
2. Blood is coughed up.
3. Blood is frothy and
bright red.
4. Blood may be mixed
with sputa,
5. Sensation of tickling in
the throat usually pre-
cedes.
6. Dyspnea and pains in
the chest.
7. Is not usually succeed-
ed by melena.
— (Hughes' Practice of Medicine.)
6. Treatment of pulmonary tuberculosis: — "By day
the consumptive should be, short of actual fatigue,
as much as possible in the open, and at night the win-
dows should be widely open top and bottom. Where
there is fever he must keep to bed; but when possible
the bed should be outside, and where that is not pos-
sible the windows must remain open in presence of
fever or any other acute symptom. In ordinary cir-
cumstances he should sleep alone. A stuffy bedroom
with several people in it means rapid deterioration for
the patient, and infection for the rest. Sanatorium
treatment is not yet possible for all, nor, except in in-
cipient cases, and in the rich, can it be continued long
enough for cure ; but it reduces the disease to a quiescent
stage, and trains the patient in the habits he must
afterwards continue. Sea voyages undoubtedly do good
in many cases of early phthisis, the comparative steril-
ity of the air contributing to the result; but no con-
sumptive who is not a good sailor should be sent on
such a voyage, nor any one who is unable to travel in
comparative comfort, or who must travel alone. In the
later stages sea voyages are contraindicated. If
change of climate is decided upon, the place selected
should be sunny, and should give facilities for the open-
air life. Either a dry cold climate may be chosen or a
warm one, according to circumstances. In the earlier
stages cold dry air is best. High altitudes are, how-
ever, unsuitable for those with a tendency to hemopty-
sis, Adjuvants to the open-air treatment are exercise
574
OHIO.
and dietetic treatment. The consumptive should wear
wool or flannel next the skin, but should not be over-
loaded with heavy clothes. Tepid baths, followed by
brisk rubbing, are of benefit, and much good is done
by carefully graduated exercise, which promotes a regu-
lated auto-inoculation. The food must be nourishing
and varied, and ample in quantity, systematic over-
feeding, indeed, being advocated by many. Everything
must be done to combat the very common anorexia and
dyspepsia.
Medicinal Treatment is (a) General. — Creosote or
guaiacol, cod-liver oil, and tonics, such as the hypophos-
phites and arsenic, are the principal remedies, (b)
Symptomatic. — The following symptoms call for special
treatment: — (1) The cough. — As this is a persistent
and constant feature of the disease, avoid rushing at
once to cough mixtures. A common exciting cause of
the nightly cough is the changing from a warm room
to a cold bedroom; or again, tickling of the fauces by
the uvula. A useful combination is that of morphine,
spirits of chloroform, and dilute hydrocyanic acid. For
laryngeal and bronchial irritation, inhalations of tinc-
ture of benzoin or creosote are of much value. (2)
The night-sweats. — Picrotoxin, aromatic sulphuric acid,
atropine, and oxide of zinc are the favorite remedies.
Atropine gr. 1/100 to 1/80 in pill at night, is the most
reliable. (3) The diarrhea is usually best controlled
by mineral astringents, in combination with opium.
(4) Fever should be treated by rest, fresh air, quinine,
and cold sponging, or, if need be, the cold bath. Anti-
pyrin, etc., may be occasionally used. Hemoptysis de-
mands rest in bed, quiet, light food given cold, ice to
suck, injections of morphine and atropine or inhalation
of nitrite of amyl." (Wheeler and Jack's Handbook
of Medicine.)
7. Lobar pneumonia. "The first stage is character-
ized by sudden onset with chill, a sharp pain in the
side, rise of temperature, a short and sharp cough,
rusty-colored, viscid sputum, and dyspnea. There may
be headache, insomnia, scanty urine with diminution
of urea, chlorides, phosphates, and sulphates, insomnia,
and herpetic vesicles on the face, and there is always an
increase in the number of leucocytes in the blood.
Physical examination will reveal diminished expansion,
impairment of the normal percussion note, feeble or
suppressed respiratory murmur, moist or dry rales,
crepitation, and sometimes a pleural friction sound.
In the second stage the dyspnea is more marked; the
face is more or less livid in color; the temperature is
575
MEDICAL RECORD.
high (104°-105° F.) ; and the pulse increases in rate
(110-120), its tension and fullness lessening with the
progress of the disease, and groAving feeble and inter-
mittent. Headache, delirium, and various other nerv-
ous symptoms may be present. Expansion is dimin-
ished and vocal fremitus is exaggerated upon the af-
fected side. There is dullness with increased resistance
over the consolidated lung, and auscultation detects
bronchophony or bronchial breathing over this same
area.
The third stage is ushered in by a sudden drop of tem-
perature on or about the fifth or ninth day, followed
by a natural sleep, free sweating, and relief from suf-
fering. In this stage the subcrepitant rale (rale re-
dux) is heard in the midst of the bronchial breathing,
together with numerous moist rales. Dullness may per-
sist for some time, but usually by the twelfth or four-
teenth day the lung has returned to its normal state."
Treatment: "Consists in rest in bed, milk diet, and
the administration of fractional doses of calomel fol-
lowed by a saline in the early stage. The nervous
symptoms and temperature may be controlled by apply-
ing ice-bags or compresses wrung out of cold water
(60°-70° F.) to the chest or by the use of the warm
or cold wet-pack. The heart and pulse should be sus-
tained by the administration of alcohol, strychnine (gr.
1/60-1/20), atropine, caffeine, strophanthus, and nitro-
glycerin. Digitalis may also be employed. Inhala-
tions of oxygen afford temporary relief when the
dyspnea and cyanosis are extreme. In young, vigorous,
and plethoric adults, with hyperpyrexia and a high-ten-
sion pulse, bleeding may be beneficial in the first 48
hours. Convalescence should be guarded, and tonics,
stimulants, etc., will be found very useful in this period
of the disease." {Pocket Cyclopedia.)
8. Acute myelitis is generally of rapid onset, the feet
and legs become heavy and numb, twitching and con-
vulsions may occur, the flexors are more affected than
the extensors, walking is difficult, paraplegia develops,
there is usually some fever, there may be girdle sensa-
tion at the level of the lesions, anesthesia of bladder
and rectum are common, the reflexes will be absent if
the lesion extends completely across the cord, priapism
is common.
In multiple neuritis the onset is slower, the sphincters
are rarely involved, the sensory disturbances are more
severe, the extensors are more involved than the flex-
ors, atrophy of the affected muscles rapidly supervenes,
the mental condition is frequently affected.
576
OHIO.
9. Indications of cerebral syphilis: Headache, usually
worse at night; insomnia; vertigo; hemiplegia, and
aphasia; tendency to improvement and relapse; there
may be paralysis or unconsciousness, optic neuritis. The
diagnosis is made by a Wassermann reaction, which
must be positive.
Treatment consists of inunctions of mercury (either
the ointment or the oleate) or intramuscular injection
of a mercurial salt; potassium iodide, either alone
or in combination with mercury; sulphur baths are
said to aid the elimination of the mercury from the
system. Small doses of salvarsan have been recom-
mended by some.
10. "The treatment of acute articular rheumatism
consists in rest of the parts, and the patient should lie
between blankets. The joints should be enveloped in
soft wool or flannel. Restricted diet is essential. Frac-
tional doses of calomel (gr. ^4 every hour for 6 hours)
should be administered, followed by a saline purgative.
Salicylic acid or its derivatives may be given in full
doses, and diuretics are especially indicated. Hyper-
pyrexia may be controlled by phenacetine (gr. 5.). Dur-
ing the convalescence, tonics are of decided advantage.
Locally, lead-water and laudanum or belladonna lini-
ment may be used. The diet should be carefully regu-
lated." {Pocket Cyclopedia.)
DERMATOLOGY, SYPHILOLOGY, AND DISEASES OF EYE, EAR,
NOSE, AND THROAT.
1. Psoriasis "is a common chronic inflammatory dis-
ease of the skin, characterized by variously sized lesions,
having red bases, covered with white scales resembling
mother-of-pearl. It affects by preference the extensor
surface of the body. The lesions are infiltrated, ele-
vated, clearly defined, covered with white, shining,
easily detachable scales which, upon removal, reveal a
red, punctate, bleeding surface. The eruption is ab-
solutely dry, and itching is usually absent."
"The treatment consists of the internal administra-
tion of arsenic, cod-liver oil, oil of copaiba, or potas-
sium iodide, and the use of local applications. The
scales should be removed by soap and water, alkaline
baths, or oily substances. Ointments containing sali-
cylic acid (3 per cent, to 10 per cent.), tar (3 1 to 5 1
of ointment), ichthyol (3 1 to 5 1), chrysarobin (gr.
20 or 30 to 3 1), ammoniated mercury (gr. 15 or 20 to
3 1), etc., are very beneficial, and should be used after
the scales have been removed." {Pocket Cyclopedia.)
2. Pruritus ani is a frequent sign of hemorrhoids,
577
MEDICAL RECORD.
diabetes mellitus, thread-worms, and fissure of the anus,
o. A patient may be considered cured of gonorrhea
in the continued absence of discharge, gonococci, and
shreds.
4. Signs and symptoms of congenital syphilis, — Im-
peded breathing, snuiiles, necrosis of nasal bones, ery-
thematous rash on buttocks, general atrophy with a
wizened "old man" appearance, ' fissures of lips and
angles of mouth, mucous patches in the mouth, condy-
lomata, hemorrhages under the skin, onychia, enlarge-
ment of spleen, prominent forehead, Hutchinson teeth,
interstitial keratitis, periostitis, and gummata of the
internal organs.
5. Treatment of syphilis.- — Intravenous or intramus-
cular injection of Salvarsan in dose of 0.5 gram, to be
repeated twice at intervals of a fortnight. Intramuscu-
lar injection of calomel or administration of mercury
with chalk by mouth. Iodide of sodium or potassium
must also be administered during the second year. This
may be combined with the mercury by the administration
of the protiodide of mercury. Sometimes mercury may
be given by inunction. The patient must have his teeth
attended to, use a mild antiseptic mouth-wash, and
should give up alcohol and tobacco. Calomel or iodo-
form may be used as a dusting powder for the chancre.
6. The dangers of acute suppurative inflammation of
the middle ear are: Chronic purulent otitis media, per-
foration of ear drum, boils of external auditory meatus,
ankylosis or necrosis of ossicles, mastoiditis, facial pa-
ralysis, meningitis, thrombosis of lateral sinus, abscess
of brain or cerebellum.
7. Trachoma is an inflammatory condition of the con-
junctiva, accompanied by hypertrophy, granule forma-
tion, and subsequent cicatricial changes.
Etiology. — It is caused by contagion from another eye,
being transferred by means of the secretion.
Treatment "consists in an attempt to reduce the in-
flammatory symptoms and secretion, and to check and
remove hypertrophy of the conjunctiva, thus shortening
the duration and diminishing the liability to conjunc-
tival cicatrization and to sequelae. This is accomplshed
either by the use of certain irritating applications or
by mechanical (surgical) means.
Irritating applications. — Sulphate of copper in the
form of a crystal or pencil is the favorite local applica-
tion. Nitrate of silver (1 or 2 per cent, solution),
glycerole of tannin (5 to 25 per cent.), and the alum
stick are also employed.
Mechanical (surgical) treatment includes expression,
578
OHIO.
grattage, excision, curetting, electrolysis, x-rays, and
galvanocautery." (May's Diseases of the Eye.)
8. Tuberculous laryngitis is generally secondary to
pulmonary tuberculosis. The mucosa of the larynx is
swollen, and small tubercles may be found on the vocal
cords. The tuberculous masses caseate and ulcerate;
the pharynx, epiglottis, and trachea may become in-
volved by extension. The signs and symptoms are those
of the primary tuberculosis, with the addition of hoarse-
ness, dyspnea, and dysphagia.
9. Acute suppurative inflammation of the frontal
sinus is treated by opening the sinus by an incision
along the inner part of the eyebrow, and then by tre-
phining and curetting the wall of the cavity; the
infundibulum is enlarged, and a drainage tube inserted
for a few days; the cavity is then washed out daily,
through the nose, till all discharge has ceased.
10. Nasal polypi, if mucous, are to be removed by a
wire snare; if they recur, the bone should be curetted;
if there is much bleeding, the nasal cavity is to be
packed with gauze for twenty-four hours. In case of
fibrous polypi these must be scraped away; but treat-
ment is only possible in the early stage.
OBSTETRICS.
1. Conditions that justify the induction of premature
labor: (1) Certain pelvic deformities; (2) placenta
praevia; (3) pernicious anemia; (4) toxemia of preg-
nancy; (5) habitual death of a fetus toward the end of
pregnancy; (6) hydatidif orm mole ; (7) habitually large
fetal head.
2. Positive sig?is of pregnancy: (1) Hearing the
fetal heart sound; (2) active movement of the fetus;
(3) ballottement ; (4) outlining the fetus in whole or
part by palpation; and (5) the umbilical or funic souffle.
Doubtful signs of pregnancy : (1) Progressive enlarge-
ment of the uterus; (2) Hegar's sign; (3) Braxton
Hick's sign; (4) uterine murmur; (5) cessation of
menstruation; (6) changes in the breasts; (7) discolo-
ration of the vagina and cervix; (8) pigmentation and
striae; (9) morning sickness. Subjective signs of preg-
nancy, in the order of their appearance, are: Cessa-
tion of menstruation, morning sickness, increased fre-
quency of urination, active fetal movemets. Objective
signs of pregnancy, in the order of their appearance,
are: Softening of the cervix, changes in the mammary
glands, discoloration of the vulva and vagina, pulsation
in the vaginal vault, Hegar's sign, active fetal move-
ments, ballottement, palpation of the fetus, intermittent
579
MEDICAL RECORD.
uterine contractions, hearing the fetal heartbeat, rate of
growth of the uterine tumor.
3. Symptoms of death of the fetus during the later
months of pregnancy are: Cessation of the signs of
pregnancy, the abdomen and uterus are both diminished
in size, the fetal heart sounds and movements cease,
there is no pulsation in the cord, the mother's breasts
become flaccid and occasionally secrete milk. If the
fetus has been dead for some time crepitus of its cranial
bones may be elicited.
4. Curettage is indicated: (1) For removal of pla-
cental debris (2) in hemorrhagic endometritis, (3) in
some forms of dysmenorrhea (membranous), (4) for
diagnostic purposes, (5) in some cases of puerperal
sepsis, (6) -sometimes to check hemorrhage, due to fib-
roids. Contraindications: (1) The least suspicion of
even the possibility of pregnancy; (2) menstruation;
(3) acute endometritis; (4) malignant disease of the
uterus or vagina; (4) acute pelvic inflammation.
Technique, — All antiseptic and aseptic precautions
are necessary, the patient should be in the dorsal posi-
tion, the vagina is to be disinfected, and the cervical
canal dilated; a speculum is introduced -into the vagina
and the cervix is drawn down with volsella; the uterine
cavity is irrigated with creolin or lysol; a curette is
inserted to the fundus and moved down to the internal
os; the operator should begin at one cornu and go in
the same direction all around till he reaches the starting
point, and if necessary repeat till no more spongy or
hyperplastic tissue appears; the fundus should be
scraped separately by moving the curette along it from
side to side; in going toward the fundus no scraping
should be done, and care must be taken not to perforate
the uterus; should this happen no fluid must be in-
jected ; otherwise the uterus and vagina are again irri-
tated, and one or more strips of iodoform gauze are in-
serted into the cavity to act either as a hemostatic
plug or as a drain, which is diminished with two days'
interval and withdrawn on the sixth day. A hemostatic
tampon should be placed in the vagina and withdrawn
the following day. If any fever arises, the tampon
is at once removed and the vagina douched with anti-
septic fluid every three hours. If not, the vagina is
only swabbed with the same every day, and packed
loosely with iodoform gauze. After the final removal
of the gauze the antiseptic douche is given twice a day
until there is no more discharge. The patient should
remain in bed for a week.
5. Labor is divided into three stages : The first stage
580
OHIO.
begins with the commencement of labor, and ends with
the complete dilatation of the os uteri. The second
stage begins with the complete dilatation of the os uteri,
and ends with the birth of the child. The third stage
immediately follows the second, and ends with the ex-
pulsion of the placenta and the beginning contraction of
the uterus.
In the third stage of labor the physician should seize
the fundus of the uterus through the abdominal wall
and knead and rub it until it contracts vigorously; then
he should press it down in the direction of the axis of
the pelvic inlet. This should last for about a quarter
of an hour after the child is born. The placenta, after
it is expressed, should be carefully taken by the physi-
cian so as to be sure that it is all expelled; at the same
time care must be taken that no particle of membrane
remains behind. Fluidextract of ergot may be admin-
istered. The dangers are: hemorrhage; retained pla-
centa or clots or pieces of the membranes and sepsis.
SURGERY.
1. Shock is the name given to a sudden and general
depression of the vital powers; due to some strong
stimulation (such as injury or emotion), acting on the
vital centers in the medulla and producing vasomotor
paralysis. Shock is primary when the symptoms ap-
pear promptly; it is secondary when the symptoms
don't appear for several hours (often observed after
railway accidents, intoxication, etc.)
Symptoms of shock, — The blood pressure is lowered
considerably; the pulse is very compressible, rapid,
short, and often difficult to count; the respirations are
quick, sighing, and irregular; the skin is cold, clammy,
and pale; perspiration may be profuse, but other secre-
tions are diminished; body temperature is subnormal;
muscles are relaxed; and reflexes are diminished.
Treatment. — Place the patient in the recumbent posi-
tion, with the head low, apply warmth to the body,
administer a stimulant, and give a hot saline infusion;
morphine, hypodermically, may be necessary for the
relief of pain. Adrenalin solution is administered into
the arterial system.
In surgical operations shock may be largely prevented
by reassuring nervous patients, keeping the patient
warm, the avoidance of the excessive catharsis, and
semi-starvation that often prevails before operation, the
administration of strychnine and atropine before opera-
tion, the avoidance of delay and undue handling of
parts during the operation, prompt checking of hem-
orrhage, and by using the utmost gentleness.
581
MEDICAL RECORD.
2. Acute suppurative appendicitis begins suddenly
with pain about the umbilicus or right iliac fossa, vom-
iting, constipation, and slight fever. There is some ten-
derness at or about McBurney's point, a spot at the
junction of the outer and middle thirds of a line join-
ing the umbilicus and anterior superior iliac spine, and
rigidity of the right rectus muscle.
A well-marked swelling is usually present, and the
pulse steadily increases in frequency. There is also a
steadily-increasing leucocytosis. A persistently high
temperature, or a subnormal temperature with an in-
creasing pulse-rate, are strong indications as to the
presence of pus. Three terminations may occur : 1. The
attack may subside, leaving the pus shut up. 2. The
abscess may point and discharge itself into the bowel
or on the surface, or it may track upward along or
behind the colon, and form a subphrenic abscess. 3. The
localized abscess may burst and cause general periton-
itis. The rectum should always be examined, as a col-
lection of pus may be felt in Douglas's pouch. — (From
Aids to Surgery.)
Diagnosis. — This is made by the sudden and severe
abdominal pain, unilateral rigidity of lower part of
abdominal wall, tenderness over McBurney's point, with
nausea, vomiting, fever, and leucocytosis.
In distended gall-bladder. — The pain is more severe
and sudden, and is in the region of the liver; it radi-
ates to the right scapula and toward the umbilicus;
chills and sweats are common; also vomiting, and some-
times symptoms of collapse and jaundice; all the symp-
toms come on more suddenly. In gallstone colic. — The
pain is excruciating and is in the region of the liver;
it radiates to the right scapula and toward the um-
bilicus chills and sweats are common also vomiting, and
sometimes symptoms of collapse and jaundice; calculi
may be found in the feces. In ulcer of the pylorus, the
pain is in the epigastric region, may radiate to the left
shoulder, and is increased by taking food (usually about
one to three hours after a meal) ; vomiting may occur
from one to four hours after eating; hemorrhage may
be present; the acidity of the gastric contents is above
normal, owing to excess of free hydrochloric acid. In
renal colic. — The pain is in the region of the affected
kidney; it radiates down the thigh; there are intense
rigors, retraction of the testicle may be present, also his-
tory of previous attacks or of calculi; the urine may be
scanty, suppressed, or bloody. In acute peritonitis. —
Both thighs are flexed, pain and tenderness are more
general and are increased by movement, vomiting is
582
OHIO.
frequent, the abdomen in general is distended and is
tense and tympanitic.
Salpingitis is diagnosed by: A dragging sensation in
the neighborhood of the affected tube; colicky pain,
which is increased on exertion or even on standing; ab-
dominal tenderness; menstrual disorders, as amenor-
rhea, metrorrhagia, dysmenorrhea, menorrhagia; dys-
pareunia; there may be septic symptoms and perito-
nitis; sterility generally ensues. On examination there
will be found a fulness in Douglas's pouch and one or
both lateral fornices; in these latter will be felt either
the tubes, distorted and possibly adherent, or a sausage-
shaped tumor, which is very painful ; the uterus is retro-
verted or retroflexed, and may be bound down by ad-
hesions; there may be an intermittent expulsion of pus
accompanied and preceded by a burning pelvic pain.
In ovaritis the pain is not localized, but spreads to the
vagina and rectum; it is usually worse just before the
menstrual period, which sometimes affords relief; on
vaginal examination the ovary is found to be tender.
Treatment. — "Where pus is present or suspected, the
abdomen should be opened over the swelling, and in most
cases it will be found that there are adhesions to the
anterior abdominal wall, shutting off the abscess cavity
from the rest of the abdomen. A finger should be gently
inserted to feel for and remove a concretion or the ap-
pendix ; but no prolonged search should be made for the
appendix for fear of breaking down the adhesions. A
large rubber drainage tube should be inserted, and the
cavity will soon become clean and heal by granulation.
If, when the abdomen is opened, no adhesions to the an-
terior abdominal wall are found, the cavity should be
protected with gauze packing. The abscess will then be
found among a mass of matted omentum and intestine,
and can be opened by gently separating them. A drain-
age tube is inserted and the gauze packing is left in
for three days. By that time firm adhesions have
formed and the peritoneal cavity is safe from infec-
tion.
"When general peritonitis is present, the abdomen
must be opened and drained and the appendix removed ;
but these cases are almost always fatal.
"In any case in which the symptoms are excessive,
especially with a rapidly increasing pulse rate, an opera-
tion should be done, as this gives the only chance in
cases where there is suppuration without adhesions, es-
pecially in those cases due to perforation or gangrene.
"Operation for removal of the appendix. — An incision
is made at right angles to a line (at the junction of the
583
MEDICAL RECbRD.
outer and middle thirds) joining the umbilicus and
anterior superior iliac spine, one-third being above and
two-thirds below it. The cecum is found, and the an-
terior longitudinal band is traced down to the appendix,
which usually comes off from the inner side and runs
inward and downward. If not found there it should
be looked for in the retrocecal pouch or on the outer
side of the cecum. The meso-appendix should be liga-
tured and cut through, a collar of peritoneum turned
back, and the mucous and muscular coat ligatured near
the base and cut off. The peritoneum should be stitched
over the stump, and then the stump should be invagi-
nated into the wall of the cecum by running a purse-
string stitch around it." — (Aids to Surgery.)
After treatment. — This is mainly negative. "The pa-
tient should be fed by nourishing enemata, and water
should be supplied by continuous proctoclysis, which
may be repeated whenever thirst reappears. In case of
severe shock subcutaneous injection of from 500 to
1000 c.c. of normal salt solution should be administered.
In suppurative cases the Fowler position is indicated.
In cases of nausea or vomiting or gaseous distention of
the abdomen, the pharynx should be cocainized and gas-
tric lavage should be practised. This should be repeated
whenever these conditions recur. In case of pain, from
10 to 30 drops of deodorized tincture of opium dissolved
in 100 c.c. of normal salt solution should be given by
rectum as often as necessary to keep the patient com-
fortable. So long as no nourishment is given by mouth,
opium given in this manner is perfectly harmless. It
is well for the patient to chew gum in order to prevent
parotitis." — {Cyclopedia of Medicine and Surgery.)
3. Colles 9 fracture is a transverse fracture at lower
end of radius ; it is due to falls on the outstretched
palm. The line of fracture is about an inch above the
wrist, and runs obliquely downward from behind. The
lower fragment is driven backward and upward, and
rotated to the radial side, carrying the hand with it
into the position of abduction and leaving the tip of
the radius at the same level as, or higher than, the
tip of the styloid process of the ulna. The internal
lateral ligament of the wrist is ruptured or the styloid
process torn off. The fracture is usually impacted, the
upper fragment being driven into the lower. The de-
formity is characteristic, viz. : (1) The hand is ab-
ducted; (2) the styloid process is on the same level
as, or lower than, the tip of the radius; (3) the upper
end of the lower fragment projects above the back of
the wrist; on the front is a corresponding depression,
584
OHIO.
while above it the upper fragment projects forward.
Union occurs readily, but it is common to get deformity
and adhesions about the site of fracture. Treatment:
Disimpaction and reduction are brought about by
grasping the hand by the "shaking-hands" grip, ex-
tending and adducting the hand and lower fragment.
The arm is then fixed on a splint. It is very impor-
tant in this fracture to start massage and passive
movement not later than the end of the first week, to
prevent stiffness. Union is firm in three weeks. — (Aids
to Surgery.)
4. Hip Joint Disease. — Symptoms of first stage:
Night cries, lameness in the morning; a slight limp;
tendency to become tired on slight exertion; wasting;
spasm; pain; swelling and deformity (either real or
apparent) .
Symptoms of second stage: Abduction; limping;
pain, which is worse at night; apparent lengthening
of the limb; abscess; atrophy of thigh muscles; flexion
of thigh; effusion into hip joint; and there may be
crepitation in the joint.
Symptoms of third stage: Flexion, abduction, and
shortening of the limb; the joint may be dislocated or
ankylosed, or suppuration may occur.
"The cardinal symptoms of hip- joint disease are the
spasm, wasting, lameness, deformity (real and ap-
parent) , pain, and swelling. Careful attention to these
will make the diagnosis easy. The tendency of the dis-
ease is toward recovery, but the prognosis is greatly
influenced by the age, type of disease, complications,
and treatment. Death usually occurs from amyloid
changes in the viscera.
t( Constitutional treatment consists of improved hy-
giene, good food, fresh air, and the administration of
tonics, such as iron and the hypophosphites, and alter-
atives, such as cod-liver oil, iodine, and its salts. A
change of climate is sometimes beneficial. Locally,
iodine, blisters, hot-water bottles, or hot-water dressing
may be applied.
"The special treatments consist of the mechanical
treatment, treatment of the complications, and the sur-
gical treatment. The mechanical treatment consists of
recumbency for two or three weeks in uncomplicated
cases, with fixation and traction. Continuous traction
may be first obtained by Buck's or Sayre's extension
apparatus, made of adhesive plaster, later by means of
a traction splint, with crutches, and still later by the
traction splint alone, a high shoe being worn on the
sound side, which in a year or two may be discarded.
585
MEDICAL RECORD.
A modified traction splint may be made of plaster of
Paris. Differences of opinion exist as to when the ab-
scesses should be incised, but always the strictest asep-
sis or antisepsis is necessary. Irrigation of the cavi-
ties with sterile water, boric acid solution, or mercuric
chloride solution, 1:4000, and the injection of sterile
iodoform oil, 5 to 10 per cent., are commonly resorted
to. Osteotomy and fixation may be required for the de-
formity arising as a complication. The surgical treat-
ment consists of aspiration, incision, erasion, and ex-
cision." — (Pocket Cyclopedia of Medicine and Surgery.)
5. Gunshot wounds. Regarding probing, Da Costa
says: — "The surgeon must not feel it his duty to probe
in all cases. In many cases it is better not to probe
at all. Explore for the ball when sure that it has
carried with it foreign bodies; when its presence -at the
point of lodgment interferes with repair; when it is in
or near a vital region (as the brain) ; and when it is
necessary to know the position of the bullet in order to
determine the question of amputation or resection. If
the wound is large enough the finger is the best probe."
Regarding immediate operation, there is difference of
opinion, some authorities holding that unless the bullet
causes definite symptoms it should be let alone; others
advocate its removal to relieve the mind of the patient
and to obviate possible complications later on.
Gunshot wound of the knee should be treated con-
servatively, if possible; the wound should not be ex-
plored except to remove foreign bodies, loose frag-
ments, etc. Incision may be necessary for such re-
moval. The joint is irrigated with a weak antiseptic
solution, drained, dressed, and immobilized. Suppura-
tion calls for incision and drainage. If there is ex-
tensive laceration of tissue with much splintering of
bone and interference with blood and nerve supply the
condition may call for amputation.
STATE BOARD EXAMINATION QUESTIONS. '
Oklahoma State Board of Medical Examiners.
anatomy.
1. Discuss briefly the skin and its appendages.
2. Name and locate the various serous membranes.
3. Discuss the vocal cords.
4. Give boundaries of the pelvis.
5. Where would you make the spinal puncture in
treatment of cerebrospinal meningitis?
6. Discuss the hip joint; nerve, blood supply, etc.
586
OKLAHOiMA.
7. Discuss one of the vertebrae.
8. Discuss the action of the following muscles: Flexor
profundus digitorum; Brachialis anticus; Psoas mag-
nus.
9. What vessels, nerves, and other structures are
located in Scarpa's triangle?
10. Give histology of prostate gland.
PHYSIOLOGY.
1. What are the functions of the spinal cord?
2. What is the origin of urea and of uric acid?
3. Describe the vasomotor nervous system and ex-
plain its functions. Where is the vasomotor center
located ?
4. Give the functions of the suprarenal glands.
5. What kind of membrane lines the mastoid cells
and why?
6. Explain the portal circulation.
7. What are the functions of bile? Give its con-
stituents.
8. Describe the pleurae, giving kind of tissue and
functions.
9. Give functions of cerebellum. What is the result
of extirpation.
10. Give the functions of the medulla oblongata.
Name the "centers''' located in the bulb.
MATERIA MEDICA.
1. What is the antidote for strychnine?
2. Mention the principal uses of adrenalin.
3. Give the treatment of a case of opium poisoning.
4. Give the common name, therapeutic uses, and dose
of sodium sulphate.
5. Describe the therapeutic uses of jalap and state
how it differs in effect from aloes.
6. W T hat effect has pilocarpus on (a) the heart; (b)
the skin; (c) the salivary glands?
7. How do potassium acetate and potassium bitar-
trate compare as diuretics and purgatives?
8. What action on the heart has valerian in full
doses? State the therapeutic uses of valerian.
9. What is heroin? Describe its physical properties
and physiological action. Give some indications for
its use.
10. Name three drugs used to arrest hemorrhage
from the lungs and explain how they accomplish the
result.
CHEMISTRY.
1. State the occurrence of phosphorus in nature and
antidotes in case of poisoning from phosphorous.
587
MEDICAL RECORD.
2. What are proteins and what elements do they
contain ?
3. What is ptyalin and what action characterizes it?
4. In examining the urine of primiparae and multi-
parse, what would you especially examine for in the
sample?
5. Name the varieties of the urinary calculi.
6. Give antidotes for the following: Carbolic acid;
iodine; and caustic alkalies.
7. What is the common name for trichlormethane
and tri-iodide of methane?
8. What metallic element is constantly present in
the coloring matter of the blood, and what element is
present in all acids?
9. What are alkaloids?
10. 2NaN0 3 +H 2 S0 4 equals what?
BACTERIOLOGY AND PATHOLOGY.
1. What do you understand by immunity? How ob-
tained?
2. Differentiate morphologically the following micro-
organisms : Diphtheria bacillus and typhoid bacillus;
gonococci and Diplococcus meningitidis intracellularis
3. Give bacteriological manifestation in typhoid fever.
4. Discuss serum-therapy in treatment of diphtheria.
5. What do you understand by the term anaphylaxis?
6. Define inflammation, infection, intoxication.
7. Describe the inflammatory reaction in vascular
tissues.
8. Define cholangitis and give its pathology.
9. Give pathology of acute pelvic peritonitis.
10. Classify tumors. Give name of one in each class.
Describe one tumor of the three named.
PHYSICAL DIAGNOSIS.
1. Where do you feel for the pulse and why, and
what points are noted?
2. What is the rate of pulse in the adult male and
in the female?
3. How many periods may we discriminate in the
prognosis of a case of valvular disease of the heart?
4. Describe the failure of compensation.
5. Name the physical signs of acute dilatation of the
heart.
6. Name the rales in acute bronchitis (or broncho-
pneumonia).
7. Diagnose a moderately advanced case of phthisis.
8. Describe in your own way a case of hydrocephalus.
9. What do retinal hemorrhages indicate?
10. Diagnose syphilitic heart disease.
588
OKLAHOMA.
PRACTICE.
1. Give the physical signs of pleuritic effusion.
2. How may pleuritic friction be distinguished from
rales occurring in bronchial tubes?
3. Give the physical signs in most usual valvular
lesions of the heart.
4. Name five diseases caused by a known germ.
5. Name places where yellow fever is known to be
endemic.
6. On what symptoms would you base a diagnosis of
typhoid fever?
7. Define rubeola and describe its symptoms.
8. Give the treatment of whooping cough.
9. Differentiate between acute articular rheumatism
and periostitis.
10. Describe the Wassermann reaction for the serum
diagnosis of syphillis.
HYGIENE.
1. Mention six desirable factors in the location of a
resort for consumptives.
2. Define Hygiene.
3. What hygienic measures should be employed by
persons prone to "catch cold"?
4. Differentiate between endemic and epidemic dis-
eases.
5. How does the hookworm usually enter the human
body? What measures would you employ to prevent
its spread?
6. What are the most common sources of infection of
diphtheria?
7. Describe the most approved method of perform-
ing vaccination, and relatethe complications that may
occur as results of faulty methods.
8. How can malarial districts be made healthy?
9. What habits of school children tend to produce
myopia?
10. Give the dimensions of a sanitary school room
necessary for fifty pupils.
OBSTETRICS AND GYNECOLOGY.
1. Define the fetal circulation.
2. Name the three embryonic layers. From which
is the skin produced? The bones?
3. Give etiology and treatment of puerperal in-
fection. Of puerperal eclampsia.
4. Name the contents of your obstetrical bag. What
is pituitrin and when should it be used?
589
MEDICAL RECORD.
5. Differentiate the indications for pubiotomy, crani-
otomy, and cesarean section.
6. Give the anatomy of the uterus and appendages.
7. Under what conditions is curettage indicated?
8-9. Define and give etiology, prognosis, and treat-
ment of amenorrhea, dysmenorrhea, retroflexion, retro-
version, rectocele, cystocele, pyosalpingitis, and en-
dometritis.
10. Give etiology, diagnosis, prognosis, and treatment
of gonorrhea in the female.
SURGERY.
1. Discuss the tonsil surgically: (a) Anatomy; (6)
Infections; (c) Pathology; (d) Treatment, including
operative technique.
2. Give description, etiology, and treatment of ptery-
gium.
3. Give three dressings suitable for fracture of
clavicle.
4. In fracture of middle of humerus what nerve may
be injured? Give localization of symptoms leading to
diagnosis of nerve injury.
5. Name two inflammatory diseases of the skin and
give treatment.
6. Differentiate chancre and chancroid. Give treat-
ment for chancroid.
7. In non-operative treatment of acute appendicitis
give the salient points advocated by Ochsner, Murphy
and Fowler.
8. How would you treat a severe lacerated, contused
wound of hand not requiring amputation?
9. Discuss briefly the value of radiography in sur-
gical diagnosis and treatment.
10. Give treatment for gunshot wound of chest; of
abdomen.
TOXICOLOGY AND MEDICAL JURISPRUDENCE.
1. Give the differential diagnosis between strychnine
poisoning and tetanic convulsions.
2. Name two drugs that, given in lethal doses, will
produce convulsions, and give antidote.
3. Mention the antidote in the case of poisoning from
silver nitrate. How does the antidote act?
4. Discuss briefly the symptoms of cocaine poisoning.
5. Name the antidote for alkaloids. How does it act?
6. Define Medical Jurisprudence.
7. Differentiate between burns inflicted during life
and after death.
8. When is it legally permitted to produce abortion?
590
OKLAHOMA.
9. For what reasons may a physician refuse to give
expert testimony?
10. Define expert testimony.
ANSWERS TO STATE BOARD EXAMINATION
QUESTIONS.
Oklahoma State Board of Medical Examiners.
anatomy.
1. The skin consists of (1) epidermis, and (2) dermis.
The appendages are the sweat glands, sebaceous glands,
hair, and nails.
"The epidermis is made up of three principal layers :
(a) the horny layer, or Stratum comeum, is the most
superficial, and consists of layers of flattened cells,
which are dry and horny without any nucleus; (b) the
Stratum lucidum, composed of several layers of nu-
cleated cells, which are more or less indistinct, and in
section appear as an almost homogeneous layer; (c) the
Rete mucosum or Malpighian layer contains, in its
upper part, layers of 'prickle' cells, and its inferior
layer consists of a single stratum of columnar cells.
Pigment is principally found in the lowest layer.
"The dermis, or true skin, is made up of an inter-
lacing network of connective tissue, formed of white
fibrous tissue, yellow elastic tissue, corpuscles, vessels,
and nerves. In. some parts of the body, as in the skin of
the scrotum, perineum, penis, the cutis vera contains un-
striated muscular fibers. There are also small muscular
fibers in connection with the hair follicles. Beneath the
skin the subcutaneous tissues contain abundant adipose
tissue." — (Ashby's Notes on Physiology.)
The sweat glands are invaginated epithelial tubes
which are situated in the dermis and in the subcutaneous
fatty tissue. The largest of these glands occur in the
axilla and the groin.
The sebaceous glands are found wherever hairs occur,
and they usually open into the hair follicles. They also
occur on the external genitals and in the eyelids.
Hairs consist of a root which is embedded in the skin,
and a shaft or stem which projects beyond the surface
of the body. The root is contained in an invaginated
tube of skin called a follicle. The medulla, or pith, of
the hair consists of polyhedral cells and air spaces. The
follicle consists of outer and inner root sheath, Henle's
layer, Huxley's layer, hyaline layer and cuticle.
591
MEDICAL RECORD.
Nails consist of a body, free edge, root, and borders.
The nail bed is the Malpighian layer of the skin.
2. The serous membranes are: (1) Peritoneum, lining
the abdominal cavity; (2) pleurae, covering the lungs;
(3) pericardium, surrounding the heart; (4) tunica
vaginalis, investing the testicles; (5) capsule of Tenon,
in connection with the eyeball; (6) the lining membrane
of the cavity of the cerebrospinal axis. Sometimes the
lining membrane of the heart, lymphatics and blood-
vessels is considered as a serous membrane.
3. The vocal cords are fibrous bands covered with
mucous membrane, and situated inside the larynx. The
two true vocal cords are attached in front to the angle
between the alse of the thyroid cartilage, and behind
to the anterior tubercles at the base of the arytenoid
cartilages. Their free edges are directed upwards.
The two false vocal cords are situated above the true
vocal cords.
4. The false pelvis is bounded on either side by the
ilium; in front it is incomplete, having a wide gap be-
tween the anterior borders of the ilia; this is filled in
(in the recent state) by the anterior abdominal walls;
behind there is a notch between the ilia and the base of
the sacrum.
The true pelvis is bounded in front and below by the
symphysis pubis and the superior rami of the pubes;
above and behind, by the sacrum and coccyx ; laterally by
the ischium and ilium.
5. Spinal puncture should be made in the space be-
tween the third and fourth lumbar vertebrae; a line
drawn connecting the highest points of the iliac crests
passes through the spine of the fourth lumbar vertebra.
The puncture is to be made in the first interspace above
this line, and a little to one side of the median line.
6. The hip joint is an enarthrodial joint, formed by
the head of the femur and the acetabulum. The artic-
ular surfaces are covered with cartilage. Near the
center of the head of the femur is attached the liga-
mentum teres. The ligaments are: (1) The capsular,
which embraces the margin of the acetabulum above,
and the neck of the femur below. (2) The iliofemoral
or Y ligament, which passes obliquely across the front
of the joint, and is attached above to the anterior
inferior spine of the ilium, and below to the anterior
intertrochanteric line. (3) The ligamentum teres. (4)
The cotyloid ligament, which deepens the acetabulum,
and bridges over the cotyloid notch, being there called
(5) the transverse ligament. The joint has a very ex-
592
OKLAHOMA.
tensive synovial membrane. It is capable of the follow-
ing movements: Flexion, extension, abduction, adduc-
tion, circumduction, and rotation. The arterial supply
is from the obturator, circumflex (of femoral) and supe-
rior and inferior gluteal arteries. The nerve supply
is from the sacral plexus, sciatic, obturator and acces-
sory obturator nerves.
7. The fourth cervical vertebra has a small, trans-
versely elongated body, with no facets for ribs; the
laminas are long and slender; the spinous process is
short, nearly horizontal, and bifid; the transverse proc-
esses are short, and contain a foramen for the vertebral
artery ; the superior articular process is directed upward
and slightly backward; the inferior articular process is
directed downward and slightly forward; the spinal
foramen is large and triangular.
8. Flexor profundus digitorum flexes the phalanges.
Brachialis anticus flexes the forearm; and, if the
forearm is fixed, it flexes the arm upon the forearm.
Psoas magnus flexes the thigh upon the pelvis, and
bends the lumbar part of the vertebral column for-
ward and to its own side; it helps to maintain the
body in the erect position.
9. Contents of Scarpa's triangle: The femoral ves-
sels pass from about the center of the base to the
apex, the artery being on the outer side of the vein;
the artery gives off the superficial and profunda
branches, and the vein receives the deep femoral and
internal saphenous; the anterior crural nerve lies to
the outer side of the femoral artery; the external
cutaneous nerve is still further external, lying in the
outer corner of the space; just to the outer side of the
femoral artery, and in the sheath with it, is the crural
branch of the genitocrural nerve. At the apex, the vein
(which at the base was internal to the artery) lies
behind the artery. The triangle also contains fat and
lymphatics.
10. Structure of prostate, "The prostate is a com-
pound tubulo-alveolar gland whose ducts open into the
prostate portion of the urethra. Smooth muscle fibers
not only surround the organ, but interlace radially
toward its center, forming a network in whose meshes
the glandular parts are located. Areolar tissue and
blood-vessels accompany the muscle tissue. The alveoli
of the glands are lined by simple columnar epithelium,
which sometimes show two rows of nuclei. These al-
veoli contain a serous acid coagulum, and usually oval
laminated concretions called prostatic bodies. The lat-
593
MEDICAL RECORD.
ter are more numerous in old men. The numerous
excretory ducts unite to form twelve to fifteen collect-
ing tubes which open into the urethra, most of them
into the prostatic sinus. These ducts are lined by sim-
ple columnar epithelium, except near their terminations,
where it is transitional. The organ dorsal or in front
of the urethra is mostly smooth muscle tissue. ,, (Hill's
Histology.)
PHYSIOLOGY.
1. The functions of the spinal cord are: (1) The con-
duction of nerve impulses; (2) reflex action; (3) co-
ordination; it also contains special centers which pre-
side over definite functions.
In the spinal cord: (a) The white substance simply
conducts nerve impulses; (6) the gray substance con-
tains groups of cells which act as centers for and dis-
tributors of nerve impulses, and are also concerned in
reflexes; (c) the anterior cornua have a motor and
trophic function; (d) the posterior cornua are sensory.
2. "The greater part of the urea produced in the
body is formed in the liver. The liver cells form the
urea from two sources: (1) The larger amount, pro-
duced by the liver cells, is derived from the aminoacids
which have been absorbed from the small intestine,
and which are not required by the tissues; this con-
stitutes the exogenous urea. (2) The smaller amount,
produced by the liver cells, is derived from the am-
monium carbonate, which is derived from the tissues;
some is also produced by the action of the uricolytic
enzyme upon uric acid; this constitutes the endogenous
urea J* (Lyle's Physiology.)
Uric acid: "In man, uric acid has a twofold origin;
one portion, coming from the breaking down of the
nuclein-containing tissues or cell elements of the man's
own body, and hence is of endogenous origin, while the
other portion — usually the larger — is of exogenous ori-
gin, coming from the transformation of free and com-
bined purin compounds present in the food." — (Chitten-
den.)
3. The vasomotor nervous system consists of (1) a
vasomotor center in the bulb, (2) of some subsidiary
centers in the spinal cord, and (3) of vasomotor nerves,
which are of two kinds: (a) those causing constriction
of the vessels, and so-called vasoconstrictor nerves; and
(b) those causing dilatation of the vessels, and so-
called vasodilator nerves. These nerves supply the
muscle tissue in the walls of the blood-vessels and
regulate their caliber, thus influencing the quantity of
594
OKLAHOMA.
blood supplied to a part; at the same time they regulate
the quality of blood supplied to a part; they also regu-
late the nutrition of a part, also secretion and heat
production. They are concerned, too, in the control of
the heart-beat. The center is in the medulla, in the
floor of the fourth ventricle, near the calamus scrip-
torius.
4. The active principle of the suprarenal gland is
adrenalin or suprarenin. Its function is to keep up
the blood pressure by stimulation of the ends of the
vasomotor nerves; an exception to this is the vaso-
motor nerve of the kidneys; its action here is to dilate
the kidney arterioles and so produce diuresis. The
secretion from the cortical portion of the gland helps
to maintain general body strength and nutrition; it
also has some influence on the growth and development
of the body; it may also help to destroy toxins. It
stimulates the heart, dilates the coronary vessels, in-
hibits the movement of the intestines, and may cause
sweating, dilatation of the pupils, and erection of the
hairs.
5. The mastoid cells are lined with mucous membrane
continuous with that of the mastoid antrum and the
tympanum.
6. The portal system. The veins of the portal sys-
tem collect the blood from the digestive tract. They
form a trunk, the vena porta?, which enters the liver
and breaks up into small branches in its substance.
The following veins form the portal system: The infe-
rior mesenteric, superior mesenteric, splenic and gastric.
The portal vein is formed by the union of the splenic
and superior mesenteric veins in front of the right
crus of diaphragm and inferior vena cava, and behind
the neck of the pancreas. Passes up behind the first
part of duodenum and then between the layers of the
small omentum, behind and between the common bile-
duct and hepatic artery, the duct being placed on the
right and artery on the left, to transverse fissure of
liver, where it divides into right and left branches
to corresponding lobes, and also gives an offset to the
Spigelian lobe. Connected with the branch to the left
lobe are in front the obliterated umbilical vein and be-
hind the ductus venosus, the remains of a fetal connec-
tion with the inferior vena cava. — (Aids to Anatomy.)
7. Bile. Functions: (1) To assist in the emulsifica-
tion and saponification of fats; (2) to aid in the ab-
sorption of fats; (3) to stimulate the cells of the intes-
tine to increased secretory activity, and so promote per-
595
MEDICAL RECORD.
istalsis, and at the same time tend to keep the feces
moist; (4) to eliminate waste products of metabolism,
such as lecithin and cholesterin; (5) it has a slight
action in converting starch into sugar; (6) it neutral-
izes the acid chyme from the stomach, and thus inhibits
peptic digestion; (7) it has a very feeble antiseptic
action. Composition: Water, sodium glycocholate, so-
dium taurocholate, lecithin, cholesterin, pigment, and in-
organic salts.
8. The pleurae are two serous sacs enclosing and in-
vesting the lungs. Each pleura consists of a visceral
and parietal layer. The visceral portion covers the
lungs, and the parietal layer lines the inner surface of
the chest walls, the upper surface of the diaphragm,
and the sides of the pericardium. The visceral and
parietal layers of the corresponding pleura become con-
tinuous in front and behind the root of the lung; and
below the root a fold, the ligamentum latum pulmonis,
extends downward along the inner surface of the lung
to the diaphragm. The mediastina are formed by the
visceral layers of each side approaching one another
toward the median line.
Their function is to prevent the friction which would
otherwise occur between the lungs and the chest walls
at every respiration.
9. The functions of the cerebellum are: Co-ordina-
tion of muscular movements, and maintenance of equi-
librium.
If the cerebellum is removed there is a lack of co-
ordination, and loss of equilibrium; but sensation in
general is not affected.
10. The functions of the medulla oblongata are: (1)
It is a conductor of nervous impulses or impressions
from the cord to the cerebrum, from the brain to the
spinal cord, also of coordinating impulses from the
cerebellum to the cord; (2) it contains collections of
gray matter which serve as special nerve centers for
the following functions or actions: respiration, salivary
secretion, mastication, sucking, deglutition, vomiting,
voice, facial expression; it also contains the cardiac
and vasomotor centers.
MATERIA MEDICA.
1. The chemical antidote for strychnine is potassium
permanganate.
2. Adrenalin is used as a local vasoconstrictor, to
arrest small hemorrhages, to allay itching; it has also
been used in cases of shock, Addison's disease, spasmodic
596
OKLAHOMA.
bronchitis, edema of the glottis, hemoptysis, congestion
and edema of the lungs, hemorrhoids, and inflamed
mucous surfaces.
3. Treatment of opium poisoning consists in washing
out the stomach, preferably with a dilute solution of
potassium permanganate ; ambulatory treatment to keep
the patient awake; artificial respiration is indicated,
and strong coffee should be administered by the mouth
or rectum; the bladder should be emptied by the cathe-
ter.
4. Sodium Sulphate. Common name : Glauber's salt.
Therapeutic uses: As a cathartic, to alkalinize the
urine, as a cholagogue, and in some cases of gallstones.
Dose: Four drams.
5. Jalap is used as a purgative and diuretic; in cases
of dropsy, nephritis, and cerebral congestion.
Jalap takes about three hours to act; aloes, about
eight or ten hours. Jalap acts chiefly on the small in-
testine; aloes, chiefly on the large intestine.
6. Action of pilocarpus on the heart : The heart is at
first accelerated, then slowed; and the blood pressure
first rises, then falls. On the skin, it causes hyperemia,
sweating, elevation of temperature for a short time,
but the evaporation of the sweat soon causes a fall of
temperature. On the salivary glands, it causes an in-
crease in the secretion of these glands.
7. Potassium acetate is the better diuretic ; and potas-
sium bitartrate is the more active purgative.
8. Valerian, in full doses, is said to increase the
action of the heart and to produce exhilaration.
Therapeutic uses of valerian: It is used in cases of
syncope, flatulence, palpitation of the heart, chorea,
epilepsy, nervousness, and hysterical conditions gener-
ally.
9. Heroine is a derivative of morphine. It is a color-
less, odorless, crystalline powder with a slightly bitter
taste; it is insoluble in water, but is soluble in dilute
acids. Its action is that of a sedative to the respiratory
mucous membrane, and it is used chiefly for controlling
cough.
10. Three drugs to arrest hemorrhage from the lungs :
(1) Adrenalin, which acts as a vasoconstrictor; (2)
ergot, which acts as a constrictor of the involuntary
muscle and as a vasoconstrictor; (3) hamamelis, which
owes its styptic properties to the tannin which it con-
tains.
CHEMISTRY.
1. Phosphorus occurs only in combination; in miner-
597
MEDICAL RECORD.
als and vegetables, as phosphates of calcium, mag-
nesium, sodium, potassium, aluminum and lead; in ani-
mals, as phosphates of calcium, sodium, potassium and
magnesium.
There is no known chemical antidote to phosphorus;
potassium permanganate is efficacious; old French oil
of turpentine is said to be the physiological antidote;
fixed oils or fats must not be administered.
2. Proteins are complex organic substances of un-
known constitution and high molecular weight; they
are present in all living matter. They are composed
of carbon, hydrogen, oxygen and nitrogen; they may
also contain sulphur, phosphorus, iron, copper, or iodine.
3. Ptyalin is an enzyme which is found in the saliva;
it converts starch into maltose.
4. In examining the urine of pregnant women, special
care should be made to ascertain the amount of urine
voided, the quantity of solids excreted, the amount of
urea excreted, and the presence or absence of albumin,
sugar, and of casts.
5. Varieties of urinary calculi: Uric acid, sodium
urate, ammonium urate, calcium oxalate, calcium phos-
phate, ammonio-magnesium phosphate, cystin, xanthin,
calcium carbonate, potassium urate, calcium urate and
magnesium urate.
6. Antidote for carbolic acid, sodium sulphate, alco-
hol ; for iodine, starch ; for caustic alkalies, diluted vine-
gar.
7. The common name of trichlormethane is chloro-
form; of tri-iodide of methane is iodoform.
8. Iron is present in the hemoglobin of the blood.
Hydrogen is present in all acids.
9. Alkaloids are organic, nitrogenous substances, al-
kaline in reaction, and capable of combining with acids
(to form salts) in the same way that ammonia does
10. 2 NaNOa + H 2 S0 4 = Na 2 S0 4 + 2 HN0 3 .
BACTERIOLOGY AND PATHOLOGY.
1. Immunity is the power of resistance of cells and
tissues to the action of pathogenic microorganisms.
Immunity may be either natural or acquired.
Natural immunity is that power of resistance, natural
and inherited, and peculiar to certain groups of animals,
but common to every individual of these groups.
Acquired immunity is this resistance acquired (1) by
a previous attack of the disease, or (2) by the person
being made artificially insusceptible. The chief con-
ditions which give immunity are : (1) A previous at-
598
OKLAHOMA.
tack of the disease; (2) inoculation with the specific
microorganisms in small numbers or of diminished
virulence, so as to produce a mild attack of the disease ;
(3) vaccination; (4) the introduction of antitoxins;
(5) the introduction of the toxins of the bacteria.
2. The bacillus of diphtheria is longer than the
typhoid bacillus; the bacillus of diphtheria has a club-
shaped thickening at one or both ends; the typhoid
bacillus has ends which are rounded but are never club-
shaped; the diphtheria bacillus has no flagella, the
typhoid bacillus has flagella.
The gonococcus is of uniform size and shape, the
diplococcus intracellulars meningitidis varies consider-
ably in size and shape.
3. In typhoid fever, the bacilli may be found in the
blood, in the rose spots, in the urine, in the feces, in
the sputum, and in the gall bladder. For the blood,
the Widal test is most commonly employed.
WidaVs reaction "depends upon the fact that serum
from the blood of one ill with typhoid fever, mixed with
a recent culture, will cause the typhoid bacilli to lose
their motility and gather in groups, the whole called
'clumping.' Three drops of the blood are taken from
the well washed aseptic finger tip or lobe of the ear,
and each lies by itself on a sterile slide, passed through
a flame and cooled just before use; this slide may be
wrapped in cotton and transported for examination at
the laboratory. Here one drop is mixed with a large
drop of sterile water, to redissolve it. A drop from
the summit of this is then mixed with six drops of
fresh broth culture of the bacillus (not over twenty-
four hours old) on a sterile slide. From this a small
drop of mingled culture and blood is placed in the
middle of a sterile cover glass, and this is inverted
over a sterile hollow-ground slide and examined. A
positive reaction is obtained when all the bacilli present
gather in one or two masses or clumps and cease their
rapid movement inside of twenty minutes. " — (From
Thayer's Pathology.)
4. "An antitoxic serum is a blood serum containing
antitoxin, produced therein by the cells of the organism
as a result of the repeated injection of a toxin into
the tissues of the animal from which the serum is
taken."
"Diphtheria antitoxin is obtained from the horse, the
animal having been rendered artificially immune by re-
peated injections extending over a period of several
months of gradually increasing quantities of the strong-
599
MEDICAL RECORD.
est diphtheria toxin. As the bacilli themselves are not
injected, the horse does not become infected with diph-
theria, but he gradually acquires a tolerance for the
toxins of the disease and develops in his blood a sub-
stance (antitoxin) which has the power to neutralize
those toxins. At the proper time, when it is thought
that his blood has acquired the requisite degree of
potency, the animal is bled, and the serum — the part
of the blood containing the antitoxin — is carefully sep-
arated from the clot, filtered and standardized. The
last procedure is accomplished by determining the quan-
tity of antitoxin serum required to offset the effects
of the minimum quantity of toxin necessary to kill a
guinea-pig in a definite time. The strength of the
antitoxin is measured in units, a unit containing the
amount of antitoxin required to save the life of a
guinea-pig which has been injected with 100 fatal doses
of toxin." — (Stevens' Materia Medica.)
5. Anaphylaxis is a condition of hypersusceptibility
induced by the injection of a serum. It is (to some
extent) the opposite of prophylaxis, and in place of
rendering the person injected immune the serum ren-
ders him particularly susceptible.
6. Inflammation is the name given to the series of
changes occurring in a part as the result of injury,
provided that the injury does not at once destroy the
vitality of the part.
Infection means the successful invasion of the tissues
by a pathogenic microorganism.
Intoxication is the condition in which the body has
absorbed the toxic products of bacteria, but the infect-
ing microorganisms remain at the site of inoculation.
7. The phenomena of inflammation are dilatation of
the arterioles, capillaries, and small veins. At first the
blood current is quickened, then retardation occurs, and
may progress to stasis and thrombosis. During this
time exudation of plasma and white corpuscles from
the small veins, and perhaps the capillaries, is going on.
The fate of the white cell may be either to break up
and set free prothrombin or to act as food for con-
nective tissue cells, or to act as a phagocyte, and be
transformed into a pus corpuscle. Red corpuscles may
be exuded and broken up, setting free their coloring
matter. The prothrombin of the white cells unites with
the calcium chloride of the plasma and forms thrombin,
or fibrin ferment, which acts upon the fibrinogen of
plasma to form fibrin.
8. "Cholangitis is inflammation of the bile ducts, and
600
OKLAHOMA.
is generally found in the common duct. It may, how-
ever, extend through the smaller ducts and capillaries.
It is commonly secondary to inflammatory conditions
in the stomach or duodenum. It may be due to bac-
teria entering from the intestine or to irritation by
the presence of a gallstone. In the catarrhal form
the mucosa becomes reddened, swollen, edematous, and
covered by mucus. In the suppurative type the biliary
ducts are dilated, filled with purulent material, and
commonly stained with bile. The walls of the ducts
are much thickened, softened, and infiltrated by pus.
The mucosa is congested, edematous, covered with mu-
cus, and in advanced cases, irregularly ulcerated. About
the terminal branches of the ducts there are usually
small abscesses. The liver is enlarged, swollen, soft-
ened, and opaque. The surface is irregular in conse-
quence of the projection of many small abscesses. The
cut surface shows more or less enormously dilated bile
ducts filled with pus. The intervening liver tissue is
the seat of marked periductal congestion, parenchyma-
tous degeneration and necrosis." — (McConnelPs Path-
ology.)
9. "Peritonitis is brought about by infections inflam-
mations of neighboring tissues, particularly in septic
conditions of the female genital organs, by perfora-
tions of the stomach or intestines, by appendicitis, by
strangulation of the bowels, etc. According to the
extent of the lesion the peritonitis may be localized
or general. The membrane at the point of infection
is at first hyperemic, is dull, and a serous or serofibri-
nous exudation soon appears. This rapidly becomes
purulent, or may have been so from the beginning. If
the process has not been a very rapid one the affected
area will be covered by a thick whitish or creamy layer
of fibrin. As the exudate increases in quantity it col-
lects in localized pockets among the coils of intestine.
The fibrin may undergo organization, adhesions form,
and the purulent matter be surrounded and walled off.
It may be absorbed, infiltrated with lime salts, or re-
placed by fibrous tissue. The pus may burrow and
empty either externally or into some hollow organ. If
the adhesions have not been sufficiently dense the ab-
scess may break through and infect the greater part
of the peritoneum. In such a severe form the serous
membrane becomes infiltrated and partially disorgan-
ized. Localized peritonitis is not usually fatal, but in
the general form recovery is rare, When peritonitis
subsides, and the individual lives, adhesions of varying
601
MEDICAL RECORD.
extent remain. These eventually become transformed
into dense fibrous bands that may cause very severe
trouble by binding the coils of intestine together, or
by so compressing them that the bowel becomes more
or less obstructed. As a result of the acute inflamma-
tion the peristaltic action of the intestines is at first
stopped by spasmodic contractions. In a very short time
the muscle fibers become paralyzed, and there is then
almost complete cessation of motion. General septi-
cemia may follow the peritonitis. " — (McConnell's Pa-
thology.)
10. Tumors are classified as follows :
I. Those derived from mesoblast:
(a) Benign: Lipoma, fibroma, chondroma, os-
teoma, myxoma, myoma, neuroma, glioma,
angioma, lymphangioma.
(b) Malignant: Sarcoma.
II. Those derived from epiblast or hypoblast:
(a) Benign: Adenoma, papilloma.
(b) Malignant: Carcinoma.
III. Cystic tumors.
IV. Teratomata.
Epithelioma, or squamous-celled carcinoma, may
arise on any surface covered with stratified epithelium.
It usually arises in the middle-aged or elderly, but may
also occur in the young. It often results from long-
continued irritation, and may arise in old scars or ul-
cers. It may appear in one of three forms: (1) A
wartlike growth with an indurated base; (2) a small
circular ulcer with raised, rampartlike edges; (3) an
indurated fissure. The growth extends to the deeper
structures; the surface ulcerates and becomes foul from
contamination with putrefactive organisms. The near-
est lymphatic glands always become infected sooner or
later, and a fatal termination occurs rapidly unless
treatment is early and thorough. Secondary deposits,
except in the glands, are rarer than in glandular car-
cinoma. The glands sometimes undergo cystic change
invade the skin, ulcerate, become foul, and may cause
death by secondary hemorrhage from ulceration into
large blood-vessels.
PHYSICAL DIAGNOSIS.
1. The radial pulse is selected on account of its ac-
cessibility. The points to be noted are: The rate,
rhythm, tension, regularity, duration and strength of
the pulse; also the size of the artery, any abnormal
thickening of the artery, and the synchronism of the
pulse on the right and left sides.
602
OKLAHOMA.
2. The average pulse rate in the adult male is about
75 to 80 beats per minute; in the female it is about five
to eight beats faster per minute,
3. The periods are those of good compensation im-
paired compensation, and lost compensation.
4. Complete Incompensation. "This term should be
applied to those cases in which the heart muscle has
completely lost its recuperative quality, as seen in the
terminal stages of all chronic heart affections that
terminate gradually, or by sudden though not immedi-
ately fatal rupture of compensation. The best exam-
ples are seen in terminal cases of coronary sclerosis,
fatty heart, and chronic myocarditis in general. So
also in mitral lesions there comes a time when the
heart that has alone, or with assistance, again and
again recovered itself, finally yields, and resists all
therapeutic measures. In such terminal and irrecov-
erable cases the orthopneic patient often rolls the head
aimlessly from side to side, and wears a peculiarly
listless, yet distressed and hopeless, expression. The
term is frequently erroneously applied to cases of very
marked and extreme cardiac weakness, and especially
to that of mitral regurgitation or stenosis, associated
with secondary tricuspid leakage and general anasarca.
In mitral regurgitation especially, the assumption of
terminal incompensation is seldom justified as a pri-
mary assumption, for there is no cardiac lesion in which
proper treatment can do so much, however extreme
may be the manifestations. Indeed, in the case of all
heart lesions it is only after trying and failing that
surrender is justifiable on the part of the physician. "
— (Greene's Medical Diagnosis.)
5. Cardiac Dilatation : "Inspection detects enlarge-
ment and distention of the superficial veins and an in-
distinct, often wavy and diffused, cardiac impulse. If
tricuspid regurgitation is present, jugular pulsation will
be observed. Palpation confirms inspection ; the impulse
is feeble, irregular, and heaving. Percussion serves to
determine extension of the area of cardiac dullness
transversely, and especially toward the right side.
Auscultation in the presence of valvular lesions reveals
characteristic murmurs. If there are no valvular le-
sions the cardiac sounds are weaker than normal and
the first sound is sharper in quality than usual." —
(Hughes' Practice of Medicine.)
6. In acute bronchitis, the following rales may be
heard: Sibilant, sonorous, mucous, bubbling and gur-
gling.
603
MEDICAL RECORD.
7. Pulmonary phthisis. The early subjective symp-
toms of the ulcerative form are progressive weakness
and emaciation, nocturnal sweats, cough, hemoptysis,
morning nausea, chest pains with localized constriction,
dyspnea, and laryngitis. The objective symptoms in-
clude diminished expansion over the affected area,
slightly increased fremitus, impaired resonance on per-
cussion, inspiration harsh and high pitched, with pro-
longed expiration, exaggerated vocal resonance, the
presence of mucous rales at the apex and sometimes
PQsteriorly at the base of the lungs, evening rise of
temperature, rapid and feeble pulse, and the appearance
of tubercle bacilli in the sputum. In the later stages
the symptoms are all greatly exaggerated: Bacilli
are more abundant, the weakness and emaciation be-
come more profound, night sweats excessive, higher
temperature and hectic symptoms, diarrhea, mucus
often greenish, containing small, nummular lumps,
cheesy in character and containing many bacilli. —
(From Cyclopedia of Medicine and Surgery.)
8. Congenital or chronic hydrocephalus. "The first
manifestation of the disease to attract attention is the
increased size of the head in an emaciated child whose
appetite is good and who seemingly partakes of food
well. The head appears too heavy; the eyes are promi-
nent, and have a downward direction; the face is de-
void of expression, old and wrinkled, the voice feeble,
and the mental development is not in keeping with
the age. When the period for standing or walking ar-
rives the power is found wanting. The further history
is but a continuation and exaggeration of this state,
until convulsions occur, which sooner or later termi-
nate fatally. The course of congenital hydrocephalus
is usually slow, but becomes progressively worse. The
majority terminate within the first year, cases are
recorded, however, of ten and fifteen years' duration."
— (Hughes' Practice of Medicine.)
9. Retinal hemor?*hage may indicate: Degenerated
arteries, chronic nephritis, cardiac hypertrophy, gout,
scurvy, purpura, severe anemia, hemophilia, malaria,
ulcerative endocarditis, pyemia.
10. Syphilitic heart disease. "A sense of oppression,
palpitation, and extreme irregularity of the heart ac-
tion, dyspnea, and precordial pain or anginal attacks,
occurring in a patient who is known to be the subject
of tertiary syphilis, may enable at least a probable
diagnosis of cardiac syphilis. Sudden death occurs in
33 per c^nt. of these cases." — (Butler's Diagnostics of
Internal Medicine.)
604
OKLAHOMA.
PRACTICE.
1. Physical Signs of Pleuritic Effusion. Inspec-
tion shows immobility of the chest wails, with some en-
largement on the affected side; the intercostal spaces
may bulge, and there is displacement of the heart beat.
Palpation shows the vocal fremitus to be absent. Per-
cussion shows flatness or dullness, with increased re-
sistance to the pleximeter finger. Auscultation shows
absence of respiratory sounds except at the upper part
of the compressed lung, where bronchial respiration
and bronchophony or egophony are heard. Over the
healthy lung the respiratory sounds are exaggerated.
2. As compared with rales in the bronchial tubes,
pleuritic friction is more superficial, coarser, and is
heard with both inspiration and expiration.
3. Physical Signs of Mitral Regurgitation. ''Inspec-
tion shows displacement of the apex beat downward
and to the left. In children and youths, bulging of
the precordium and increased cardiac impulse are pres-
ent. In emaciated individuals, an auricular impulse
may be observed to the left of the pulmonic area in
the second interspace. Palpation serves to confirm in-
spection. The displaced cardiac impulse is forcible and
diffused in the early stage; as compensation fails, the
impulse becomes feeble or absent. Percussion shows an
increase in the area of cardiac dullness transversely
and vertically. Auscultation reveals a systolic or blow-
ing murmur, heard best in the mitral area and trans-
mitted to the apex, left axilla, and under the angle of
the scapula. It may occur with or take the place of
the first sound of the heart, the second sound being
markedly accentuated, particularly in the pulmonic
area."— (Hughes' Practice of Medicine.)
4. Five diseases caused by a known germ: Typhoid,
diphtheria, syphilis, cholera, tuberculosis, and erysipe-
las.
5. Yellow fever is endemic in the southern part of
the United States, Mexico, some of the islands in the
Caribbean Sea, Central America, Venezuela, Guiana,
Brazil, andthe west coast of Africa.
6. The diagnosis of typhoid is based on the charac-
teristic temperature chart, the rose rash, enlarged
spleen, and a positive diazo-reaction and Widal test;
the absence of leucocytosis and epistaxis, and an early
dicrotic pulse have a diagnostic significance. The find-
ing of the typhoid bacilli in the blood, urine, or feces
is valuable.
7. Rubeola: Period of incubation ten to twelve days.
605
MEDICAL RECORD.
Stage of invasion, four days. Character of eruption,
small, dark red papules with crescentic borders, begin-
ning on face and rapidly spreading over the entire
body; desquamation is branny. As compared with scar-
latina, the eruption is darker, less uniform, more shotty ;
the temperature is lower, pulse slower, the tongue is
not of the "strawberry" type; coryza, coughing, and
sneezing may be present; Koplik's spots are present.
8. Treatment of whooping-cough: "Isolation of the
patient, disinfection of all articles used by him, fresh
air, sunlight, light but nutritious diet, a saline cathar-
tic, belladonna or antipyrin or bromoform or chloral,
antiseptic and sedative sprays for the throat; vaccine
treatment has been recommended by some; during con-
valescence, tonics, especially iron, quinine, strychnine,
and cod liver oil, are of service.
9. In acute articular rheumatism, the joint is affected
rather than the shaft of the bone; the disease is apt
to affect more than one joint; the constitutional symp-
toms are less marked; movement of the joint produces
pain; administration of salicylates often relieves the
pain and other symptoms; tonsilitis and cardiac mur-
murs are common accompaniments.
In periostitis the shaft of the bone is chiefly affected ;
as a rule, only one bone is involved; the constitutional
symptoms are more severe; the joint may be moved
without pain, but pressure on the shaft of the bone
causes very severe pain; salicylates have no effect on
the disease; tonsilitis and cardiac murmurs have no
connection with periostitis.
10. The Wassermann reaction. "A guinea-pig or rab-
bit is inoculated several times intravenously with the
washed blood corpuscles of a rabbit or sheep, with the
consequent production of a hemolytic serum specific for
the corpuscles of a rabbit or sheep respectively, and
the serum is inactivated. An antigen is prepared by
mincing and triturating the liver of a syphilitic fetus
in physiological salt solution. The serum from the
patient is inactivated in the same way as the hemolytic
serum — by heating to 56 deg. C. for thirty minutes,
thus destroying the alexin. A complement is made
by diluting guinea-pig serum tenfold. The test fluid
is added to the antigen extract, some complement is
added, and the mixture left for four hours at 20 deg. C.
The hemolytic system (a mixture of inactivated hemo-
lytic serum and the washed blood corpuscles for which
it is specific) is added, and if after four hours no hemo-
lysis has taken place syphilitic taint is present. The
606
OKLAHOMA.
antibody in the patient's blood has attacked the trepo-
nemes which abound in the liver of the infected fetus,
the complement is absorbed, and there is none left to
cause the inactivated hemolytic serum to dissolve the
blood corpuscles. Conversely, if no syphilitic antibody
exists in the patient's blood, the complement is left free,
and is deviated to the sensitizer of the hemolytic serum,
and allows this to cause hemolysis of the blood corpus-
cles. Controls with normal and with syphilitic sera,
with and without antigen, are put through at the same
time." — (Aids to Bacteriology.)
HYGIENE.
1. Six desirable factors in the location of a resort for
consumptives : "The ideal place for a patient with
pulmonary tuberculosis should possess purity of air,
a dry, porous, salubrious soil, good potable water in
sufficient quantities, good sewage disposal, relative pro-
tection from wind, and such a temperature that the
patient can spend hours out of doors without discom-
fort. Abundant sunshine, infrequency of fogs, the per-
sistence of snow throughout the winter, are all of
value." — (Osier's Modern Medicine.)
2. Hygiene is the art and science of all that pertains
to the preservation, promotion and improvement of
health and the prevention of disease.
3. Persons who are prone to catch cold should wear
suitable clothing, especially during changeable weather ;
should avoid overheated and un ventilated rooms; should
also avoid draughts and exposure to wet and damp;
should take frequent baths and adequate exercise; and
should keep themselves in the best possible health.
4. A disease is said to be endemic when it is found
in a certain locality more or less constantly; it is said
to be epidemic when it affects a large part or the whole
of a certain community.
5. Hookworm disease enters the human body by the
mouth; the ova are transferred to the mouth on un-
clean hands or by contaminated drinking water.
To prevent its spread: Children and adults should
be made to wear shoes ; proper toilet facilities should be
provided, and their use enforced; bathing or wading in
shallow water should be forbidden; a proper water
supply should be available for drinking purposes; and
prompt recognition and treatment of all cases should
be encouraged.
6. Diphtheria is conveyed through the air or by the
mouth; it is transmitted by contact with those already
607
MEDICAL RECORD.
infected, by fomites, by cats or pigeons, etc., by careless
disposal of the nasal and oral secretions, by careless
coughing or sneezing, whereby the bacilli are carried
through the air to the nose or mouth of others.
7. Vaccination. "The arm (near the insertion of the
deltoid muscle) or the calf of the leg is usually se-
lected for vaccination. The skin having been cleansed
with water and soap (no antiseptics, since they destroy
the vaccine), an area one-eighth to one-quarter inch in
diameter should be scarified with a sterile scalpel or
needle so as to remove only the epidermis, whereupon
the vaccine should be rubbed in. One should be care-
ful not to draw blood. A single area for inoculation is
sufficient. After the vaccine has dried it should be
covered with an antiseptic dressing and the wound
thereafter treated aseptically. Most of the cases of
serious inflammation of the arm following vaccination
are attributable to secondary infection of tne wound."
Possible complications are: Erythema, urticaria, vesic-
ular and bullous eruptions, erysipelas, impetigo, ulcer-
ation, glandular abscess, septic infections, gangrene,
syphilis; septic infection is the most common complica-
tion; tetanus has also been transmitted. — (From Kelly's
Practice of Medicine.)
8. Malaria is transmitted by the bite of the anopheles
mosquito. Prophylaxis of malaria: Individuals should
use mosquito netting around their beds and wire gauze
in doors and windows so as to keep out the mosquitoes
as much as possible. During residence in malarial dis-
tricts quinine should be taken every morning, before
breakfast. All pools, stagnant water, etc., where ano-
pheles may breed, should be removed. All mosquitoes,
larvae, etc., should be destroyed as far as possible. By
staying indoors during dusk and darkness, opportuni-
ties for infection may be avoided. Occasional fumiga-
tion with formaydehyde or sulphur is also beneficial.
9. Habits of school children which tend to produce
myopia are: Reading fine or indistinct print, reading
in poor illumination, improper positions in reading or
writing, using the eyes when tired, excessive study com-
bined with insufficient exercise, and the use of glazed
and shiny blackboards.
10. The room should be 40 feet long, 30 feet wide,
and 15 feet high; this will allow 360 cubic feet of
space for each child.
OBSTETRICS AND GYNECOLOGY.
1. Fetal circulation: "The blood returning from the
608
OKLAHOMA.
placenta, after having received oxygen and being freed
from carbonic acid, is carried by the umbilical vein to
the under surface of the liver; here a portion of it
passes through the ductus venosus into the ascending
vena cava, while the remainder flows through the liver
and passes into the vena cava by the hepatic veins.
When the blood is emptied into the right auricle it is
directed by the Eustachian valve through the foramen
ovale, into the left auricle, thence into the left ventricle,
and so into the aorta and to all parts of the system. The
venous blood returning from the head and upper ex-
tremities is emptied by the superior vena cava into
the right auricle, from which it passes into the right
ventricle, and thence into the pulmonary artery. Owing
to the condition of the lung, only a small portion flows
through the pulmonary capillaries, the greater part
passing through the ductus arteriosus, which opens into
the aorta at a point below the origin of the carotid and
subclavian arteries. The mixed blood now passes down
the aorta to supply the lower extremities, but a portion
of it is directed by the hypogastric arteries to the
placenta, to be again oxygenated." — (Brubaker.)
2. The three embryonic layers are the epiblast, the
mesoblast, and the hypoblast. The skin is derived from
the epiblast; the bones from the mesoblast.
3. The bacteria which cause puerperal infection are:
Steptococcus pyogenes, staphylococcus pyogenes aureus,
gonococcus, bacillus coli communis, bacillus diphtheria,
bacillus typhosus. They are generally introduced by
the fingers of the physician or nurse, or by instruments,
or general -lack of cleanliness. Treatment: Prophy-
laxis is of the greatest importance. Purgatives ; vaginal
douches; some recommend curettage, others decry it;
the introduction of antiseptics into the uterus; sup-
portive and general treatment are indicated; specific
sera and vaccines have been recommended by some.
"The treatment of puerperal sepsis is both local and
general. Locally a thorough disinfection of the whole
genital canal is called for in every case. It may appear
unnecessary, and may prove, on actual experience, to
be even harmful, but no one can tell beforehand how
necessary this procedure is. In the vast majority of
cases it is productive of the greatest good. It is only
occasionally useless, and very rarely actually harmful.
It should precede all other treatment for puerperal
infection. The method of disinfecting the genital canal
may be described as follows: A double tenaculum, a
large, dull curette, a placental forceps, and an intra-
609
MEDICAL RECORD.
uterine catheter are boiled for fifteen minutes. The
operator disinfects his hands and arms and wears ster-
ile gloves. The patient is placed in the dorsal posture
across the bed, with her buttocks resting on a rubber
pad. The external genitalia and the vagina are scrubbed
with tincture of green soap and pledgets of cotton;
the vagina is douched with a sublimate solution 1:2000.
The operator then seizes the anterior lip of the cervix
with a tenaculum. An intrauterine douche of sterile
water, at least a quart, is administered. Then, with
the placental forceps, and, if necessary,, with a dull
curette, the uterine walls are gone over thoroughly but
lightly in all directions, six to twelve times, until noth-
ing is brought away but bright blood. A second intrau-
terine douche concludes the treatment. If the womb
is flabby and large, with a tendency to flexion, so that
the drainage of the uterine cavity is not good, it is
advisable to pack it with iodoform or sterile gauze.
In addition to cleansing the uterine cavity, false mem-
branes or areas of inflammation and localized infection
on the cervix or vagina should be treated by the appli-
cation of a solution of nitrate of silver, a dram to the
ounce. It may be necessary to repeat the intrauterine
douches several times — in fact, several times a day
for many days; in this case plain sterile water only
should be used. The general treatment is stimulating.
The patient should have as much food of an easily di-
gestible character, chiefly milk, as she can assimilate,
and as much alcohol as she can consume without show-
ing the physiological effects of it. Digitalis is useful
as long as the pulse is above 110. Strychnine may be
combined with it in suitable cases. To tide the patient
over emergencies carbonate of ammonium in large doses,
by the bowel, and nitroglycerin hypodermatically, may
be required. Inhalations of oxygen may be of service.
Absolute rest and freedom from all disturbances, mental
and physical, must be insisted upon, and the patient
should be given the best nursing that the family can
afford." (Hirst's Obstetrics,)
Puerperal eclampsia. Etiology: Uremia, albumi-
nuria, imperfect elimination of carbon dioxide by the
lungs, medicinal poisons, septic infection; predisposing
causes are renal disease and imperfect elimination by
the skin, bowels, and kidneys. "The treatment of the
attack consists of the administration of chloroform by
inhalation, chloral hydrate (gr. 60) by enema, and the
fluidextract of veratrum viride hypodermically (gtt.
15 followed by gtt. 5, repeated frequently enough to keep
610
OKLAHOMA.
the pulse at about 60 beats a minute), to control the
convulsions, and free purgation by croton oil (gtt. 2,
or 3, in sweet oil or glycerin), free sweating by the
hot pack, and sometimes depletion by venesection to
eliminate the poison. The after treatment consists of
free purgation by the salines, restriction of diet, and
later the administration of tonics and stimulants. The
obstetric treatment is usually non-interference."
(Pocket Cyclopedia,) Sometimes accouchment force is
indicated.
4. The contents of the obstetrical bag will vary with
the requirements and experience of its owner, and the
preparations already made by the patient. In any case
the following articles should be taken by the accoucheur
to a confinement: Tablets of bichloride of mercury, or
some other material for making antiseptic solution ; for-
ceps; ether or chloroform, with inhaler or mask; fluid
extract of ergot; hypodermic syringe, with tablets of
strychnine, morphine, etc.; needles, sutures, and needle
holder; nail brush and nail cleaner; umbilical scissors;
carbolized vaseline; stethoscope; male catheter (rub-
ber) ; a 1 per cent, solution of nitrate of silver, with
eye dropper.
In addition to the above some would also include: A
sterile apron or suit; a Kelly pad; solution of cocaine;
soap, boric acid, and gauze, all sterilized; absorbent
cotton, iodoform gauze, chloral hydrate; dilators and
other instruments.
A bag or grip made of canvas, or a metal case covered
with canvas, is better than a leather bag, as the former
can be sterilized.
Pituitrin is an extract from the posterior lobe of the
pituitary gland; it may be given cautiously in cases of
uterine inertia ; the dose is 1 cc. by intramuscular injec-
tion. As it may cause very severe uterine contractions,
it should not be given unless the os is dilated and there
is no obstruction to delivery.
5. The absolute indications for cesarean section are:
Extreme pelvic contraction or deformity in which deliv-
ery by forceps or version or symphyseotomy is impos-
sible, and" in which craniotomy is either impossible or
would be more dangerous to the mother; the presence
of extreme atresia of the vagina ; rupture of the uterus ;
sudden maternal death.
"Owing to the present low mortality of cesarean
section, the indications for its performance have been
considerably extended in recent years. It is now per-
formed under most of the conditions which were pre-.
611
MEDICAL RECORD.
viously held to necessitate craniotomy upon the living
child, and it will probably in time almost replace sym-
physeotomy; while, owing to the uncertainty of the
survival of the child after induction of premature
labor it is encroaching upon the field of this operation
also. As regards maternal risk, it compares unfavor-
ably with induction of premature labor, in which there
is practically none; but the chances of the survival of
the child in the second degree of pelvic contraction are
very much greater by cesarean section than by induc-
tion. It must, however, be understood that this oper-
ation is only justifiable for moderate degrees of pelvic
contraction, when it can be performed with adequate
preparation and under favorable surgical conditions.
In the case of patients seen for the first time when in
labor the alternatives of craniotomy and symphyse-
otomy will sometimes have to be considered even when
the child is living. There is no doubt that it is better
to perform craniotomy than to attempt to deliver a child
by cesarean section hurriedly undertaken, with insuffi-
cient antiseptic preparation, in insanitary surround-
ings, or by an operator unaccustomed to the technique
of aseptic surgery. And further, it may be wiser to
perform craniotomy than cesarean section when re-
peated unsuccessful attempts have been previously
made to deliver through the natural passages; for
apart altogether from the possible risk of infection
having occurred, the chances of the survival of the
child, even if delivered alive by cesarean section, have
been necessarily prejudiced by repeated and prolonged
attempts to extract it with forceps through a narrow
pelvis. Cranial injuries may thus be caused from which
the child will almost inevitably die, even if born alive.
If there are any positive signs of infection having oc-
curred, such as offensive smell of the liquor amnii, or
fever associated with signs of illness or exhaustion on
the part of the mother, the child's life should be un-
hesitatingly sacrificed, cesarean section in such a case
being ^ an extremely dangerous operation." — (Eden's
Practical Obstetrics.)
6. In the nulliparous adult the uterus is about three
inches long, about two inches wide at the upper part,
and about one inch thick. It is pear-shaped, and lies
between the rectum behind and the bladder in front; it
is below the abdominal cavity and above the vagina. Its
position is one of slight anteflexion, with its long axis
at right angles to the long axis of the vagina. The
anterior surface of its body rests on the bladder, and
612
OKLAHOMA.
the cervix points backward toward the coccyx. The
uterus is not fixed, but moves freely within certain lim-
its. It is held in place by ligaments — broad ligaments,
round ligaments, vesicouterine, rectouterine, ovarian and
uterosacral. The arteries are the uterine and ovarian;
the nerves are from the uterovaginal plexus, the hypo-
gastric plexus, and the vesical plexus.
The Fallopian tubes are about 4% inches long, and
extend from the cornua of the uterus outward to the
free surface of the ovary. The lumen of the tube is
much greater at the ovarian end than at the uterine
end. At the outer end it is surrounded by fringed
processes called the fimbriae. It lies at the upper edge
between the two layers of the broad ligament.
The ovaries are almond shaped, about 1% x % x %
inch; they are attached to the posterior layer of the
broad ligament, at the outer end of and a little below
the Fallopian tube.
7. Curettage is indicated: (1) For removal of pla-
cental debris, (2) in hemorrhagic endometritis, (3) in
some forms of dysmenorrhea (membranous), (4) for
diagnostic purposes, (5) in some cases of puerperal
sepsis, (6) sometimes to check hemorrhage due to
fibroids. Contraindications: (1) The least suspicion
of even the possibility of pregnancy, (2) menstruation,
(3) acute endometritis, (4) malignant disease of the
uterus or vagina, (5) acute pelvic inflammation.
8 and 9. Amenorrhea is absence of menstruation. It
is physiological: Before puberty, during pregnancy and
early lactation, and after the menopause. It may also
be due to: Absence or imperfect development of the
generative organs; also to stenosis, obstructions, or
atresia of the genital tract ; also to operative removal of
the uterus or its appendages. Other causative factors
are: Acute infectious diseases, anemia, chlorosis,
obesity, drug habits, alcoholism, overstudy, lack of exer-
cise, exposure to cold, and various emotional causes.
The prognosis depends upon the cause. Treatment con-
sists in: (1) Removing the cause, if possible; (2) gen-
eral treatment by means of proper hygiene, rest, diet,
bathing, attention to the bowels, exercise, etc.; (3)
drugs reputed to be emmenagogues, such as iron, man-
ganese, aloes, strychnine, apiol, oxalic acid, savine, rue,
and tansy.
Dysmenorrhea is painful menstruation. Causes : Pel-
vic congestion, pelvic inflammation, malnutrition, over-
work, lack of development, neuralgia, stenosis, or ob-
struction of the cervix, prolapse or displacement of the
613
MEDICAL RECORD.
uterus. The 'prognosis depends upon the cause. Treat-
ment: If possible, remove cause; attend to the general
condition, hygiene, tonics, regular habits, etc. ; curettage
may be necessary, and may have to be repeated (per-
haps more than once).
Retroflexion. — Etiology: Tight lacing and tight
clothing; congenital conditions; pressure by tumors;
metrititis and parametritis with adhesions; atonic con-
ditions of the uterus following labor, and the condi-
tions that cause retroversion. Prognosis depends upon
the cause. Treatment: If there are no adhesions, the
flexion should be corrected by digital manipulation and
a pessary introduced; hysteropexy may be necessary.
Retroversion. — Etiology : Relaxation of uterine liga-
ments; increased weight of fundus; subinvolution;
ovarian or other tumor pressing on front of uterus;
distended bladder; peritonitis or cystitis; prolonged
dorsal decubitus and tight bandaging in the puerperium.
Prognosis depends upon the cause. Treatment: Re-
move the cause, if possible ; replace the uterus and keep
it in position by pessaries, tampons, and knee-chest posi-
tion; pelvic massage and vaginal douches; proper hy-
giene, particular attention being paid to the bowels,
clothing, and exercise. Curative treatment: The choice
lies between ventral suspension of the uterus and short-
ening of the round ligaments.
Cystocele is a hernia of part of the bladder into the
vagina, covered by the mucous membrane of the anterior
vaginal wall. Rectocele is a hernia of the rectum into
the vagina, covered by the mucous membrane of the
posterior vaginal wall. The two conditions are gener-
ally found together. Causes: Laceration of the peri-
neum, prolapse of the uterus, relaxation of the struc-
tures forming the pelvic floor, and subinvolution of the
vagina after labor.
Treatment consists of a plastic operation — repair
of the perineum and colporrhaphy.
Pyosalpingitis is a purulent inflammation of the
Fallopian tube. Etiology: Septic infection or gonor-
rhea. The treatment of the acute form consists in rest
in bed, free purgation with Rochelle salts (31 every
hour), hot vaginal douches, and hot applications to the
abdomen. If the symptoms become more severe celiot-
omy is indicated. The chronic form may be treated
during the menstrual period by rest in bed, free purga-
tion, hot vaginal douches, local applications of iodine to
the cervix and vaginal vaults, and glycerin tampons.
If these measures fail, removal of the tube and ovary
614
OKLAHOMA.
and replacing the retroverted uterus, etc., are neces-
sary.
Endometritis is inflammation of the mucous mem-
brane lining the uterus. The acute form is due to the
introduction of septic bacteria, and is manifested by
pain, constipation, irritability of bladder, rapid pulse,
rise of temperature, and a profuse discharge. Treat-
ment following miscarriage or labor consists in curet-
tage, intrauterine hot sterile douche, free purgation, hot
stupes over the lower abdomen, milk diet and stimulants.
Chronic endometritis may accompany numerous path-
ological uterine conditions, but is generally due to gon-
orrhea. The symptoms are backache, headache, leucor-
rhea, profuse menstruation, and impairment of the
general health. Treatment consists in removing the
cause when possible, and when due to gonorrhea curet-
tage and irrigation of the uterus, with the application
of an antiseptic.
10. Gonorrhea. — Etiology: The gonococcus of Neis-
ser. Symptoms, — Pain and burning in the vulva; pain
and burning on micturition; dyspareunia; yellowish or
greenish discharge, in which the gonococcus can be
found; the vagina is hot, red, swollen, and tender.
Possible results. — Cystitis, urethritis, vulvitis, endom-
etritis, salpingitis, septic peritonitis, sterility, condy-
lomala of vulva, abscess of Bartholin's glands. Diag-
nosis is made from the symptoms, particularly from
finding the gonococcus in the discharge. It is so serious
on account of the possible results enumerated above; it
often leads to chronic invalidism, and may be the cause
of death.
Treatment: Rest, if possible in bed; freedom from
alcoholic or sexual excitement; a mild and unirritating
diet; salines and diuretics; plenty of water to drink;
a warm sitz bath; douching of vagina with about a
gallon of a 1:5000 bichloride solution, or of borax (1
dram to the quart), or of potassium permanganate (1
per cent, solution) ; the douche is to be taken in the
recumbent position.
SURGERY.
1. The tonsils occupy the recesses between the pillars
of the fauces, the anterior pillar being formed by the
palato-glossus and the posterior by the palato-pharyn-
geus. On the outer side of each is the superior con-
strictor, and internally the buccal mucous membrane.
Their arterial supply is large, from the ascending
pharyngeal, ascending and descending palatine, tonsil-
litic and dorsalis linguae arteries. — (From Aids to
Anatomy) .
615
MEDICAL RECORD.
Acute Tonsillitis probably arises from infection with
micro-organisms, but cold is a predisposing cause. The
inflammation may be superficial, and only portion of a
general catarrhal inflammation of the velum and
pharynx. Treatment is by a gargle of chlorate of potash.
Acute Follicular Tonsillitis is marked by general en-
largement of the tonsils, with consequent obstruction
to breathing and swallowing. Patches of exudation are
seen at the mouths of the follicles, the temperature is
raised, the bowels are confined, and the submaxillary
glands are enlarged and tender.
Acute Parenchymatous Tonsillitis is inflammation of
the tonsil, soft palate, and fauces, and often results in
a peritonsillar abscess. The palate and anterior pillar
are dusky and swollen, and the tonsil is pushed across
to the mid-line. These conditions are distinguished from
scarlet fever by the absence of the characteristic rash.
Follicular tonsillitis is treated by giving calomel (5
grains), salicylate of soda, and an antiseptic throat
spray. Peritonsillar abscesses must be opened by punc-
turing the most prominent part of the swelling and en-
larging the opening with forceps.
Chronic Tonsillitis results in hypertrophy, and is
usually associated with adenoids. The tonsils are large
and pale, and show the large orifices of the crypts.
Recurrent attacks of inflammation are common. The
patients are usually mouth-breathers and snore at night.
Deafness may occur from associated swelling of the
orifice of the Eustachian tube. Treatment. — Fresh air
and good food, together with painting the tonsils daily
with glycerine of tannic acid, will cure some cases;
but most resist this treatment, and so tonsillotomy is
required. This may be done with cocaine or gas, and
the tonsil is best removed with the spade guillotine.
Forceps and a tonsil bistoury may also be used. Hemor-
rhage soon ceases in children. If it continues, iced
lotion should be applied; if that fails, the galvano-
cautery. The tonsil may also be shelled out with the
finger after snipping the mucous membrane in front
of it. — (Aids to Surgery).
2. Pterygium is a triangular fold of membrane ex-
tending from the inner or outer part of the ocular con-
junctiva to the cornea; the apex is immovably united
to the cornea, the base spreads out and merges with
the conjunctiva. It is thought by some to originate
from Pinguecula, the process extending to the cornea
and drawing the conjunctiva after it. It occurs in
elderly persons who are exposed to wind or dust.
616
OKLAHOMA.
Treatment: The pterygium may be dissected away
with a sharp scalpel or Beer's knife, and cut off, the
conjunctival defect being closed by uniting the upper
and lower borders, undermining the conjunctiva if
necessary to bring the edges together. The apex of
the pterygium must be thoroughly excised from the cor-
nea, and its attachment in this situation scraped or cau-
terized with the actual cautery, to prevent recurrence.
Instead of cutting off the pterygium, it may be dis-
sected up and stitched underneath the detached con-
junctiva, either above or below; or it may be divided
into two halves, of which one is transplanted above and
the other below, being held in the conjunctival pocket
by a stitch. — (May's Diseases of the Eye.)
3. Three dressings suitable for fractured clavicle.
(1) Velpeau's bandage: "First place the arm in the
Velpeau position, the hand of the injured side on the
opposite shoulder. From the axilla of the sound side
pass across the back, over the outer part of the injured
shoulder, down across the middle of the arm, behind
the elbow, across the chest, and through the axilla of
the sound side to the point of starting. Next apply a
horizontal turn on a level with the affected elbow. Re-
peat these turns until the elbow is covered with the
vertical, and the wrist with the horizontal turns. The
vertical turns should overlap two-thirds of each pre-
ceding turn, and the horizontal ones one-third. Secure
the bandage by strips of adhesive plaster. (2) De-
sauWs bandage: "Three bandages and a wedge-shaped
pad are required. The pad is placed in the axilla of
the injured side, base up. The arm is allowed to hang
by the side, and the forearm is flexed at a right angle.
The first bandage is used to hold the pad in place.
Beginning at the base of the pad, descending spiral
turns, encircling the chest, are applied down to its apex
near the elbow, and then ascending spiral turns back
to its base. To hold the pad up in the axilla, the first
bandage may be terminated with a figure-of-8 turn of
the opposite shoulder. The second bandage binds the
arm to the side. Beginning at the axilla of the sound
side, on a level with the base of the pad, descending
spiral turns are applied, with increasing firmness, down
to the elbow, so as to carry the shoulder outwards. The
third bandage is applied in the form of an anterior
and a posterior triangle, the apex of each being formed
by the axilla of the sound side, and the base by the
humerus of the injured side. Begin the bandage at the
axilla of the sound side posteriorly, pass over the af-
fected shoulder, down in front of and parallel with the
617
MEDICAL RECORD.
humerus, under the elbow, and across the back to the
starting point. The anterior triangle is applied in the
same way, by continuing the bandage through the
axilla, across the chest, over the shoulder of the in-
jured side, down behind the humerus, under the elbow,
and back across the front of the chest to the starting
point. (3) Sayre's dressing: "Two strips of adhesive
plaster three or four inches wide, and long enough to
extend around the chest one and a half times are pre-
pared. Lint powdered with zinc stearate is placed in
the fold of the elbow and between the arm and the
chest. A collar of lint as wide as the adhesive strip
is placed about the arm just below the axilla, and over
this is applied the end of one of the strips of plaster,
so as to form a loop; the strip is now used to pull the
arm backwards, and is fastened around the chest. The
hand of the affected side is placed on the opposite shoul-
der, and the second strip of plaster, with a hole for
the point of the elbow, is run from the back of the
sound shoulder, under the elbow of the affected side,
over the sound shoulder, to the back, thus drawing the
elbow forwards and upwards, and with the aid of the
first strip, which acts as a fulcrum, forcing the shoul-
der backwards and outwards. A pad, held in place by
a strip of adhesive plaster, may be placed just above
the clavicle to press the fragment downwards." — (Stew-
art's Surgery.)
4. In fracture of the middle of the humerus, the
inusculospiral nerve may be injured. If this injury is
sufficient to produce paralysis, the patient is unable to
extend the wrist and fingers, or to supinate the fore-
arm. Sensation, in the lower half of the outer and
anterior aspect of the arm and in the middle of the
back of the forearm, is lost or impaired.
5. The treatment of carbuncle is excision in those
cases in which the carbuncle is favorable situated; the
wound is allowed to granulate under antiseptic dress-
ings. In other cases the honeycombed mass should be
opened freely by crucial incisions, and as much of the
necrotic tissue as possible removed by forceps and
scissors. The wound should then be disinfected with
peroxide of hydrogen and bichloride of mercury solu-
tion, 1 to 1,000, and dressed with warm antiseptic fo-
mentations. The constitutional treatment is that of
sepsis.
The treatment of furuncle is incision, when the boil
is mature. Tonics, calx sulphurata, dilute sulphuric
acid, brewer's yeast, and vaccines have been recom-
mended in the treatment of this trouble.
618
OKLAHOMA.
CHANCRE.
First lesion of a constitu-
tional disease, viz., syph-
ilis.
Due to syphilitic infection.
Generally a venereal infec-
tion.
May occur anywhere on
the body.
Period of incubation never
so short as ten days.
Generally single.
Not autoinoculable.
Secretion slight.
Slightly or not at all pain-
ful.
As a rule only occurs once
in any patient.
Buboes are painless and
seldom suppurate.
CHANCROID.
A local disease.
Due to contact with se-
cretion from chancroid.
Always a venereal infec-
tion.
Nearly always on genitals.
Period of incubation al-
ways less than ten days
(generally about three) .
Generally multiple.
Autoinoculable.
Secretion profuse and pu-
rulent.
Generally painful.
May reoccur in same pa-
tient.
Buboes are painful and
usually suppurate.
Chancroid of the penis may be treated by being
sprayed with peroxide of hydrogen, dried with cotton,
then touched with pure carbolic acid and then with
pure nitric acid; afterwards a dressing soaked with
black wash may be applied. The penis should be soaked
in hot salt water (a teaspoonful of salt to a pint of hot
water) every few hours; and the peroxide of hydrogen
spray, the drying with cotton, and the application of
the dressing should be repeated.
_ 7. In the non-operative treatment of acute appendi-
citis: Ochsner recommends that hot moist compresses
be applied to the abdomen; he advises hot boric acid
solution and alcohol.
Murphy recommended enteroclysis by the drop
method, to relieve the thirst.
Fowler recommended that the patient be put in the
semi-sitting posture.
8. "The treatment of a severe contased-lacerated
wound, in the absence of urgent hemorrhage, is directed
to the shock. After this has subsided, the patient should
be anesthetized in order thoroughly to disinfect the
wound. Tissue whose vitality is questioned should be
619
MEDICAL RECORD.
removed if it is unimportant, in other cases it should
be retained unless known to be badly infected. All
visible vessels, whether bleeding or not, are ligated,
and provision made for abundant drainage. It is im-
portant to introduce as few sutures as possible, and
to be sure that they do not unduly constrict the tis-
sues, otherwise the subsequent swelling will cause
necrosis. The wound is dressed with hot antiseptic
fomentations. The later treatment depends upon the
complications. If there are symptoms # of sepsis, the
whole wound should be opened, redisinfected, and
packed with antiseptic gauze. Sloughing demands hot
antiseptic fomentations, and removal of the slough at
the earliest possible moment. Secondary hemorrhage
may occur at this period from the separation of a
slough involving the wall of an artery. The general
health should, of course, receive proper attention." —
(Stewart's Surgery.)
9. Radiography has been employed as an aid to diag-
nosis in the case of: Foreign bodies, fractures, dislo-
cation, epiphyseal separation, injuries around a joint,
diseases and tumors of bones, pathological conditions
of the mastoid and accessory sinuses of the skull, tu-
berculous deposit or cavity formation in the lungs,
thickened pleura, aneurysms, enlarged glands, tumors,
various diseases of the esophagus, stomach and intes-
tines, renal calculi, movable kidney, tuberculosis of the
kidney, pus kidney, ureteral calculi, vesical calculi, and
other conditions. Radiography is an aid in the treat-
ment of disease, as follows: (1) It causes atrophy of
the appendages of the skin; (2) it destroys organisms
in living tissues; (3) it stimulates the metabolism of
tissues; (4) it destroys certain pathological tissues; (5)
it has an anodyne effect. It has been used in various
skin diseases, malignant growths, ulcers, exophthalmic
goitre and numerous other conditions.
10. Gunshot wound of the chest. — "The treatment, in
the absence of serious hemorrhage or the lodgment of
a foreign body, is disinfection and suture of the ex-
ternal wound and immobilization of the affected side
of the chest. Hemorrhage from the internal mammary
or intercostal artery may be controlled by ligation, or
by pushing a gauze sac between the ribs and filling the
inner end of the sac with gauze so that when drawn
upon it will make pressure from within outwards. Ex-
cepting extensive wounds, bleeding from the lung is
rarely fatal, as the bleeding is checked by collapse of
the lung. In the absence of external hemorrhage, seri-
620
OKLAHOMA.
ous loss of blood is diagnosticated by the constitutional
signs of acute anemia, and a rapidly accumulating
hemothorax. Cases of this sort have been treated by
the introduction of a drainage tube in order to admit
air and favor collapse of the lung, but in the presence
of serious symptoms one or more ribs should be re-
sected, and the wounded lung dealt with directly by
sutures or gauze packing. Foreign bodies should be
removed if easily accessible, and the same rules as to
the examination of the clothing, etc., apply here as
elsewhere. If the foreign body is not easily found, it
should be allowed to remain, unless it gives rise to
subsequent trouble, when it may be definitely localized
by the #-ray and its removal effected, if such be deemed
advisable."
Perforating gunshot wound of the abdomen. "The
treatment, even without symptoms of visceral injury,
is immediate enlargement of the wound, in order to ex-
plore the abdomen, check hemorrhage, and close such
visceral perforations as may be found. The abdomen
is then flushed with salt solution, and closed or drained,
according to the amount of soiling present. If the
omentum protrudes it should be ligated and removed,
while coils of intestine should be carefully washed with
salt solution and returned to the cavity. In cases in
which there is doubt as to whether or not a wound
enters the peritoneal cavity, such wound should be en-
larged and the diagnosis positively made, being pre-
pared at the same time to treat any visceral injuries
that may be found. In gunshot wounds on the battle
field an exception has been made to the rule of imme-
diate exploration, because it has been found that the
chances of recovery are somewhat better without than
with operation undertaken in the absence of proper
facilities." — (Stewart's Surgery.)
TOXICOLOGY AND MEDICAL JURISPRUDENCE.
1. The symptoms of strychnine poisoning are as fol-
lows: "Strychnine produces a sense of suffocation,
thirst, tetanic spasms, usually opisthotonos, sometimes
emprosthotonos, occasionally vomiting, contraction of
the pupils during the spasms, and death, either by
asphyxia during a paroxysm, or by exhaustion during
a remission. The symptoms appear in from a few min-
utes to an hour after taking the poison, usually in less
than twenty minutes; and death in from five minutes
to six hours, usually within two hours." — (Witthaus'
Essentials of Chemistry.)
621
MEDICAL RECORD.
In tetanus, the onset is gradual, is apt to begin with
trismus, swallowing is difficult or impossible, the con-
dition is persistent, consciousness is dulled or lost, and
there is history of a wound or injury. In strychnine
poisoning the onset is more sudden, the muscles of
the jaw and neck are generally the last to be affected,
there are marked remissions with muscular relaxation,
consciousness is retained, and there is no history of a
wound or injury.
2. Two drugs that produce convulsions: Strychnine
and picrotoxin.
Antidote to strychnine: There is no chemical anti-
dote; chloral or chloroform may control the convulsions.
Antidote to picrotoxin: There is no chemical antidote;
chloral or chloroform may control the convulsions.
3. The antidote to silver nitrate is solution of sodium
chloride; it acts by converting the silver nitrate into the
insoluble silver chloride : AgN0 2 +NaCl=AgCl-fNa-
N0 3 .
4. Symptoms of cocaine poisoning: "When a large
dose has been taken the symptoms are not unlike those
of atropine poisoning. There is dryness of the throat,
tongue, and nose, difficulty of swallowing, faintness, and
sometimes nausea and vomiting. The pulse is usually
increased in fullness and frequency at first. The res-
piration also becomes more rapid, and there is much
general nervous excitement, with general hyperesthesia.
The eyes are bright and staring and the pupils dilated.
The patient talks volubly and incoherently. Sometimes
an erythematous eruption appears on the skin. The
stage of depression soon comes on, when the breathing
becomes shallow, the heart's action more rapid, and
the face pale or cyanotic. The surface becomes anes-
thetic, and muscular twitchings and paralysis precede
death, which is generally caused by paralysis of res-
piration." — ( Riley's Toxicology. )
5. The antidote for alkaloids is tannic acid; it acts
by forming a precipitate with the alkaloid which is
practically insoluble.
6. Medical jurisprudence is the application of the
knowledge of any of the branches of medicine to the
problems and requirements of the law.
7. In burns produced before death: there is usually a
blister, with a bright, red base, and containing a serous
fluid, which is albuminous; occasionally, there will be
no blister if there has been excessive shock; also, there
will be a red line of demarcation between the injured
and the uninjured parts, and this, being a vital process,
is only developed during life.
622
OKLAHOMA.
In burns produced after death there is no true blister,
no red base, and gas is present in place of serous fluid.
8.* Abortion is justifiable: "(1) In pelvic deformity
where there is sufficient space for a seven months' child
to be delivered without injury. The object is twofold:
(a) to save the child's life by obviating the necessity
for craniotomy; (b) to spare the mother the dangers
of craniotomy, cesarean section, symphyseotomy, or
other operations that might be required if the preg-
nancy went to full term. (2) In cases where, in previ-
ous labors, the head of the child at full term has been
prematurely ossified, or unusually large, so that labor
has been difficult and dangerous, even though the pelvis
were normal. The period of delivery need only be two
or three weeks before 'term' in these cases. (3) In cases
where the children of previous pregnancies have died
in utero during the later weeks of gestation from dis-
ease (fatty, calcareous, or amyloid degeneration, etc.)
of the placenta. (4) In conditions where the continu-
ance of pregnancy seriously endangers the mother's
life, such as: excessive vomiting; albuminuria; uremic
convulsions, or paralysis; chorea; mania; organic dis-
ease of the heart, lungs, liver, blood-vessels, etc., threat-
ening fatal disturbance of the respiration, circulation,
and other vital functions; irreducible displacements of
uterus; placenta praevia with hemorrhage; and in dan-
gerous pressure upon neighboring organs from over-
distention of uterus, due to dropsy of amnion, tumors,
multiple pregnancy, etc." — (King's Manual of Obstet-
rics.)
9. In some states a physician is not allowed to dis-
close certain information without the consent of the
patient concerned ; such information is considered "priv-
ileged communication." In other states, such exemption
is not allowed. The physician, however, must obey the
ruling of the court.
10. In expert testimony the witness may give his
opinion on facts or supposed facts as noted by himself
or asserted by others. Theoretically, this can only be
done by those perfectly familiar with the subject in
question; but practically any (or almost any) physician
with a license to practise is accepted as an expert wit-
ness.
623
MEDICAL RECORD.
STATE BOARD EXAMINATION QUESTIONS,
Pennsylvania Bureau of Medical Education and
Licensure.
physiology, pathology and bacteriology.
1. Name two bacilli that are apt to attack the respi-
ratory tract. Describe the characteristic lesion of each.
Outline the laboratory tests used in identifying each.
2. Describe briefly gastric digestion. Diagnose by
laboratory methods each of two lesions which seriously
impair it.
3. Outline briefly ways in which hypertrophied lym-
phoid tissue in the pharynx may be detrimental to
health, (a) physiologically, (6) pathologically.
4. Given a case of pyuria (pus in the urine) outline
the investigations and tests which may locate the
source of the trouble.
5. Temperature of the body: Tell briefly how the
heat is produced, (b) how regulated, the (c) physio-
logical and the (d) pathological significance of any in-
crease or decrease from normal.
6. Describe the gross lesion in (a) tabes dorsaiis,
(b) apoplexy. What alteration in function does each
produce?
7. Give a general outline of the essential equipment
for a clinical laboratory. Outline the type of work
which should be performed in such a laboratory.
8. Given a case of irregular fever in an adult which
persists, give the laboratory tests which would aid in
establishing the diagnosis.
9. State the significance of each of the following:
(a) Jacksonian epilepsy, (6) choked disc, (c) Bell's
palsy, (d) nystagmus, (e) Argyll-Robertson pupil.
10. Name three localized lymphatic glandular en-
largements and give causes for each.
SYMPTOMATOLOGY, DIAGNOSIS, TOXICOLOGY AND MEDICAL
JURISPRUDENCE.
1. Enumerate the symptoms diagnostic of typhoid
-fever. Name one disease with which it may be con-
fused and differentiate them.
2. Enumerate the symptoms of cancer of the stomach.
Differentiate it from cholecystitis.
3. Enumerate the symptoms of lobar pneumonia and
differentiate it from acute pleurisy with effusion.
4. Enumerate the symptoms of scarlet fever. Name
two sequelae which may follow and describe the sym-
toms of each.
624
PENNSYLVANIA.
5. Enumerate the symptoms diagnostic of acute alco-
holism. Differentiate it from uremia.
6. Differentiate the secondary eruptions of syphilis
from other skin lesions.
7. Differentiate acute inflammatory glaucoma from
iritis.
8. Enumerate the symptoms cf chronic laryngitis.
Differentiate it from laryngeal tuberculosis.
9. Enumerate the symptoms of ptomaine poisoning.
Differentiate it from other forms of gastroenteritis.
10. Name four conditions of a pregnant female in
which a physician would be justified in causing prema-
ture birth. What are his duties from a medicolegal
standpoint?
OBSTETRICS AND GYNECOLOGY AND PHYSIOLOGICAL
CHEMISTRY.
1. Given a patient eight w r eeks pregnant with a retro-
displaced uterus: How would you distinguish the dis-
placement? What are the possible results? How would
you manage the case?
2. Given a case of labor with a prolapsed cord : What
are the possible results? How would you manage the
case? How would you treat the child after delivery?
3. Given a patient six hours in labor who has begun
to bleed freely: What are the possibilities in the case
and how w T ould you differentiate between them? How
would you treat any two of the possible conditions?
4. Given a patient with persistent itching about the
vulva: Name four common causes for the condition.
Give the local treatment.
5. Name four abdominal enlargements (as large as
pregnancy at the seventh month) other than pregnancy.
Differentiate them one from the other.
6. Name the more usual bacteria which cause puer-
peral fever, together with the methods of their intro-
duction into the birth canal. Name the results that
may occur from their presence and the prevention of
these possible results after the introduction of the
bacteria.
7. Should you be called upon to deliver a woman at
full term of pregnancy discuss the status of the use
of (a) the vaginal douche; the use of (b) an anesthetic;
the use of (c) ergot; the use of (d) pituitrin.
8. Discuss the thyroid gland from the chemical and
physiological standpoints and state the effect of any
change in equilibrium of the essential constituent.
9. Describe a test for each of the following patho-
625
MEDICAL RECORD.
logical urinary constituents: (a) Bile; (b) blood;
(c) acetone.
10. What is cholesterol (cholesterin) ? Where is it
found normally and in what pathological conditions is
it of importance?
ANATOMY AND SURGERY.
1. In a patient upon whom an abdominal operation
is to be performed, what local and general preparation
would you advise?
2. In posterior luxation of the hip joint: Give meth-
od of reduction, with anatomical and mechanical
reasons for manipulations employed.
3. What conditions may cause gangrene of the leg?
State indications for and against the amputation of a
leg in which gangrene has occurred.
4. Name the more usual localities in which carcinoma
appears. State the more usual early symptoms present.
5. What surgical conditions may cause hematuria?
Give the special symptoms of any one surgical condition
capable of causing hematuria, and outline the surgical
procedure for its correction.
6. What blood vessels may be involved in severe
epistaxis? Describe methods of controlling severe
epistaxis.
7. In fractures of the bones of the forearm, state
three forms of splints that may be employed. Indicate
location of fracture in which you would employ each,
with anatomical reasons for the selection of the same.
8. Enumerate the conditions that would warrant the
amputation of a leg. Outline the technic of amputa-
tion of the leg (upper third). State the anatomical
structures severed.
9. For what conditions may resection of the elbow
joint be performed? Outline the technic of the opera-
tion, giving the surgical anatomy of the parts.
10. Enumerate the various forms of hernia found in
the groin. Upon what is the anatomical classification
based? Describe a method of reducing by taxis in any
one form selected, naming the form selected. Briefly
outline the anatomical points to be considered in the
radical operation for femoral hernia.
PRACTICE, MATERIA MEDICA, THERAPEUTICS AND HYGIENE.
1. Give the medicinal and dietetic treatment, and
state your reasons therefor, of a case of vomiting of
pregnancy.
2. Outline in brief the effects of the excessive use
of: (a) Coffee, (b) tea, (c) chocolate, (d) alcohol,
and (e) tobacco.
626
PENNSYLVANIA.
3. Describe the therapeutic action of: (a) Cocaine,
of (b) veratrum viride, and of (c) apomorphine.
4. Outline the treatment of a case of pneumonia:
(a) during the onset, (b) during the height of the
disease, and (c) during convalescence.
5. (a) Describe the administration of spinal an-
esthesia, (b) What are the dangers of ether or chloro-
form anesthesia? (c) What precautions would you
take in furtherance of their avoidance?
6. Outline the medicinal and dietetic treatment of
chronic constipation. Describe any other means or
measures you consider of importance in such a con-
dition.
7. How would you combat therapeutically: (a) Ex-
cessive cough in tuberculosis? (b) a paroxysm of an-
gina pectoris? (c) puerperal eclampsia?
8. Describe the local effects produced by a solution
of: (a) Atropine sulphate, and of (6) pilocarpine
hydrochlorate when dropped into the eye. What
strength of the solution of each would you prescribe
for the usual purposes for which they are used? What
are the contraindications to the use of each?
9. State what articles of diet you would prohibit and
what ones you would permit in a patient with arterio-
sclerosis and high blood pressure. What benefits would
you expect from a reduction in weight of the patient?
10. How would you treat, other than by operative
measures, abdominal ascites and the general edema
occurring as a complication in heoatic and renal
disease?
ANSWERS TO STATE BOAED EXAMINATION
QUESTIONS.
Pennsylvania Bureau of Medical Education and
Licensure.
physiology, pathology and bacteriology.
1. Two bacilli that are apt to attack the respiratory
tract: The bacillus diphtherise and the bacillus influ-
enzae.
Lesions. In diphtheria, the false membrane may be
found on the fauces, larynx, pharynx, trachea, or other
mucous membrane. This membrane consists of a net-
work of fibrin which enmeshes round cells, connective
tissue cells, streptococci and the specific bacilli; in the
fauces and nares the membrane is adherent. The
superficial layer of epithelium is necrosed, later on
627
MEDICAL RECORD.
the deeper layers suffer in the same way, the zone of
inflammation extends, and the membrane becomes a
mass of dead cells undergoing hyaline degeneration and
mingled with fibrin. In influenza, there is an inflam-
matory swelling with hyperemia of the nasal mucous
membrane and sometimes of the nasal sinuses and
trachea and bronchi; the latter may be covered with
muco-pus.
The characteristics of the bacillus of diphtheria : The
bacilli are from 2 to 6 mikrons in length and from 0.2
to 1.0 mikron in breadth; are slightly curved, and often
have clubbed and rounded ends; occur either singly or
in pairs, or in irregular groups, but do not form chains ;
they have no flagella, are nonmotiie, and aerobic; they
are noted for their pleomorphism ; they do not stain
uniformly, but stain well by Gram's method and very
beautifully with Loeffler's alkaline methylene blue.
A sterile swab is rubbed over any visible membrane
on the tonsils or throat, and is then immediately passed
over the surface of the serum in a culture tube. The tube
of culture, thus inoculated, is placed in an incubator at
37° C. for about twelve hours, when it is ready for
examination. A sterile platinum wire is inserted into
the culture tube, and a number of colonies of a whitish
color are removed by it and placed on a clean cover
slip and smeared over its surface. The smear is al-
lowed to dry, is passeoV two or three times through a
flame to fix the bacteria, and is then covered for about
five or six minutes with a Loeffler's methylene-blue solu-
tion. The cover slip is then rinsed in clean water, dried,
and mounted. The bacilli of diphtheria appear as short,
thick rods with rounded ends ; irregular forms are char-
acteristic of his bacillus, and the staining will appear
pronounced in some parts of the bacilli and deficient
in other parts. Methods of culture: The bacillus of
diphtheria grows upon all the ordinary culture media,
and can be readily obtained in pure culture. Loeffler's
blood serum, particularly with the addition of a little
glucose, is an admirable medium for the rapid growth of
this bacillus. The medium should be alkaline and not
less than 20° C. Method of staining: It stains with
any aqueous solution of an aniline dye, and quite char-
acteristically with Loeffler's alkaline methylene blue.
Neisser's stain is also recognized. The bacilli also stain
well by Gram's method.
The bacillus of influenza is a very small bacillus,
generally found in pus cells in the nasal or bronchial
secretions; it is Gram negative, and stains more deeply
at the ends than in the middle; the colonies are small,
discrete and transparent.
628
PENNSYLVANIA.
2. On entering the stomach the food is already
crushed, mixed with saliva, and reduced to a pulp ; it is
rendered slightly alkaline, and a small amount of the
starch has been converted into maltose; the proteids
and fats are unaltered. In the stomachy where the
contents are rendered acid, conversion of starch into
sugar ceases, connective tissue of fats is dissolved, and
fats are set free. Proteids are dissolved and peptones
formed. The albuminous foods are dissolved for the
most part, and a grumous mixture of peptones, liquid
fats, and starches is formed, which is termed chyme,
and is gradually passed through the pylorus into the
intestine. The contents of the stomach at the close of
gastric digestion are: Water, inorganic salts, acidified
proteids, peptones, liquid fats, starch, cellulose, and the
indigestible residues of various foods.
In gastric carcinoma there may be noted absence of
free hydrochloric acid, presence of lactic acid, and
presence of Boas-Oppler bacillus. In gastric ulcer, there
is excess of free hydrochloric acid generally, and blood
is often present; lactic acid and the Boas-Oppler bacil-
lus are not present.
3. Hypertrophied lymphoid tissue in the pharynx may
result in: Mouth-breathing; snoring; open-mouth; a
vacant, dull expression of the face; modification of the
voice (nasal twang), with inability to pronounce cer-
tain letters. Earache and other ear affections; mental
deficiency; frequent attacks of coryza; nose-bleed;
stunted growth; convulsions, laryngismus, stridulus,
and various other neuroses may also be noticed.
4. In a general way, it may be said that if pus ap-
pears in the first part of the urine, it is from the
urethra; if it appears in the last part chiefly, or at the
end of urination, it is from the bladder; if the pus and
urine are mixed, the pus probably comes from the kid-
ney. Further, if the pus is from the bladder, the urine
is more or less alkaline; if from the kidney or from
some outside source, it is usually acid. By the use of a
cystoscope, urethroscope or ureteral catheterization, the
lesion may be located; a sound may detect a vesical
calculus; x-ray examination may show lesion in kid-
ney, and a bacteriological examination of the pus may
also aid.
5. The normal body temperature is regulated and
maintained by the thermotactic centers in the brain and
cord keeping an equilibrium between the heat gained
or produced in the body and the heat lost.
Heat is produced in the body by: (1) Muscular ac-
tion; (2) the action of the glands, chiefly of the liver;
629
MEDICAL RECORD.
(3) the food and drink ingested ; (4) the brain; (5) the
heart; and (6) the thermogenetic centers in the brain,
pons, medulla and spinal cord.
Heat is given off from the body by: (1) The skin,
through evaporation, radiation, and conduction; (2) the
expired air; (3) the excretions — urine and feces.
Increase of body temperature may indicate the pres-
ence of infectious diseases, toxemias, inflammation, or
some interference with the nerve mechanism of heat
regulation.
Decrease of body temperature may indicate wasting
diseases, # starvation, alcoholism, convalescence from
fever, poisoning or collapse.
6. In tabes dorsalis the posterior columns of the spinal
cord and the posterior nerve roots are involved. The
posterior columns of the spinal cord are gray and
shrunken, and show considerable overgrowth of con-
nective tissue in the columns of Goll, Burdach, and
Lissauer; this process extends upward from the lumbo-
sacral region; the posterior nerve roots degenerate and
become atrophic. The meninges over the affected parts
become opaque and adherent. Some of the cranial
nerves may also atrophy, notably the optic, but also
the motor oculi and vagus. The process is destructive
and progressive; it is not a simple wasting, although
the nerve fibers are atrophied, but it is characterized
by irritation, changes in the axis cylinders, overgrowth
of the connective tissue, and sometimes congestion ; the
spinal ganglia may be affected.
In apoplexy "the primary effects are tearing and com-
pression of the brain-substance. If the patient does
not die immediately, softening occurs. As a result of
the staining by the retained hemoglobin the area is
known as red softening. Shortly after the blood escapes
it undergoes coagulation, forming a cerebral hematoma.
This acts as a foreign body, and sets up an inflam-
matory reaction, with more or less hyperplasia of the
surrounding neuroglia. The fluid portion finally be-
comes absorbed, the corpuscles broken down, and the
pigment liberated, which stains the walls of the cavity.
Occasionally a cyst filled with a clear fluid may form.
If all fluids are absorbed, the walls of the cavity
may come in contact and a scar result." (McConneirs
Pathology.)
In tabes dorsalis the disturbance of function includes
loss of sensation in the feet, girdle sensation, loss of
coordination of muscles, inability to preserve the erect
position with the feet together, impairment of vision,
Argyll-Robertson pupil, abolition of patellar reflex,
330
PENNSYLVANIA.
muscular atrophy, loss of sexual power, and paralysis.
In apoplexy the disturbances of function depend on
the site of the lesion; if this is above the first cervical
segment of the pyramidal tract, there will be paralysis
of the opposite side of the body; if above the middle
of the pons, paralysis of the lower portion of the face
on the opposite side is also produced; if below this
point, paralysis of the same side. Monoplegias are
likely to occur if only a small portion of the fanlike
projection-fibers of the pyramidal tract is involved,
such as would be produced by a lesion in the cortex or
in the centrum ovale. Spasticity arises in the muscles;
subsequently their nutrition is impaired, and they
contract. Amnesia or aphasia will occur if the lesion
is in those portions of the cortex which have to do with
speech. Lesions of the optic tract posterior to the
chiasm cause hemianopsia. (From Stengel's Path-
ology.)
7. A clinical laboratory should be provided with a
sink, running water, gas, electric light, tables, benches,
stools, shelves, reagents, test tubes, beakers, slides,
coverslips, microscope, centrifuge, apparatus for esti-
mating hemoglobin and counting blood corpuscles, Petri
dishes, flasks, pipettes, litmus paper, distilled water,
Bunsen burner, alcohol lamp, burettes, holders for
burettes and test tubes, stomach tube, urinometer,
ureometer, Esbach's albuminometer, funnels, tripod,
wire gauze, sphygmomanometer, incubator, thermom-
eters, steam sterilizer, thermoregulator, platinum wire
loops, pure culture of typhoid bacillus. The work which
can be done will depend on the size and equipment
of the laboratory, the number and experience of the
workers, and the time that can be given to such work.
It should include uranalysis (at least qualitative and
microscopic) ; examination of gastric contents, and spu-
tum; blood examinations (counting corpuscles, estimat-
ing hemoglobin, and searching for parasite of malaria) ;
Widal's test; examination of smears for gonococcus;
examination of blood for anemia, chlorosis, leucemia,
and the Treponema pallidum; estimation of blood pres-
sure; examination of feces for parasites, protozoa, bac-
teria, and occult blood ; cerebrospinal fluid ; milk, and
various bacteriological methods (such as sputum for
tubercle bacillus, nasal secretion or smear from throat
for diphtheria bacillus). Wassermann's reaction and
Noguchi's reaction may also be included.
8. Irregular fevers are of a negative character, and
indicate the absence of any febrile disease which has
a characteristic temperature curve, such as malaria,
631
MEDICAL RECORD.
typhoid, pneumonia. Some other symptom will have
to be taken as a guide, and the laboratory tests (sputum,
urine, cerebrospinal fluid, and blood) will have to fol-
low such indications as these other symptoms supply.
9. Jacksonian epilepsy may indicate: Tumor, soft-
ening, abscess, hemorrhage or injury of the brain;
general paresis; uremia; it may occur as a sequel to
hemiplegia in children.
Choked disc may occur in: Retinitis, tumors of cere-
brum or cerebellum, cerebral abscess, tuberculous menin-
gitis.
BelVs palsy may occur in rheumatism and as a result
of infection or exposure; it may be found in cases of
multiple neuritis or locomotor ataxia, and may follow
ear disease and injuries to the petrous portion of the
temporal bone.
Nystagmus may indicate: Irritation of the ocular
muscle centers, cataract, errors of refraction, optic
atrophy, epilepsy, neurasthenia, hysteria, chorea, tu-
mors of brain, Friedreich's ataxia, locomotor ataxia,
and chronic hydrocephalus.
Argyll-Robertson pupil may signify: Locomotor
ataxia, intracranial syphilis, and general paralysis of
the insane.
10. Enlarged lymphatic glands in the neck may be
due to: Inflammation, tuberculosis, syphilis, Hodgkin's
disease, leucemia; in the groin, the cause may be:
Syphilis, gonorrhea, chancroid, Hodgkin's disease, tuber-
culosis, malignant disease; in the axilla, the cause may
be: malignant disease or suppuration in the breast.
SYMPTOMATOLOGY, DIAGNOSIS, TOXICOLOGY AND MEDICAL
JURISPRUDENCE.
1. Typhoid fever. Symptoms: Insidious onset, weak-
ness, headache, epistaxis, vague pains. The tempera-
ture rises gradually, about 2° in the evening, fall-
ing 1° in the morning. Diarrhea, tenderness in the right
iliac fossa, enlarged spleen, and a characteristic rash
which appears from seventh to twelfth day. During
the second week the temperature remains at a uniform
level; typhoid state and delirium may be present.
The pulse becomes rapid, weak, and dicrotic; the heart
sounds are feeble; the tongue is coated, fissured, and
tremulous; sordes appear on the teeth; the abdomen is
distended; the stools are yellowish and offensive (said
to be like pea soup) ; the Widal reaction may be positive.
In the fourth week the temperature becomes normal.
It may be confused with malarial (remittent) fever.
The following table is taken from an elaborate one
by Thayer:
632
PENNSYLVANIA.
TYPHOID FEVER.
Blood shows no leucocyto-
sis ; eosinophiles dimin-
ished or absent; serum
causes agglomeration of
typhoid bacilli; malarial
parasites and pigment
absent.
by
Fever uninfluenced
quinine.
Usually epidemic; prevail
ing commonly in cities.
Anemia absent, excepting
in later stages.
Characteristic roseola.
Has a fairly characteristic
course.
Urine high-colored ; bile
absent; Ehrlich's diazo-
reaction present during
the height of the process.
The temperataure does not
reach 40° C. (104° F.)
before the third or fourth
day.
The apathetic expression
of the face, the dryness
of the tongue, and sordes
upon the teeth are well
marked and progressive.
Herpes rare .
MALARIAL (REMITTENT)
FEVER
Blood shows no leucocy-
tosis; eosinophiles not
notably diminished se-
rum does not cause ag-
glomeration of typhoid
bacilli ; malarial para-
sites and pigmented leu-
cocytes present.
Fever disappears under
quinine.
Is an endemic disease oc-
curring particularly in
rural districts ; rarely
epidemic.
Anemia more or less
marked early in the
course.
No characteristic exan-
them; urticaria not un-
common.
No distinct course.
Urine high-colored ; may
show a trace of bile;
Ehrlich's diazo-reaction
rarely present.
The temperature may ar-
rive at 40° C. (104° F.)
within twenty-four hours.
These symptoms are not
very marked.
Herpes common.
2. Symptoms of cancer of the stomach. It does not
usually occur before forty years of age, is more com-
mon in males, the pain is localized and constant, vomit-
ing is copious and occurs some time after eating; the
vomitus contains "coffee ground" material; hemor-
rhages are common; a tumor may be palpated, and
examination of the gastric contents shows absence of
free HC1 and presence of lactic acid; severe anemia
and cachexia are also present.
Cholecystitis is not accompanied by the "coffee
633
MEDICAL RECORD.
ground" vomitus, and the gastric contents do not show
lactic acid or absence of free hydrochloric acid. Fur-
ther, there may be obstinate constipation and jaundice;
the pain is at first more diffuse, and bears no relation
to the time of eating.
3.
PLEURISY WITH EFFUSION.
Onset marked by chilliness
persisting for a few
days.
Cough is irritating; no ex-
pectoration, or, if pres-
ent, catarrhal in char-
acter.
Sputum negative ; tuber-
cle bacilli rare.
Moderate fever of con-
tinuous type; declines by
lysis.
Prostration moderate.
Unilateral distention of
the thorax.
Countenance pale and
anxious.
Limited expansion at base
of chest on the affected
side.
Tactile fremitus dimin-
ished or absent.
Interspaces bulging at
base of chest.
Percussion shows flatness,
with great resistance to
the pleximeter finger.
Diminished or absent
breath-sounds over effu-
sion the rule. Respira-
tion murmur diffuse,
distant, and generally
unaccompanied by rales.
Bronchial breathing may
be present over the en-
tire affected side of the
chest.
Friction sound heard in
early and late stages.
LOBAR PNEUMONIA.
Onset acute, with rigor,
lasting one hour or
longer.
Cough more marked, and
accompanied by rusty
or bloody, tenacious ex-
pectoration.
Dense aggregations of
pneumococci present.
Fever, 102° to 104° F.;
falls by crisis.
Prostration extreme.
Absent.
Mahogany-colored flush of
cheeks.
Degree of expansion
slightly, if at all, in-
hibited.
Increased over area of
consolidation.
Absent.
Dullness with less resist-
ance, and sometimes a
tympanitic note.
Harsh bronchial breathing
and presence of rales
in first and third stages,
unless a bronchus is
plugged.
No friction murmur; rales
present.
(Anders and Boston's Medical Diagnosis.)
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PENNSYLVANIA.
4. Scarlet fever. Symptoms: Abrupt onset, with
rigors, vomiting, sore throat, anorexia, rise of temper-
ature on first or second day to 100° to 104° F. On first
or second day a typical scarlet rash appears, on a red
background ; after a few days desquamation commences,
and the epidermis peels off in large flakes.
Two sequelae: Nephritis and inflammation of the
middle ear.
Nephritis is indicated by the presence of urine of a
high color and containing albumin, blood, and casts;
dropsy of ankles or eyelids or general; and possibly
uremia, with convulsions or coma.
Otitis media is indicated by pain in the ear, tinnitus,
difficulty in hearing, swelling in the ear; the membrane
presents a glistening red and sunken appearance; sup-
puration may occur, with perforation of the membrane,
and possibly facial paralysis or meningitis.
5.
UREMIC COMA.
Deep coma. Slow onset
unless convulsions have
preceded the coma.
Albuminuric retinitis.
Pulse rapid.
Respiration, frequent and
irregular.
Urine shows albumin,
casts and low urea per-
centage.
ALCOHOLIC COMA.
Can be aroused by supra-
orbital pressure unless
very profound.
Pupils normal or some-
what dilated.
Pulse more rapid than
normal and full.
Regular respiration.
Normal.
6. The secondary skin eruptions of syphilis are poly-
morphic in character, do not itch, are roughly sym-
metrical, are of the color of copper or raw ham, are
painless.
Age
Tension . .
Congestion
Cornea . . ,
GLAUCOMA.
Over forty.
Plus.
General, espe-
cially scleral.
Cloudy and
steamy surface.
635
IRITIS.
Any.
Normal.
General, especial-
ly circumcor-
neal.
Cloudy.
MEDICAL RECORD.
Anterior chamber-
Pupil
Pain
Vision
GLAUCOMA.
Shallow.
Dilated, oval.
Severe, continu-
ous.
Much reduced.
IRITIS.
Unchanged.
Contracted, sy-
nechia.
Especially at
night.
Somewhat re-
duced.
(From Ailing and Griffin's Diseases of the Eye and
Ear.)
8. The symptoms of chronic laryngitis are: Hoarse-
ness and discomfort in the use of the voice, a tendency
to cough, and possibly aphonia.
Laryngeal tuberculosis has, in addition, dysphagia
with severe pain as an additional symptom. Further,
the laryngoscope will show tuberculous ulcers.
9. The symptoms of ptomaine poisoning are: Onset
more or less sudden, abdominal pain, persistent nausea
and vomiting, chill, diarrhea, headache, weakness, ver-
tigo, faintness, neuromuscular pains, sometimes fever.
In other forms of gastroenteritis, the vomiting
ceases when the stomach is emptied, but in ptomaine
poisoning the nausea, retching, and vomiting are per-
sistent; in gastroenteritis the onset is less sudden, and
the symptoms not so severe.
10. Four conditions which may justify the induction
of premature labor : Certain pelvic deformities ; toxemia
of pregnancy; habitual death of a fetus toward the end
of pregnancy, and when the mother's life is in immi-
nent danger owing to the presence of disease of the
heart or kidney.
The physician must obtain the consent of the woman
or of her husband or guardian, and he should be sus-
tained in his view by a recognized consultant.
OBSTETRICS AND GYNECOLOGY AND PHYSIOLOGICAL CHEM-
ISTRY.
1. At eight weeks, the retrodisplaced uterus will
cause pain and difficulty in micturition, owing to the
' pressure of the cervix on the bladder; similarly, pres-
sure of the fundus may cause pain in the sacrum and
constipation; vomiting, and other reflex phenomena
may occur; the cervix is found higher up than usual,
and the body of the uterus is in Douglas' pouch.
The condition may right itself (spontaneous reposi-
tion), or the uterus may become incarcerated, or spon-
636
PENNSYLVANIA.
taneous abortion may occur. The patient should be
placed in the knee-chest position, and the bladder being
empty, the uterus should be replaced by the physician's
fingers or a repositor; it should be kept in place by
adequate tampons or pessary. Incarceration is not
likely to occur till the third month.
2. The possible results of a prolapsed cord are com-
pression of the cord causing death of the fetus, and for
the mother, hemorrhage due to premature detachment
of the placenta and breast complications due to the
death of the fetus.
Treatment of prolapsed funis consists in: (1) Not
rupturing the membranes prematurely unless there is
some positive indication; (2) postural treatment, in
which the woman is placed on her back or on the oppo-
site side to that on which the cord lies, with hips and
pelvis elevated, or the knee-chest position may be adopt-
ed; (3) reposition of the cord, either manually or with
some form of repositor; (4) speedy delivery, by forceps
or podalic version. If the child shows signs of asphyx-
iation, the various methods of artificial respiration
should be tried and persisted in.
3. The possibilities are: Placenta praevia, premature
detachment of a normally placed placenta, rupture of
the uterus, and lacerations of the lower part of the
birth canal.
In placenta prsevia, the hemorrhage is abrupt, pain-
less, and there are generally repeated hemorrhages of
increasing severity; the placenta may be felt through
the cervix.
In premature detachment, the hemorrhage is sudden,
and is generally attended with sharp pain; the hemor-
rhage persists until the uterus is emptied or the patient
dies; vaginal examination shows nothing abnormal.
Ruptured uterus is announced by a sudden, acute,
and persistent pain. Sometimes the sound of the rup-
ture is heard by the patient; the symptoms of internal
hemorrhage and shock are present — collapse, air-hun-
ger, cyanosis, rapid, feeble pulse; the uterine contrac-
tions cease. Vaginal examination shows that the pre-
senting part of the child has receded from its former
situation owing to escape of the fetus (partially or
completely) through the rent into the abdominal cavity,
where it may be felt by abdominal palpation.
Treatment of placenta przevia, at term: (1) Introduce
one or two fingers within the os (the hand being in the
vagina) and dissect the placenta from the uterine wall
for about three inches from the os uteri in all directions,
pushing it to one side if necessary. (2) Rupture the
637
MEDICAL RECORD.
membranes, and if there is an unfavorable presentation
turn the child and make the breech engage in the os ; or,
if the head presents forceps may be used if speedy de-
livery is necessary. The strength of the woman is then
the main point to be cared for, and if in a reasonable
time the uterus seems to be incompetent, the child may
be delivered by art. In some cases of central placenta
praevia, where rapid delivery is required, cesarean sec-
tion may give good results for mother and child. (Lan-
dis' Obstetrics.)
Treatment of rupture of the uterus: "After rupture
has occurred, especially if it be 'complete' and exten-
sive, and the child should have escaped, wholly or in
great part, through the rent into the abdominal cavity,
laparotomy should be. done at once, child, placenta,
blood clots, etc., being removed through the abdominal
incision; the peritoneal cavity cleansed with hot saline
solution; the rent in the uterus repaired by suture; or
in case of an infected uterus, or one that will not con-
tract, or in which the rupture cannot be well secured,
the entire uterus should be removed." (King's Obstet-
rics.)
4. Pruritus vulvae may be caused by: Parasites; dis-
eases of the vulva, as inflammation, edema, vegeta-
tions, congestion, irritating discharges, lack of cleanli-
ness, diabetic urine; it may also be of nervous origin
or idiopathic. Local treatment consists in applica-
tions of solution of bichloride of mercury, 1:2000; or
carbolic acid, 1:100; or lead and opium; dusting pow-
ders of bismuth subnitrate, calomel, or zinc oxide are
also useful.
5. Pregnancy : The tumor is hard and does not fluc-
tuate, is situated in the median line, and may give fetal
heart sounds and movements; the cervix is soft, and
the other signs of pregnancy are present. The rate of
growth of the tumor and the general condition of the
patient's health may also help in arriving at a diag-
nosis.
Uterine fibroid: Menstruation is irregular and some-
times very profuse ; absence of the signs of pregnancy ;
the tumor is nodular, firm, irregular in outline, and
while generally placed somewhat centrally is not in the
median line, and is not symmetrical ; the rate of growth |
is irregular, being, as a rule, slow, and sometimes ex-
tending over years.
Ascites: Absence of the signs of pregnancy; the abdo-
men is distended, but the shape varies with the position I
of the patient; on lying down there is bulging at the|
sides, the tumor fluctuates, and percussion shows dull-
638
PENNSYLVANIA.
ness in the flanks, with resonance in the median line,
but the dullness varies with the position of the patient.
Fat: Absence of signs of pregnancy, also of fibroid,
or ascites.
Pseudocy esis : The uterus is not enlarged, and the
administration of a general anesthetic causes the col-
lapse of the "tumor."
6. The bacteria which cause puerperal fever are:
Streptococcus pyogenes, staphylococcus pyogenes aureus,
gonococcus, bacillus coli communis, bacillus diphtherise,
bacillus typhosus. They are generally introduced by
the fingers of the physician or nurse, or by instruments,
or general lack of cleanliness. The results are shown
by chill; rapid rise in temperature, to about 103° or
104°, higher in the evening than in the morning;
sweats; rapid pulse; depression; dry tongue; anorexia;
carphologia; scanty, high-colored, albuminous urine;
restlessness; sometimes delirium or coma. The uterus
is large, and tender; the lochia are diminished or sup-
pressed ; the milk secretion Is often suppressed ; pain in
the abdomen; peritonitis may develop. Treatment:
Prophylaxis is of the greatest importance. Purgatives ;
vaginal douches; some recommend curettage, others de-
cry it; the introduction of antiseptics into the uterus;
supportive and general treatment are indicated ; specific
sera and vaccines have been recommended by some.
7. Vaginal douches should not be given unless dis-
tinctly indicated, such as in cases that are probably
septic or prior to version or forceps or other operative
procedure.
Anesthetics are used in labor to lessen suffering pro-
duced by labor pains; to lessen the pain attending
obstetric operations; to relax the uterus when its rigid
contraction interferes with version; to promote dilata-
tion of the os uteri; to reduce excessive nervous excite-
ment which may interfere with progress of early stage
of labor ; to relieve eclamptic convulsions and mania ; in
cases of uterine inversion to relax the constructing cer-
vix and so facilitate replacement; in bipolar version to
lessen pain of introducing the hand into vagina ; in pre-
cipitate labor to suspend action of voluntary muscles
and retard delivery; in all cutting operations upon the
abdomen; and sometitmes in sewing up a lacerated
perineum when many sutures are required. (From
King's Obstetrics.)
Dangers : They lessen the efficiency of the uterine con-
tractions; predispose to postpartum hemorrhage; and,
if given too freely, may be followed by headache,
nausea, and vomiting.
639
MEDICAL RECORD.
Ergot should be used after the placenta is expelled, so
as to secure uterine contractions. Before this period,
the use of ergot is dangerous, the objections being:
(1) That it may produce tetanic contractions of the
uterus and so cause rupture of the uterus, death of the
mother, or asphyxiation of the child; (2) that it in-
creases the chances of lacerations of the cervix and
perineum; (3) that it tends to cause retention of clots
and membranes, etc.; and (4) that it retards the secre-
tion of milk.
Pituitrin may be used in cases of uterine inertia, pro-
vided the os is dilated and there is no obstruction to
delivery.
8. The function of the thyroid is not definitely
settled; (1) it has some trophic function, regulating
oxidation in the body, and it is supposed to have also a
special influence on the vasomotor nerves, the skin, the
bones, and on the sexual functions; (2) it is supposed
to antagonize toxic substances; and (3) it produces an
internal secretion.
Removal of the thyroid gland causes mental and
bodily dullness and apathy, tremors, twitchings, over-
growth of the connective tissues, and development of
fat; the hairs fall out, and the patient becomes un-
wieldly and clumsy in both body and mind. The com-
plete removal causes death in most animals, and it is
not considered justifiable in man.
Removal of all the parathyroids causes death from
acute tetany. Their exact function is unknown, but it
is supposed that some of the evil effects attributed to
removal of the thyroids is really due to the removal of
all the parathyroids as well, and that if the parathy-
roids are left (with their blood supply intact) these
results will not ensue. Thyroid substance is composed
of water, 82 per cent., and solids 18 per cent. The
solids consist of nucleoprotein and iodothyrin. This
latter is found in the colloidal substance, and contains
carbon, hydrogen, oxygen, nitrogen, phosphorus, and
iodine. The thyroid is the only tissue in the body which
normally contains iodine, and it is believed that the
changes which occur in disorders of the gland are due
to the excess or lack of the iodothyrin.
9. Test for bile pigments in urine : Put 33 cc. of nitric
acid in a test tube and heat until the acid is yellow;
cool ; then float some of the urine on the surface of the
acid. If bile pigments are present a green band is
formed at the junction of the two liquids, which gradu-
ally rises and is succeeded from below by blue, reddish
violet, and yellow.
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PENNSYLVANIA.
Test for blood in urine: Place a few drops of the
urine in a test tube, and add a drop of freshly prepared
tincture of guaiacum and a little ozonic ether; then
agitate. In the presence of blood the ether, which rises
to the surface, is blue.
Test for acetone in urine: Add a few drops of a
freshly prepared solution of sodium nitroprusside, and
then solution of KHO, when, in the presence of acetone,
the liquid is colored ruby-red, and on supersaturation
with acetic acid, changes to purple.
b 10. Cholesterol is a monoatomic alcohol, with the em-
pirical formula C 2 tH 4 50H, but of unknown constitution.
It is found chiefly in bile, but also in blood, nerve tissue,
brain, and nearly every animal tissue and fluid. Path-
ologically, it occurs in biliary calculi, pus, hydrocele
fluid, cancer, brain tumors, atheromatous patches, der-
moid cysts.
ANATOMY AND SURGERY.
"1. If possible, the patient should be under observa-
tion for at least twenty-four hours prior to the oper-
ation. During this time a careful study is made of the
urine and the condition of the heart and lungs, and
necessary treatment instituted. The diet should be re-
stricted, and a purgative given the night before, fol-
lowed by an enema on the morning of the operation.
No breakfast, or merely a cup of beef tea, should be
given on the day of the operation. The abdomen should
be shaved and scrubbed thoroughly with tincture of
green soap and sterile water for at least ten minutes
on the night before the operation. A general bath
should then be taken, giving special attention to the
inside surfaces of the thighs and to the umbilicus. A
soap poultice is applied to the abdomen and allowed
to remain for several hours; this is removed, and the
abdomen is scrubbed with alcohol and washed with mer-
curic chloride solution (1:1000). A towel wet with this
solution is placed over the abdomen, and a binder is
applied. (Pocket Cyclopedia).
2. In posterior luxation of the hip joint, the patient
is placed on a mattress on the floor, and anesthetized.
The leg is then flexed on the thigh and the thigh on
the abdomen; this relaxes the Y-ligament, and brings
the head of the femur down to the lower part of the
acetabulum. The leg is then circumducted outward;
this brings the head of the femur to the rent in the
capsule. The limb is then extended to bring the head of
the femur into the acetabulum.
3. The causes of gangrene are thus given by Stewart:
(1) Indirect gangrene, which is caused by interference
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MEDICAL RECORD.
with the blood supply, includes senile, presenile, dia-
betic, post-febrile, Raynaud's, ergot gangrene, ainhum,
gangrene from embolus, ligature of the principal artery
of a limb, thrombosis of an artery, the result of injury,
and obstruction of the principal artery and vein; (2)
direct gangrene, the result of trauma, includes gan-
grene from severe crushes, prolonged pressure, chem-
ical injuries, the #-ray, frost bites, and burns and
scalds; (3) mixed or microbic gangrene, in which the
tissue cells are directly killed by bacterial toxins and
the blood vessels occluded by thrombosis, includes trau-
matic spreading gangrene, and hospital gangrene.
Amputation is indicated in all cases except, perhaps,
senile gangrene with marked calcareous arteries and
albuminuria or general debility; (2) diabetic gangrene
with pronounced acidosis or beginning coma; (3) acute
infective gangrene which has already invaded the trunk
or in which septicemia is present.
4. Carcinoma is most usually found in the breast,
uterus, stomach, pylorus, rectum, ovary and testicle.
The chief early symptom is often impairment of func-
tion, without swelling or pain, these latter occurring
later. Pain is due to the involvement of nerve-endings ;
when ulceration occurs, cachexia becomes marked.
Other symptoms depend upon the location of the lesion.
5. Hematuria may be caused by renal calculus, tu-
mors or injuries of the kidneys, cystitis, vesical cal-
culus, prostatic congestion or ulceration or tumor, trau-
matism of urethra, parasites (especially the bilharzia
hsematobia. Symptoms of renal calculus consist of pain
in the loin, markedly increased by exercise, especially
on jolting. The pain may be referred to the thigh,
groin, or testicle. The colic is associated with hema-
turia, and often pyuria exists with frequency of mictu-
rition. The kidney may be enlarged, and tender on
pressure. A large stone may exist without any symp-
tom whatever.
The most typical symptom consists in a sudden attack
of excruciating and paroxysmal pain shooting down the
loin to the bladder and testis. The attack is accom-
panied by vomiting, faintness, and collapse. Fre-
quent efforts to pass urine are made, but only a scanty
amount of blood-stained urine is passed (strangury).
The pain ceases suddenly when the calculus slips back
into the pelvis or reaches the bladder. (Aids to Sur-
gery).
6. The blood vessels liable to be involved in epistaxis
are: The spheno-palatine and descending palatine
branches of the internal maxillary artery; the anterior
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and posterior ethmoidal branches of the ophthalmic,
and the artery to the septum from the superior coronary
branch of the facial.
Treatment. — In severe epistaxis, examine the nose
by means of a head-mirror and a speculum. If a little
point of ulceration is found, touch it with a hot iron.
If the bleeding is a general ooze, if it is high up, or if
the cautery does not arrest it, pack the nares. It may be
necessary to pack one nostril or both. Pass a Bellocq
cannula along the floor of one nostril into the pharynx,
project the stem into the mouth, tie a plug of lint or
gauze wet with Carnot's solution of salt and gelatin to
the stem, and withdraw it. Hold the double string
which emerges from the nostril in the hand and pack
gauze wet with gelatin solution from before backward.
Tie the strings together over the plug; if both nostrils
are plugged, the strings from one nostril are fastened
to the strings from the other. Do not use subsulphate of
iron, as it forms a disgusting, clotty, adherent mass.
If a Bellocq cannula is not obtainable, push a soft
catheter into the pharynx, catch it with a finger, pull it
forward and tie the plug to it. Remove the plug in two
or three days. Do not leave it longer. It blocks up
decomposing fluids and may lead to blood-poisoning.
Pick out the front plug first, hold the string of the
second plug in the hand, push the plug back into the
pharynx, catch it with forceps, and withdraw plug and
string through the mouth. (DaCosta's Modern Sur-
gery).
7. In fracture of the shaft of the radius, above the
insertion of the pronator radii teres, the forearm is
placed in full supination on an anterior angular splint,
in order to bring the lower fragment in contact with
the upper.
In fracture of the shaft of the ulna, an internal
angular splint is used; this immobilizes the elbow, and
places the forearm in a position half way between pro-
nation and supination, and so keeps the two bones as
far away from each other as possible and thus mini-
mizes the danger of their union by a callus.
In Colles 9 fracture, a padded Bond splint or Levis
splint may be used, so that the hand is semiflexed and
adducted. A pad is placed on the back of the forearm
over the lower fragment, and another on the flexor sur-
face over the lower end of the upper fragment.
8. Indications for amputation of the leg: Compound
fracture, compound dislocation, fracture with great
comminution of bone, extensive laceration, laceration of
important vessels, gunshot injuries, gangrene, exten-
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MEDICAL RECORD.
sive bone disease, elephantiasis, snake-bite, aneurysm;
provided that these conditions are not amenable to less
radical treatment.
In Sedillot's "method of amputation of the leg the
point of the knife is entered a nnger's breadth external
to the spine of the tibia and carried outward, grazing
the fibula, and is brought out as far as possible to the
inner side; a flap three or four inches in length is then
cut from within outward ; the extremities of the incision
are next united by an incision across the inner side of
the limb, involving the skin only; any remaining mus-
cular tissue is next divided and the bones are sawed.
The long external flap is then brought over the ends
of the bones and fastened to the edges of the incision
on the inner side of the Kmb. Ashhurst modified this
operation by cutting the long external flap from with-
out inward, and made also a short internal flap in the
same manner. By either method the resulting stump
is a good one, with the ends of the bones covered by
the tissues of the external flap." (Wharton's Minor
Surgery).
The parts cut through in amputation at the upper
third of the leg are: Skin, fascia; bones, tibia, and
fibula; interosseous membrane; muscles, tibialis anticus,
tibialis posticus, extensor longus digitorum, extensor
proprius hallucis, flexor longus hallucis, flexor longus
digitorum, peroneus longus, peroneus brevis, soleus, gas-
trocnemius, and the tendon of the plantaris; arteries,
anterior tibial, posterior tibial, peroneal; veins, the
venae comites of the arteries, external saphenous, inter-
nal saphenous; nerves, anterior tibial, posterior tibial,
external saphenous, communicans peronei, musculo-
cutaneous.
9. Excision of the elbow is performed for: Chronic
joint disease (generally tuberculosis); wounds; faulty
ankylosis, or other deformity; disease of the articular
ends of the bones; fracture dislocation; compound com-
minuted fracture.
"In excising the elbow joint, the forearm is slightly
flexed and a longitudinal incision is begun about two
inches above the olecranon process and a little to its
inner side, and carried about three or four inches down
in the line of the ulna; the tissues are then divided
down to the bones, and the ulnar nerve is dissected from
its groove behind the inner condyle of the humerus and
held aside by a retractor; the tendon of the triceps is
divided, and its attachment to the fascia and periosteum
over the olecranon process is separated with an elevator
or periosteotome and turned downward; the joint is
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PENNSYLVANIA.
next opened and the lateral ligaments divided as the
forearm is flexed upon the arm. The upper part of the
ulna and the head of the radius are freed with a probe-
pointed knife and removed with a narrow-bladed saw,
care being taken in making the section of the radius
to divide its neck so that the attachment of the biceps
muscle is not interfered with. The condyles of the
humerus are next freed and removed with a saw. In
freeing the bones at the anterior portion of the joint,
great care should be used to avoid injury of the brachial
artery and vein and the median nerve." (Wharton's
Minor Surgery. )
10. The various forms of hernia found in the groin
are inguinal and femoral hernia.
The anatomical classification is based on the rela-
tion of the hernia to (1) the inguinal canal and inguinal
rings, and (2) to the femoral opening. The former are
above Poupart's ligament, the latter below it.
The forms of inguinal hernia are :
(1) The Direct, in which the hernia does not oc-
cupy the inguinal canal, but leaves the abdomen
to the inner side of the deep epigastric artery,
through the space known as Hesselbach's tri-
angle. There are two forms of this variety: (a)
the hernia may escape between the epigastric
artery and the obliterated hypogastric artery;
(6) or it may escape between the obliterated
hypogastric artery and the outer edge of the
rectus muscle.
(2) The Indirect or Oblique, in which the hernia
occupies, wholly or in part, the inguinal canal.
An oblique inguinal hernia may pass into the
scrotum or labium majus, when it is called com-
plete; or may be retained in the inguinal canal,
when it is called incomplete or a bubonocele.
Other varieties are the congenital, infantile, and
encysted.
Femoral hernia leaves the abdomen through the fem-
oral ring and descends into the femoral canal ; this canal
is funnel-shaped, is about half an inch in length, and
ends at the saphenous opening. Its course is first ver-
tical, then forward, then upward over Poupart's liga-
ment. The neck of the hernia is situated at the femoral
ring; to its outer side lies the femoral vein, and to
its inner side is Gimbernat's ligament; in front of
it is Poupart's ligament, and behind it are the pubis, the
pectineus, and the public portion of the fascia lata.
"Taxis, or the manipulations for the reduction of
a hernia, should always be gentle, and should rarely be
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MEDICAL RECORD.
tried for more than five or ten minutes, because of the
danger of rupture of the bowel. It should not be em-
ployed in the presence of inflammation or gangrene.
Reduction is facilitated by having the patient recum-
bent, the thighs flexed (and that of the affected side
adducted in femoral or inguinal hernia) , and the pelvis
raised. The administration of opium and belladonna
and the application of heat or cold also are useful in
securing relaxation. One hand is used to steady the neck
of the sac, while with the other the hernia is com-
pressed and pushed back into the abdomen. In direct
inguinal and umbilical herniae the pressure is back-
ward; in oblique inguinal hernia it is upward, outward,
and backward; in femoral hernia it is at first down-
ward and inward, then upward and backward. The
successful reduction of bowel is sudden and accom-
panied by a gurgle; omentum is forced back slowly
without gurgling." (Stewart's Surgery.)
In addition to the points given above on femoral
hernia, it must be remembered that sometimes the ob-
turator artery arises (abnormally) from the deep epi-
gastric artery. When this abnormal artery passes down
the outer side of the crural ring, it is out of harm's
way; but when it passes down the inner side of the
crural ring it is very apt to be wounded in herniotomy.
PRACTICE, MATERIA MEDICA, THERAPEUTICS AND HYGIENE.
1. The vomiting of pregnancy is generally viewed as
a toxemia with disordered protein metabolism and
pathological conditions in liver and kidneys. The treat-
ment then consists in diminishing the intake of protein
food, and the administration of cathartics and diuretics.
If the stomach rejects food, enemata may be tried.
Sodium bicarbonate is useful because it hinders the
production of acetone bodies and acidosis. Irrigations
of the colon, particularly with solution of sodium bicar-
bonate, remove toxins from the colon and also supply
fluid and an alkali to the body. The best food is milk,
and cereals. Many drugs have been used in the past with
doubtful benefit, such as: Cerium oxalate, bismuth sub-
nitrate, iodine, bromide of potassium, citrated caffeine
and chloral.
2. The excessive use of coffee retards peptic diges-
tion; incites or keeps up gastric catarrh; induces mus-
cular tremors, anxiety, nervousness, palpitation, brady-
cardia, heartburn, vertigo, constipation and insomnia.
The excessive use of tea retards digestion; causes
gastric irritation and catarrh, flatulency, constipation
or diarrhea, nervousness, insomnia, muscular tremors
and palpitation.
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PENNSYLVANIA.
The excessive use of chocolate may cause gastric
dyspepsia.
The excessive use of alcohol may cause changes
(chiefly cirrhotic) in the blood vessels, liver, kidneys,
and other tissues; the brain and nervous system are
likely to be affected by degenerative changes; it is said
to be a predisposing factor in the following: gastritis,
liver disorders, dilatation and hypertrophy of the heart,
arteriosclerosis, aneurysm, nephritis, neuritis, apoplexy.
"The continued use of tobacco, by smoking or chewing
it to excess, produces granular inflammation of the
fauces and pharynx, atrophy of the retina, dyspepsia,
lowered sexual power, sudden faints, nervous depres-
sion, cardiac irritability and occasionally angina pec-
toris. Used by the young it hinders the development
of the higher nerve centers and impairs the nutrition of
the body by interfering with the processes of digestion
and assimilation. It has been credited with causing
cancer of the lips and tongue, blunting of the moral
sense, mental aberration and even insanity." (Potter's
Materia Me&ica, etc.)
3. "Cocaine is a protoplasmic poison and induces com-
plete local anesthesia. Coca leaves, when chewed, re-
lieve hunger and fatigue and allay irritability of the
stomach. The drug tends to stimulate the vagus centre,
increase the pulse-rate, constrict the arterioles, and
cause a marked rise in blood-pressure, though later the
blood-pressure falls; the respiratory functions are at
first stimulated and afterwards depressed, and under
poisonous doses death occurs from asphyxia. The higher
parts of the brain are at first stimulated and the
muscular power greatly increased, while the various
medullary centers are first stimulated and then de-
pressed. There is primary stimulation of the spinal
cord also, with exaggeration of the reflexes, and very
large doses may cause strychnine-like convulsions. In
the eye mydriasis is produced and accommodation im-
paired. Cocaine is eliminated chiefly in the urine.
Cocaine is more largely employed to produce local anes-
thesia than any other agent ; injected into the arachnoid
space of the spinal cord it has also been used to cause
general anesthesia for surgical operations. The prep-
arations of coca are prescribed as stomachic tonics and
in the debility of convalescence from acute diseases,
and cocaine has been given internally in chorea,
paralysis agitans, alcoholic tremors, and senile trem-
bling." (Wilcox's Materia Medica.)
Veratrum viride: "On the skin it causes tingling,
numbness and anesthesia, and, applied to the mucous
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MEDICAL RECORD.
membrane of the nose and throat, violent sneezing and
coughing. Internally it produces gastrointestinal irrita-
tion, prolonged relaxation of striped and cardiac muscle,
reduction of arterial pressure, depression of respiration,
convulsions from stimulation of the spinal cord, free
diaphoresis, and reduction of temperature. As a circu-
latory depressant, given early, in croupous pneumonia,
pleurisy, hepatitis, maniacal delirium, etc., with strong,
bounding pulse and other sthenic conditions; in puer-
peral convulsions and the early stage of peritonitis,
phlebitis and other inflammatory affections of the puer-
peral state; also acute rheumatism, tonsilitis, aneurysm
and wounds of the head, pericardium and peritoneum."
(Wilcox, Materia Medica.)
Apomorphine acts on the vomiting center in the
medulla, hence is emetic; it increases pulse, blood pres-
sure, and rate of respiration; it is also an expectorant.
Its indications are chiefly those requiring a prompt
emetic ; also as an expectorant in bronchitis and lobular
pneumonia.
4. The treatment of pneumonia "depends entirely on
the type of case, and the condition of the patient.
Routine treatment is the worst of all treatments. An-
swer the following questions before prescribing: Is
the patient full-blooded, and is there a full bounding
pulse? Is the pulse feeble, irregular, or intermittent?
"In the first case, in a young and previously healthy
adult, if there be cyanosis, or signs of dilatation of the
right heart, blood-letting to the extent of a few ounces
may perhaps relieve the strain, but more generally
treatment should be directed to maintaining the
strength from the outset.
"In the latter case we can hope for nothing from a
depressing treatment, so stimulants must be resorted to,
such as alcohol, ammonium carbonate, egg and brandy
mixture, quinine, ether, etc. The giving or withholding
of alcohol depends upon its effect upon the pulse; should
the pulse rate fall and the tongue become moist it may
be continued. In asthenic cases, strychnine hypodermic-
ally is necessary from the outset, and normal saline may
be given by the rectum or by the skin. Oxygen inhala-
tions are used where there is cyanosis, but it is doubtful
whether thev have saved many lives. When there is
evidence of failure of the heart (weakness of the second
pulmonary sound, etc.) digitalis should be resorted to.
Many prescribe it from the outset.
"The diet should consist of milk, beef-tea or broths,
white of egg 9 and so on. The patient should be as little
moved as possible, and the bed-pan must be used. As
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PENNSYLVANIA.
in other fevers, an airy room and good nursing are
essential.
"Remember that narcotics are not well borne in res-
piratory embarrassment as a rule. Chloral should be
avoided, but if pain be excessive a hypodermic injection
of morphine does more good than harm, notwithstand-
ing that theoretically morphine is contraindicated. It
should not be given later than the first few days of the
illness. The pain may also be relieved by poultices,
which, however, are of doubtful use if carelessly made,
or by application of ice. Cold packs applied to the trunk
only, and frequently repeated, are very useful in re-
lieving both pain and fever. Depressant antipyretics
are to be avoided.
"The results of serum treatment are not unequivocally
encouraging, but vaccine treatment would seem to be of
better promise. Where possible, an autogenous vaccine
should be used." (Wheeler and Jack's Handbook of
Medicine) .
5. By spinal anesthesia is meant the employment of
subarachnoid injections of cocaine or eucaine for the
purpose of producing analgesia for surgical purposes.
Between the fourth and fifth lumbar vertebrae is the
spot usually selected. The surface is sterilized and
the skin is made anesthetic by injecting into it one
of Schleich's solutions. An exploring needle is then
made to find its way into the subarachnoidean space,
which is evidenced by the escape of some fluid. The
syringe containing the cocaine or eucaine is then at-
tached, and the anesthetic is injected. Rigid asepsis is
necessary, and even then the procedure is dangerous.
(Pocket Cyclopedia.)
The dangers of ether anesthesia are asphyxia (fail-
ure of respiration), and to a much less extent, heart
failure. In chloroform anesthesia the chief danger is
sudden death from reflex arrest of the heart; failure
of respiration, and fall of blood pressure may also
occur; delayed chloroform poisoning or toxemia is also
possible.
The chief precautions against these dangers are: The
employment of an expert anesthetist, and the use of the
purest anesthetic; a thorough examination of the pa-
tient and due preparation for the operation; the elim-
ination of all unnecessary dangers, such as undue ex-
posure or prolongation of the operation, and hav-
ing in readiness everything likely to be needed in
an emergency.
(>. Treatment of chronic constipation: "The cultiva-
tion of habits of regularity is of the utmost importance.
649
MEDICAL RECORD.
The patient should go to stool at the same time every
day, whether there is a desire to evacuate the bowels
or not, and every such desire should be immediately
gratified. The diet should comprise considerable fruit
and vegetables (which leave a residue). A glassful of
cold water before breakfast, an orange or oatmeal at
breakfast, and stewed fruits and salads at dinner sub-
serve a useful purpose in many cases. Persons of
sedentary habits are often benefited by exercise; ab-
dominal massage is useful in some cases, and an
abdominal binder is of value to those with a pendulous
flabby abdomen and visceroptosis.
Drugs should be dispensed with as long as possible.
Medicinal measures when necessary vary with the na-
ture of the causal factor, which must be diligently
searched for. At the beginning of the treatment it is
often advisable to clear the intestine thoroughly with
castor oil, a blue mass pill, or calomel, followed by a
saline aperient. In many cases, the best results are
obtained by a daily injection of tepid water with or
without soap; in other cases injections of oil are much
better; but enemas should not be too long continued.
Some patients are much benefited by a saline aperient
water, sodium phosphate, or other saline, taken a half
hour before breakfast. Should a course of medicine be
necessary, the desired results may usually be secured
by the use of cascara sagrada, which has the advantage
that, having been continued for some time, the dose
necessary to secure a daily evacuation may be grad-
ually reduced, and the drug ultimately dispensed with,
should the patient continue habits of regularity. The
pill of aloin (Vs grain), strychnine (1/40 grain), and
extract of belladonna (1/10 grain), though much
abused, is very useful in many cases." (Kelly's Prac-
tice of Medicine.)
7. For excessive cough in tuberculosis: Best, fresh
air, and drugs such as creosote, guaiacol carbonate,
codeine, heroine, morphine, and diluted hydrocyanic
acid; the ordinary expectorants should be avoided on
account of their nauseating tendencies.
In angina pectoris : Inhalation of amyl nitrite, and a
hypodermic of morphine and atropine or inhalation of
chloroform.
In puerperal eclampsia: "The treatment of the attack
consists of the administration of chloroform by inhala-
tion, chloral hydrate (gr. 60) by enema, and the fluid
extract of veratrum viride hypodermically (gtt. 15 fol-
lowed by gtt. 5, repeated frequently enough to keep
the pulse at about 60 beats a minute, to control the
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PENNSYLVANIA.
convulsions, and free purgation by croton oil (gtt. 2, or
3, in sweet oil or glycerin), free sweating by the hot
pack, and sometimes depletion by venesection to elim-
inate the poison. The after-treatment consists of free
purgation by the salines, restriction of diet, and later
the administration of tonics and stimulants. The ob-
stetric treatment is usually noninterference." {Pocket
Cyclopedia.) Sometimes accouchment force is indi-
cated.
8. Atropine sulphate, when dropped into the eye
dilates the pupil, destroys the power of accommodation,
and increases intra-ocular tension. As a simple mydri-
atic a solution of V± grain to the ounce is generally
used; as a cyclopegic a solution of 4 grains to the
ounce may be used. It is contraindicated in glaucoma
and old age.
Pilocarpine hydrochloride, when dropped into the eye
causes the pupil to contract and lessens intra-ocular
tension; it may also produce spasm of accommodation.
It is used in solution of 1 to 4 grains to the ounce.
It is said to be contraindicated in severe cardiac or
pulmonary lesions.
9. In arteriosclerosis, the following should be pro-
hibited: All indigestible food; dried, salted or preserved
meats; cheese, pastry, sweets, nuts, cabbages, carrots,
turnips. The following may be allowed: White fish,
chicken, rabbit, game, one potato a day, mutton or well-
grown lamb once a day, spinach, asparagus tops, onions,
tomatoes, peas, beans, water, milk, weak tea, alcohol
only when necessary. Only as much food should be
taken as is necessary.
If the reduction in the patient's weight is due to the
lessened intake of food, we may expect diminished blood
pressure, less toxemia or intoxications, and general
amelioration of health. If the patient had been over-
weight, a reduction should be accompanied by diminu-
tion in blood pressure, avoidance of the danger of im-
pending apoplexy, and amelioration of subjective symp-
toms such as headache, dizziness, dyspnea, precordial
oppression.
10. Purgatives and diuretics may be of use; elaterin.
in doses of 1/20 grain; compound jalap powder, 30
grains ; if salines are used they should be given in con-
centrated or saturated solution; citrated caffeine, and
pilocarpine may be of service; the external application
of heat may be tried. The amount of fluid ingested
should be limited, and meat and meat products should
be avoided ; in renal cases salt is prohibited.
651
MEDICAL RECORD.
STATE BOARD EXAMINATION QUESTIONS.
State Board of Medical Examiners of South Caro-
lina.
junior anatomy.
1. Describe the liver and give its blood supply.
2. Describe the urinary bladder.
3. Describe the left lung and give its blood supply.
4. Describe the inferior maxillary bone.
5. Describe the formation of the brachial plexus.
SENIOR ANATOMY.
1. Name the blood vessels and nerves encountered in
ligation of the brachial artery in the middle of the
arm, giving their positions in relation to the artery.
2. For what anatomical reason should wounds of
the scalp be closed loosely?
3. Where is the pain located when the maxillary divi-
sion of the fifth nerve is affected?
4. When sarcomata wander from the seat of primary
growth, where do they appear and why?
5. Describe the space that should be selected for do-
ing a paracentesis of the pericardium and give your
reason for this selection.
6. With pus beneath the thick middle portion of the
palmar fascia, name the points at which the abscess is
liable to point.
7. How is collateral circulation established after liga-
tion of the common carotid artery.
8. With a hemorrhage into the pons below the point
of decussation of the seventh nerve, what portions of
body will oe paralyzed?
9. Where, in the stomach, is carcinoma most apt to
occur and why?
PHYSIOLOGY.
1. What is an enzyme? Mention one and describe
its action.
2. What important centers are situated in the
medulla oblongata?
3. Discuss the lymphatic system.
4. What changes occur in the course of the circula-
tion at birth?
5. Mention the glands of internal secretion. What
are the theories in regard to their respective functions?
CHEMISTRY.
1. What is the amount of C0 2 in the atmosphere and
why does it not increase?
652
SOUTH CAROLINA.
2. How does ferric hydrate act as an antidote for
the poisonous properties of arsenic?
3. What are the chemical properties of HNO, and
into the composition of what explosive does it enter?
4. What is calcium sulphate? What peculiar prop-
erty renders it useful in surgery?
5. What are the diagnostic uses of electricity?
MATERIA MEDICA.
1. What preparation of iodine and mercury would
you combine for internal use? what is the dose of each?
2. Name two or more preparations of digitalis and
give dose of each.
3. Give dose and therapeutic effect of atropine, tr.
nux vomica, Fowler's sol., arsenic, fl. ext. ergot, tr.
opium.
4. Name a vasodilator, a vasoconstrictor, a hydro-
gogue cathartic, a cholagogue cathartic, a diuretic, and
give dose of each.
5. Write a prescription in compliance with "The
Harrison Anti-Narcotic Act" for a cough mixture
containing codeine.
THERAPEUTICS.
What drugs would you use in treating the following
diseases: Give dose, .frequency, and therapeutic effect.
If therapeutic agents employed other than drugs tell
how they should be used.
(1) Gastroenteritis in child two years old. (2)
Measles. (3) Acute catarrhal dysentery in adult. (4)
Diabetic coma. (5) General anasarca accompanying
cardiac insufficiency. (6) Spasmodic croup. (7)
Renal colic. (8) Cholera morbus, (9) Chlorosis. (10)
Scarlet fever.
PRACTICE OF MEDICINE.
1. Describe a case of Landry's paralysis: acute as-
cending paralysis.
2. Give etiology, symptoms, physical signs and pos-
sible terminations of pulmonary infarction.
3. Mention the causes of cardiac hypertrophy.
4. Describe a case of acute hemorrhagic pancreatitis,
stating the diseases with which it might be con-
founded. Give their diagnostic differences. What
treatment would you recommend for a case of acute
hemorrhagic pancreatitis?
5. Mention the characteristic blood findings in (a)
pernicious anemia; (b) myeloid leucemia; (c) lymph-
atic leucemia.
6. Define diphtheria. State its most frequent
sequelae.
653
MEDICAL RECORD.
7. A man fifty years old complains that he has a
cough, dyspnea on exertion, has noticed for the past
three months that his feet were swollen at night. What
diseases might cause such symptoms? Briefly differ-
entiate the diseases mentioned.
8. How would you recognize dilatation of the
stomach? What are the causes and how would you dif-
ferentiate them?
9. Enumerate the conditions of the kidney which may
give rise to an abdominal tumor, and state how you
would make your diagnosis as to its nature and origin.
10. What are the most reliable physical signs of fluid
in the pleural cavity?
OBSTETRICS.
1. Name the fetal envelopes from without inward.
2. Describe the vitellus, the allantois, the amnion and
its contents.
3. Describe the development of the placenta.
4. As pregnancy progresses state the important
changes, physical and mental, that occur, or may occur,
in the disposition and organism of the pregnant woman.
5. Describe the gross anatomy of the mammary
glands, give the changes which occur in them during
pregnancy, and give the management of the glands in
case the infant is stillborn or if for any reason nursing
is considered inadvisable.
6. Name the varieties of glycosuria that may occur in
pregnancy; give their significance and management.
7. Give the etiology, symptoms and treatment of the
albuminuria of pregnancy without anatomical kidney
lesion.
8. Describe the conditions, mandatory and elective,
under which cesarean section is done and give in gen-
eral terms the method of doing the operation.
9. Diagnose a face presentation, L. M. A. position,
and give mechanism and management of the same.
10. Give management of a brow presentation, R. M.
P. position.
11. Name and describe the common varieties of ob-
stetric forceps, give general indication for their use,
and describe their use in any given condition that you
may choose.
12. Summoned to a patient about seventy4wo hours
into her puerperium, and given a history of a recent
chill, and present rise of temperature, with diminution
of lochia, name the conditions, one of which is probably
present, and differentiate between them.
N. B. — Answer any two of questions 1, 2, 3, and 4.
Each of the remaining questions demands an answer.
654
SOUTH CAROLINA.
GYNECOLOGY.
1. Mention two common causes of hemorrhage from
the non-pregnant uterus. How would you differentiate
them?
2* Give the causes and treatment of retrodisplace-
ments of the uterus.
3. Differentiate salpingitis in the right side from
appendicitis.
4. Describe an operation for removal of the uterus.
When is it indicated?
5. Give the causes and treatment of amenorrhea.
SURGERY.
1. Differentiate between acute synovitis of knee
joint and acute osteomyelitis about joint, and give
treatment of each.
2. In excision of knee joint give details of operation
and after treatment. Outline flap used.
3. Describe and outline various flaps used in ampu-
tating in different regions from ankle joint to middle
of thigh.
4. Make a preparative diagnosis in a woman suffer-
ing with tenderness in right side of abdomen from ribs
to pelvis, with occasional paroxysms of pain; daily
slight rise of fever with albumin in urine.
5. Give indications for enucleating an eyeball and
describe an enucleation.
6. Describe the anesthetic state from ether and
chloroform.
7. Operate for necrosis of shaft of tibia. If you
found all of a section of the bone destroyed and the
periosteum intact what would you do?
8. What organs and regions does a right rectus in-
cision allow access to. Describe the technique of mak-
ing the incision and the closing of it.
9. Give the varieties of hemorrhoids and give in
detail the operation of removal of internal hemorrhoids
by both suture and clamp and cautery methods.
10. Treat fracture, both impacted and unimpacted,
in a very old person.
PEDIATRICS.
1. How would you diagnose and treat flatulent colic
in an infant? What food constituent is the usual cause
of this condition?
2. Give the causes, consequences and treatment of
otitis media.
3. What diseases may diphtheria simulate and how
would you differentiate them?
655
MEDICAL RECORD.
4. Give the symptoms and treatment of pertussis.
What is its most serious complication?
5. Give the symptoms and treatment of acute an-
terior poliomyelitis.
URANALYSIS MICROSCOPY, TOXICOLOGY, AND MEDICAL
JURISPRUDENCE.
1. In the examination of urine, how would you dif-
ferentiate precipitates of urates, earthy phosphates
and albumin?
2. Name several drugs that render the urine alka-
line; give their indications and methods of administra-
tion. What class of acids would you give to acidify
alkaline urine?
3. What casts are frequently found in albuminous
urine and what do they denote?
4. What is hematuria? What conditions cause it and
how does it appear microscopically?
5. Name four conditions in the physical organism
which would modify the effects of poisonous drugs.
6. What two remedies are especially indicated in
chronic lead poisoning? Describe the action in said
condition.
7. How would you differentiate between true poison-
ing and diseases which simulate poisoning?
8. In examining vomited matter or a stomach sus-
pected to contain phosphorus, what simple methods
would show its presence?
9. How would you distinguish between intentional
and accidental abortion?
10. What are the signs of death?
HYGIENE.
1. Discuss briefly artificial heating in its relation to
vent^ation.
2. What are the general rules for ventilating a room
by providing inlets and outlets, as to size, location
and number?
3. What are the sources of water supply?
4. Discuss milk as a factor in the spread of disease.
5. What diseases are transmitted by mosquitos?
6. (a) Describe the mosquitos causing malaria, (b)
What measures would you adopt to destroy them?
7. (a) Discuss room disinfection. (b) Municipal
quarantine.
8. What diseases threaten soldiers and civilians in
the tropics?
9. If you were a surgeon of a post or camp, what
measures would you adopt to prevent disease among
the troops?
656
SOUTH CAROLINA.
10. How would you deal with an epidemic of cerebro-
spinal meningitis?
BACTERIOLOGY AND PATHOLOGY.
1. How do bacteria multiply? What is meant by the
terms aerobic and anaerobic bacteria?
2. What are the staining peculiarities of the Bacillus
tuberculosis?
3. Describe the Diplococcus intracellularis. Where is
the organism found and how is it identified?
4. What are the causes, results and terminations of
thrombosis?
5. Describe the microscopical structure of sarcomata
and carcinomata and give the usual mode of extension
of each.
ANSWERS TO STATE BOARD EXAMINATION
QUESTIONS.
State Board of Medical Examiners of South Caro-
lina.
junior anatomy.
1. "The liver is the largest gland in the body, meas-
uring in its transverse diameter from ten to twelve
inches, and its antero-posterior six to seven, and its
thickest part about three inches, and weighing about
from three to four pounds. It occupies the upper part
of the abdominal cavity, and the right hypochondriac,
epigastric, and a portion of the left hypochondriac re-
gions. Its upper surface is convex and rests against
the diaphragm and a small portion of the abdominal
parietes in front. Its lower surface is in contact with
the duodenum and stomach, the , right kidney and
suprarenal capsules, and the hepatic flexure of the
colon. It is divided by the longitudinal fissure into
the right and left lobes. The liver has five fissures,
five lobes, five ligaments, five sets of vessels, and is
inclosed in a fibrous coat, continuous at the transverse
fissure with the capsule of Glisson. It is also invested
by the peritoneum, except at the attachment of the
coronary ligament." (Young's Anatomy.)
The fissures are: umbilical, of ductus venosus, of gall
bladder, transverse, and for inferior vena cava.
The lobes are: right, left, caudate, quadrate, and
spigelian.
The ligaments are: Falciform, 2 lateral, coronary,
round and of ductus venosus.
The vessels are: Hepatic artery and veins, portal
vein, and hepatic duct.
657
MEDICAL RECORD.
2. The male bladder is a musculo-membranous pouch,
situated in the pelvis, behind the pubes and in front of
the rectum. It has a superior surface, anteroinferior
surface, two lateral surfaces, a base or fundus, and a
summit or apex. It is retained in its place by the two
anterior ligaments, two lateral ligaments, and the
urachus; there are also five false ligaments formed by
folds of the peritoneum. Internally, on the floor, is the
trigone, between the openings of the two ureters and
the urethra. The anterior part of the bladder is un-
covered by peritoneum, and is in relation with the tri-
angular ligament, the symphysis pubis, and the pubo-
prostatic ligament. Above it is covered with periton-
eum and is in relation with the rectum and small in-
testines. The base is in relation with the rectovesical
pouch, vasa deferentia, and seminal vesicles, all of
which separate it from the rectum. It is supplied by
the superior, middle, and inferior vesical arteries; and
the pelvic plexus of the sympathetic, and the third and
fourth sacral nerves.
3. "The lung is cone shaped, with the base down-
wards. The apex projects upwards into the root of the
neck behind the clavicle and anterior scalene muscle.
Above the first rib, the first part of the subclavian
artery lies in front, being separated from it by the
pleura. The base is concave, resting upon the
diaphragm, and following the attachment of the midriff
is placed lower externally and posteriorly than an-
teriorly. The outer surface is convex, and corre-
sponds to the chest wall. The inner surface is con-
cave, corresponding in part to the convex outer sur-
face of the pericardium. It presents about its middle,
and towards the posterior part, a slit, the hilum pul-
monis, where the bronchi and vessels pass in to form
the root. The anterior margin is thin, and overlaps
the pericardium, and presents on the left side a notch
for the apex of the heart. The posterior margin is
rounded, and occupies the groove by the side of the
vertebrae. The left lung is smaller and narrower than
the right, and is divided into an upper and lower lobe
by a fissure, which passes upwards and backwards
from the anterior border nearly to the root. The root
consists of the bronchus, a branch of the pulmonary
artery, two pulmonary veins, nutritive bronchial ves-
sels, anterior and posterior pulmonary plexuses,
lymphatic vessels and glands, all held together by
areolar tissue, and covered by the pleura." (Aids to
Anatomy.)
Blood-Supply: Left bronchial artery for nutrition.
658
SOUTH CAROLINA.
4. Inferior maxilla consists of a body and two rami.
The body is horse-shoe shaped and contains the lower
teeth; externally it presents the symphysis, mental
process, mental foramen, incisive fossa, and external
oblique line; internally it presents the four genial
tubercles, sublingual fossa, internal oblique line, sub-
maxillary fossa. The alveolar border has sixteen cav-
ities for teeth. The ramus is quadrilateral, and pre-
sents the inferior dental foramen and a spine. Above
it has the coronoid and condyloid processes, separated
by the sigmoid notch. The muscles attached are:
Levator menti, depressor labii inferioris, depressor
anguli oris, platysma myoides, buccinator, masseter,
orbicularis oris, geniohyoid, geniohyoglossus, mylo-
hyoid, digastric, superior constrictor of pharynx, tem-
poral, internal and external pterygoids.
5. The brachial plexus is formed by the union and
subsequent division of the anterior divisions of the
fifth, sixth, seventh, and eighth cervical and the first
dorsal nerves. The union of the fifth and sixth makes
the upper trunk; the seventh forms the middle trunk,
and the eighth cervical and first dorsal make the lower
trunk. Each of these trunks is divided into an an-
terior and a posterior branch. The anterior branches,
from the upper and middle trunks, make the upper or
outer cord of the plexus; the anterior branch of the
lower trunk becomes the lower or inner cord; the three
posterior branches unite to form the posterior or mid-
dle cord. The plexus lies between the Scalenus anticus
and medius. The branches are: (1) Above the clav-
icle; communicating, muscular, posterior thoracic, and
suprascapular. (2) From outer cord: External an-
terior thoracic, musculocutaneous, and outer head of
median. (3) From inner cord: Internal anterior
thoracic, lesser internal cutaneous, ulnar, and inner
head of median. (4) From posterior cord: Subscapu-
lar, circumflex, and musculospiral.
SENIOR ANATOMY.
1. In ligating the brachial artery in the middle of
the arm, the following blood-vessels and nerves are en-
countered: The basilic vein and internal cutaneous
nerve, to the inner side of the artery; the median
nerve, crossing the artery from without inwards; the
venae comites, one on each side of the artery.
2. To allow for drainage and to prevent infection
from spreading along the emissary veins to the men-
inges or intracranial sinuses.
3. Second, or superior maxiliary branch, supplies
sensation to skin and conjunctiva of lower lid, nose,
659
MEDICAL RECORD.
cheek, upper lip, upper teeth and alveolar processes,
and palate. Third, or inferior maxillary branch, sup-
plies sensation to external auditory meatus, side of
head, mucous membrane of mouth, anterior two-thirds
of tongue, lower teeth, lower lip and skin of the lower
part of the face.
4. Metastasis is allied to embolism; small particles
may be carried by the blood vessels or lymphatic chan-
nels to neighboring or distant parts pf the body where
they may lodge in the capillaries. Hence secondary
sarcomata may appear wherever the blood vessels or
lymph channels are able to carry particles of the origi-
nal tumor.
5. Paracentesis of the pericardium should be done
"in either the fifth or sixth interspace, and either in-
ternal to or external to the internal mammary artery.
In the fifth interspace, the width is greater near the
sternal border, and is the space usually chosen. In
the sixth interspace, the internal mammary artery and
the pleura are both further from the left sternal bor-
der, and puncture may be made more directly inward.
Where sufficient width of space exists, the sixth inter-
space may be chosen. Puncture should, by preference,
be made internal to the internal mammary artery, as
the pleura is in less danger of injury, especially in the
fifth space — and even in the sixth space, the puncture
would have to be about one inch outside of the border
of the sternum to be sure of avoiding the internal
mammary artery, and then it is apt to strike the
pleura." (Bickham's Operative Surgery.)
6. With pus beneath the thick middle portion of the
palmar fascia, the abscess is liable to point above the
clefts of the fingers, on the dorsum of the hand, or
in the forearm.
7. After ligation of the common carotid artery, the
collateral circulation is carried on as follows:- "(1)
Branches of the external carotid on the side tied, anas-
tomosing with the corresponding branches of the oppo-
site side, viz., (a) Facial with facial; (6) temporal
with temporal; (c) occipital with occipital; and (d)
superior thyroid with superior thyroid. (2) Anas-
tomoses between the internal carotids of opposite sides
through the anterior segment of the circle of Willis —
anterior cerebral of one side with the anterior cerebral
of the other, through the anterior communicating. (3)
Anastomoses between the subclavian and the external
carotid of the side tied, viz., (a) The deep cervical with
the princeps cervicis of occipital; (6) the vertebral
with the occipital; (c) inferior thyroid with superior
660
SOUTH CAROLINA.
thyroid. (4) Anastomoses between the subclavian and
the internal carotid of the side tied, the vertebral
through the basilar and posterior cerebral with pos-
terior communicating from internal carotid. (5)
Anastomoses of the ophthalmic, from the internal caro-
tid with branches of the external carotid on the side
tied, viz., (a) Nasal of ophthalmic with angular of
facial; (6) infraorbital, from internal maxillary, with
twigs of facial; (c) supraorbital and frontal, from
ophthalmic, with terminations of the anterior temporal."
(McLachlan's Applied Anatomy.^
8. Hemorrhage into the pons below the point of
decussation of the seventh nerve will result in a
crossed hemiplegia, there will be facial paralysis on
the same side as the lesion, and paralysis of the ex-
tremities on the opposite side.
9. Carcinoma of the stomach is most apt to occur at
or near the pylorus, because that is the most common
site of gastric ulcer, and gastric carcinoma is most fre-
quently found to develop in an old gastric ulcer.
PHYSIOLOGY.
1. An enzyme is a body produced by a living organ-
ism or cell and is capable of effecting certain chemical
changes in certain bodies without itself undergoing
alteration in the process. An amylolytic enzyme, such
as the amylopsin of the pancreatic juice, by a hydro-
lytic cleavage of the starch molecule, converts poly-
saccharides into dextrose and maltose.
2. The medulla oblongata contains collections of gray
matter which serve as special nerve centers for the
following functions or actions: respiration, salivary
secretion, mastication, sucking, deglutition, vomiting,
voice, facial expression; it also contains the cardiac
and vasomotor centers.
3. The lymphatic system consists of: lymphatic
glands, lymph vessels, perivascular lymph spaces, the
lymph canalicular system, the pericardial, pleural,
peritoneal, and synovial cavities, and the lacteals.
The lymphatic circulation is, strictly speaking, not a
circulation at all, since the lymph flows only in one
direction, namely, toward the heart. The lymph ca-
pillaries take up any excess of the blood plasma which
is not required for the nutrition of the tissues. These
capillaries consist of a single layer of epithelium, and
empty themselves into vessels very like the veins. The
lymph vessels' are well provided with valves, which are
so closely approximated as to give the vessels a beadeb!
appearance. All the lymphatic vessels, except those of
631
MEDICAL RECORD.
the right upper half of the body, empty into the
thoracic duct, which terminates in the left subclavian
vein, where the left internal jugular vein also enters.
Those from the right upper half of the body discharge
into the right lymphatic duct, which, in turn, empties
into the right subclavian vein at its junction with the
right internal jugular vein.
The forces concerned in the circulation of the lymph
are: (1) The pressure of the blood in the blood-vessels;
(2) thoracic aspiration; (3) muscular contractions of
the voluntary muscles; (4) contractions of the intestine;
(5) the action of the valves in the lacteals and
lymphatics.
The function of the lymphatic system is to provide
the tissues with material necessary to their functional
activity, growth, and repair ; to receive from the tissues
their waste products; and to convey the products of
digestion and absorption to the blood-current.
The lymph capillaries differ from the blood-cap-
illaries, chiefly, in their larger and very variable cali-
ber and also in their numerous communications with
the lymph spaces. The lymph vessels in general have
thinner coats than the blood-vessels; and the valves
in the lymph vessels are much more abundant than in
the veins.
4. Changes that occur in the fetal circulation at
birth: The hypogastric arteries dwindle and close, the
foramen ovale becomes obliterated, the ductus arte-
riosus and ductus venosus become obliterated, the um-
bilical vein becomes impervious, and the Eustachian
valve atrophies.
5. Internal secretions: It is generally held now that
the glandular organs, chiefly the pancreas, liver, and
the ductless glands, produce a secretion, peculiar in
each case to the particular gland producing it, and
which is supposed to be given off to the blood or lymph,
and to have some peculiar value in the general metab-
olism of the body. Such secretions are called internal
secretions, in contradistinction to the previously known
secretions, which are carried off by a duct, and are
known as external secretions. Very little is definitely
known of these internal secretions, but much work is
being done on the subject.
The function of the spleen: The following theories
have been held: (1) It is a source of production of the
white blood corpuscles; (2) it is a source of production
of the red blood corpuscles during fetal life; (3) it is a
place where the red blood corpuscles are destroyed;
(4) uric acid is produced in the spleen; (5) an enzyme
SOUTH CAROLINA.
is produced in the spleen and is carried by the blood to
the pancreas, where it converts the trypsinogen into
trypsin.
The function of the thyroid is not definitely settled:
(1) it has some trophic function, regulating oxidation
in the body, and it is supposed to have also a special
influence on the vasomotor nerves, the skin, the bones,
and on the sexual functions; (2) it is supposed to an-
tagonize toxic substances and (3) it produces an in-
ternal secretion.
The function of the thymus is not settled; it is said:
(1) To be a blood-forming organ; (2) to have influence
on growth and nutrition; (3) in hibernating animals it
is supposed to store up materials which can be utilized
during the period of inactivity. ■
The function of the suprarenale is not definitely set-
tled ; they produce an internal secretion which is proba-
bly necessary to life; it is supposed that they are able
to destroy or remove some toxic substance produced
elsewhere in the body.
Function of the pituitary gland: "The anterior lobe
is concerned with the process of growth, hypertrophy
leading to overgrowth of the skeleton, and partial re-
moval to failure of development of the body as a whole
and of the sexual glands. Extracts of the posterior lobe,
when injected into an animal, have a direct action on
plain muscle all over the body ; they cause constriction
of the arterioles and a rise of blood pressure, contrac-
tion of the muscular coats of the digestive tract and of
the bronchioles, and contraction of the uterus. The ex-
tracts also produce an increased flow of urine, which
was at first attributed to the presence of a substance
having a specific effect upon the renal cells; it is
probable, however, that the diuretic effect is merely an
indirect result of the more rapid flow of blood through
the kidney which follows the injection of the extract.
Extracts of the posterior lobe increase the secretion of
milk, and after the injection a larger amount of milk
is formed by the animal in the course of twenty-four
hours." (Bainbridge and Menzies' Essentials of Physi-
ology.)
CHEMISTRY,
1. There are about four parts of carbon dioxide in
10,000 parts of air. The carbon dioxide in the air does
not increase because it is being constantly removed by
the plants, the chlorophyll of which (under the influ-
ence of sunlight) decomposes the C0 2 , and returns the
oxygen to the air.
663
MEDICAL RECORD.
2. The ferric hydrate changes the arsenic into fer-
rous arsenate, which is non-poisonous.
3. Chemical properties of nitric acid: When exposed
to air and light, it is decomposed into N a 4 , H 2 0, and
oxygen; a similar result is obtained when it is exposed
to heat; it is an oxidizing agent; it destroys many
organic substances; in combination with metals, it pro-
duces nitrates.
It enters into the composition of nitroglycerin.
4. Calcium sulphate is gypsum, or plaster of Paris,
When mixed with water it "sets," making a hard
casing; it is used in the fixing of fractures, etc.
5. Electricity is used in diagnosis as a means of
illumination to be employed with the various "scopes"
for examining the cavities of the body. It is also used
in determining the reactions of degeneration. "A nor-
mal nerve or muscle will respond to any form of elec-
tric stimulation. If it is diseased, it will not respond
to a faradic current, but will give an increased re-
sponse to a galvanic current, but the reaction obtained
will be slow and sinuous, in opposition to the quick and
prompt response obtained when a nerve is normal. The
usual method of testing is to first apply a slowly in-
terrupted current to the corresponding normal nerve,
and then try the same current on the diseased nerve.
If the nerve is completely diseased or sclerosed, no re-
action will be obtained to either current. The galvanic
current is then tried and a minimum current applied
to the diseased nerve first, and the response will be
slow and sinuous. The same current applied to the
healthy nerve will not cause any reaction, and to obtain
a response it will be necessary to increase the current
to such an extent that it will be painful. Reactions
of degeneration are not obtained until about one or two
weeks after the severance of the nerve, and should
never be sought for as long as a nerve is inflamed or
there is pain on pressure. Its presence makes the prog-
nosis doubtful; its absence, good." (Anders and Bos-
ton's Medical Diagnosis.)
MATERIA MEDICA.
1. Hydrargyri iodidum flavum. Dose, gr. 1/5; and
hydrargyri iodidum rubrum. Dose, gr. 1/20.
2. Fluidextract of digitalis, dose ti^j; extract of
digitalis, dose, gr. 1/5; infusion of digitalis, dose,
3ij; tincture of digitalis, dose, ttj?xv.
3. Atropine: Dose, gr. 1/160.
Action: Anodyne, mydriatic, inhibits secretions, de-
pressant of terminations of nerves, accelerates the
heart beat, causes rise in blood pressure, but toxic
664
SOUTH CAROLINA.
doses cause the blood pressure to fall; it stimulates the
respiratory center, but large doses depress the same; it
may cause vertigo, restlessness, excitement, delirium,
or mania.
Tjncture of nux vomica: Dose, TlflV-X.
Physiological action: Strychnine is a bitter tonic,
stimulates appetite, secretion, and digestion, increases
peristalsis, stimulates the vasomotor centers, and so
raises arterial tension, and stimulates both accelerator
and inhibitory nerves of the heart. All the functions
of the spinal cord are exalted by strychnine, reflex,
motor, vasomotor, and sensory. Large doses cause di-
lated pupils, irregular and jerky respiration, increased
reflexes.
Fowler's solution of arsenic: Dose, n^i-v.
Action: It is a tonic; increases cardiac action,
respiratory power, intestinal secretions, and peristalsis;
produces edema, itching, diarrhea, epigastric pain,
irritable and feeble heart.
Fluidextract of ergot : Dose, irgxxx.
Physiological action: Ergot stimulates and causes
contraction of involuntary muscle fibers, hence it is a
vasoconstrictor, hemostatic, and oxytocic. It is also a
cardiac sedative, it raises the blood pressure, it in-
creases peristalsis, and is an emmenagogue.
Tincture of opium: Dose, rrgviij.
Physiological action: It is analgesic, hypnotic,
diaphoretic, narcotic, a respiratory and cardiac stimu-
lant (later a depressant), it checks most secretions
(not perspiration), it stimulates the brain, and con-
tracts the pupil.
4. A vasodilator: Amyl nitrite, ilEij-v (by inhala-
tion).
A vasoconstHctor : Strychnine sulphate, gr. 1/64.
A hydragogue cathartic: Elaterin, gr. 1/10.
A cholagogue cathartic: Podophyllum, gr. viij.
A diuretic : Potassium acetate, gr. xxx.
5. R
Codeinae sulphatis, gr. iij.
Ammonii chloridi, 3i.
Fluidextracti glycyrrhizse, ?j.
Aquae destillatae, q. s. ad Jij. M.
Sig.: One teaspoonful every two hours in water.
Mark Tapley, M.D.,
911 West Forty-Fourth Street,
New York City.
Registered Number, 23.
For John Jones (aged 30 years), 846 West 156th
Street, New York.
October 26, 1915.
635
MEDICAL RECORD.
THERAPEUTICS.
1. Gastroenteritis in child two years old: Two drams
of castor oil as a purgative; cool sponging or bath for
fever (if present) ; give no food, but only boiled water
or barley water for twenty-four hours. Subsequently,
the diet must be properly regulated.
2. Measles: Isolation in a well-ventilated and dark-
ened room; cool sponging or bath for fever; cool water
to drink; if a sedative is required one grain of phenac-
etin may be given every three hours for four doses;
if the cough is troublesome, three grains of sodium
bromide may be given every three hours; inunction
with 5 per cent, ichthyol in lanolin will relieve the itch-
ing; as a laxative, a quarter of a grain of calomel may
be given every hour for two or three doses.
3. Acute catarrhal dysentery in adult: "The treat-
ment consists of rest in bed and liquid diet. Rochelle
salt (3 4) or Epsom salt (3 4) should be given to
cleanse the bowels thoroughly. Castor oil (3 1) with
laudanum (gtt. 20) may be used. Pain is relieved by
opium, alone or combined with bismuth subnitrate, co-
caine or belladonna. Hope's camphor mixture (§ 2)
may be administered every 3 hours. The colon 'may
be irrigated every 2 hours with lukewarm water or
starch-water containing laudanum (3 %)." (Pocket
Cyclopedia.)
4. Diabetic coma: "The coma is usually fatal, and
little can be done to delay the result. Inhalation of
oxygen has been thought of benefit, and large doses
of sodium bicarbonate and other alkalies have rescued
from coma by reducing the acid intoxication. Normal
salt solution used by rectal irrigation, subcutaneous or
intravenous injection, has proved beneficial, to the ex-
tent of delaying coma or temporarily restoring con-
sciousness in a few instances. Sodium bicarbonate in
strong solution by intravenous injection, hypodermo-
clysis or rectal irrigation, is worthy of more extended
trial. A quart (liter) of a 1 to 2 per cent, solution
may be injected slowly into a vein every six hours in
a bad attack; when administered by other methods the
bicarbonate should be given in increasing doses up to
100 grams (3.5 ounces) a day, or until the reaction of
the urine has become alkaline." (French's Practice of
Medicine.)
5. General anasarca accompanying cardiac insuffi-
ciency: "The heart balance is best restored by the
administration of some preparation of digitalis such as
the infusion, 3i to 3iv, the tincture, irgv to xxx, or the
powder, gr. i three times daily. The possibility of
SOUTH CAROLINA.
nausea following the use of digitalis, especially the
tincture, should be remembered. The dose of the drug
is best guided by the results it produces. When for
any reason digitalis is not applicable, strophanthus,
strychnine, caffeine, and sparteine may be given. The
venous engorgement and dropsy may be relieved by the
administration of small doses of mercury and saline
purgatives. The combination of calomel, digitalis, and
squill, of each gr. i is especially valuable in this con-
nection. When the dropsy is extreme, tapping or mul-
tiple incisions may be required. The extreme and dis-
tressing shortness of breath is best relieved by mor-
phine, gr. %, and inhalations of oxygen." (Hughes'
Practice of Medicine.)
6. Spasmodic croup: "Place the child in a warm,
moist room. In mild cases an emetic dose of the wine
of ipecac, half a dram every half hour until vomiting
ensues, may be sufficient to give relief. A warm
mustard bath aids the result. An enema should be
ordered if the bowels have not recently moved. In
severer cases a croup tent should be made over the crib
and a croup kettle started in which has been placed a
dram or two of the compound tincture of benzoin.
Emesis should be brought about as rapidly as possible.
Antipyrin gr. 3 for a three-year-old child acts as an
antispasmodic. If there is cyanosis and serious ob-
struction intubation may be necessary; however, a
smear and culture should be made in these cases to ex-
clude diphtheria. The succeeding day should be spent
quietly, a light diet given and the bowels kept open.
If there are adenoids present, these should be removed
at a later date." (Chapin and Pisek's Diseases of
Children.)
7. Renal colic: "Pain is relieved by the subcutaneous
injection of morphine (gr. %-*4) or of morphine
(gr. Ys) and atropine (gr. 1/60); by inhalation of
amyl nitrite, chloroform or ether; or by drop doses of
amyl nitrite, etc. Calomel should be administered in
gr. % dose every half-hour until 4 or 5 grains are
taken, followed by citrate of magnesia. Opium may be
given with the calomel, or combined with belladonna in
suppository. A large warm-water enema should be ad-
ministered. The warm bath, mustard or turpentine
stupes, hot fomentations sprinkled with laudanum,
large, light linseed poultices, and friction are grateful."
(Pocket Cyclopedia.)
8. Cholera morbus: Hot turpentine stupes to the
abdomen or morphine (gr. %) hypodermically may be
given for the pain. Salines should be administered to
667
MEDICAL RECORD.
remove the offending particles. Should the salts move
the bowels too frequently, give paregoric (3 1) and
compound tincture of lavender (3 1) every 3 hours
until 2 or 3 doses have been taken. Should the
pain and diarrhea still continue, give the "Sun Cholera
Mixture" in teaspoonf ul doses after each evacuation of
the bowels.
9. Chlorosis: The bowels must be kept open with a
saline laxative; fresh air, sunshine, suitable food and
exercise are necessary; iron must be administered in
some form, such as the tincture of the chloride, njjx-xv
after meals, or 3 or 4 grains of Blaud's mass three
times a day.
10. Scarlet fever: The treatment is that of in-
fectious fevers in general, and in addition: "1. Serum
treatment. — Serum from convalescents, injected in
doses up to 20 c.c, has sometimes proved successful.
Good results have also been obtained with polyvalent
antistreptococcic sera (i.e. sera prepared from several
different strains of cocci). 2. The danger of spreading
the disease is greatest during the desquamative period.
Isolation must therefore be kept up for at least six
weeks from the onset, or till all desquamation and dis-
charges (nasal, aural, etc.) have ceased. 3. A mini-
mum amount of nitrogenous food, to avoid irritation
of the kidneys. This caution does not affect milk,
which may be freely used. 4. Daily toilet, tepid
sponging, or tepid baths. 5. Inunction of oily anti-
septic preparations into the skin, to prevent dissemina-"
tion of the desquamating scales. 6. Examine the urine
daily for signs of nephritis. 7. The condition of the
ears must be carefully watched." (Wheeler and Jack's
Handbook of Treatment.)
PRACTICE OP MEDICINE.
1. Landry's paralysis (acute ascending paralysis)
"is an acute disease characterized by palsy, beginning
in the feet and ascending to other muscles of the
body, finally involving the medulla. Pain and trophic
disturbances are absent. The reflexes are diminished
or absent, but the muscles do not waste, and the
sphincters are not involved. The affection is rare and
occurs most often in young male adults. The etiology
and pathology are obscure. The onset is sudden and
the course acute, terminating usually in death within
a week, occasionally being prolonged three or four
weeks. The treatment is unsatisfactory." (Hughes'
Practice of Medicine.)
2. Pulmonary infarction. Etiology: It is generally
668
SOUTH CAROLINA.
due to embolism or thrombosis of a branch of the pul-
monary artery. Symptoms: Dyspnea, dilated pupils,
livid face, pleuritic pain, hemoptysis, rapid and irregu-
lar pulse; embolism of the main artery causes sudden
death. Physical signs: None characteristic; there
may be dullness on percussion, breath sounds may be
feeble or harsh, and there may be crepitant or crack-
ling rales. Possible terminations: The circulation
may be reestablished and the blood removed; gangrene;
fibroid patch, or sloughing may result; death.
3. Causes of cardiac hypertrophy: Obstruction to
the outflow of blood such as results from valvular dis-
ease of the heart, emphysema, Bright's disease, and
arteriosclerosis; excessive functional activity, such as
is produced by prolonged muscular exertion, exophthal-
mic goiter; excessive use of tea, coffee, and tobacco.
4. Acute hemorrhagic pancreatitis is a disease which
generally attacks adult males; it is of sudden onset,
and the patient suffers intense abdominal pain; vomit-
ing, and epigastric tenderness are also present. Col-
lapse follows, and the patient usually dies in a few
days. Medical treatment is of. no avail, and surgical
treatment offers but slight hope. With regard to
diagnosis, Anders and Boston state as follows: Sum-
mary of Diagnosis. In all cases the diagnosis is made
with difficulty, the symptoms of hemorrhagic pan-
creatitis closely resembling those found in other path-
ological abdominal conditions. The age of the patient
(after middle life), the history of previous dyspepsia
or of diabetes, and a possible history of traumatism
to the abdomen are of considerable importance. Most
characteristic, however, is the sudden onset, the deep
seated epigastric pain followed by nausea, vomiting,
and circulatory collapse. Cammidge's reaction and the
presence of fat in the feces are also to be considered.
Differential Diagnosis. Obstruction of the Bowel:
When the obstruction occurs in an aged person, the
distinction is made with difficulty, (a) Acute intestinal
obstruction is more common in the young than in the
aged, and the pain is less definitely localized than that
of pancreatitis. (6) Abdominal distention is more
marked in intestinal obstruction, (c) Fecal vomiting,
a characteristic feature of obstruction, is absent in
acute hemorrhagic pancreatitis, (d) The temperature
is normal at the onset, but soon becomes subnormal
in obstruction; (e) indicanuria is a somewhat con-
stant symptom in obstruction.
Acute Gastroduodenal Catarrh: (1) In this condition
there is a distinct rise in the temperature at the onset
MEDICAL RECORD.
(2) The symptoms are not sudden and the pain is of a
different character, not deep seated or localized, as is
the case in acute inflammation of the pancreas. Cam-
midge's reaction is negative, as is also an examination
for fat in the feces. There is not the same degree of
prostration and as marked a tendency toward circula-
tory collapse as are characteristic of acute pancreatitis.
5. In pernicious anemia there is a great diminution
in the number of red corpuscles; they may fall to half
a million per cubic millimeter; the hemoglobin is also
diminished, but not in proportion to the corpuscles, so
that the color index is above unity. Poikilocytes, mi-
crocytes, macrocytes, normoblasts and megaloblasts
may be found. There is no leucocytosis.
In myeloid leucemia, there is an enormous leu-
cocytosis, with an increase of eosinophiles ; mast cells
are present, and myelocytes are present in large num-
bers. There is some diminution of hemoglobin and of
number of red corpuscles.
In lymphatic leucemia there is an enormous leu-
cocytosis involving the lymphocytes only, which may be
even 90 per cent, of the total leucocytes; there are no
myelocytes, but there may be a few nucleated red
corpuscles.
6. DiphtheHa is an acute, infectious, and contagious
disease caused by the Bacillus diphtherias, and charac-
terized by the formation of a fibrinous exudate on a
mucous membrane and by constitutional manifestations
of toxemia. The most frequent sequelae are: Paralysis
(of palate, muscles of eye, face, and larynx) ; also
cardiac and vasomotor paralysis; nephritis may also
follow the disease.
7. The symptoms might be caused by cardiac weak-
ness or disease or by renal disease. In the former case
the edema begins at the feet and extends upward, and
physical examination will show enlargement of the
heart or murmurs. In the case of renal disease the
edema begins in the face and extends downward, and
an examination of the urine may throw light on the
exact nature of the disorder.
8. Dilatation of the stomach is recognized by the
characteristic vomiting occurring at intervals of sev-
eral days, when large quantities of stagnant fluid and
scraps of partially digested or undigested food are
ejected. The vomitus is acid, and contains the Sarcina
ventriculi; on standing, it separates into layers. The
outline of the stomach (when distended) may be ob-
served, and splashing sounds may be obtained.
The condition is due to stenosis of the pylorus,
670
SOUTH CAROLINA.
pressure on the pylorus from tumors or gallstones,
kinking of the pylorus, atony.
If a tumor is found at the pylorus, atony may be
ruled out. Cancer will give cachexia, and the pres-
ence of the tumor may be detected by palpation; gall-
stones will give colic and jaundice.
9. The abdominal tumor may be due to floating kid-
ney, hydronephrosis, pyonephrosis, cancer or other
tumor of the kidney.
Floating kidney is accompanied by severe attacks of
pain, chills, DietFs crises.
Hydronephrosis may give few symptoms beyond
dragging pain, and pressure symptoms.
Pyonephrosis shows pus in the urine, and fever.
Tumor of the kidney may give pain, emaciation,
hematuria.
10. Fluid in the pleural cavity: There is imperfect
expansion on the affected side, the intercostal spaces
may bulge, the apex beat may be displaced; percussion
shows dulness or flatness, which is movable (according
to the position assumed by the patient) . The best sign
is the presence of the fluid on inserting an aspirating
needle.
OBSTETRICS.
1. The fetal envelopes from without inward: De-
cidua, chorion, and amnion.
2. The vitellus is the yolk or germinal part of the
ovum together with the substance intended for the
nutrition of the embryo. The allantois is a fetal mem-
brane developing from the lower part of the alimentary
canal very early in fetal life; it enters into the forma-
tion of the urinary bladder and also of the umbilical
cord and placenta.
The amnion is the innermost of the fetal membranes ;
it surrounds the fetus and is continuous with it at the
umbilicus; it secretes the liquor amnii, and forms the
sheath of the umbilical cord.
The liquor amnii consists chiefly of water, but con-
tains small amounts of albumin, epithelial cells, urea,
phosphates, chlorides, etc. Its specific gravity is about
1.001 to 1.008. Its source is unknown; it is probably
derived from the amnion, by transudation from the
maternal vessels of the placenta.
3. Development of the placenta: "The placenta, as a
separate organ, dates from the third month of preg-
nancy. At this time the chorion villi atrophy over the
whole periphery of the ovum, except at the point where
it comes in direct relation with the true mucous mem-
brane of the uterus — the decidua serotina. Here the
671
MEDICAL RECORD
villi take on an extraordinary growth, forming .buds
of epithelial cells (syncytium) upon their surface,
which rapidly take on the shape pf new villi, thus
sending out branches in every direction, into each of
which a loop of blood vessels is projected. Separating
the villi from one another, and dipping down to the
base of the chorion between the parent stems of the
villous projections, are processes of the decidua, carry-
ing capillary loops of maternal blood vessels. Very
early in the history of the ovum the arterioles of this
system open directly into the intervillous spaces of the
placenta, so that the placental villi are bathed directly
in maternal blood. ... It is now well established,
that the placental villi imbed themselves in the soft
interglandular substance of the decidua serotina, often
projecting into the mouth of the small veins, and that
the connective tissue cells multiply and hypertrophy
around them (decidual cells). The epithelium of the
uterine mucous membrane disappears, except in the
glands. The chorion villi are at first covered with two
distinct layers of cells; an inner layer composed of
single large nucleated cells arranged side by side with
distinct cell walls (Langhans* layer), and an outer
layer or band of protoplasm in which are imbedded
nuclei at irregular intervals (the syncytium). Both of
these layers are derived from the chorion and not from
the uterine epithelium or the endothelium of the uterine
blood vessels. Early in embryonal life (the third
month) the Langhans layer disappears and the syn-
cytium remains as the sole epithelial covering of the
villi. In the youngest ova yet observed the trophoblast
contains lacunae to which blood is conveyed from the
maternal circulation by little curling arteries that wind
their way up through the decidual cells to empty di-
rectly into the placental sinuses. These arteries are
provided with only a delicate endothelial wall. . . .
The syncytial cells of the latter have the power to pene-
trate the endothelium of the decidual arterioles and
thus open a direct communication between the placental
villi and the maternal blood. By this anatomical ar-
rangement the fetal and maternal blood is, of course,
kept separate. The former circulates within the capil-
lary system of the villi; the latter bathes the ex-
terior of the villi." (Hirst's Obstetrics.)
4. As pregnancy progresses the uterus becomes
larger in every way, is more vascular, first sinks and
then rises; the cervix becomes more vascular, softer
and edematous; later the cervix becomes shorter;
vagina and vulva become hypertrophied, more vascu-
672
SOUTH CAROLINA.
lar, discolored and secrete more freely; the vulva be-
comes more patulous. The blood is increased in quan-
tity, chiefly the fluid part and the fibrin making ele-
ments; the red cells and hemoglobin are relatively de-
creased, though absolutely increased; the white cells
are increased. The changes in the breasts are de-
scribed in the next answer. The heart is more rapid,
and the rhythm and rate more easily disturbed. The
lungs are compressed, their capacity decreased, and
the breathing oecomes more thoracic. There is in-
creased secretion of saliva, indigestion, vomiting in
the morning, and tendency to constipation. The urine
varies in quantity, and may contain albumin; micturi-
tion is more frequent. The woman's weight increases;
the skin becomes pigmented, chiefly on breasts, abdo-
men and genitals; the teeth may decay; the nervous
system becomes more irritable and unstable, and neu-
ralgia is apt to occur. There is apt to be change in the
woman's disposition.
5. "The mammary glands are compound racemose
glands, and consist of gland-tissue which is made up of
lobes, and these again of lobules. The lobes are con-
nected by fibrous tissue, and between them is fat. Each
lobule is composed of sacculated alveoli and a duct, the
lobular duct. The lobular ducts discharge into larger
ducts, which in turn discharge into a lactiferous duct,
which may be regarded as the excretory duct of a lobe.
Of these ducts, there are from fifteen to twenty; and
they open at the surface of the nipple. Under the
areola the tubuli lactiferi are dilated, forming ampullae,
in which, during the period of lactation, the milk ac-
cumulates in the intervals of nursing. The walls of
the alveoli consist of a basement membrane, covered,
during the period when the gland is not active, by a
single layer of flat or cuboidal cells with one nucleus
and presenting a granular appearance." (Raymond's
Physiology.)
During pregnancy the mammary glands increase in
size, fulness and firmness; Montgomery's follicles be-
come pronounced; the primary areola becomes larger
and darker; the secondary areola appears; the nipple
becomes larger, more prominent and more erectile; and
colostrum may be expressed.
If the infant is stillborn, or nursing is inadvisable,
the mammary glands should be anointed with a solu-
tion of atropine sulphate in glycerin (about 1:500); a
snug binder should then be applied; the patient should
be restricted to as little fluid as possible, and should re-
ceive salines to produce watery stools.
673
MEDICAL RECORD.
6. Glycosuria in pregnancy: "Sugar may be found
in the urine of pregnant women in from 5 to 25 per
cent, of cases after the fifth month or so. It is im-
portant to realize that there are other conditions be-
sides diabetes which may account for this. The fol-
lowing four conditions may be distinguished: (1)
Diabetes mellitus; (2) Lactosuria; (3) Alimentary;
(4) "Idiopathic" Pregnancy Glycosuria. True Dia-
betes must be diagnosed where the condition existed
prior to pregnancy, or where the glycosuria is accom-
panied by symptoms such as polyuria, emaciation, etc.
It is a very grave complication of pregnancy, leading
in many cases to premature labor, and in about a quar-
ter of the cases to the death of the mother from dia-
betic coma either during pregnancy or very soon after
delivery. The fetus in many cases is born dead. Lac-
tosuria. If the urine gives a reaction to Fehling's or
some other simple test for sugar, steps should at once
be taken to find out whether the sugar is glucose or
lactose. This can be done by the polariscope or the
fermentation test. In the majority of cases it is lac-
tose, reabsorbed from the milk in the breasts. In the
same way lactose is found in the urine of puerperal
women who do not nurse. Lactosuria is of no signifi-
cance. Alimentary Glycosuria. This is apparently
more easily induced in pregnant than in non-pregnant
women. A diminution in the carbohydrates in the diet
will probably lead to its disappearance. Idiopathic
Pregnancy Glycosuria. Under this head are included
unexplained cases of glycosuria in pregnancy, unac-
companied by any symptoms, and unaffected by diet.
The sugar is rarely present in any quantity, and dis-
appears shortly after labor. It is probably due in some
way, not yet understood, to the altered balance in the
secretions of the ductless glands." (Johnstone's Text-
book of Midwifery.)
7. u Albuminuria in small amounts, at irregular in-
tervals, has been regarded as physiological on account
of its frequent presence without apparent unfavorable
symptoms. The anatomical basis for this has been
supposed to be the so-called pregnancy kidney, which
has been described as a congestion from the pressure
of the altered circulation. The safer position is to as-
sume that any amount of albumin is pathological, pro-
vided we have the assurance that it is not due to the
admixture of discharges from the external genitals.
Its clinical significance may be unimportant in some
cases. The amount is generally small, not even ap-
pearing in some of the severest types until late in the
674
SOUTH CAROLINA.
disease. This may be true even in the later months in
the form that terminates in eclampsia, in which it may
suddenly appear as the attack begins. In such cases
daily and even hourly examinations may be necessary. ,,
— (Jewett's Obstetrics.)
Eclampsia is an acute morbid condition, occurring
during pregnancy, labor, or the puerperal state, and is
characterized by tonic and clonic convulsions, which
affect first the voluntary and then the involuntary mus-
cles; there is total loss of consciousness, which tends
either to coma or to sleep, and the condition may ter-
minate in recovery or death. About 75 per cent, of the
cases occur in primiparae. "The treatment of the at-
tack consists of the administration of chloroform by
inhalation, chloral hydrate (gr. 60) by enema, and the
fluidextract of veratrum viride hypodermically (gtt.
15 followed by gtt. 5 repeated frequently enough to
keep the pulse at about 60 beats a minute), to control
the convulsions, and free purgation by croton oil (gtt.
2, or 3, in sweet oil or glycerin), free sweating by the
hot pack, and sometimes depletion by venesection to
eliminate the poison. The after treatment consists of
free purgation by the salines, restriction of diet, and
later the administration of tonics and stimulants. The
obstetric treatment is usually noninterference." —
(Pocket Cyclopedia.) Sometimes accouchement force
is indicated.
8. Cesarean section. — "Indications: The cases in
which it is performed are: (1) Extreme deformity of
the pelvis, in which delivery by forceps and version is
excluded, and in which craniotomy is either impossible
or would be more dangerous to the mother than cutting
into the abdomen and uterus; and in which there is
not room for a successful symphyseotomy. Such cases
present the 'positive' indication for cesarean section;
there is nothing else to be done. Flat pelves having a
eonjugata vera of 2% inches or less, and justo-minor
pelves with a eonjugata vera of 2% inches or less,
present this positive indication; (2) cases of more
moderate pelvic contraction in which craniotomy is
possible, but cesarean section is agreed upon to save
the life of the child; (3) mechanical obstruction in the
pelvis from fibroid, cancerous, bony, or other tumors
which cannot be pushed up out of the way or be safely
removed; (4) irreducible impaction of a living^ child in
transverse presentations; (5) in women dying near
the end of pregnancy the child, if alive, is rapidly de-
livered by post-mortem cesarean section; (6) various
other obstructions from inflammatory adhesions, atre-
675
MEDICAL RECORD.
sia, constrictions, etc., of the vagina, and uterine dis-
placements, may rarely require the operation; (7) re-
cently the operation has been done in eclampsia cases,
where more conservative methods of rapid delivery
were impracticable; and (8) in placenta praevia,
chiefly with a view to lessen the infant mortality at-
tending the usual treatment of this complication." —
(King's Obstetrics.)
Cesarean section. — "Fuidextract of ergot, ir^xx, is
injected into the thigh muscles just as the anesthesia is
begun. The operator assures himself that there is no
loop of intestine between the uterus and abdominal
wall, beneath the field of incision. Should a coil of in-
testine be found there, it is pushed above the fundus.
An assistant holds the uterus in central position. The
skin incision extends one-third above and two-thirds
below the level of the umbilicus. It is best made
through the right rectus muscle. The external layer
of the rectus sheath is divided, the muscular bundles
separated with handle of scalpel and the fingers, and
the deep layer of the sheath and the peritoneum di-
vided after lifting them with tissue forceps. Bleeding
vessels are controlled by gauze sponge pressure or held
by catch-forceps before opening the peritoneum. A
short longitudinal median incision is made in the
uterine wall beginning at the fundus, avoiding the
membranes if still unbroken. This is extended down-
ward with fingers, scissors, or scalpel to a total length
of about six inches. The hand is thrust through the
membranes and the child is extracted by the head or
the feet, whichever is most accessible. In case of ante-
rior implanation of the placenta, usually the hand may
best be passed directly through it. The cord is clamped
at two points with catch-forceps, cut between them,
and the child is passed to an assistant. The uterus
slips out of the abdomen as the child is extracted, and
the intestines are kept back with hot sterilized towels
placed over the upper part of the incision. The cover-
ings help also to protect the peritoneum from soiling.
The uterus is wrapped in hot moist cloths. As a rule,
it is better not to wholly eventrate the uterus. The
placenta, if not spontaneously separated, may be peeled
off by grasping it with one hand like a sponge. If the
cervix is not sufficiently open for drainage, a large rub-
ber tube or gauze strip is passed down through it and
withdrawn from below. Irrigating or mopping the
uterine cavity is unnecessary. Asepsis is promoted by
leaving it as nearly as possible untouched. The peri-
toneum is sponged dry with the least possible friction
676
SOUTH CAROLINA.
or handling. The uterine wound is closed with deep
No. 2 chromated catgut sutures at intervals of about
1/3 inch. They are given a wide sweep laterally
through the muscular wall, falling short of the de-
cidua. The peritoneal coat of the uterus is closed with
a No. 1 continuous plain catgut suture, forming a welt
over the deep suture line. The hemorrhage is incon-
siderable and usually ceases with the introduction of
the first sutures — a hypodermic of ergotole should be
given before beginning the operation, and one of ergo-
tole and pituitrin on the delivery of the child. Retrac-
tion of the uterus is ensured by manipulating it, if
necessary, through a hot towel, or by faradism. When
there has been much blood lost, a quart or two of warm
sterilized 0.9 per cent, salt solution may be left in the
peritoneum. The parietal peritoneum is closed with a
plain running No. catgut suture. Interrupted silk-
worm-gut sutures are then passed at intervals of about
% inch: through all but the peritoneum, from within
outward. The fascia is brought together with inter-
rupted No. 2 plain catgut sutures, or with a continuous
suture. The silkworm-gut sutures are now tied. The
abdomen is cleansed, and the wound covered with a
dressing of several thicknesses of dry sterile cheese-
cloth; over this is placed a thick compress of sterile
absorbent cotton. The dressings are secured with
strips of zinc oxide adhesive plaster, and held in place
by a Scultetus binder." — (Polak's Obstetrics,)
9. Face presentation. — Diagnosis: Vaginal exam-
ination will show a high position of the presenting
part, and also a mouth or nose, which should not be
mistaken for a breech. In L. M. A. case the chin is
directed anteriorly and to the left acetabulum; no
fontanelles can be detected. Abdominal palpation may
reveal the deep groove between the child's occiput and
back. Mechanism: The successive steps are: "Exten-
sion — The head presents at the superior strait imper-
fectly extended, so that every case of face persenta-
tion may be said to begin as a brow presentation.
There is also at first imperfect engagement of the pre-
senting part, on account of the large diameters pre-
sented at the superior strait. Under the influence of
the expulsive action of the uterus and the resistance of
the pelvic walls, the brow, caught upon the pelvic brim,
is held stationary, while the chin descends lower and
lower by an extreme extension of the head. Molding,
or an accommodation of the shape of the presenting
part to the shape of pelvis, occurs to a moderate de-
gree or not at all, because the face is a loose fit in the
677
MEDICAL RECORD.
normal pelvis. The molding is confined to the back of
the skull. Lateral inclination is a constant feature, so
that one cheek is a little deeper in the pelvic canal than
the other one. Descent of the presenting part follows
the dilatation of the cervical canal, the descent of the
chin being accomplished almost solely by the extension
of the head, and not by a descent of the head as a
whole. Anterior rotation of the chin occurs as soon as
it encounters the resistance of the pelvic floor. Ante-
rior rotation is followed by the engagement of the chin
under the symphysis pubis. Then follows the delivery
of the head by flexion and propulsion, the mouth, nose,
eyes, and forehead sweeping over the perineum and
appearing successively at the posterior commissure.
Eestitution and external rotation follow the escape of
the head from the same causes that impose those move-
ments upon the head in a vertex presentation. The
delivery of the body takes place as in a vertex pres-
entation." — ( Hirst's Obstetrics. )
Management: If the chin is presenting anteriorly,
expectant treatment may suffice; but care must be
taken to observe that the chin does not rotate back-
ward. Spontaneous version may occur, and the pres-
entation become a vertex one. Failing this, or as a
means of favoring this, the postural treatment, such
as Walcher's position, has been recommended. If, in
spite of this, engagement has not occurred, cephalic
version is indicated, care being taken not to rupture
the membranes. If this is not successful podalic ver-
sion should be tried. If, after all these manipulations,
the child is still alive and the head is engaged, sym-
physeotomy is indicated; if the child is dead, craniot-
omy should be performed.
10. "In mentoposterior positions endeavor to. secure
anterior rotation of the chin when it fails to take place
spontaneously. The several methods of attempting this
are: 1. Press the forehead backward and upward dur-
ing a pain, so as to make extension more complete, and
thus cause the chin to dip lower down and touch the
anterior inclined plane upon which it may glide for-
ward. 2. Put a finger in the mouth or on the outside
of the lower jaw, and draw the chin forward during a
pain. 3. Apply the straight forceps and twist the chin
to the pubes. 4. Apply the vectis, or one blade of the
forceps, under the most posterior cheek, and over the
anterior inclined plane, thus, as it were, thickening the
latter, so as to make it reach the malar bone and con-
stitute a point oVappui which the chin can touch and so
glide forward. Should these attempts to secure ante-
678
SOUTH CAROLINA.
rior rotation fail, an effort may be made with the hand,
vectis, or fillet, to bring down the occiput and convert
the face into a head presentation. In order to succeed
in this maneuver the membranes should be unbroken,
the os uteri dilated, the face not so deeply engaged
that it cannot be lifted to or above the pelvic brim,
and an anesthetic administered. Again, failing in this
way to produce anterior rotation, the head, if it be not
too deeply engaged in the pelvis, and have not passed
through the os uteri, may be pushed back, and the child
be delivered by podalic version. Should none of these
methods be practicable and the head become impacted
in the pelvis with the chin toward the sacrum, the only
resort is craniotomy. Attempts have been made in
these cases to deliver by forceps after lateral incision
of the perineum, but they can only succeed when either
the child is small or the pelvis over-large. Usually the
child's life has been so far imperiled by delay and its
consequences that craniotomy may be done without
compunction. Possibly symphyseotomy may prove use-
ful in these cases in future. In all cases of face pres-
entation special care is necessary to avoid rupture of
the perineum." — (King's Manual of Obstetrics.)
11. "The obstetric forceps is an instrument devised
for grasping the fetal head in difficult labor and by
traction aiding its exit. There are two varieties —
namely, the simple, including the short and the long,
and the axis-traction forceps. A short forceps is one
in which the blades of the instrument are attached di-
rectly to the handles without the intervention of a
shank; it possesses the cranial or cephalic curve only
— that is, the outward bulging of the blades by which
its accurate adaptation to the fetal head may be ac-
complished; this curve should be the arc of a circle,
the radius of which is about 4% inches. The long for-
ceps is one in which a shank is placed between the
handles and the blades for the purpose of adding
length to the instrument. It has, in addition to the
cephalic the pelvic curve, or upward turning of the
blade, corresponding to the curve of the parturient
canal. By an axis-traction forceps is meant a variety
of long obstetric forceps in which, by an appliance or
supplementary handle attached to the under surface of
the blades, the traction-force is exerted in the line of
the axis of the parturient canal, and, therefore, ren-
dered more effective, while at the same time it is re-
duced to a minimum. Traction is effected entirely by
the supplementary and not by the primary handles. " —
(Dorland's Obstetrics.)
679
MEDICAL RECORD.
Indications for the use of forceps are : "1. Forces at
fault: Inertia uteri in the presence of conditions likely
to jeopardize the interests of mother or child, (a) Im-
pending exhaustion; (6) arrest of head, from feeble
pains. 2. Passages at fault: Moderate narrowing SM
to 3% inches, true conjugate; moderate obstruction in
the soft parts. 2. Passenger at fault: A. Dystocia due
to (a) occipitoposterior, (6) mentoanterior face, (c)
breech arrested in cavity. B. Evidence of fetal ex-
haustion (pulse above 160 or below 100 per minute).
Accidental complications: Hemorrhage; prolapsus
funis; eclampsia. All acute or chronic diseases or com-
plications in which immediate delivery is required in the
interest of mother and child, or both." (From Jewett's
Practice of Obstetrics.)
Manner of using forceps: "They should not be used
when the os is unailated, when the head is not en-
gaged, except in placenta prsevia, when the mem-
branes are unruptured, when the disproportion between
the child's head and the parturient canal is too great,
or in impossible positions and presentations. Before
applying the instruments they should be sterilized,
preferably by boiling; and the patient anesthetized and
placed in the lithotomy position. Two fingers of the
right hand are introduced into the vagina; the left
blade of the forceps is then held almost perpendicularly
by the left hand, with the tip of the blade opposite the
vulva; the tip is introduced into the vagina, and passed
along the floor toward the sacrum. The blade is ro-
tated outward in its long axis in order to escape the
promontory of the sacrum. The right blade is intro-
duced in a similar manner. To facilitate locking, one
of the blades must be rotated forward. If the head
occupies the right oblique diameter, as in L. O. A. and
It. 0. P. positions, the right blade must be rotated; if it
occupies the left oblique diameter, the left blade must
be rotated. Traction is made in the direction of the
pelvic axis until the perineum is well distended. The
perineum is then protected by one hand, while the face
is swept over it by an upward movement of the for-
ceps. In posterior positions it is necessary to remove
the instruments after the head is drawn down to the
pelvic floor; after anterior rotation is secured they
may be reapplied. If the occiput rotates into the hol-
low of the sacrum the hands should be depressed as the
face is swept out under the symphysis pubis." —
(Pocket Cyclopedia.)
12. The case is one of Sepsis.
680
SOUTH CAROLINA.
GYNECOLOGY.
1. Two common causes of hemorrhage from the non-
pregnant uterus are endometritis and adenocarcinoma.
To differentiate these, microscopic examination of the
scrapings may be necessary. The following table
(from Dudley's Gynecology) may help:
GUNDULAR HYPER-
TROPHIC ENDO-
METRITIS.
1. Glands in-
creased in size but
not in number.
2. No prolifera-
tion of gland epi-
thelium.
3. Gland struc-
tures nearly or
quite typical in
ouiline.
4. Hypertrophied
epithelium confined
within the limits of
the tunica propria.
5. Gland tissue
does not invade
muscularis deeply.
6. Can trace tor-
tuous glands.
7. Stroma normal
in quantity.
GLANDULAR HYPER-
PLASTIC ENDO-
METRITIS.
1. G la n d s in-
creased in size and
number.
2. Proliferation
of gland epithelium.
3. Gland struc-
tures more tortu-
ous in outline.
4. Proliferation
confined within the
limits of the tunica
propria.
5. Gland tissue
does not invade
muscularis very
deeply.
6. Can trace tor-
tuous glands.
7. Stroma de-
creased in quantity,
but clearly defined
from glands.
ADENOCARCINOMA
1. Glands very
greatly increased in
size and number.
2. Very great
proliferation of
gland epithelium.
3. Gland struc-
tures very atypical
in outline.
4. The proliferat-
ing gland epitheli-
um has broken
through the tunica
propria and is in
direct contact with
interglandular con-
nective tissue, and
is multiplying in an
atypical manner.
5. Gland tissue
may very deeply
invade muscularis.
6. Glandular lab-
yrinth ; can not
trace tortuous and
atypical gland.
7. (Treat rarefac-
tion of stroma, so
that glands touc.h
one another. Glands
have broken
through basement
membrane and in-
vaded intraglandu-
lar spaces and mus-
cularis^
2. Retroflexion. Etiology: Tight lacing and tight
clothing; congenital conditions; pressure by tumors;
metrititis and parametritis with adhesions; atonic con-
ditions of the uterus following labor, and the condi-
tions that cause retroversion. Treatment: If there are
no adhesions, the flexion should be corrected by digital
manipulation and a pessary introduced; hysteropexy
may be necessary.
Retroversion. — Etiology : Relaxation of uterine liga-
ments; increased weight of fundus; subinvolution;
681
MEDICAL RECORD.
ovarian or other tumor pressing on front of uterus;
distended bladder; peritonitis or cystitis; prolonged
dorsal decubitus and tight bandaging in the puer-
perium. Treatment: Remove the cause, if possible; re-
place the uterus and keep it in position by pessaries,
tampons, and knee-chest position; pelvic massage and
vaginal douches; proper hygiene, particular attention
being paid to the bowels, clothing, and exercise. Cura-
tive treatment: The choice lies between ventral suspen-
sion of the uterus and shortening of the round liga-
ments.
3.—
APPENDICITIS.
1. No previous local dis-
turbances.
2. Chill usually absent.
3. Pain in right iliac re-
gion, sudden onset,
acute, and not radiat-
ing to thighs.
4. Fever of variable de-
gree.
5. Muscular rigidity on
right side of the ab-
domen.
6. Inflammatory exudate
about appendix three
to five days after on-
set of symptoms.
7. Vaginal examination is
rarely painful in ap-
pendicitis.
SALPINGITIS.
1. Genitourinary func-
tions previously dis-
turbed. Usually a
history of gonorrheal
or puerperal infec-
tion.
2. Chill may precede
fever.
3. Gradual onset, pain
dull, continuous, and
radiating.
4. Fever often entirely
absent.
5. No muscular rigidity
unless complicated by
peritonitis.
6. Inflammatory exudate
in the pelvis felt by
vaginal examination
at the onset of the
symptoms.
7. Always painful in
tuboovarian disease.
— (Findley.)
4. "Indications for Hysterectomy. — Hysterectomy is
indicated if the disease is limited to the uterus. Such
limitation will be inferred: 1. By the normal mobility
of the uterus. 2. By the absence of any enlargement of
the lymphatic glands in the parametria. 3. By the ab-
sence of the disease on the vaginal walls. Enlarge-
ment of the glands is evidence that the disease has ex-
tended beyond the uterus. This does not positively
682
SOUTH CAROLINA.
contraindicate hysterectomy, but renders the prognosis
less favorable. Whether enlarged or not the glands
should, if practicable, be removed. Extension of can-
cer to the vaginal walls, if slight, does not definitely
contraindicate hysterectomy, provided the diseased por-
tion of the vagina can be removed with the uterus. Ex-
tensive involvement of the vagina and fixation of the
uterus in surrounding cancer contraindicate the opera-
tion.
"When the disease has passed beyond the hope of
radical cure, but not beyond the limits of palliative
hysterectomy, hysterectomy is sometimes performed
for the temporary relief of symptoms; its benefits,
however, are not usually sufficient to overbalance its
dangers." — ( Dudley's Gynecology. )
Abdominal hysterectomy. — "The patient must be
carefully prepared as for any other abdominal opera-
tion, but in addition the pubes and vulva must be
shaved and thoroughly purified; the vagina should be
douched for some days previously, and an antiseptic
dressing worn, and if need be the uterine canal should
be curetted and disinfected with some powerful anti-
septic.
"After anesthesia has been induced the Trendelen-
burg position is adopted, and an incision of suitable
length made in the median line. The parts are then
carefully explored, and if no adhesions exist an ab-
dominal cloth is packed in over the intestines in order
to protect and keep them from exposure and injury.
If adhesions to omentum or gut are present they must
be carefully divided; it is, of course, most desirable
that a complete peritoneal covering should be secured
for any adherent organs; omental grafts may be some-
times useful in this direction. The broad ligaments
are then examined, and a decision made as to whether
or not the ovaries and tubes are to be saved.
"A pedicle needle carrying a sufficient length of well-
boiled silk is carried through the round ligament so as
to secure the ovarian artery and veins, and tied as far
away from the uterus as possible. A broad ligament
clamp may then be placed in position close
to the uterus, so as to prevent venous re-
gurgitation, and the broad ligament is divided
half-way down. It is often possible and desirable
to pick up the divided end of the ovarian artery
on the face of this section and secure it separately,
while the littte artery which accompanies the round
ligament should also be carefully secured. The ovarian
artery on the other side is next dealt with in a similar
683
MEDICAL RECORD.
fashion. A transverse cut is now made across the front
of the uterus, involving merely the serous membrane
and connecting the two ends of the incisions in the
broad ligaments; the peritoneum below this transverse
cut is detached, together with the bladder, from the
cervix, and the intraMgamentary space is thereby
opened up on either side. In this will be found the
uterine vessels, and it may be possible to see and iso-
late the uterine artery before securing it by ligature.
Care must be taken in this part of the operation to
keep close to the uterus, as the ureter comes forward
from behind under the uterine artery to reach the blad-
der, lying about the level of the os internum. The
uterine vessels are in this way carefully secured and
divided,
"The uterus is now merely held by the connection
between the vagina and cervix and the peritoneal re-
flection in Douglas' pouch. If a supravaginal opera-
tion will suffice, the surgeon cuts across the neck of
the uterus in such a way as to fashion two flaps, and
finally the peritoneum behind is divided. A few small
vessels will probably need to be secured on the face of
the uterine stump. This having been effected, the
uterine flaps are stitched carefully together so as to
bury the open cervical canal; the uterine stump is then
covered in by uniting the divided portions of perito-
neum. This line of sutures is carried up on either
side so as to secure the two layers of the broad liga-
ment; the final result is that the pelvic floor is covered
in by a continuous layer of peritoneum, showing, a
sutured incision which runs transversely from one side
to the other. The usual peritoneal toilette follows, and
the abdomen is generally closed entirely, no drainage
being required." — (Rose and Carless' Surgery.)
5. Amenorrhea is physiological: Before puberty,
during pregnancy and early lactation, and after the
menopause. It may also be due to: Absence or imper-
fect development of the generative organs; also to ste-
nosis, obstructions, or atresia of the genital tract; also
to operative removal of the uterus or its appendages.
Other causative factors are: Acute infectious diseases,
anemia, chlorosis, obesity, drug habits, alcoholism,
overstudy, lack of exercise, exposure to cold, and vari-
ous emotional causes. Treatment consists in: (1) Re-
moving the cause, if possible; (2) general treatment
by means of proper hygiene, rest, diet, bathing, atten-
tion to the bowels, exercise, etc.; (3) drugs reputed to
be emmenagogues, such as iron, manganese, aloes,
strychnine, apiol, oxalic acid, savine, rue, and tansy.
684
SOUTH CAROLINA,
SURGERY.
1. In acute synovitis of the knee-joint, the joint is
swollen, tender, hot, and painful; there is a bulging on
either side of the patella, and the patella is floated
away from the condyles; fluctuation is felt from side
to side, and the patella may be made to tap on the
femur; the joint is fixed in a slightly flexed position,
and movement is resisted by the patient.
In acute osteomyelitis, the swelling is not localized
to the limits of the synovial membrane of the joint, as
is the case in acute synovitis; fluctuation, if present, is
not so pronounced nor is it "from side to side" behind
the patella; pain is more severe, and symptoms of
toxemia may be present; rigors and high fever are
noticed.
In synovitis of the knee-joint the treatment consists
in immobilization of the joint, bandaging, application
of lead and laudanum lotion, ice is of use in the very
early stages, later on (if pain is present) hot applica-
tions are of service; if the tension is very great leeches
or aspiration may be of benefit. Later on, massage
and passive movements are serviceable.
In acute osteomyelitis treatment must be prompt; an
incision must be made through the periosteum and the
pus evacuated, the surface of the bone removed, and
the cavity exposed, washed out, and drained.
2. Excision of the knee- joint. — "A semicircular in-
cision is to be made, with the convexity downward,
commencing at the side of one condyle of the femur
and passing immediately above the tubercle of the tibia
to a corresponding point on the opposite condyle. This
incision divides the patellar ligament, and the patella
is turned up in the flap; the crucial ligaments should
then be cut across, and any remaining lateral attach-
ments divided. The limb must now be forcibly flexed
and the knife carefully applied to the posterior part of
the head of the tibia; a blunt pointed resection knife is
best for this purpose. The articular surfaces are to
be sawed off. The lower end of the thigh bone should
first be removed; the division must be made accurately
at right angles to the shaft of the femur, in the antero-
posterior direction. A thin slice is next taken off the
tibia; the section must be accurately at right angles to
the shaft of the tibia. Care must be taken not to re-
move more of the bones than is absolutely necessary,
especially in young subjects. If the patella is much
diseased, it should be removed; if it is only slightly
carious, it may be scraped or gouged out; if healthy, it
6S5
MEDICAL RECORD.
should be left to consolidate and strengthen the joint.
But the articular surface should be destroyed to favor
firm union with the femur. To keep the bones in posi-
tion they should be drilled obliquely at the anterior
part, and secured by two strong sutures of catgut. If
the wound is septic, wire sutures are the best. Before
the wound is closed all hemorrhage must be thor-
oughly arrested. Ligatures must be applied to the
articular arteries, if necessary. The patellar tendon
should be stitched in place with catgut and the wound
drained for one or two days by tubes or numerous
strands of silkworm gut. The limb must be kept at
perfect rest for the first few weeks; a narrow, prop-
erly padded splint extending from the hip to the heel,
will meet all indications. It should be fixed in position
by a flannel bandage above and below the knee, over
which a firm plaster of Paris bandage must be applied.
An interrupted plaster splint with connecting side
irons allows free access to the joints for dressing and
prevents soiling of the splint. The first dressings
should be changed after 24 hours. After that the dry,
antiseptic wool dressings should be used, which can be
left untouched for two or three weeks." — (Cyclopedia
of Medicine and Surgery.)
3. Various flaps used in amputations. — Ordinary
circular amputation: The soft parts are divided by a
series of circular cuts, retraction of the parts taking
place between each circular sweep of the knife, so that
they are cut partly through at different levels the
sawed bone forming the apex of the funnel left upon
the proximal end of the limb, and the skin margin the
base, the distal part removed being cone shaped.
Cuff method of circular amputation: A circular divi-
sion of the skin is made, which is turned over and up-
ward upon itself as a cuff and, upon a level with this
retracted cuff of skin and fascia, the muscles are di-
vided to the bone, generally with one circular sweep of
a long knife.
Modified circular amputation: Two equal flaps, com-
posed of skin and fascia, of varying length, and hav-
ing bases equal to one-half of the circumference of the
limb at their upper ends, are cut and dissected up a
short distance followed by a circular sweep of the
knife through the retracted superficial muscles — and
by a circular sweep at a higher level through the re-
tracted deeper muscles — and completion of the opera-
tion as in the ordinary circular amputation.
Oval method of amputation: A modification of the
circular method. The skin incision is in the form of an
. 686
SOUTH CAROLINA.
oval, with one of its ends more prolonged and pointed
— the soft parts between skin and bone being divided
by cutting from without inward — and the lips of the
wound being sutured in a single line parallel with the
long axis of the wound.
Racket method of amputation: A modification of the
circular method. The same, in principle, as the oval
amputation — with the addition of a longitudinal verti-
cal cut prolonged from the apex of the oval forming
the "handle of the racket" — thus giving a better ex-
posure of joints without sacrifice of tissue and secur-
ing a better covering for the bone in the upper part of
the wound.
Amputation by single flap of skin and muscles: A
method of amputating whereby the stump is covered
with a single flap derived from one aspect of a limb —
and consists of skin, fascia, and muscles. Such an
amputation involves the maximum sacrifice of bone.
Amputation by single flap of skin: The features of
this operation are practically the same as those of the
amputation by a single flap of skin and muscles, ex-
cept that the covering here consists entirely of skin.
Amputation by equal flaps of skin and muscle: Cov-
erings for the stump are gotten from two opposite
aspects of the limb in the form of two flaps composed
of all the soft parts covering the limb — having equal
bases and lengths — and the allowance of skin being
sufficiently in excess to well cover the muscles.
Amputation by equal flaps of skin: This operation is
the same, in general contour and dimensions of the
flaps, as the last — except that the covering here con-
sists of skin only.
Amputation by unequal flaps of skin and muscles:
Coverings are furnished by two flaps taken from oppo-
site aspects of the limb — each flap having a base equal
to one-half circumference of the limb at the saw line
— and one flap having a length greater than the other.
One flap usually furnishes one-third or two-thirds of
the covering, and the opposite flap two-thirds or one-
third — the longer flap generally coming from that
aspect of the limb most thickly muscled. The flaps
may bear any relation to each other in relative length
— but the two flaps combined furnish a covering equiv-
alent to 1% diameters of the limb at the saw line.
Amputation by unequal flaps of skin: Coverings are
of skin and fascia alone and are furnished by the two
opposite aspects of the limb, in the form of two flaps
having equal bases and unequal lengths. This amputa-
tion is identical throughout with the amputation by
687
MEDICAL RECORD.
equal flaps of skin, except as to the length of the flaps.
Amputation by unequal rectangular flaps of skin and
muscles: The general method of performing this oper-
ation is similar, in principle, to that for amputation by
unequal flaps of skin and muscles— with the exception
that the flaps are rectangular (instead of rounded)
and of special dimensions.
Elliptical method of amputation: This is not a dis-
tinct form of amputation. It may be considered a
variety of the circular method (an oblique circular),
or, equally, a variety of single flap amputation — and
may be held, in an intermediate position. It is circular,
as to skin incision; and flap, as to its manner of cover-
ing the stump and in the suturing. The skin incision
is in the form of an ellipse, or a lozenge, the upper
part of the ellipse being upon one aspect of the limb
and the lower part upon the opposite — the lateral limbs
of the figure crossing the lateral aspects of the limb to
be amputated. The idea of the ellipse is brought out
by imagining the outline projected upon a flat surface.
Best methods of amputation about the leg: Oblique
elliptical for the supramalleolar region. Large ante-
rior and small posterior flaps for lower third, between
supramalleolar region and lower limit of middle third.
Large posterior and short anterior flaps for middle
third. Large external flap for upper third. Bilateral
hooded flap for "place of election," or upper part of
upper third.
Best methods of amputation through the thigh:
Shorter anterior and longer posterior flaps for trans-
condyloid region. Longer anterior and shorter pos-
terior flaps for supracondyloid osteoplastic operation.
Long anterior and short posterior flaps for thigh
throughout, where the tissue is limited. Oblique Cir-
cular, or elliptical, method for lower third. — (From
Bickham's Operative Surgery,)
4. The case is one of either pyelitis, pyelonephritis
or beginning cholecystitis or stone in the kidney. In
the case of the two latter the paroxysms of pain will
increase an intensity, and in the case of cholecystitis the
pain will radiate to the shoulder whereas in stone in
the kidney it will radiate down the course of the ureter.
Urinary examination and catheterization of the ureters
will show if it is pyelitis or pyelonephritis.
5. The indications for enucleation of the eye are:
"(1) Injuries of the ciliary region when the eye is com-
pletely blind, or the traumatism so extensive that the
form of the eyeball cannot be preserved; (2) traumatic
iridocyclitis, to prevent or cure sympathetic ophthal-
Q88
SOUTH CAROLINA.
mia; severe pain in a blind eye; (4) iridocyclitis,
phthisis bulbi, and glaucoma, when accompanied by
severe pain or inflammatory symptoms, and when the
eye is blind or is certain to become so; (5) malignant
tumors, either intraocular or epiocular, if they cannot
be removed with retention of the eyeball; (6) anterior
staphyloma, if the eye is blind, troublesome, and dis-
figuring; (7) panophthalmitis, after the suppurative
stage is passed; (8) foreign bodies in the eye when
they cannot be removed and cause irritation, or the eye
is blind."
Enucleation of the eyeball is performed as follows:
"A general anesthetic is generally given. After intro-
duction of the speculum, the conjunctiva is divided all
around the cornea, as close to its border as possible,
and dissected back as far as the insertions of the recti
muscles. A squint hook is passed beneath the tendon
of the internal rectus, and the latter is divided with the
strabismus scissors close to its insertion ; then the other
straight muscles are cut in the same way, together
with the subconjunctival connective tissue for some dis-
tance beyond the equator. The points of the scissors
must always be directed toward the eyeball and the
latter stripped as clean as possible to avoid any un-
necessary removal of orbital tissue. Instead of com-
mencing with a circumcorneal division of the conjunc-
tiva, we may begin with a tenotomy of the internal
rectus and then divide the conjunctiva as we pass from
tendon to tendon. The hook is passed around the globe
to make sure that the attachments of the muscles have
been completely divided. The eyeball is then dislocated
forward by pressing the speculum backward, and thus
the optic nerve is put on the stretch. A pair of enu-
cleation scissors, closed, are passed between sclera and
conjunctiva, feeling for the optic nerve; they are with-
drawn, slightly opened, and the nerve is divided close
to the sclera. The eyeball is held between the thumb
and index finger of the left hand, and the oblique mus-
cles and other unsevered attachments are divided. The
orbit is plugged for a few minutes to control hemor-
rhage, and the conjunctiva is usually closed with a sin-
gle suture, which is passed through its edge at inter-
vals and tied like the string of a pouch. The eye is
bandaged and the patient kept in bed for a day."
(May, Diseases of the Eye.)
6. Ether anesthesia: "During the first stage of
anesthesia, which ends with the loss of consciousness,
the pulse is accelerated, the pupils large and mobile,
and a rather pleasant feeling of drowsiness, and
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MEDICAL RECORD.
tingling in the extremities, is experienced. Many
patients breathe deeply, others hold their breath; in
the latter instance all that need be done is to remove
the cone for a moment. Cough is rarely annoying if
the drop method be employed. With the onset of uncon-
sciousness there is a short period of analgesia (pri-
mary anasthesia), during which brief operations may
be performed. The second stage, or the stage of ex-
citement, extends from the loss of consciousness to the
loss of reflexes. Memory, volition, and intelligence are
abolished, while laughing, shouting, and struggling
may occur. Slight movements of the extremities
should not be restrained unless they interfere with the
anesthetist, as such often evokes greater struggling.
The pulse is rapid, the pupils are dilated and react to
light, and the muscles may be rigid or thrown into
clonic contractions. At this time the breathing may be
irregular or temporarily suspended. The face is con-
gested, sometimes cyanotic, and often covered with
perspiration. More or less frothy mucus is present in
the mouth and throat, and sometimes it becomes ex-
cessive. During the third stage the breathing is deep
and audible, the pulse full and regular, the muscles
relaxed, and the corneal reflex abolished. Touching
the cornea with the finger, however, may produce irri-
tation, and it is much better simply to separate the lids
and notice the presence or absence of flaccidity. The
pupils are of moderate size and react to light. Dilated
pupils failing to react to light indicate a dangerous
degree of anesthesia. During this stage a transient
roseolous rash may be noticed.
Chloroform anesthesia: "The phenomena of chloro-
form anesthesia are in the main similar to those of
ether. The first and second stages are shorter, the va-
por is more pleasant, and being less irritating than
ether, not so much mucus is poured out. An excess
of chloroform causes the patient to hold his breath,
and if the inhaler is not withdrawn at this time, the
patient may take a deep inspiration and get an over-
dose. This accident has resulted in death, and should
be recalled when chloroforming crying children, and
when a surgeon attempts to operate before the third
stage is reached, thus causing the patient to breathe
deeply. During the stage of muscular excitement,
which is less marked than with ether, the respirations
should be watched with great care. Chloroform vapor
is not inflammable, but in the presence of a naked
flame gives off irritating products (phosgene and hy-
drochloric acid), which, in a small room, may cause
690
SOUTH CAROLINA.
irritation of the eyes and respiratory passages. The
third stage is characterized by quiet respirations which
are often difficult to appreciate. The pulse is sluggish
and feeble in contrast to the full and rapid pulse of
ether. The pupil is moderately contracted unless the
anesthesia is profound, when it dilates. As with ether,
dilated pupils, failing to react to light, indicate a dan-
gerous degree of anesthesia." (Stewart's Manual of
Surgery.)
7. The treatment of central necrosis comprises free
incisions for drainage, antiseptic dressing, frequent
cleansing, rest, nourishing food, stimulants, and tonics.
When the sequestrum becomes loose the operation of
sequestrectomy or necrotomy is performed, the extrem-
ity is drained of blood, an Esmarch band is applied,
the bone is exposed by a longitudinal incision, the
periosteum is reflected on each side, and the involucrum
is broken through and the opening is enlarged with
the chisel, gouge, and rongeur. The dead bone should
be removed by sequestrum forceps, the cavity scraped
by a sharp spoon, the lateral edges of the involucrum
cut down until the cavity which formerly contained
the sequestrum is very shallow, the wound is irrigated
with hot salt solution, dried, painted with pure carbolic
acid and then with alcohol, again irrigated with salt
solution and firmly packed with iodoform gauze. Remove
the Esmarch band, tie the vessels in the soft parts,
suture the wound, and apply dressings. The simple
removal of a sequestrum i.e., the operation of se-
questrectomy, often fails to effect a cure, and even in
the most satisfactory cases healing requires a very
long time. ... If the periosteum is found not to
be infected, it may be stitched together at the gap
where the bone has been removed, so that a periosteal
cord exists between the two ends of the bone; and the
soft parts above this may be closed. . . . The cavity
that is left by the removal of a sequestrum and the
chiseling of the walls of the involucrum, if large, may
be filled by various methods more or less satisfactory.
In some cases of widespread necrosis, due to diffuse
infective osteoperiostitis, or to osteomyelitis, extensive
resection or even amputation, may be necessary."
(DaCosta's Surgery.)
8. A right rectus incision gives access to the gall
bladder and ducts, duodenum, ascending colon, right
kidney, ureter, liver, appendix, stomach. A vertical in-
cision is made in the skin and fascia, about three
inches long, and calculated to fall about three quar-
ters of an inch internal to the outer border of the
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MEDICAL RECORD.
rectus; clamp vessels; retract overlying tissues, and
expose the rectal sheath. Incise the anterior sheath
of the rectus. Retract outwards the outer portion of
the divided sheath of the rectus, so as to expose the
outer border of the rectus muscle, and then retract the
intact rectus muscle inward. Incise the posterior layer
of the rectal sheath somewhat nearer the median line
than in the case of the anterior layer. Or, in operating
in the neighborhood of the deep epigastric artery, in or-
der to avoid this vessel, the incision in the posterior
layer may be made somewhat further outward than the
incision through the anterior layer. The artery may,
however, be readily ligated if in the way. In the same
line as the division of the posterior layer of the rectal
sheath, incise vertically the subjacent tissues which
will consist of transversalis fascia, subperitoneal aero-
lar tissue, and peritoneum, except below the similunar
fold of Douglas, below which line the posterior layer
of the sheath itself consists of transversalis fascia
alone, and the subjacent tissues consist of subperi-
toneal areolar tisue and peritoneum. Having accom-
plished the object of the operation, the structures are
to be sutured in the following layers— peritoneum, sub-
serous areolar tissue, and posterior layer of the rectal
sheath, with interrupted or continuous catgut suture;
—anterior layer of rectal sheath with interrupted gut
sutures, which also pass partly through the rectus
muscle (the displaced border of the rectus should also
be sutured to the outer margin of the rectal sheath) ; —
the fascia, with gut — and the skin with subcuticular
silk, or interrupted silkworm gut sutures (or skin and
fascia may be sutured together). (Bickham's Opera-
tive Surgery.)
9. The varieties of hemorrhoids are external, inter-
nal and mixed. The application of a ligature is the
operation most often performed. The patient is placed
in the Sims position, and after the field of operation
has been rendered aseptic, the sphincter is divided.
The rectum is irrigated with a mercuric chloride solu-
tion, 1:5,000. A needle carrying a ligature is passed
through the base of the tumor. The thread is cut and
the ligature is firmly tied on each side. At least two-
thirds of the pile should be excised by the scissors.
Iodoform gauze is inserted, and a T-bandage is applied.
Morphine (gr. *4) is then given. The bowels should be
moved on the third day. (Pocket Cyclopedia.)
Clamp and cautery. Radical treatment is advisable
when there is much pain and bleeding. It must be
ascertained first that the piles are not due to disease
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SOUTH CAROLINA.
elsewhere, as cirrhosis or stricture, or to pregnancy.
The bowels are emptied and the patient is placed in the
lithotomy position. The sphincter is then dilated with
two thumbs, to expose the piles, which are caught up
with ring torceps. A clamp is applied to the piles in
turn, and they are removed by the cautery. The
bowels are kept confined for five or six days, when
castor oil is given. Very little pain and no bleeding
follow this operation. Removal can be done by snip-
ping the mucous membrane around the pile and liga-
turing its base. Crushing is also done. (Aids to
Surgery.)
10. In the case of very old persons the impacted
fracture should be left impacted; the unimpacted frac-
tures should be reduced; both fractures should be re-
tained in position by a splint; but it is unadvisable to
keep the patient for any length of time on his back.
The dangers to old people are hypostatic pneumonia
and the formation of bed sores; in the case of the im-
pacted fracture the fixation should not be as thorough
as is practised in young people, and massage may also
be employed. Ambulant treatment should be instituted
as early as possible.
PEDIATRICS.
1. Flatulent colic comes on rather suddenly; the child
cries, and has a distended abdomen; the thighs are
flexed on the abdomen, and the extremities may be
cold. The treatment consists of hot applications to
the abdomen, hot rectal and colonic irrigations with
saline solution; the abdomen may be massaged with
warm olive oil; a mixture containing chloral hydrate,
sodium bicarbonate and peppermint water may be of
service. It is frequently due to an excess of sugar in
the food.
2. Otilis media generally occurs during one of the
exanthematous diseases, or following diphtheria, ton-
sillitis or typhoid; it is due to a streptococcus. It may
lead to perforation of the drum membrane, sinus
thrombosis, or meningitis. The treatment consists of
hot irrigations with saline solution, and early incision
of drum membrane.
3. Diphtheria may simulate follicular tonsillitis and
non-diphtheritic laryngitis or croup. In both cases a
smear taken, and followed by proper culture and bac-
teriological examination will show absence of the
Klebs-Loeffler bacillus. Further, the follicular ton-
sillitis is accompanied by a high fever (diphtheria is
not); and in diphtheria the membrane is adherent to
the underlying tissues, is removed with difficulty,
698
MEDICAL RECORD.
bleeds when removed, and reforms; whereas in other
similar conditions the membrane is easily removed,
does not bleed, and does not form again.
4. In pertussis the incubation period is from 4 to 14
days, and is followed by a stage in which catarrhal
symptoms, loss of appetite, fever, and restlessness are
present. The paroxysms begin about the second week
and consist of a number of short, spasmodic, expira-
tory coughs, succeeded by a long-drawn inspiration
and a peculiar whoop, often terminating in vomiting.
The eyes are suffused and the under lids are swollen
and pinkish in color. The number of paroxysms may
be very great, and this stage lasts from 3 to 4 weeks
or longer. The symptoms then gradually ameliorate,
and the stage of decline lasts 2 or 3 weeks longer.
Convulsions, vomiting, bronchitis, and bronchopneu-
monia are the chief complications.
5. Acute poliomyelitis is a disease peculiar to child-
hood, and characterized by sudden paralysis of one or
more limbs or of individual muscle-groups, and fol-
lowed by rapid wasting of the affected parts, with
reaction of degeneration and deformity. The onset is
sudden and marked by fever, vomiting, convulsions,
or even coma. Paralysis and atrophy of the muscles,
with reactions of degeneration, then present them-
selves. It occurs usually during the first three years
of life and most often during the summer months. It
sometimes occurs in epidemics.
The treatment during the initial stage consists in
rest in bed, restricted diet, fractional doses of calomel,
and sponging, or small doses of phenacetin if the fever
and nervous symptoms are marked. An ice-bag should
be placed along the spine, or mild counterirritation to
the spine by mustard plasters may be practised. After
the acute symptoms have subsided, electricity and pass-
ive movements may be employed. Deformities may re-
sult and will require the application of mechanic ap-
paratus or the performance of surgical operations for
their correction. (Pocket Cyclopedia.)
URANALYSIS MICROSCOPY, TOXICOLOGY, AND MEDICAL
JURISPRUDENCE.
1. Urates cause a pinkish deposit, dissolve when the
urine is warmed, and are generally amorphous.
Both phosphates and albumin are precipitated if the
urine is boiled; on the addition of a few drops of acetic
acid the phosphates dissolve, but the albumin does not.
2. Drugs that render the urine alkaline: Potassium
and lithium salts; they are given in cases of gout,
694
SOUTH CAROLINA.
lithemia, when diuretics are needed, in eases of strong-
ly acid urine. They are given largely diluted with
water. To acidify alkaline urine, one may use vege-
table acids, benzoic acid, and salicylic acid.
3. Casts. Epithelial, are found in desquamative
nephritis. Blood, are found in acute renal hyperemia,
acute nephritis, renal hematuria, and hemorrhagic in-
farction. Pus, in suppurative nephritis. Bacterial, in
pyelonephritis, and suppurative nephritis. Granular,
in chronic or degenerative nephritic processes. Fatty,
in large white kidney, subacute or chronic nephritis
with fatty degeneration. Hyaline, in all inflammatory
conditions of the kidneys, also in circulatory dis-
turbances (without organic change) of the kidneys.
Waxy, in chronic nephritis.
4. Hematuria is the presence of blood in the urine
when voided. It may be caused by : Infectious dis-
eases, scurvy, purpura, pernicious anemia, congestion
of the kidneys, traumatism or inflammation in any
part of the urinary tract. On miscroscopical examina-
tion red blood corpuscles can be distinguished.
5. The effects of poisonous drugs may be modified
by: Race, age, sex, weight, condition of health, and
idiosyncrasy or tolerance.
6. In lead poisoning, magnesium sulphate is given:
this converts the lead into the insoluble lead sulphate.
Potassium iodide is also given, to aid in the elimination
of such lead as is absorbed.
7. "In order to raise a valid inference in the mind
of a medical attendant that poison has been adminis-
tered to a patient, certain facts must be brought under
his notice; and without the concurrence of at least two
or more of these, the actuality of poisoning cannot be
maintained. The sources of evidence in cases of sus-
pected poisoning are the symptoms; the post-mortem
appearances; chemical analysis of articles of food or
drink, or of the body and the excretions; and experi-
ments upon animals. The evidence derived from these
sources, being compared with the known properties and
effects of various poisons in authenticated cases, will
enable the physician to form a correct opinion as to
the probable administration or not of a poison. It is
rarely that the symptoms exhibited during life do not
afford some clue to the cause of illness; and most fre-
quently the symptoms are all that the medical at-
tendant has to guide him to a diagnosis of the nature
of the case, during the lifetime of the patient. Some-
times, however, persons are found dead as the result of
poison, concerning the manner of whose death nothing
695
MEDICAL RECORD.
whatever can be learned; a suspicion of poisoning
arising from the circumstances under which the corpse
is found. Here the aid of chemical analysis ought in-
variably to be invoked; and fortunately in these cases
the delay involved in making an analysis is of com-
paratively little moment. . . . The general condi-
tions which should excite a suspicion of poisoning
are the sudden onset of serious and increas-
ingly alarming symptoms in a person previously in
good health, especially if a prominent symptom be
epigastric pain; or where there is complete prostra-
tion of the vital powers, a cadaverous expression
of the countenance, an abundant perspiration,
and speedy death. In all such cases the aid of the
chemist is required, either to confirm well-founded, or
to rebut ill-founded suspicions." (Quain's Dictionary
of Medicine.)
8. If the vomited matters are agitated in the dark
they are luminous.
9. "As natural abortion usually occurs at about the
third or fourth month of pregnancy, and as this period
is also the one at which a criminal operation is per-
formed, the fact that the fetus comes away entire
would indicate that abortion was due to natural causes,
or at least not to instrumental violence. If, however,
the fetus be expelled first and the ruptured membranes
afterward, the conclusion would be that instruments
had been used.
"If death follows within three days after abortion,
the post-mortem examination will generally establish
the fact that an abortion was committed. If several
weeks, however, have elapsed, little or nothing will be
learned by the autopsy, as the parts involved will have
usually reassumed by that time their usual condition."
(Chapman's Medical Jurisprudence.)
10. Phenomena and signs of death, are: The com-
plete and permanent cessation of circulation and
respiration, rigor mortis, loss of body heat, pallor of
the body, putrefaction.
HYGIENE.
1. "The principal methods of heating houses and
rooms are: 1. Open fires. 2. Stoves. 3. Furnaces. 4.
Hot-water pipes. 5. Steam pipes. The method ir">sfc
applicable in any particular case will depend upon the
size of the room and the number of rooms in the build-
ing. In general, it may be stated that the smaller the
space, the more simple the method. For a single room,
an open fire or a stove will be sufficient; for a small
696
SOUTH CAROLINA.
house, stoves or a furnace; for a large one, one or
more furnaces or hot-water or steam apparatus; and
for large buildings — office buildings, for instance — 'di-
rect' or 'indirect* steam." (Harrington's Hygiene.)
2. Principles of ventilation: "(1) There must be a
constant stream of pure air admitted into the room.
(2) The inlets and outlets should be placed as far apart
as possible, so as to allow of proper diffusion through-
out the room. If possible they should be placed on op-
posite sides of the room with natural ventilation, but
on the same side with artificial ventilation. (3) The
inlets for cold air must discharge some five or six feet
above the level of the floor, and the outlets for vitiated
air must be near the ceiling. (4) The admission of
warm air can be permitted near the floor. (5) The in-
coming air should be itself pure and of sufficient quan-
tity. (6) The inlets for each person in the room must
equal in total area 24 square inches, and the outlets
should contain the same area. (7) The incoming air
must not produce a draught. (8) The ventilation of a
large room is always easier than that of a small one.
(9) A large room will not" compensate after the first
hour for a proper system of ventilation. (10) If proper
inlets and outlets are constructed, all other means for
the admission of air should be closed. (11) The win-
dows of all unoccupied rooms should be opened wide so
that they may be flushed with a stream of pure air."
(From Evans' Student's Hygiene.)
3. Water supply from: (1) Rain water collected im-
mediately as it falls as rain, dew, snow, etc. (2) Sur-
face water collected in ponds, lakes, streams, etc., and
in free contact with air. (3) Ground water , or sub-soil
water, derived from the rain water of the district, but
which percolates through the subsoil, and so is not di-
rectly exposed to the atmosphere. (4) Deep or artesian
water, which is separated from the ground water by
one or more impermeable layers.
4. Diseases specially liable to be conveyed by the in-
gestion of milk: Tuberculosis, typhoid fever, scarlet
fever, diphtheria, tonsillitis, cholera, and gastrointes-
tinal disorders.
The milk may come from a diseased cow; it may be-
come contaminated by the milker, the container, the
surroundings, the water used to wash the cans or to
adulterate the milk; or it may become contaminated
at the dealer's or purchaser's house by being left un-
covered, exposed to flies, etc., or by not being kept in
a cool place. The only way to prevent the transmission
of disease by milk is to insist on a thorough inspection
697
MEDICAL RECORD.
of all dairies and sources of milk supply, and to edu-
cate the public in the care of milk between the time of
its purchase and its consumption. The inspection
should include: the color, reaction, specific gravity,
sediment, taste, odor, acidity, total quantity of solids
and of water; the percentage of cream, fats, lactose,
casein, and ash; the presence or absence of preserva-
tives, coloring matter, added solids, dilution, pathogenic
microorganism, dirt, or other foreign matter. There
should also be thorough investigation as to its source,
the cows and their environment, the method employed
in caring for, milking, storing, and transporting the
milk.
5. Diseases transmitted by mosquitoes: Malaria,
yellow fever, dengue, and filariasis.
6. The mosquito which transmits malaria is the
Anopheles. Its wings are usually spotted; in the rest-
ing posture, the axis of the head, proboscis and body
are in the same straight line; its body is of a dark
gray or brown color; the female alone bites and trans-
mits the Plasmodium malaria; the larvae float on the
surface of water.
"The most efficient way of getting rid of mosquitoes
is to make it impossible for them to breed. The eggs
of a mosquito are laid in water, and water is abso-
lutely necessary for the larval and pupal stages, which
must be passed through before the adult mosquito is
produced. Fish destroy developing mosquitoes and
large sheets of water are too rough for them; so mos-
quitoes must have, for breeding, rather small collec-
tions of fresh water free from fish. Mosquitoes will
soon disappear from a locality if all such collections of
water, within a quarter of a mile of it, are filled up,
drained, or covered with a film of coal oil so as to make
it impossible for the mosquitoes to breed in them. Those
who live in a malarious district should protect them-
selves from mosquito bites by the careful use of mos-
quito netting;. By the simple observance of these evi-
dent indications, malaria has already been banished
from several localities in which it was formerly en-
demic." (Marshall's Microbiology.)
7. Disinfection of Rooms: "Practical disinfection is
a process which needs scientific precision and atten-
tion to details. The disinfection must be adjusted to
the form and nature of infection and the infected mate-
rials and objects, each of which may need a different
method of handling and disinfection. The room air
needs no disinfection, for whatever germs may be
found in dust of the air in a room will settle upon the
SOUTH CAROLINA.
sux-faces whenever the room is closed and left undis-
turbed. The room walls if covered with paper may be
efficiently disinfected by thorough rubbing with stale
bread. Painted surfaces of walls and ceilings may be
disinfected by washing with 3 per cent, solution of car-
bolic acid or a 1 to 500 solution of sublimate of mer-
cury. Floors and other surfaces of rooms may also
be conveniently scrubbed with hot water and a solu-
tion of carbolic acid or sublimate, or one of the cresols.
Carpets, rugs, etc., may be efficiently disinfected by a
strong solution of formalin, by gaseous disinfection
with formaldehyde, or may be taken up and subjected
to superheated steam under pressure. Curtains,
hangings, etc., within the rooms are disinfected with
formaldehyde, and may also be washed in boiling
water. Wooden bedsteads may be washed with a 3
per cent, carbolic solution or a 5 per cent, formalin
solution. Bedding, linen, etc., may be disinfected by
steam, by formalin, and also by formaldehyde. For
the successful disinfection of rooms with a gas it is
necessary to close all openings, cracks and crevices,
keyholes, etc., completely, and especially the crevices
about windows and doors. This is done by means of
cotton, or, better, by means of gummed paper strips.
Raising the temperature of the room assists disinfec-
tion. The room is then closed and all openings and
crevices sealed with gummed paper, and the room is
left for at least twenty-four hours." (Price's Hygiene
and Public Health.)
Sulphur and formaldehyde are the two commonest
agents used to disinfect rooms.
"Municipal quarantine comprehends measures for
isolating those sick with certain of the infectious dis-
eases, such as scarlet fever, diphtheria, and smallpox,
keeping others under observation, and disinfecting
rooms and houses and objects contained therein which
may be capable of harboring infection. It is beyond
dispute that public safety requires that certain sick
should be shut off from free communication with the
outside world. The isolation is most complete and en-
tails less hardship when it can be carried out at a
special hospital for contagious diseases, but generally
it is enforced, if at all, at the patient's home. Room
and house quarantines are commonly difficult or im-
possible of enforcement, especially in tenement dis-
tricts among the very poor, for it is among this class
that danger of infection is least understood and mutual
help and neighborly visiting most extensively practised,
and thus the foci of infection may become increased
699
MEDICAL RECORD.
indefinitely. In hospitals, on the other hand, where
indiscriminate egress and ingress are under control
and facilities for the disinfection of discharges are at
hand, the danger of spread is reduced to a minimum.
Especially difficult and productive of hardship is the
isolation not only of the patient, but also of the other
members of his family. This is commonly practised
in the case of smallpox, but is unnecessary if the other
members have undergone recent successful vaccination,
and their clothing and other effects are disinfected and
they are then separated from all possible contact and
communication with the patient. But even then, they
should be kept under surveillance for a time equal to
the period of incubation. In times of epidemics of yel-
low fever in the South, house quarantine of entire fam-
ilies has proved to be the cause of much hardship and
anything but an unqualified success. It causes great
popular dissatisfaction, leads to concealment of cases,
and tends, therefore, to spread rather than restrict the
disease. Treatment of the sick in isolation hospitals
and removal of those who have been exposed to infec-
tion to camps of detention for five full days have been
found to give far better results. In some outbreaks
of infectious diseases, it is necessary or advisable to
conduct a house to house inspection for the discovery
and isolation of unreported cases. When such a course
is undertaken, the visits should be repeated at inter-
vals equal to the period of incubation. The making
of regulations for municipal quarantine and inspection
is subject to no general rule, each local authority being
a law unto itself. In some cities, the rules governing
notification, isolation, and disinfection are exceedingly
thorough and strictly enforced; in others, they are in-
adequate in varying degrees and enforced with laxity."
( Harrington's Hygiene. )
8. In addition to many of the diseases which are
found in temperate climates, people in the tropics are
liable to: Ancylostomiasis, beriberi, cholera, black-
water fever, dengue, dysentery, filariasis, leprosy, ma-
laria, Malta fever, pellagra, plague, tick fever, try-
panosomiasis, yaws.
9. To prevent disease among the troops, the surgeon
should see that, as far as possible, the soldiers have
pure air, pure water, and good, suitable and digestible
food; that personal cleanliness is the rule; that dissi-
pation and excesses are avoided; that protective inocu-
lation is practised where possible; that the soldiers
are instructed as to the dangers of venereal diseases:
that frequent and thorough inspections are made, and
700
SOUTH CAROLINA.
that those who have any infections or communicable
disease are isolated. Powers of endurance should be
increased by suitable exercises; and undue fatigue and
idleness must be prevented.
10. Those suffering from cerebrospinal meningitis
should be quarantined till recovery; all bodily dis-
charges, especially those from the nose and throat must
be disinfected. "Carriers" must be sought for, as in
diphtheria; and if found must be isolated. The pub-
lic must be instructed as to the nature and seriousness
of the disease.
BACTERIOLOGY AND PATHOLOGY.
1. Bacteria multiply by division or fission, and also
(indirectly) by spore formation. Cocci may divide
in one, two, or three directions of space. Bacilli di-
vide transversely to their long axis. Spirilla divide
transversely to their long diameter. A bacterium about
to divide seems to be larger than normal, and if it is a
coccus it becomes more ovoid; changes occur first in the
nucleus, and the bacterium thus simply falls in two.
It has been calculated that a single bacterium could,
by fission, produce two in one hour. Fortunately they
seldom obtain food enough to keep up this process for
any length of time.
Aerobic bacteria are such as cannot ordinarily live
and grow without air or oxygen. Anaerobic bacteria
can usually live and grow only in the absence of air or
oxygen.
2. Staining peculiarities of the tubercle bacillus. It
does not stain readily with the usual anilin dyes, but
take the stain only when the staining solution is heated,
or the exposure unduly prolonged. When once the
stain is taken it is held tenaciously and even resists
the action of acids. Hence it is said to be "acid-fast,"
and this property is made use of in staining sputum
or other material for the tubercle bacilli, when other
bacteria are counterstained after having the first stain
removed by acid. It is Gram-positive.
3. The diplococcus intracellularis meningitidis is a
non-motile, non-flagellated coccus, does not form spores,
is aerobic and optionally anaerobic, pathogenic, stains
by ordinary methods, is Gram-negative; it is a biscuit-
shaped diplococcus somewhat resembling the gono-
coccus. It can be grown on blood-serum and on gly-
cerin agar.
4. A thrombus is a blood clot formed in the blood
vessels during life. The process of formation of a
thrombus is called thrombosis.
101
MEDICAL RECORD.
Causes: Changes in the blood current; changes in the
vessel wall; anything within the blood current not cov-
ered with endothelium. Generally more than one of
these conditions are present.
Results: Among the consequences of thrombosis may
be mentioned the formation of emboli; infarction; heart
clot, and sudden death; cerebral softening; the thrombi
may become organized, liquefy, soften, become calci-
fied, putrefy, become discolored, or they may undergo
revolution.
5.
1. Origin,
2. Stroma,
3. Cells.
4. Intercellular
substance.
5. Ve
6. Spreads.
Sarcoma
Entirely meso-
blastic ( connective
tissue type).
In t ercellular.
Rarely forms alve-
oli.
Granulation tis-
sue or embryonic
connective tissue
cells ; shape and
size vary.
May be present.
Embryonic in
character. They are
in direct contact
with, or may be
formed by, the
special cells, slight-
ly modified, of
which the tumor is
composed.
Primarily and
secondarily by
blood vessels, rare-
ly by the lymphat-
ics.
Carcinoma
Eipiblastic and
hypoblastic. (Epi-
thelial tissue type.)
Vascular connect-
ive tissue, which
surrounds and
forms the walls of
the alveoli ; these
communicate with
one another, and
contain masses of
epithelial cells.
Epithelial cells
contained within
alveoli ; shape and
size vary.
Absent, or merely
fluid.
Well developed ;
entirely contained
within the connect-
ive tissue stroma,
and supported by
the walls of the al-
veoli. Seldom in
contact with the
cells.
Primarily by
lymphatics, except
in the later stages,
when it may also
spread by blood
vessels, in which
case it spreads with
very great rapidity.
Secon dar ily by
blood vessels.
(Cyclopedia of Medicine and Surgery)
702
TENNESSEE.
STATE BOARD EXAMINATION QUESTIONS.
Tennessee State Board of Medical Examiners.
anatomy.
1. Give the formation of brachial plexus and the prin-
cipal branches of same.
2. Name the branches of the femoral artery and give
its anatomical relations in Scarpa's triangle.
3. Describe the shoulder joint and give its blood and
nerve supply.
4. What is origin, point of escape, and distribution
of the seventh cranial nerve.
5. Describe the temporal bone and give its articula-
tions.
6. Name the superficial and deep groups of the flexor
muscles of the forearm.
7. Give the boundaries of the inguinal canal.
8. Describe the colon.
PHYSIOLOGY.
1. Give relations of chemical changes in muscular con-
traction to fatigue and give the chemical theory of
fatigue.
2. Give briefly the theories of muscular contraction.
3. Give the neuron doctrine.
4. Give the general properties of the blood and its
histological structure.
5. Give the neurogenic and myogenic theories of the
heart-beat and describe the automaticity of the heart.
6. Define dyspnea, giving its physiological causes;
hyperpnea, and apnea, giving their physiological causes.
7. Describe dichromatic vision and give the tests for
it, also describe achromatic vision.
8. Briefly define diffusion, dialysis, and osmosis and
describe osmotic pressure.
materia medica.
1. Give antidotes for arsenic, carbolic acid, strych-
nine, and chloral hydrate.
2. Describe the physiological action and give the
therapeutic use of digitalis.
3. Differentiate between apoplexy and opium poison-
ing.
4. What is ergot? What are its most pronounced
physiological actions?
5. Give indications for the use of the following: nux
vomica; arsenic; belladonna.
6. What is mercury? Source; physical properties;
uses; dosage? Remarks.
703
MEDICAL RECORD.
7. Give five drugs and their incompatibles.
8. Name two acids, two alkalies, and two mineral
poisons. Symptoms, cause of death in, and their anti-
dotes.
CHEMISTRY.
1. Define the following: allotropism; endosmosis;
alloy; amalgam.
2. Select the five most important reagents for a
uranalysis outfit, and state why vou select each.
3. What is the explanation of souring and curdling
of milk? How is soured milk supposed to prolong life?
4. What are ptomaines? Name some of the best
known ptomaines.
5. Give the chemical names and formulas of the fol-
lowing: sugar of lead; flowers of sulphur; blue vitriol;
white lead; red lead; baking soda; quick lime; lime
water; lime stone; blue stone.
6. Point out the analogy between marsh-gas (par-
affin) and the benzine series of hydrocarbons. Name
two prominent members of each group.
7. Describe a test for (a) albumin, (6) sugar, (c)
pus, (d) indican, (e) chyle.
8. How would you test milk for impurities? For
adulterants?
PATHOLOGY.
1. Explain why and how obstructive disease of the
coronary arteries causes myocardial degeneration.
2. What is the pathology of acute appendicitis, going
on to suppuration?
8. Discuss primary, concurrent (or mixed) , and ter-
minal infections.
4. Give the pathology of acute anterior poliomyelitis.
5. In the case of a woman, who a few days after
childbirth, is suddenly taken with dyspnea and cardiac
syncope and quickly dies, describe the pathological con-
ditions you would expect to find post-mortem.
6. Describe the appearance of the heart in an ad-
vanced case of mitral stenosis. What are the results
of mitral stenosis on other organs? Explain how these
results are brought about.
7. What part of the spine is affected in Pott's dis-
ease? Describe the pathological changes taking place
in the bone in Pott's disease.
8. What is an "autogenous vaccine?" On what prin-
ciple or principles is vaccine therapy based?
PRACTICE.
1. What conditions are accompanied by sever© pain
704
TENNESSEE.
in the chest, and what characteristic symptoms would
enable you to differentiate them?
2. In a case of uremia, indicate the various conditions
that must be considered ; state the appropriate remedies
for each condition and give definite reasons for the use
of each remedy.
3. Describe briefly the following diagnostic signs or
tests and name opposite each, the disease or diseases
in which they may be found: Koplik's spots; Romberg's
symptoms; Argyll-Robertson pupil; Babinski's reflex;
Kernig's sign; Stokes-Adams syndrome.
4. (a) Name the cardinal symptoms of tumor of the
brain, (b) What is the diagnostic value of pulsating
jugulars.
5. Differentiate cardiac hypertrophy and dilatation.
6. Give the cause, symptoms, and treatment of cere-
brospinal meningitis; the symptoms of tuberculous
meningitis.
7. Name the causes of displaced apex-beat and state
the physical signs of one of the conditions mentioned.
8. (a) Diagnose and treat herpes zoster, (b) What
causes a large per cent, of all cases of early blindness?
Give preventive treatment.
OBSTETRICS.
1. Give (a) bones, (6) divisions, (c) straits, and
(d) symphyses of the obstetric pelvis. In what way
does it differ from the male pelvis?
2. Name the internal female organs of generation.
Describe the uterus fully, and give its relations to the
other organs in the pelvis.
3. What is menstruation? How soon would a woman
menstruate after parturition?
4. Describe the pregnant uterus, and state how it
differs from a normal uterus. How early can you diag-
nose pregnancy? Give the signs by which you would
do it.
5. Give a differential diagnosis between a supposed
six months' pregnancy and an ovarian tumor ; a uterine
fibroid; ascites; a gaseous accumulation.
6. Give the proper management of the breasts before
and after labor.
7. Give all the means or drugs that you know to
facilitate a tedious and painful labor.
8. What precautions would you take in obstetric work
in case of a doctor or nurse who had been in attendance
on a septic case?
SURGERY.
1. Give the symptoms, complications, and treatment
of fracture of ribs.
705
MEDICAL RECORD.
2. Define toxemia, septicemia, pyemia, sapremia.
3. Give the causes, symptoms, and treatment of sup-
purative mastoiditis.
4. Give symptoms of simple, compound, and com-
pound comminuted fracture of tibia and fibula and
treatment of each condition.
5. What articular changes take place in dislocations?
What are the general principles governing the treat-
ment of dislocations?
6. Differentiate benign and malignant tumors. Name
two of each.
7. Give symptoms, diagnosis, and treatment of tuber-
culous kidney.
8. Give the etiology* symptoms, and varieties of ery-
sipelas.
ANSWERS TO STATE BOARD EXAMINATION
QUESTIONS.
Tennessee State Board of Medical Examiners,
anatomy.
- 1. The brachial plexus is formed by the union and
subsequent division of the anterior divisions of the
fifth, sixth, seventh, and eighth cervical and the first
dorsal nerves. The union of the fifth and sixth makes
the upper trunk; the seventh forms the middle trunk,
and the eighth cervical and first dorsal make the lower
trunk. Each of these trunks is divided into an anterior
and a posterior branch. The anterior branches, from
the upper and middle trunks, make the upper or outer
cord of the plexus; the anterior branch of the lower
trunk becomes the lower or inner cord; the three pos-
terior branches unite to form the posterior or middle
cord. The plexus lies between the Scalenus anticus
and medius. The branches are: (1) Above the clavicle;
communicating, muscular, posterior thoracic, and supra-
scapular. (2) From outer cord: External anterior
thoracic, musculocutaneous, and outer head of median.
(3) From inner cord: Internal anterior thoracic, lesser
internal cutaneous, ulnar, and inner head of median.
(4) From posterior cord: Subscapular, circumflex, and
musculospiral.
2. The branches of the femoral artery, are: Super-
ficial epigastric, superficial circumflex iliac, superficial
external pudic, deep external pudic, muscular, anas-
tomotica magna, and profunda femoris (with branches:
external circumflex, internal circumflex, and three per-
forating) . The artery passes from the base to the apex
706
TENNESSEE.
of Scarpa's triangle, it has the femoral vein on its inner
side, and the anterior crural nerve on its outer side;
it is covered by the skin and superficial fascia.
3. The shoulder- joint is an enarthrodial joint formed
above by the glenoid cavity of the scapula and below by
the head of the humerus. Its ligaments are glenoid,
coraco-humeral, and capsular. The glenoid surrounds
the edge, deepens the glenoid cavity, and is continuous
above with the long head of the biceps tendon. The
capsular ligament, extensive and loose, arises above it
from circumference of glenoid cavity behind the liga-
ment, is attached below to the anatomical neck of
humerus, and is pierced by tendons of two or three
muscles. The coraco-humeral, or accessory, is a fi-
brous band which extends obliquely downward and out-
ward from the coracoid process to the anterior part of
great tuberosity, strengthening the capsular ligament.
A synovial membrane lines the joint, and forms the
bursa under the subscapularis. It is reflected round
the tendon of the biceps, and lines the bicipital groove.
The nerve supply is from the circumflex and suprascap-
ular nerves. The arteries are branches of the anterior
and posterior circumflex, and the suprascapular.
4. The seventh cranial nerve has its superficial origin
in the medulla oblongata, in the groove between the
olivary and restif orm bodies ; it leaves the skull through
the stylomastoid foramen; it is distributed to the
muscles of expression of the face, the muscles of the
external ear, the Platysma, Buccinator, Stylohyoid, and
the posterior belly of the Digastric.
5. The temporal bone consists of three parts — the
squamous, the mastoid and the petrous parts. The
squamous portion is the anterior and upper part of the
bone, and presents an external and internal surface,
and a superior and inferior border; the chief points on
it are the zygoma, temporal ridge, eminentia articularis
and glenoid fossa. The mastoid portion consists of an
outer and inner surface, and presents mastoid foramen,
mastoid process, digastric fossa, sigmoid fossa, mastoid
cells and mastoid antrum. The petrous portion pre-
sents an apex; superior, anterior, posterior and in-
ferior surfaces, and three borders; on it are the cana]
of Huguier, internal auditory meatus, aqueduct of
Fallopius, jugular fossa, stylomastoid foramen, carotid
canal, and styloid process. It gives attachment to the
following muscles: Temporal, masseter, occipitofront-
alis, sternomastoid, splenius capitis, trachelomastoid,
digastric, posterior, auricular, stylohyoid, stylophar-
yngeus, styloglossus, levator palati, tensor tympani,
707
MEDICAL RECORD.
tensor palati, and stapedius. It articulates with: Oc-
cipital, parietal, sphenoid, malar, and inferior maxil-
lary bones.
6. Flexor muscles of forearm. Superficial group:
Pronator radii teres, flexor carpi ulnaris, flexor carpi
radialis, palmaris longus, and flexor sublimis digito-
rum. Deep group: Flexor profundus digitorum, flexor
longus pollicis, and pronator quadratus.
7. Boundaries of the inguinal canal. In front:
the skin, superficial fascia, aponeurosis of the external
oblique, and (for its outer third) the internal oblique.
Behind: the conjoined tendon, the triangular fascia, the
transversalis fascia, subperitoneal fat, and peritoneum.
Above: the fibers of the internal oblique and transver-
salis. Below: Poupart's ligament and the transversalis
fascia.
8. The colon is divided into ascending, transverse de-
scending, iliac, and pelvic.
The ascending colon extends from the cecum to the
under surface of the liver to the right of the gall-blad-
der, where it turns to the left, forming the hepatic
flexure. It lies in the right iliac and right hypochron-
driac regions. The peritoneum covers the anterior and
lateral surfaces. Length, 8 inches. Relations. — In
front: The convolutions of the ileum; behind: Iliacus,
quadratus lumborum, outer side of right kidney.
The transverse colon passes from right to left, from
the gall-bladder to the spleen. It forms an arch, con-
vex anteriorly and below: the transverse arch of the
colon. It is entirely surrounded by peritoneum, which
is attached posteriorly to the spine, forming the meso-
colon. Length, 20 inches. Relations. — Above: Liver,
gall-bladder, large curvature of stomach, lower end of
spleen; below: small intestines; anteriorly: anterior
layers of great omentum, anterior abdominal wall;
posteriorly: right kidney, second part of duodenum,
transverse mesocolon, pancreas, and small intestines.
The descending colon passes from the end of the
transverse colon by a bend, the splenic flexure. Between
the splenic flexure and the diaphragm, opposite the
tenth left rib, is a fold of the peritoneum, the costocolic
ligament, which slings up the spleen. The gut then
passes downward to the iliac crest, ending in the iliac
colon. The peritoneum invests its anterior and lateral
surfaces. Length, 4 to 6 inches. Relations. — Behind:
left crus, left kidney, quadratus lumborum, and psoas;
in front: small intestines; inner side: outer border
of left kidney.
The iliac colon is continuous with the descending
708
TENNESSEE.
colon at the left iliac crest, and ends at the inner border
of the left psoas. Peritoneum invests its anterior and
lateral surfaces; it has no mesentery. Length, 5 to 6
inches. Relations. — In front: Small intestines; when
distended, the anterior abdominal wall; behind: left
iliopsoas.
The pelvic colon extends from the inner border of the
psoas to the level of the third sacral vertebra. Length,
16 or 17 inches; very variable. It has an extensive
mesentery. Relations. — Passing over left brim of pelvis,
it crosses the left external iliac vessels and left ureter,
and passes to right margin of pelvis, resting on blad-
der in male and uterus in female; above lie coils of
small intestine. It then turns back to midline on pos-
terior wall of pelvis, and, forming a second bend, de-
scends to end in the rectum. — (From Aids to Anatomy.)
PHYSIOLOGY
1. Fatigue. "If several successive stimuli are sent
into a nerve of a nerve-muscle preparation, each suc-
ceeding one not taking effect, however, until the in-
fluence of the preceding one has passed off, after a time
the contracting muscle becomes fatigued In fatigue
thus produced, the structures present are the nerve,
motor end organs, and the muscle; the nerve was ex-
cited by repeated single induction shocks. Fatigue in
this case is due: (i) to the consumption of those sub-
stances, especially carbohydrates, which normally exist
in muscle, and which are available for the supply of
muscle energy, and (ii) to the accumulation of the
waste product of contraction, such as C0 2 and sarco-
lactic acid. These seem to be the chief source of fa-
tigue, for if the muscle is allowed to rest and is then
washed with 0.9 per cent. NaCl solution which contains
a little alkali, fatigue gradually passes off. Moreover,
fatigue may be artificially produced in muscle by feed-
ing it with a weak solution of sarco-lactic acid In
conclusion, it may be stated that the chief seat of fa-
tigue is in the nerve cells of the brain and spinal cord,
but that it also occurs in the motor end organs; that,
in ordinary circumstances, fatigue cannot be demon-
strated as occurring either in medullated or in non-
medullated nerves. The fatigue, which occurs in the
muscular fibers themselves, is due to the using up of
those substances present in the tissue which, when
oxidized, give rise to heat and energy. As in normal
circumstances these substances are readily replaced
by means of the blood and the lymph, it may be con-
cluded that, under normal conditions of nutrition, fa-
709
MEDICAL RECORD.
tigue does not occur in the muscle fibres themselves." —
(Lyle's Physiology.)
2. The modes of action of muscle. "We know the
probable structure of cross-striated muscle, substan-
tially, so far, at least, as appearances go. We know
that it consists of two sorts of substances, one (aniso-
tropic) doubly refracting polarized light, the other
(isotropic) refracting it singly. We know that when
the contraction occurs in cross-striated muscle the lat-
ter kind of material changes its place somewhat, while
the former kind does not do so. We are sure that the
metabolism of all sorts of muscle is, in part, the oxida-
tion of carbohydrates and of protein, sarcolactic acid
being a way-product, and carbon dioxide and water
among the end-products. The more active the contrac-
tion of the muscle the more oxygen it consumes and the
more carbon dioxide is liberated from it. We know
that, as often happens in protoplasm, the chemism of
metabolism gives rise to at least three sorts of kinetic
energy: movement, heat, and electricity, for these may
be measured and variously studied. If we start out
with the fact that it is chemism undoubtedly which
liberates these energies, we have the basis of the chief
various theories of muscle-action. To one (Engelmann)
it seems clear enough that the chemism gives rise to
heat, which, by causing imbibition of sarcoplasm, brings
about the contraction. Another "school" (Pfliiger,
Bernstein, Verworn, Fick) supposes that the chemism
directly, i. e., without the intervention of heat, alters
the two differing substances in such a way that the
isotropic one swells into the anisotropic. A recent
group of thinkers (Miiller, Loeb) supposes that elec-
tricity is involved in causing the contraction. To others
(e. g., Weber), the chemism seems to alter the natural
elasticity of the myoids or fibrils, making them shorten
and then lengthen. Numerous other hypotheses still
less probable have been published at various times." —
(Dearborn's Physiology.) Other theories are the ther-
modynamic theory and the surface tension theory.
3. The neurone doctrine teaches that the nervous
system is composed of neurones; these neurones consist
of a nerve cell and various processes; the peripheral
nerves are the long processes. The neurones connect
with each other by contact only, and are not continu-
ous. The axon of the neurones is in contact with the
dendrites or cell body of another neurone. The nerve
conduction in the dendrites is away from the nerve cell,
that in the axons is towards the cell body.
4. The physical properties of blood: Fluid, somewhat
710
TENNESSEE.
viscid, red; specific gravity, from 1055 to 1062; alkaline
reaction; saltish taste; characteristic odor; variable
temperature (average, about 100° F.).
The constituents of the blood are plasma and cor-
puscles. The plasma consists of water and solids (pro-
teids, extractives, and inorganic salts). The red cor-
puscles consist of water and solids (hemoglobin, pro-
teids, fat, and inorganic salts). The white corpuscles
consist of water and solids (proteid, leuconuclein, leci-
thin, histon, etc.).
The red blood corpuscles are biconcave discs, about
1-3200 of an inch in diameter; they are non-nucleated,
and there are about 4,500,000 or 5,000,000 of them in
each cubic millimeter of blood. They are elastic and
soft, and their shape is changed by pressure, but is
promptly regained on the removal of the pressure.
Their color is yellowish. They contain hemoglobin.
Their function is to carry oxygen from the lungs to
the tissues.
The white blood cells are spheroidal masses, varying
in size, having no cell wall, and containing one or more
nuclei; there are about 7,000 to 10,000 of them in each
cubic millimeter of blood. They differ much in appear-
ance, and are divided into (1) small mononuclear leuco-
cytes, or lymphocytes, (2) large mononuclear, (3)
transitional, (4) polynuclear, or polymorphonuclear,
or neutrophile, and (5) eosinophile. They are all more
or less granular, particularly the last two varieties
named. They are probably formed in the spleen, lym-
phatic glands, and lymphoid tissues. Their fate is un-
certain; it has been asserted that they are converted
into red blood cells; they play a part in the formation
of fibrin ferment; they are sometimes converted into
pus cells. Their functions are (1) to serve as a protec-
tion to the body from the incursions of pathogenic
microrganisms ; (2) they take some part in the process
of the coagulation of the blood; (3) they aid in the ab-
sorption of fats and peptones from the intestine, and
(4) they help to maintain the proper proteid content
of the blood plasma.
There are also platelets, which are very small, color-
less, irregular shaped bodies; they are about one-fourth
the diameter of a red corpuscle. Their function is not
determined; it is possible that they take some part in
the coagulation of the blood. In number they vary
from about 200,000 to more than 500,000 in each cubic
millimeter of blood.
Plasma conveys nutriment to the tissue; it holds in
solution the carbon dioxide and water which it receives
711
MEDICAL RECORD.
from the tissues, and takes them to be eliminated by
the lungs, kidneys, and skin; it also holds in solution
urea and other nitrogenous substances that are taken
to and excreted by the liver or kidneys.
5. "The neurogenic theory of heart beat supposes that
the internal stimulus to the heart beat arises within
the nerve cells which are present at the venous end
of the heart, and that the excitatory wave is conducted
by nerves."
"The myogenic theory supposes that the heart muscle
itself possesses the property of automatic rhythmical-
ity, and that this property is most marked at the venous
end of the heart, and at the sinu-auricular and auri-
culo- ventricular junctions. The contraction wave is
generated at the venous end of the heart in the muscle,
and, in virtue of the conductivity of cardiac muscle,
spreads over the muscle tissue of the auricles, and
thence over the ventricles. In other words, the con-
traction wave commences in muscle and is conducted
by muscle. The muscular continuity of the auricles
and ventricles is brought about by the auriculo-ven-
tricular bundle of His." — (Lyle's Physiology.)
"Automaticity. — Inasmuch as the heart continues to
contract in a perfectly rhythmic manner after removal
from the body and apparently without the aid of an
external stimulus, it is said that the heart-muscle is
automatic or spontaneous in action. Strictly speaking,
however, this is not the case, for the reason that all
movement, that of the heart included, is the resultant
of the action of natural causes though their true nature
may be beyond the reach of present methods of in-
vestigation." — (Brubaker's Physiology.)
6. Dyspnea means difficult breathing, and denotes
any increase in the force or rate of the respiratory
movements.
Dyspnea may be caused by: Stimulation of sensory
nerves, increase of carbon dioxide or diminution of
oxygen in the blood.
Hyperpnea means exaggerated respiratory action.
Apnea means cessation of respiratory action; it is
often used for the term asphyxiation. It is due to
prolonged and rapid ventilation of the lung. Asphyxia
is suffocation, due to depriving the lungs of oxygen.
It is caused by preventing oxygen from reaching the
lungs; by obstruction of the respiratory passages; by
inhaling a gas without oxygen, or one which strongly
tends to displace oxygen from the hemoglobin, as
carbon monoxide; or by interfering with the change of
gases which should take place between the air and the
blood.
712
TENNESSEE.
7. In the dichromatic, color vision is represented by
two fundamental colors and their combinations with
white or black; the achromatic are totally color blind,
and only see the white-gray-black lines.
The most common form of dichromatic vision is red
or red-green blindness.
Tests are made by means of Holmgren's skeins of
wool. "A number of skeins of wool are used and three
test colors are chosen, namely, (1) a pale pure green
skein, which must not incline toward yellow green;
(2) a medium purple (magenta) skein; and (3) a
vivid red skein. The person under investigation is
given skein 1 and is asked to select from the pile of
assorted colored skeins those that have a similar color
value. He is not to make an exact match, but to
select those that appear to have the same color. Those
who are red or green blind will see the test skein as
a gray with some yellow or blue shade and will select,
therefore, not only the green skeins, but the grays or
grayish yellow and blue skeins. To ascertain whether
the individual is red or green blind tests 2 and 3 may
then be employed. With test 2, medium purple, the
red blind will select, in addition to other purples, only
blues or violets; the green blind will select as "con-
fusion colors" only greens and grays. With test 3,
red, the red blind will select as confusion colors greens,
grays, or browns less luminous than the test color,
while the green blind will select greens, grays, or
browns or a greater brightness than the test*"—
(Howell's Physiology.)
8. "The term diffusion has long been applied to the
regular mixing of the molecules of two gases when
brought into contact in a confined space. More recently
it has been applied to the mixing of the molecules of
two solutions when brought into contact. If, however,
the two solutions are separated by a membrane,
permeable to the solutions, diffusion will still occur.
To this form of diffusion the term Osmosis has been
applied in the case of water, and Dialysis in the case
of diffusible substances. All bodies can be divided into
two groups, crystalloids and colloids. To the former
group belong bodies having a crystalline form, which
readily go into solution in water. All such bodies are
diffusible (dialyzable), their power of dialysis, how-
ever, varying considerably. To the second group be-
long such bodies as have no crystalline form (amorph-
ous). These are generally bodies with a large mole-
cule, which form colloidal suspensions in water, and are
only slightly or not at all diffusible. An exception to
713
MEDICAL RECORD.
this second group is hemoglobin, which has a very large
molecule but is crystalline and is diffusible." — Kirkes*
Physiology.)
"Osmotic pressure may be defined as the pressure
exerted by the molecules of the substance in solution
against an enclosing wall, in consequence of which
there is an osmosis of the surrounding solvent towards
it. The reason for this pressure lies in the fact that,
when the molecules of a substance are separated a
certain distance, as they are when in solution, they
repulse one another as do the molecules of a gas and
in their flight strike against the outer layer of the
solvent. The pressure of the molecules of a substance
in solution is therefore comparable to the pressure of
the molecules of a gas. Three methods may be em-
ployed for measuring the force of the osmotic pressure
of different substances, viz.: 1. Physical. 2. The de-
termination of the freezing point. 3. By calculation. "
— (Brubaker's Physiology.)
MATERIA MEDICA
1. Antidote for arsenic is freshly prepared solution
of ferric hydroxide; for carbolic acid, sodium sulphate,
or alcohol; for strychnine, tannic acid; for chloral
hydrate, solution of potassium hydroxide, or strychnine.
2. Digitalis. Physiological action: It is a gastroin-
testinal irritant, it slows the rate of the heart, pro-
longs diastole, increases the force of the heart, it con-
tracts the blood-vessels, and causes a rise in blood
pressure, it also acts as a diuretic.
Therapeutic use: Digitalis is indicated in diseases of
the heart: (1) when the heart action is rapid and
feeble, with low arterial tension; (2) in mitral lesions
when compensation has begun to fail; (3) in non val-
vular cardiac affections; (4) in irritable heart, due to
nerve exhaustion. Digitalis is contraindicated in dis-
eases of the heart: (1) in aortic lesions when uncom-
bined with mitral lesions; (2) when the heart action
is strong, and arterial tension high. Digitalis is also
a diuretic; and it is also used in some forms of
nephritis, exophthalmic goiter, pneumonia, chronic
bronchitis, etc.
3.—
APOPLECTIC COMA.
OPIUM POISONING.
Deep coma; sudden on-
set. If any injury, only
a scalp wound.
Can be aroused unless
very deep.
714
TENNESSEE.
APOPLECTIC COMA.
Pupils unequal or di-
lated. Contracted in
hemorrhage into the
pons.
Pulse full and slow, often
arteriosclerotic high-
tension pulse.
Respiration slow and ir-
regular.
Temperature higher on
paralyzed side, but
lower in rectum.
Urine contains trace of
albumin, but may be
same as in uremia.
Hemiplegia with convul-
sions on one side.
OPIUM POISONING.
Pupils contracted to pin-
point size.
Pulse rapid, may be ir-
regular.
Respiration very slow —
may be 6 to 8 per
minute.
Normal or subnormal.
Normal.
No hemiplegia.
4. Ergot is the sclerotium of the Claviceps purpurea.
It should be moderately dried, preserved in a close
vessel, and a few drops of chloroform should be
dropped upon it occasionally. It is not fit for use if
more than a year old.
Ergot stimulates and causes contraction of involun-
tary muscle fibers, hence it is a vasoconstrictor, hemo-
static, and oxytocic. It is also a cardiac sedative, it
is an emmenagogue.
5. IndicoMons for the use of nux vomica: As a gen-
eral tonic or bitter; in indigestion, cardiac depression,
impaired peristalsis, pneumonia, phthisis, amenorrhea,
dysmenorrhea, impotence, some forms of paralysis,
chorea, epilepsy, neuralgia, alcoholism, and urinary
incontinence.
Indications for the use of arsenic: In stomach dis-
orders, bronchial and pulmonary affections, diabetes,
diarrhea, anemia and chlorosis, chorea, malaria, and
chronic skin diseases.
Indications for belladonna: To relieve pain, relax
spasm, check sweating, as a mydriatic, to check
griping of purgatives; in asthma, to check fevers,
in heart disease, shock and collapse, acute coryza, uri-
nary incontinence, chordee, low delirium of fevers,
mania, alcoholism; as an antigalactagogue, spasmodic
cough.
6. Mercury is an absorbable rnetal. Its action on the
circulation: In small doses it has a tonic effect: in
ris
MEDICAL RECORD.
larger doses it diminishes the number of red-blood cells,
impoverishes the blood, and thus upsets the digestion,
and disturbs the general nutrition of the body.
It is prepared from cinnabar by distilling it in a
current of air. It is a bright metallic liquid, volatile,
very heavy, insoluble in water, and readily unites with
many metals to form amalgams.
Preparations and doses: Emplastrum hydrargyri;
Hydrargyrum cum creta, dose, 4 grains ; Massa hydrar-
gyri, dose, 4 grains. Unguentum hydrargyri; Un-
guentum hydrargyri dilutum; Hydrargyri oxidum
rubrum; Unguentum hydrargyri oxidi rubri; Hydrar-
gyri oxidum, flavum; Unguentum hydrargyri oxidi
flavi; Oleatum hydrargyri; Hydrargyri chloridum cor-
rosivum, dose 1/20 grain; Hydrargyri chloridum mite,
dose (laxative), 2 grains; (alterative) 1 grain; Piluiae
catharticse composite, dose 2 pills; Hydrargyri iodidum
rubrum, dose, 1/20 grain; Liquor arseni et hydrargyri
iodidi, dose 1% minims; Hydrargyri iodidum flavum,
dose, 1/5 grain; Liquor hydrargyri nitratis; Unguen-
tum hydrargyri nitratis; Hydrargyrum ammoniatum;
Unguentum hydrargyri ammoniati.
Uses: "Mercurials (especially the bichloride) are
extensively used for antiseptic purposes in surgery and
midwifery. The acid solution of mercuric nitrate is
employed, as a caustic for warts, chancroids, mucous
patches, etc., and citrine and red precipitate ointments
as stimulating applications to ulcers and sores. Mer-
curial ointments and washes are very serviceable in
the treatment of parasitic affections, and also in a
variety of other skin diseases, as well as in ophthalmo-
logical practice. Internally blue mass and calomel are
largely employed as purgatives, and the latter is a
good intestinal antiseptic. It is used in serous and
other inflammations, and both it and the bichloride
have been given in diphtheria. The most important
use of mercury is in the treatment of syphilis. In
order to secure the best results in this disease it should
be commenced early and continued for a considerable
time after all symptoms have disappeared. In tertiary
syphilis it is commonly combined with the iodides.
Modes of administration of mercurials: By the mouth;
endermatically; by inunction; hypodermatically ; in-
travenous injection; fumigation; inhalation; baths." —
(Wilcox's Materia Medica.)
7. Incompatibles of colocynth: Alkalies, ferrous sul-
phate, lead sulphate, lime water, mercuric chloride,
silver nitrate; of copaiba: Mineral acids, caustic
alkalies, calcium hydrate, magnesia, water; of creosote:
716
TENNESSEE.
Acacia, albumin, nitric acid, oxidizers, and salts of
copper, iron, gold and silver ; of aconite : Acids, alkalies,
hot water; of alum: Alkaline hydrates, borax, car-
bonates, galls, kino, lead acetate, lime water, magnesia,
magnesium carbonate, mercury salts, phosphates, tar-
taric acid, potassium chlorate. — (From Potter's
Materia Medica.)
18. Hydrocyanic acid poisoning. Symptoms: "Its
action is always rapid. Relatively small doses cause
an immediate sense of constriction of the throat, fol-
lowed in one to two minutes by sense of pressure in
the head, vertigo, confusion of intellect, and loss of
muscular power. The pulse is quick, the respiration
slow and stertorous. Tetanic convulsions and involun-
tary discharges of urine and feces occur, followed by
paralysis. Death follows in from two hours to two
days from asphyxia. When large doses are taken no
subjective symptoms are observed. The patient loses
consciousness in less than one minute. There is a
short convulsive seizure, usually accompanied by
evacuation of feces, after which the patient lies per-
fectly still, with no sign of life, save an almost imper-
ceptible pulse and infrequent spasmodic respiratory
efforts, in which inspiration is short and expiration
protracted. Death follows in from five to twenty
minutes." — (Witthaus' Essentials of Chemistry and
Toxicology.) Death is due to paralysis of the respira-
tory center and of the motor ganglia of the heart.
There is no antidote.
Symptoms of poisoning by oxalic acid: "The sour
taste of the acid is rapidly followed by a burning pain,
increasing in intensity, in the mouth, throat, and
stomach, and persistent vomiting of a dark, 'coffee-
ground' material. The pulse becomes small and im-
perceptible, and the patient dies in collapse, pre-
ceded frequently by convulsions, within half an hour.
If the case be prolonged, swallowing becomes very dif-
ficult and painful; there are numbness and tingling of
the skin; twitchings of the facial muscles; convulsions,
frequently tetanic; delirium, and lumbar pain. Death
occurs in some cases within three to ten minutes,
sometimes almost immediately, and in some cases it is
delayed for several days."
Cause of death, paralysis of nerve centers. Anti-
dote, syrup of lime.
"The symptoms presented in cases of poisoning by
potash and soda are so similar that one description
will do for both. There is burning pain during swal-
lowing, and an acrid, caustic taste. If the fluid pene-
717
MEDICAL RECORD.
trates to the stomach, there is persistent burning pain.
Vomiting may or may not occur. When it does, the
vomitus will usually be brown in color; it may or may
not contain blood, and will simulate very closely in ap-
pearance that found after the taking of any of the
strong acids. Ammonia presents rather more violent
symptoms in proportion of its strength than does
potash or soda, and on account of the irritating quality
of its fumes symptoms due to its inhalation are very
marked." — (Dwight's Epitome of Toxicology).
Cause of death is generally starvation due to
stenosis of esophagus, or stomach, or pylorus or intes-
tine. Antidote is vinegar, citric acid, or tartaric acid.
Silver nitrate poisoning. Symptoms: Pain; vomit-
ing of white, cheesy matter, which becomes black in the
sunlight; cramps; purging; depression; convulsions;
coma or collapse. Antidote : Solution of sodium chloride.
The symptoms of acute lead poisoning are: "Metal-
lic taste; dryness of the throat; thirst; severe colicky
abdominal pains, referred particularly to the umbilical
region, and relieved by pressure; pulse very feeble and
slow; great prostration; constipation; urine scanty
and red; violent cramps; paralysis of the lower ex-
tremities; convulsions, and tetanic spasms."
The antidotal treatment consists in administering
"magnesium sulphate, which brings about the forma-
tion of the insoluble lead sulphate, while the purga-
tive action of the magnesia is also useful. It should
be preceded by an emetic, or by the use of the stomach
tube."
CHEMISTRY.
1. Allotropism is the capability of a substance to
assume different physical properties while retaining
the same chemical properties.
Endosmosis is osmosis toward the interior of a ves-
sel or cavity. (Osynosis is the passage of a fluid or
solution through a membrane or other porous sub-
stance.)
Alloy is a substance composed of two or more metals.
Amalgam is an alloy containing mercury.
2. (1) Dilute acetic acid (to acidify alkaline urines
before testing for albumin). (2) Nitric acid (to test
for albumin and for bile pigments). (3) Fehling's
solution (to test for sugar) . (4) and (5) Hydrochloric
acid and chloroform (to test for excess of indican).
3. Souring of milk is due to the formation of lactic
acid and succinic acid from the lactose by micro-
organisms. Curdling of milk is due to the presence
718
TENNESSEE.
of rennin and lactic acid. Soured milk is supposed to
prolong life by reducing intestinal putrefaction.
4. Ptomaines are basic nitrogenized compounds pro-
duced from protein material by the bacteria which
cause putrefaction. Examples: Putrescin, cadaverin,
cholin, neuridin, amantin, muscarin, mydalein.
Sugar of lead
Flowers of sulphur
Blue vitriol
White lead
Red lead
Baking soda
Quick lime
Lime water
Lime stone
Blue stone
CHEMICAL NAME
Lead acetate
Sublimed sulphur
Cupric sulphate
Lead carbonate
Plumboso-plumbic
oxide
Monosodic carbonate
Calcium monoxide
Calcium hydroxide
Calcium carbonate
Cupric sulphate
FORMULA
Pb(C a H 3 O a ),
S.
CuS0 4
(PbC0 3 ) 2 . PbH 2 O s
Pb 3 4
NaHCOg
CaO
CaH 2 O a
CaC0 3
CuSO^
6. The paraffin and benzene series are somewhat sim-
ilar in that they both form halogen derivatives and also
alcohols, aldehydes, acids, ketones, nitro compounds and
amido compounds.
Two members of the paraffin group — Methane and
ethane.
Tivo members of the benzene group — Benzene and
toluene.
7. Test for albumin in the urine : The urine must be
perfectly clear. If not so, it is to be filtered, and if this
does not render it transparent it is to be treated with a
few drops of magnesia mixture and again filtered. The
reaction is first observed. If it be acid, the urine is
simply heated to near the boiling point. If the urine
be neutral or alkaline, it is rendered faintly acid by the
addition of dilute acetic acid and heated. If albumin be
present a coagulum is formed, varying in quantity from
a faint cloudiness to entire soldification, according to
the quantity of albumin present. The coagulum is not
redissolved upon the addition of HNOs.
For sugar: Render the urine strongly alkaline by
addition of Na 2 C0 3 . Divide about 6 c.c. of the alkaline
liquid in two test-tubes. To one test-tube add a very
minute quantity of powdered subnitrate of bismuth; to
the other as much powdered litharge. Boil the contents
of both tubes. The presence of glucose is indicated by
a dark or black color of the bismuth powder, the litharge
retaining its natural color.
For pus in the urine: Acidify the urine with acetic
acid, then filter it, and treat the filter with a few drops
of freshly prepared tincture of guaiacum; a deep blue
color denotes the presence of pus.
719
MEDICAL RECORD.
To examine for indicanuria : "The urine is mixed
with one-fifth of its volume of 20 per cent, solution of
lead acetate and filtered. The filtrate is mixed with an
equal volume of fuming hydrochloric acid containing
3:1000 of ferric chloride, a few drops of chloroform are
added, and the mixture strongly shaken one to two
minutes. With normal urine the chloroform remains
colorless or almost so; but if an excess of indoxyl com-
pounds be present the chloroform is colored blue, and
the depth of the color is a rough indication of the de-
gree of the excess." — (Witthaus* Essentials of Chemis-
try and Toxicology.)
Test for chyle in the urine: "As the chyle contains
serum albumin it would respond to the tests for that
substance. To make out the fatty character of the
molecular basis, a portion of the urine should be agi-
tated with ether and potassium hydroxide, which dis-
solves the envelopes, and melts the fat particles to-
gether as a surface layer, leaving the urine clear be-
neath. The microscopic character is much like that of
milk — that is, it contains myriads of small bright round
particles which dissolve in ether." — (Holland's Medical
Chemistry.)
8. "Milk is adulterated by the addition of water, by
dilution, by subtraction of cream or skimming, by both
watering and skimming, by the addition of thick-
eners, coloring, etc., and by the addition of artificial
preservatives; it is also regarded as adulterated when
it is below a certain chemical or bacteriological stand-
ard which is prescribed by a state or municipality." —
(Price's Epitome of Hygiene.)
To test, a lactometer and creamometer are
necessary, and various chemical tests should be
made for the presence of formaldehyde, boric
acid, borax, salicylic acid, and sodium carbonate
or bicarbonate. These tests are too lengthy to be de-
scribed here; and can be found in standard works on
Food Analysis.
PATHOLOGY
1. "The terminal branches of the coronary vessels
are end-arteries; that is, the communication between
neighboring branches is through capillaries only. The
blocking of one of these vessels by a thrombus or an
embolus leads usually to a condition which is known as
— (a) anemic necrosis, or white infarct. When this
does not occur the reason may be sought in (1) the ex-
istence of abnormal anastomoses, which by their pres-
ence take the coronary system out of the group of end-
720
TENNESSEE.
arteries; or (2) the vicarious flow through the vessels of
Thebesius and the coronary veins. The condition is
most commonly seen in the left ventricle and in the
septum, in the territory of distribution of the anterior
coronary artery. (6) The second important effect of
coronary-artery disease upon the myocardium is seen
in the production of fibrous myocarditis. This may re-
sult from the gradual transformation of areas of
anemic necrosis. More commonly it is caused by the
narrowing of a coronary branch in a process of obliter-
ative endarteritis. Where the process is gradual evi-
dences of granulation tissues are often wanting, and
any distinction between the necrotic muscle fibers and
the new scar tissue is difficult to establish. The scler-
osis is most frequently seen at the apex of the left ven-
tricle in the septum, but it may occur in any portion.
In the septum and walls there are often streaks and
patches which are only seen in carefully made serial
section. Hypertrophy of the heart is commonly asso-
ciated with this degeneration. It is the invariable
precursor of aneurism of the heart." — (Osier's Practice
of Medicine.)
2. Appendicitis: "In the mildest or catarrhal form
there is merely retention of the contents of the appendix
and slight disease (swelling and erosion) of the mucosa.
The muscularis and serous coat may be congested and
edematous, but are not extensively involved. The con-
tents of the appendix are more or less mucopurulent in
character. In the necrotic or gangrenous form the
mucous membrane suffers rapid destruction and the
muscular and serous coats are quickly invaded. Fibrin-
ous peritonitis soon develops in the serous coat and
over the adjacent intestines, either as a result of pene-
tration of bacteria through the walls of the appendix,
or in consequence of perforation of the walls. The local
peritonitis serves the purpose of restraining the infec-
tive disease and prevents diffuse peritonitis. In cases
of rapid gangrene, with early rupture or escape of
abundant bacteria, general peritonitis may result be-
fore a restraining wall can be formed."— (Stengel's
Pathology.)
^ 3. By infection is meant the invasion of the living
tissues by living microorganisms which grow and multi-
ply at the expense of the host. If only one kind of
microorganism invades the host, it is a primary infec-
tion; if two or more kinds of bacteria are associated
in this invasion, the result is a concurrent or mixed
infection; a terminal infection is one occurring after a
long period of weakness of the host, when a micro-
721
MEDICAL RECORD.
organism which would be powerless under ordinary
conditions causes an infective process which is often
fatal.
4. Pathology of acute anterior poliomyelitis: "The
primary changes are in the vessels of the anterior horn
(anterior spinal artery), which are congested, dis-
tended, and surrounded by small-celled infiltratibn.
Thrombosis is common, but not necessarily present.
Secondary interstitial changes take place in the gray
matter, and its multipolar cells undergo cloudy swell-
ing and ultimate destruction. Degenerative changes
can be traced into the anterior roots. Later, the motor
nerve trunks show marked change, the fibers being
smaller and fewer in number. The neuroglia becomes
increased, and the anterior horn as a whole is sclerosed
and shrunken. The muscles are pale and flabby;
atrophy begins early and is well marked; and micro-
scopically, they show the changes already referred to,
as the result of destruction of their trophic center. In
the epidemic form there may be vascular irritation and
cellular infiltration in the higher centers, but the gang-
lion cells of the medulla, pons, and optic thalamus
usually escape; Flexner describes extensive hyperplasia
of lymphoid tissues, and necrosis of small groups of
liver cells."— (Wheeler and Jack's Handbook of Medi-
cine.)
5. "The causes of rapid death in the puerperium may
be any of the following: Accidents of labor, such as
hemorrhage and shock following placenta praevia, ac-
cidental or post-partum hemorrhage, rupture or inver-
sion of the uterus; rupture of a hematoma situated
either externally on the vulva or within the pelvic
cavity; rupture of peritoneal adhesions or of a broad
ligament or an ovarian vein; acute purpura hsemor-
rhagica; cerebral embolism or apoplexy; hemoptysis;
pre-existing diseases of the respiratory or circulatory
system so grave as not to withstand the strain of labor,
which is followed by extreme exhaustion and rapid
death.
"Analysis of the recorded cases of sudden death in-
clude the following causes: Heart failure which has
resulted from rupture of the heart due to fatty de-
generation, to a patch of fibroid degeneration, to acute
myocarditis. Sudden arrest of the heart's action has
followed primary thrombosis in the right side of the
heart, the thrombus extending into the pulmonary ar-
tery, or more frequently the cause of death has been
embolism of the pulmonary artery. Rupture of a cyst in
the auricular septum of the heart, of an aneurysm, of
722
TENNESSEE.
the aorta itself, and an attack of angina pectoris have
caused immediate death. Mental emotion, such as pro-
found impression of sorrow, of joy, of anger, of exag-
gerated shame, of excessive pain, or of fear, has caused
sudden death by producing syncope, the heart's action
being interrupted by energetic and persistent excitation
of the inhibitory nerves of the heart. Sudden death has
followed the entrance of air into the uterine sinuses; a
fatal case has been recorded from embolus of fat from
the pelvic connective tissue, and death in the puerperium
has followed rupture of a gastric ulcer and of a liver-
abscess. The most frequent causes of sudden death in
the puerperium, arranged in the order of their relative
frequency, are embolism, entrance of air into the
uterine veins, and heart failure, due usually to organic
disease." — (American Text-Book of Obstetrics.)
The post-mortem findings will depend on the patho-
logical condition present.
6. "In mitral stenosis there is an increase in the in-
tra-auricular pressure toward the end of auricular dias-
tole, due to the blood from the lungs flowing into an
insufficiently emptied auricle; the consequent dilatation
and stretching excite the auricle to very vigorous con-
tractions, which become augmented in consequence of
the obstruction to the discharge of blood. The result
is an extraordinary enlargement (hypertrophy and
dilatation) of the left auricle, which may attain dimen-
sions three or four times the normal. Increased intra-
pulmonary pressure is followed by hypertrophy and
dilatation of the right ventricle, which as in mitral in-
sufficiency is the efficient factor in maintaining com-
pensation. In some cases, for a time at least, the in-
creased power of the left auricle serves to supply a
normal amount of blood to the left ventricle, which in
consequence presents no noteworthy deviations from
the normal. In many cases, however, on account of as-
sociated mitral insufficiency, the left ventricle is some-
what enlarged; in most cases the amount of blood sup-
plied to the left ventricle is less than normal, in con-
sequence of which it is often said to become reduced in
size (this is more apparent than real)." — (Kelly's
Practice of Medicine.)
"When compensation fails the various organs of the
body suffer congestion. The lungs are first affected in
disease of the left heart (mitral and aortic disease).
The capillaries of the pulmonary alveoli become over
full and encroach upon the lumen of the alveoli, or by
elongation stretch the alveolar walls and render them
inelastic. In either case proper respiration is prevented
723
MEDICAL RECORD.
— a condition which is further aided by the retarded
pulmonary circulation. As a result of these conditions,
dyspnea (cardiac asthma), cough, and expectoration
develop. In extreme cases edematous exudation takes
place, and in long-continued cases cyanotic induration
of the lung occurs. In such instances, there may be con-
tinuous cough and respiratory insufficiency. When the
right heart fails, the liver, spleen, gastro-intestinal
mucosa, the kidneys, and the peripheral circulation suf-
fer congestion. The liver may become greatly engorged,
and in certain cases actually pulsates with each ven-
tricular systole. The swollen liver-cells and the en-
gorged vessels cause obstruction of the biliary capil-
laries, arid consequently produce jaundice. To some
extent this may be due to associated congestion of the
biliary channels. Congestion of the gastro-intestinal
mucosa may occasion various forms, of gastric or in-
testinal derangement." — (Stengel's Pathology.)
7. "Pott's disease": The lower dorsal region is the
commonest situation, but any part may be affected.
The disease begins — (1) Under the periosteum of the
anterior surface of the bodies of the vertebrae. The
disease spreads to the adjacent vertebrae. The bodies
and intervertebral discs are destroyed, so that a grad-
ual curvature is produced. (2) In the interior of the
bones, near the intervetebral cartilages, and rarely af-
fecting more than one or two vertebrae. As the bones
become destroyed the weight of the body causes the
vertebrae above to sink down, and so more or less acute
curvature results. The disease may run its course with
or without suppuration." — (Aids to Surgery.)
8. An autogenous vaccine is one that is prepared
from material derived directly from the patient who is
to be inoculated with it. Vaccine therapy is based on
the supposition that bacterial vaccines when introduced
into the patient's body cause a condition of active im-
munity against the corresponding pathogenic germs or
their toxins; it is further believed that they raise the
opsonic value of the blood and so promote phagocytosis
of the invading bacteria.
PRACTICE.
1. Pain in the chest may be due to: Anemia, inter-
costal neuralgia, pleurodynia, pleurisy, pneumonia,
phthisis, mediastinal tumor, enlarged bronchial glands,
herpes zoster, disease of the vertebrae, angina pectoris,
pseudo-angina, pericarditis, gastralgia, gastric neuro-
ses, gastric ulcer, gastric cancer, ulcer of duodenum,
aneurysm.
724
TENNESSEE.
2. Uremia may occur in the course of acute nephritis,
chronic nephritis, puerperal eclampsia, and when there
is obstruction to urinary excretion. Remedies — Hot
pack, to increase elimination by the skin; elaterin, to
increase elimination by the bowels; nitroglycerin, to
lower arterial tension; strychnine and digitalis, to sup-
port the heart; chloral or chloroform for the convul-
sions; sometimes venesection and hypodermoclysis will
cause general relief from all the symptoms.
3. Koplik's spots are small red spots with a bluish -
white center, found on the inner surface of the cheeks;
tney occur in the beginning of measles, prior to the ap-
pearance of the rash.
Romberg's Symptom: The patient stands with eyes
closed and heels together; extensive swaying of the
body occurs if the patient has ataxia of the lower ex-
tremities; found in locomotor ataxia.
Argyll-Robertson pupil: The pupil responds to ac-
commodation, but not to light; found in locomotor
ataxia, intracranial syphilis, and progressive paralysis
of the insane.
Babinski's reflex: When the sole of the foot is
tickled there is extension of the toes instead of flexion;
occurs in lesions of the pyramidal tract, organic
hemiplegia.
Kernig's sign : The patient lies with the thighs flexed
upon the abdomen and the legs flexed upon the thighs;
if cerebrospinal meningitis is present it will be impos-
sible to extend the legs.
Stokes- Adams syndrome is a complex consisting of
slow pulse, cerebral disorders (as vertigo, syncope),
and visible auricular pulsation in the veins of the neck.
It occurs in heartblock.
4. Tumor of the brain: Chief symptoms are head-
ache, vertigo, vomiting, optic atrophy, choked disc, slow
pulse, convulsions, and the focal symptoms (which vary
according to the location of the tumor).
Pulsating jugulars may denote: Anemia, tricuspid
stenosis or regurgitation ; the condition may be ob-
served in health.
5. Cardiac Hypertrophy: ''Inspection reveals full-
ness or prominence of the precordium with a distinct
impulse. Palpation detects the impulse one or two in-
tercostal spaces lower down and to the left, ft is
stronger and more or less diffused — the heaving im-
pulse. Percussion determines an increase in the area
of cardiac dullness vertically and transversely on the
left side of the sternum, unless the right ventricle is
also hypertrophied, when the cardiac dullness is in-
725
MEDICAL RECORD.
creased to the right of the sternum. Auscultation in
simple hypertrophy without any valvular changes de-
tects a loud first sound of a somewhat metallic quality,
the second sound being strongly accentuated. In the
presence of valvular disease the characteristic mur-
murs are heard in addition." — (Hughes' Practice of
Medicine.)
Cardiac Dilatation: "Inspection detects enlarge-
ment and distention of the superficial veins and an in-
distinct, often wavy and diffused, cardiac impulse. If
tricuspid regurgitation is present jugular pulsation will
be observed. Palpation confirms inspection; the im-
pulse is , feeble, irregular, and heaving. Percussion
serves to determine extension of the area of cardiac
dullness transversely and especially toward the right
side. Auscultation in the presence of valvular lesions
reveals characteristic murmurs. If there are no valvu-
lar lesions the cardiac sounds are weaker than normal
and the first sound is sharper in quality than usual." —
(Hughes' Practice of Medicine.)
6. Cerebrospinal Meningitis. Cause: The diplococ-
cus intracellulars meningitidis. Symptoms: "The
symptoms depend upon the area most affected. If the
meninges of the brain are diseased, there are delirium,
stupor, paralysis of ocular muscles, disturbed vision,
deafness and semi-consciousness. If the meninges of
the cord are the seat, there will be opisthotonos, hyper-
esthesia, paresthesia, rigidity and tremor of the extrem-
ities, localized spasms of the muscles, which, if irri-
tated, often cause a general convulsion. The onset is
characterized by anorexia, malaise, pain in the back of
neck, head, and down the spine, slight rise of tempera-
ture, chill, or convulsion. Vomiting comes on early,
and the pain in the back and head increases. The tem-
perature is not usually high — about 102°— very irreg-
ular, and. without the diurnal variation so common in
typhoid fever. The pulse is full and strong. Intoler-
ance to light and sound is a prominent feature. The
skin becomes hypersensitive and a petechial rash ap-
pears, hence the synonym — spotted fever. Trophic
changes may occur and herpes is common. This is gen-
erally a leucocytosis. To test for the distinctive Ker-
nig's sign, the patient lies with the thighs flexed upon
the abdomen and the legs flexed upon the thighs; if
meningitis is present extension of the legs is impos-
sible, being prevented by the contraction of the ham-
strings. Delirium is present usually from the onset,
and may be so prominent as to give rise to maniacal
outbreaks. The urine is high-colored, scanty, and may
726
TENNESSEE.
contain albumin. Late in the disease it may be passed
involuntarily. Occasionally the joints may be swollen."
Treatment: "Rest in bed, liquid diet, ice-bags to the
head, and counterirritation to the back are essential.
Pain and restlessness are relieved by morphine, the
bromides and chloral. The bowels should be freely
opened, and the bladder should be emptied by catheteri-
zation, if necessary. The fluidextract of ergot, gtt. 10-
20, may be given. Lumbar puncture and laminectomy
are sometimes necessary. Alcohol, digitalis and quinine
are of value. During convalescence potassium iodide,
tonics, rest and quiet, massage, and electricity are in-
dicated. In case of epidemic cerebrospinal meningitis
the serum treatment should be resorted to." — (Pocket
Cyclopedia of Medicine and Surgery.)
Symptoms of Tuberculous Meningitis. "Prodromal:
The child usually shows more or less definite symp-
toms of the tuberculous diathesis, such as emaciation,
want of appetite, or constipation alternating with diar-
rhea. Irritability of temper and headache are per-
haps the most common features previous to the onset
of definite symptoms of the meningeal affection. Such
a condition may last a few weeks or months. Irritative
Stage.— The symptoms are similar to those of the sim-
ple variety, but the head is usually more retracted and
the neck more rigid; the abdomen is hollowed out or
boat-shaped; the temperature oscillates; internal stra-
bismus or other paralysis of cranial nerves may be
present, and there is often marked vasomotor paraly-
sis, manifested by the tache cerebrale (a red line upon
the skin rapidly following a stroke of the finger nail).
This, however, is not diagnostic. Vomiting is very con-
stantly present, and may or may not be related to
food. The pulse is irregular and slow. This stage con-
tinues for a week or so. Compression Stage. — The
pulse becomes more rapid with the exhaustion of the
heart, the symptoms that accompany coma develop, and
death may take place in from ten days to six weeks
from the onset of acute symptoms. In the adult deli-
rium may take the place of convulsions. The course of
the disease is more rapid than in children, as the skull
cannot expand, and hence intracranial pressure develops
more quickly." — (Wheeler and Jack's Handbook of
Medicine.)
7. Displaced apex-beat may be due to: Pericardial
effusion, distention of abdomen, pleural effusion, dila-
tation or hypertrophy of the heart, emphysema, aneu-
rysm of arch of aorta, mediastinal tumors, hydrotjiorax,
pneumothorax.
727
MEDICAL RECORD.
For physical signs of dilatation and hypertrophy of
the heart, see Question 5.
8. Herpes Zoster: Diagnosis is made by the pain,
and eruption along the course of a cutaneous nerve
(generally one of the intercostal nerves) ; it is generally
unilateral; the vesicles show no tendency to rupture.
Treatment: Flexible collodion or a dusting powder
locally, to protect the vesicles; antipyrin or phenacetin
or morphine for the pain, and zinc phosphide and nux
vomica as a nerve tonic.
The gonococcus or some other pyogenic microorgan-
ism is the cause of most cases of early blindness. Pre-
ventive treatment: Whenever there is the possibility
of infection, or in every case, wash the eyelids of the
newborn child with clean warm water, and drop on the
cornea of each eye one drop of a 1 per cent, solution
of nitrate of silver, immediately after birth.
obstetrics.
1. The bones of the pelvis are: Innominate (consist-
ing of ilium, ischium and pubes), sacrum and coccyx;
the divisions are true and false pelvis; the straits are
superior and inferior; the symphyses are pubic, sacro-
iliac and sacrococcygeal.
The chief differences between the male and female
pelvis are thus tabulated in Morris's Anatomy:
male.
Bones heavier and rougher.
Ilia less vertical.
Iliac fossae deeper.
False pelvis relatively
wider.
True pelvis deeper.
True pelvis narrower.
Inlet more heart-shaped.
Symphysis deeper.
Tuberosities of ischia in-
flexed.
Pubic arch narrower and
more pointed.
Margins of ischiopubic
rami more everted.
Obturator foramen oval.
Sacrum narrower and
more curved.
Capacity of true pelvis
less.
female.
Bones more slender.
Ilia more vertical.
Illiac fossae shallower.
False pelvis relatively nar-
rower.
True pelvis shallower.
True pelvis wider.
Inlet more oval.
Symphysis shallower.
Tuberosities of ischia
everted.
Pubic arch wider and more
rounded.
Margins of ischiopubic
rami less everted.
Obturator foramen trian-
gular.
Sacrum wider and less
curved.
Capacity of true pelvis
greater.
728
TENNESSEE.
2. The internal female organs of generation are:
Ovaries, Fallopian tubes, uterus and vagina.
The virgin uterus is about three inches long, about
two inches wide at the upper part, and about one inch
thick; it weighs about an ounce, or an ounce and a
half. The uterus lies between the rectum behind and
the bladder in front; it is below the abdominal cavity
and above the vagina. Its position is one of slight ante-
flexion, with its long axis at right angles to the long
axis of the vagina. The anterior surface of its body
rests on the bladder, and the cervix points backward
toward the coccyx. The uterus is not fixed, but moves
freely within certain limits. It is held in place by
ligaments — broad ligaments, round ligaments, vesi-
couterine and rectouterine. It is pear-shaped; its cav-
ity is very small; it is divided into fundus and cervix;
besides the opening at the os there is an opening on
each side near the fundus leading into a Fallopian tube ;
it is lined by mucous membrane, and covered by serous
membrane. The nerves are from the hypogastric and
sacral plexus, and from 3d and 4th sacral nerves. The
arteries are the uterine and ovarian.
3. Menstruation is a periodical disturbance in the fe-
male, characterized by a bloody mucus discharge from
the uterine cavity ; it lasts during the period of woman's
sexual activity, but is temporarily suspended during
pregnancy and early lactation.
A woman usually menstruates about two or three
months after her confinement if she is not nursing her
child, and about seven months after the confinement if
she is nursing her child.
4. During 'pregnancy the uterus increases in size
(from 3 to 12 inches in length; from 1% to 9 inches in
breadth), in weight (from about one ounce to two
pounds, not including its contents). The cavity is en-
larged over 500 times. All the tissues, muscles, liga-
ments, arteries, veins, lymphatics, and nerves become
tremendously hypertrophied. The uterus also changes
its position; at first it drops, later it gradually rises,
till just before labor (when it again drops) .
VIRGIN UTERUS
The cavity is of normal
length and triangular.
The cervix is small, hard,
and cartilaginous, and
of the same length as
the body.
UTERUS OF MULTIPARA
The cavity is increased in
length and oval.
The cervix is large and
soft; it is about one-
half the length of the
bodv.
729
MEDICAL RECORD.
_
VIRGIN UTERUS.
UTERUS OF MULTIPARA.
The external os is a trans-
verse slit or pinhole ori-
fice with smooth edges.
The sides of the cavity of
the body are convex in-
ward.
The uterus is normally
anteflexed.
There is more or less flat-
tening of the anterior
and posterior uterine
surfaces.
The fundus is nearly flat
The internal os is closed.
The external os is irreg-
ular and its edges are
fissured.
The sides of the cavity of
the body are convex
outward.
The uterus is straighter,
or even retrodisplaced.
The contour of the uterus
is more rounded, while
its diameters are in-
creased.
The fundus is convex.
The internal os is patu-
lous.
— (From Dorland's Obstetrics.)
5. As a rule a diagnosis cannot be made till the preg-
nancy is nearly half over, and the most skilful can
hardly obtain absolutely positive signs during the first
sixteen weeks.
Positive signs of pregnancy: (1) Hearing the fetal
heart sound; (2) active movements of the fetus; (3)
ballottement; (4) outlining the fetus in whole or part
by palpation, and (5) the umbilical or funic souffle.
5.—
PREGNANCY.
The usual signs of preg-
nancy are present.
The patient is generally
in good health, with an in-
crease of body- weight ;
there is no characteristic
faeies.
The abdominal tumor is
hard, non-fluctuating, sit-
uated in the median line,
and reveals the fetal signs.
There is generally a
suppression of menstrua-
tion.
OVARIAN TUMOR.
There is an absence of
the chief sign of preg-
nancy, as a general rule.
In advanced cases the
ovarian faeies is present
— a pale, drawn expres-
sion, with yellowness of
the skin and general ema-
ciation.
The abdominal tumor is
soft, fluctuating, showing
usually more or less
growth to one or the other
side, and does not reveal
the fetal signs.
Continuance of men-
struation is the rule, al-
though it may be altered
in character; suppression
has been noted.
730
TENNESSEE.
PREGNANCY.
The cervix is soft (Good-
ell's sign).
There is history of ex-
posure to the possibility of
impregnation, with rap-
idly-developing enlarge-
ment in the median line.
OVARIAN TUMOR.
The cervix is probably
not altered.
The history is obscure,
with a slowly-developing
tumor beginning on one or
the other side.
— (Dorland's Obstetrics.)
Pregnancy: The tumor is hard and does not fluc-
tuate, is situated in the median line, and may give fetal
heart sounds and movements; the cervix is soft, and
the other signs of pregnancy are present. The rate of
growth of the tumor and the general condition of the
patient's health may also help in arriving at a diag-
nosis.
Uterine fibroid: Menstruation is irregular and
sometimes very profuse; absence of the signs of preg-
nancy; the tumor is nodular, firm, irregular in outline,
and while generally placed somewhat centrally is not" in
the median line, and is not symmetrical; the rate of
growth is irregular, being, as a rule, slow, and some-
times extending over years.
Ascites: Absence of the signs of pregnancy; the ab-
domen is distended, but the shape varies with the
position of the patient; on lying down there is bulging
at the sides, the tumor fluctuates, and percussion shows
dullness in the flanks, with resonance in the median
line, but the dullness varies with the position of the
patient.
Gas: Absence of signs of pregnancy; the uterus en-'
larges more slowly than in pregnancy, and when large
enough is resonant on percussion and lighter to the pal-
pating finger in the vagina.
6. Before Labor: "Comparatively little can be accom-
plished by any specific treatment of the breasts and
nipples, except frequent bathing to prevent the accu-
mulation of crusts from the drying of the secretion
which in many instances is considerable. Small and
slightly protruding nipples may be lengthened some-
what by gentle traction practised two or three times a
day during the latter part of pregnancy. Nipples that
are markedly retracted cannot be appreciably improved.
Daily bathing with a mild solution of alum in 50 per
cent, alcohol will help to harden them and thus aid
in the prevention of fissures during the puerperium." —
(Jewett's Gbstetrics.)
731
MEDICAL RECORD.
"After the birth, the nipples need special care to pre-
vent the formation of fissures. The nurse should cleanse
the nipple before and after each nursing with a bland
antiseptic solution such as a saturated solution of boric
acid, to which one-eighth (%) part of glycerin has been
added ; while before each nursing the child's mouth
should be cleansed in a like manner with a saturated
solution of boric acid, care being used to avoid injury
to the buccal epithelium from too vigorous handling.
Excessive nursing must not be permitted, for the nipple
is injured by long continued maceration, and avenues for
infection are opened. The nurse must be warned of the
risk of carrying infection to the nipples or to the child,
when her hands are soiled from handling the lochial
guard. The nipple should never be touched by the nurse
until she has first thoroughly disinfected her hands." —
(Polak's Obstetrics.)
7. To facilitate a tedious or painful labor: Remove
the cause, if possible; see that the bladder and rectum
are empty; rectal injections of glycerin; pituitrin,
strychnine, quinine or other stimulants may be admin-
istered ; uterine massage may be tried ; the patient may
assume the semi-recumbent or squatting posture during
the pains.
8. They should not undertake any obstetric work
without having taken more than the ordinary antisep-
tic precautions. A thorough bath, use of antiseptics,
and clean clothes should form part of this care.
SURGERY.
1. The patient feels a snap at the time of injury,
and suffers from pain, increased during inspiration. If
.the back is fixed and the sternum firmly pressed back,
pain is felt at the middle of the rib. Crepitus may or
may not be felt. Complications: Puncture of pericar-
dium, pleura, heart, lung, or other viscera ; emphysema ;
pneumothorax; pyothorax; pleurisy; pneumonia.
Treatment: Strips of plaster reaching from the spine
to the sternum should be placed over the injured side
during deep inspiration. The strips should overlap,
and a bandage should be put on over the plaster. If
the fracture is due to direct violence, no strapping
should be used, but the patient kept still by placing
sand-bags on either side. — (Aids to Surgery.)
2. Toxemia or sapremia is due to absorption of toxins
only.
Septicemia is due to organisms multiplying in the
blood.
Pyemia is due to particles of blood-clot carrying or-
732
TENNESSEE.
ganisms to parts distant from the original source, and
there setting up abscesses.
3. Etiology: Infection from nasopharynx or ear, ex-
anthemata, grippe, inflammation of middle ear. Symp-
toms: Tenderness, pain, swelling, and redness over the
mastoid; bulging of the superior and posterior parts of
the auditory canal; temperature variable, from normal
up to about 104° F. Treatment : Hot water, or cold water,
or ice; leeches; purgatives; light diet; acetanilid; in-
cision, or mastoid operation. Operation : A semicircular
incision of the soft parts is carried from a point about
one-half inch above the attachment to the auricle, back-
ward and downward, keeping parallel to the auricular
attachment and terminating at the tip of the mastoid.
The periosteum is now elevated or dissected from the
bone and the osseous structure thoroughly exposed by
means of retractors, which are held by an assistant,
the auricle being pulled forward so as to lie upon the
side of the head. The hemorrhage is controlled by the
use of hot sponges and artery forceps. The surface of
the mastoid is thoroughly examined for areas of ne-
crosis or the existence of a fistulous opening, especially
if a fluctuating swelling obtains previous to the opera-
tion. If these exist, the openings are enlarged by
means of a gouge or a chisel and mallet, and followed
inward to their origin. Should the surface present a
healthy appearance, the primary opening of the mastoid
is made into the antrum by means of the chisel, the
point of entrance being effected just below the line of
the superior wall of the meatus and about one-quarter
of an inch backward from the posterior wall or anterior
edge of the mastoid bone. When the antrum has been
exposed, the cortex of the mastoid is chiselled away
from this point downward toward the tip until a suffi-
cient amount has been removed to expose all parts of
the mastoid process. The cells are now all broken
down, and every vestige of a necrotic or granulating
area is completely eradicated. A free communication
of the antrum with the tympanum should be estab-
lished, which may be proved by syringing an antiseptic
solution into the antrum, when it will escape from the
external auditory meatus through a previous perfora-
tion of the drumhead. The cavity of the mastoid is
packed with sterile gauze, and the flaps of overlying
tissue allowed to regain their former position, when a
gap remains between their edges, through which the
dressings may be changed. — (From Ailing and Griffin's
Epitome on Eye and Ear.)
4. In a simple fracture, there is history of the in-
733
MEDICAL RECORD.
jury, disability, deformity, pain, false point of motion,
and possibly crepitus; in compound fracture, in addi-
tion to the above, there is an open wound leading down
to the site of fracture; in comminuted fracture, the
bone or bones are broken into small pieces. Constitu-
tional effects (due to hemorrhage, shock, sepsis, or
other complications) may follow. Treatment of simple
fracture: First of all, prevent it from becoming com-
pound, then reduce it, coapt the edges of the broken
bone, immobilize the parts, and attend to the general
condition of the patient. In compound fractures: Give
an anesthetic, thoroughly asepticize the parts, stop the
hemorrhage, remove loose fragments of bone, fix the
bones, drain, and immobilize; the wound wants careful
antiseptic treatment. The leg must be flexed on the
thigh to aid in reducing the fracture, and it may be
necessary to cut the tendo Achillis. Splints will be
necessary.
5. The damages produced by dislocation are tearing
of the capsule and surrounding muscles, and perhaps
fracture of the cartilaginous or bony surfaces. The
joint and surrounding soft tissues are infiltrated with
blood. Vessels and nerves in the neighborhood may be
contused or compressed. If allowed to remain unre-
duced, the displaced head becomes surrounded by a false
joint capsule, the true articular cavity becomes filled
up with fibrous tissue, and the muscles and tendons
around become shortened, while adhesions to big ves-
sels close at hand constitute a danger in attempted re-
duction.
Treatment: All dislocations should be reduced in the
earliest stages, either by manipulation or extension.
Manipulation aims at making the bone retrace the
course by which it left its proper position. Anesthesia
renders this very easy by overcoming the spasmodic
contraction of the muscles. Extension is employed to
overcome muscular contraction. The hands, a jack-
towel, and pulleys are used for this purpose. The re-
duction is usually marked by a distinct snap. The
bones are then felt to be in their normal relation, and
normal mobility is restored. Rest for a few days and
early passive movements soon repair the damage done.
— (Aids to Surgery.)
6. Malignant tumors are not encapsulated, tend to in-
filtrate the surrounding tissues, give rise to metastatic
growths, have a tendency to recur after removal, give a
cachexia, have a fatal tendency.
Benign tumors are encapsulated, do not tend to infil-
trate the surrounding tissues, do not give rise to meta-
784
TENNESSEE.
static growths, do not tend to recur after removal, do
not produce cachexia, and do not have a fatal tendency
(except from their location.)
Two malignant tumors: Carcinoma and sarcoma.
Two benign tumors: Fibroma and lipoma.
7. The sym,ptoms consist of aching pain in the loin
and frequent micturition. Hematuria comes on
early and without apparent cause, is not increased by
movement or improved by rest. Pus is usually present
in acid urine, and the Bacillus tuberculosis may in some
cases be detected. In the late stages the kidneys may
be felt much enlarged. The diagnosis is doubtful in
the early stages, unless bacilli can be demonstrated by
the microscope or inoculation of a guinea-pig. The
hematuria is much slighter than in cases of renal cal-
culus, and is not influenced by rest. The hemorrhage
is not so profuse as in cases of new growth. Slight
attacks of renal colic may occur from the passage of
caseous matter, but not severe attacks like those due
to calculus. An exploratory incision settles the diag-
nosis in doubtful cases. Treatment: If on exposure of
the kidney a limited portion is found to be diseased, a
wedge-shaped portion is excised. If, as is more usual,
the kidney is extensively affected, two methods may be
adopted: (1) If the other kidney is healthy, nephrec-
tomy with removal of as much of the ureter as possible
is done. (2) Nephrotomy, followed by drainage, is
done w T hen the patient's condition is bad.
8. Erysipelas. "Etiology: Predisposing causes: (1)
A wound or abrasion; (2) constitutional debility; (3)
bad hygiene. Exciting cause: Streptococcus erysipe-
latis, which is indistinguishable from S. pyogenes.
Symptoms: Malaise with rigor and headache. Rash
appears within twenty-four hours; it appears first
round the wound, which breaks open; it is of a vivid
red color, which fades on pressure. Pain and swelling
are not much marked. The eyelids and scrotum when
affected become very edematous. Vesicles and bullae
form superficially, and a fine desquamation occurs, with
some staining of the skin as the rash fades away. Lym-
phatic glands in the neighborhood are enlarged and
tender. The patient is very ill, with high tem-
perature — 102°-104° F. Delirium is frequent, especially
when the scalp is affected. Vomiting is common.^
Varieties: Facial erysipelas is often apparently idio-
pathic and recurrent. Faucial erysipelas spreads from
the exterior to the pharynx; causes great swelling of
the parts, with a tendency to edema glottidis. Scrotal
erysipelas causes great edema, and in children a ten-
735
MEDICAL RECORD.
dency to sloughing. Cellule-cutaneous erysipelas par-
takes of the character of both cellulitis and erysipelas,
affecting the skin and subcutaneous tissue. — (Grove's
Synopsis of Surgery.)
STATE BOARD EXAMINATION QUESTIONS.
The Texas State Board op Medical Examiners.
ANATOMY.
1. Give the location and shape of the frontal bone,
and name the bones with which it articulates.
2. What structures are used in the formation of an
articulation, and what three classes of articulations are
there?
3. Name the triangles of the neck and their subdivi-
sions, and give boundaries of each.
4. Describe the diaphragm and give origin and inser-
tion.
5. Give location of the subclavian arteries and tell
origin of.
6. Give origin and distribution of the pneumogastric
nerve.
7. Where does the liver get its blood supply?
8. Give abdominal surface location of the gall-bladder
and appendix.
9. What constitutes the sympathetic nervous system?
10. Describe and give location of the inguinal canal.
PHYSIOLOGY.
1. Define physiology.
2. Name the elementary tissues.
3. Name the kinds of muscular tissue.
4. Describe briefly the blood.
5. What is an "internal secretion"? Name five or-
gans which have such.
6. If the pneumogastric nerves were severed, what
would be the effect on the heart?
7. Where are the plexuses of Auerbach and Meissner
located? Their function?
8. Where are the Malpighian bodies found? State
their function.
9. Name the organs of excretion in order of their
importance.
10. Where are the cardioinhibitory and cardioac-
celerator centers located?
CHEMISTRY.
1. What is an element? A compound? An example
of each.
736
TEXAS.
2. Define a deliquescent salt; efflorescent salt.
3. In Marsh's test for arsenic, how do you differ-
entiate arsenic from antimony spots?
4. (a) Give a process for making chlorine gas. (6)
Give properties of chlorine gas. (c) Of what value is
this gas?
5. What is an acid? What is a base? Complete the
equation 2NAC1 + H 2 S0 4 .
6. Define normal salt, basic salt, acid salt.
7. Describe iodine as found in the market, (b) Test
for iodine.
8. How is chloral hydrate prepared? (6) Physio-
logical properties of chloral hydrate.
9. From what source do we obtain pure genuine
salicylic acid?
10. Give test for morphine sulphate.
HISTOLOGY.
1. Name and describe membranes of brain.
2. Give the structure of human skin.
3. Locate and give structures of Peyer's patches.
4. Give structure of the thyroid gland.
5. Give a histological difference between pyloric and
cardiac ends of stomach.
6. Give the development of bone.
7. Draw cross section of spinal cord at tenth dorsal,
and name findings.
8. Give histological difference between veins and ar-
teries.
9. Give histological structure of lymphatic gland.
BACTERIOLOGY.
1. Describe the Wassermann reaction.
2. Define alexins, agglutinins, and precipitins.
3. Define diapedesis, phagocytosis ; of what use is the
process of phagocytosis in the human system?
4. State names of the stains used to demonstrate the
presence of the following microorganisms: staphylo-
coccus, streptococcus; the negri bodies of hydrophobia.
5. State methods of making a culture of the Klebs-
Loeffler bacillus.
6. Define toxins, endotoxins, and autotoxins.
7. Give morphology of pneumococcus and the para-
site of malaria (any variety).
8. Describe the Widal reaction and von Pirquet's
method of cutaneous diagnosis of tuberculosis.
9. What pus-producing microorganism causes the
greatest mortality, and give names of principal dis-
eases in which it is a principal cause of destruction.
10. Define flagellated and name all the flagellated
pathogenic organisms.
737
MEDICAL RECORD.
OBSTETRICS.
1. Give the symptoms and management of puerperal
infection.
2. Give the blood supply of the uterus.
3. What are the changes that take place in the cir-
culatory apparatus of the fetus after birth?
4. Give differential diagnosis between uterine fibroma
and pregnancy.
5. Give indications for use of forceps and for
cesarean section.
6. Give the hygiene of pregnancy.
7. Name three of the most frequent diseases to which
pregnancy predisposes, select one and give symptoms
of same.
8. Give three indications for induction of premature
labor and describe one method of performing the same.
9. Give the proper treatment of ophthalmia neona-
torum.
10. Give the definition of premature labor and abor-
tion.
„ GYNECOLOGY.
1. Outline your scheme for taking a gynecological
history.
2. (a) What are the advantages and disadvantages
of PfannensteiPs incision? (b) Enumerate in order of
importance the causes of metrorrhagia.
3. Describe a standard perineorrhaphy (secondary).
4. What precautions should be taken in making a
vaginal examination of a virgin?
5. A married woman, aged 40 years, with one child,
aged 14 years, and no subsequent pregnancies, is in
good health until suddenly seized with violent pain in
left lower abdomen and collapses; suggest two diag-
noses.
6. Criticise ventrofixation and ventrosuspension uteri.
7. What conditions justify double ovariectomy?
8. What surgical procedure would you advise to cor-
rect procidentia with cystocele and rectocele in a woman
50 years of age?
9. Name the contraindications of uterine curettage
10. Would you leave the appendix, in abdominal oper-
ations for other conditions? Reasons for your answer
PATHOLOGY.
1. What is a tumor (new growth) ? (a) Classify
tumors as to the tissues from which they arise, (b)
Give examples.
2. What constitutes malignancy? (a) By what chan-
nels are metastases carried?
738
TEXAS.
3. Describe the stages of simple inflammation.
4. Describe the pathological process leading to de-
struction of the valve in mitral insufficiency.
5. Give in detail the blood picture of pernicious
anemia.
6. What systemic pathological changes are usually
associated with contracted kidney? (Interstitial
nephritis.)
7. Give the pathological changes in the intestines in
typhoid.
8. Describe the gross and microscopical appearance of
a gumma of the liver.
9. Describe in detail the pulmonary changes in the
various stages of croupous pneumonia.
10. Give pathological changes in amebic dysentery.
PHYSICAL DIAGNOSIS.
1. What are the methods of physical diagnosis?
2. By what symptoms would you diagnose Pott's dis-
ease (of spine) ?
3. Give use of sphygmomanometer. (6) What is
blood pressure?
4. State in what diseases we would most likely ob-
serve hypertension and hypotension.
5. Describe the characteristics and significance of the
several kinds of arterial pulse.
6. Differentiate organic and functional heart mur-
mur.
7. What are the normal sounds obtained by percus-
sion on the thorax?
8. In what diseases can we employ the microscope as
an aid in diagnosis?
9. What are the physical signs of sciatica?
10. What are the physical signs of pellagra?
SURGERY.
1. Difference between acute abscess and carbuncle;
organisms usually present in both.
2. Preparation of patient for abdominal section be-
ginning thirty-six hours beforehand. Give after-treat-
ment.
3. Define acute osteomyelitis — give treatment and
differential diagnosis between it and acute rheumatism.
4. Treatment of simple fracture at junction of upper
with middle third of femur.
5. Diagnosis of chronic duodenal ulcer.
6. What surgical complications may arise in typhoid
fever?
7. Differential diagnosis between tuberculous kidney
and stone in kidney.
739
MEDICAL RECORD.
8. How would you put an old man in best physical
condition for removal of prostate?
9. Treatment of penetrating wound of right chest,
10. A man receives a blow on top of head; you are
called in and observe him unconscious, and with a scalp
wound; how would you handle the case?
MEDICAL JURISPRUDENCE.
1. Define rigor mortis; say where it commences, how
long it lasts, and its importance from medicolegal stand-
point.
2. Differentiate the male and female skeleton.
3. How would you determine whether a stab wound
on dead body was made before or after death?
4. What points would help to determine whether a
gunshot wound was self-inflicted?
5. Under what conditions may pregnancy become a
subject of medicolegal inquiry?
6. Under what conditions is the destruction of a liv-
ing fetus not considered murder?
7. Give the classifications of insanity.
8. In suspected infanticide how would you determine
that the child was born alive?
9. In case of doubtful paternity what points would
help to fix the responsibility?
10. Upon what evidence could you sustain a charge
of recent abortion?
HYGIENE.
1. Name some of the diseases believed to be acquired
by inhalation of microorganisms from the air.
2. How much O does an adult human being at rest
ordinarily take from the air and how much C0 2 does
he add to it in twenty-four hours? (a) How would you
arrange for natural ventilation of a schoolroom during
cold weather?
3. What quantity of water should be supplied per
capita daily by towns and cities for all purposes? (a)
Mention some diseases that are frequently transmitted
by water.
4. What is the probable significance of nitrites or
nitrates in water?
5. How is milk most frequently adulterated, and what
is the greatest danger in such adulteration?
6. What conditions may render meat unfit for food?
7. Of what disease or diseases is the house-fly a car-
rier?
8. What precaution should be taken in locating the
well or cistern for drinking water on a farm?
9. What precautions should be taken in the handling
740
TEXAS.
of a case of typhoid to prevent the infection of others?
(Explain fully.),
10. Describe a reliable method for the disinfection
of a room which has been occupied by an infectious
patient.
ANSWERS TO STATE BOARD EXAMINATION
QUESTIONS.
The Texas State Board of Medical Examiners.
anatomy.
1. The frontal bone is located at the anterior part
of the cranium; its shape is that of a cockle-shell; it
articulates with the two parietal, the sphenoid, the
ethmoid, two nasal, two superior maxillary, two
lacrymal, and two malar bones.
2. Structures entering into the formation of a joint,
are: Bone, cartilage, fibrocartilage, ligament, and syn-
ovial membrane.
The three forms of articulations are: (1) Syn-
arthrosis, or immovable articulation, such as that be-
tween the two parietal bones. (2) Amphiarthrosis, or
mixed articulation, such as that between the two pubic
bones. (3) Diarthrosis, or freely movable articulation,
such as that between the humerus and the ulna.
3. The anterior triangle of the neck is bounded:
In front by a line from the chin to the sternum ; behind
by the anterior margin of the sternomastoid ; base is
upward, and is formed by the lower border of the body
of the lower jaw and a line from the angle of the jaw
to the mastoid process. It is divided into three smaller
triangles (inferior carotid, superior carotid, and sub-
maxillary) by the digastric muscle and the anterior
belly of the omohyoid. The inferior carotid triangle
is bounded, in front by the median line of the neck;
behind, by the anterior margin of the stermomastoid ;
and above, by the anterior belly of the omohyoid. The
superior carotid triangle is bounded, behind by the
sternomastoid; below, by the anterior belly of the
omohyoid ; and above by the posterior belly of the digas-
tric. The submaxillary triangle is bounded, above by
the lower border of the body of the mandible and a line
drawn from its angle to the mastoid process; below,
by the posterior belly of the digastric and the stylo-
hyoid ; and in front, by the anterior belly of the digas-
tric.
The posterior triangle of the neck is bounded: Jn
front by the sternomastoid; behind, by the anterior
margin of the trapezius; and its base corresponds to
741
MEDICAL RECORD.
the middle third of the clavicle. It is divided into two
smaller triangles (the occipital and the subclavian) by
the posterior belly of the omohyoid. The occipital tri-
angle is bounded in front, by the sternomastoid; behind,
by the trapezius; and below, by the omohyoid. The
subclavian triangle is bounded above, by the posterior
belly of the omohyoid; below, by the clavicle; and in
front, by the sternomastoid.
4. The diaphragm is a musculofibrous septum which
divides the thoracic from the abdominal cavity; it is
fan-shaped; the broad elliptical portion is horizontal,
and the crura are vertical. It is attached to the ensi-
form, to the internal surfaces of the lower six costal
cartilages, to bodies and intervertebral substances of
first, second, and third lumbar vertebrae. Its openings
are: (1) The aortic, transmitting the aorta, vena
azygos major, and the thoracic duct; (2) the esopha-
geal, transmitting the esophagus, pneumogastric nerves,
and some small esophageal arteries; (3) the opening
for the vena cava, transmitting the inferior vena cava,
and small branches of the right phrenic nerve; (4) the
right crural, transmitting the right splanchnic nerves;
(5) the left crural, transmitting the left splanchnic
nerves and the vena azygos minor. — Nerve Supply:
Phrenic, lower intercostals, and sympathetic.
5. Subclavian artery arises on the right side from the
innominate artery, on the left from the arch of the
aorta; and it passes outward, arching over the pleura,
lying on the first rib, betwen the scalenus anticus and
medius, and ends at the lower border of the first rib.
It is divided into three parts by the scalenus anticus;
the first part being from the origin of the artery to the
inner border of the scalenus anticus; the second part,
posterior to that muscle; and the third part from the
outer edge of the muscle to the lower border of the first
rib.
6. Pneumogastric nerve. Superficial origin: Groove
between restiform and olivary bodies. Deep origin:
Nuclei in floor of fourth ventricle. DistHbution is
shown by the names of the branches: Meningeal, auri-
cular, pharyngeal, superior and inferior laryngeal,
cardiac, pulmonary, esophageal, and gastric.
7. The blood supply of the liver: Hepatic artery and
hepatic veins ; the portal vein also conveys blood to the
liver.
8. The gall-bladder is situated in a fossa on the under
surface of the right lobe of the liver. It is in relation,
in front, with the anterior abdominal wall, immediately
below the ninth costal cartilage.
742
TEXAS.
Relations of vermiform appendix. Owing to the
variable position of the appendix, these are not definite.
As a rule, the appendix is given off from the lower,
posterior surface of the cecum, and points upward and
to the left, but it may hang down into the pelvic cavity,
or take almost any other position with reference to the
lower end of the cecum. The point at which the appen-
dix joins the cecum is generally indicated on the ante-
rior abdominal wall by McBurney's point. (A line is
drawn from the anterior superior spine of the ilium to
the umbilicus, and a point is marked off on this line at
a distance of two and a half inches from the spine of
the ilium.)
9. "The sympathetic nervous system consists of (1) a
series of ganglia connected together by a great gangli-
onic cord, the gangliated cord, extending from the base
of the skull to the coccyx, one gangliated cord on each
side of the middle line of the body, partly in front and
partly on each side of the vertebral column; (2) of
three great gangliated plexuses or aggregations of
nerves and ganglia, situated in front of the spine in
the thoracic, abdominal, and pelvic cavities respectively ;
(3) of smaller or terminal ganglia, situated in relation
with the abdominal viscera; and (4) of numerous
fibers."
10. The inguinal canal is an oblique canal situated a
little above and running parallel with Poupart's liga-
ment. It is from an inch and a half to two inches in
length, runs downward and inward, and extends from
the internal abdominal ring to the external abdominal
ring.
Its boundaries are : In front : the skin, superficial fas-
cia, aponeurosis of the external oblique, and (for its
outer third) the internal oblique. Behind: the conjoined
tendon, the triangular fascia, the transversalis fascia,
subperitoneal fat, and peritoneum. Above: the fibers
of the internal oblique and transversalis. Below: Pou-
part's ligament and the transversalis fascia.
Contents : the spermatic cord in the male, and the
round ligament in the female.
PHYSIOLOGY.
1. Physiology is that branch of science which treats
of the functions of living tissues and organisms in a
state of health.
2. The elementary tissues are: Epithelial, connective,
muscular, and nerve tissues.
3. Varieties of muscle tissue: (1) Voluntary striated
muscle; (2) involuntary, non-striated muscle ; (3) invol-
untary striated or cardiac muscle.
743
MEDICAL RECORD.
4. The physical properties of blood: Fluid, somewhat
viscid, red; specific gravity, from 1055 to 1062; alkaline
reaction; saltish taste; characteristic odor; variable
temperature (average, about 100° F.).
The constituents of the blood are plasma and cor-
puscles. The plasma consists of water and solids (pro-
teids, extractives, and inorganic salts). The red cor-
puscles consist of water and solids (hemoglobin, pro-
terds, fat, and inorganic salts). The white corpuscles
consist of water and solids (proteid, leuconuclein, leci-
thin, histon, etc.)
The red blood corpuscles are biconcave discs, about
1-3200 of an inch in diameter; they are non-nucleated,
and there are about 4,500,000 or 5,000,000 of them in
each cubic millimeter of blood. They are elastic and
soft, and their shape is changed by pressure, but is
promptly regained on the removal of the pressure.
Their color is yellowish. They contain hemoglobin.
Their function is to carry oxygen from the lungs to
the tissues.
The white blood cells are spheroidal masses, varying
in size, having no cell wall, and containing one or more
nuclei; there are about 7,000 to 10,000 of them in each
cubic millimeter of blood. They differ much in appear-
ance, and are divided into (1) small mononuclear leuco-
cytes, or lymphocytes, (2) large mononuclear, (3)
transitional, (4) polynuclear, or polymorphonuclear,
or neutrophile, and (5) eosinophile. They are all more
or less granular, particularly the last two varieties
named. They are probably formed in the spleen, lym-
phatic glands, and lymphoid tissues. Their fate is un-
certain : it has been asserted" that they are converted
into red blood cells; they play a part in the formation
of fibrin ferment; they are sometimes converted into
pus cells. Their functions are (1) to serve as a protec-
tion to the body from the incursions of pathogenic
microorganisms; (2) they take some part in the process
of the coagulation of the blood; (3) they aid in the ab-
sorption of fats and peptones from the intestine, and
(4) they help to maintain the proper proteid content
of the blood plasma.
There are also platelets, which are very small, color-
less, irregular shaped bodies ; they are about one-fourth
the diameter of a red corpuscle. Their function is not
determined; it is possible that they take some part in
the coagulation of the blood. In number they vary
from about 200,000 to more than 500,000 in each cubic
millimeter of blood.
Plasma conveys nutriment to the tissue: it holds in
744
TEXAS.
solution the carbon dioxide and water which it receives
from the tissues, and takes them to be eliminated by
the lungs, kidneys, and skin; it also holds in solution
urea and other nitrogenous substances that are taken
to and excreted by the liver or kidneys.
5. Internal secretions: It is generally held now that
the glandular organs, chiefly the pancreas, liver, and
the ductless glands, produce a secretion, peculiar in
each case to the particular gland producing it, and
which is supposed to be given off to the blood or lymph,
and to have some peculiar value in the general metab-
olism of the body. Such secretions are called internal
secretions, in contradistinction to the previously known
secretions, which are carried off by a duct, and are
known as external secretions. Very little is definitely
known of these internal secretions, but much work is
being done on the subject.
Internal secretions are produced by the liver, pan-
creas, ovaries, testes, thyroids, parathyroids, spleen,
suprarenals, pituitary body, and by the fetus.
6. If the pneumogastric nerves were severed the
heart would beat more rapidly, as the inhibitory im-
pulses would no longer reach the heart.
7. AuerbacKs plexus is situated in the walls of the
intestine between the circular and longitudinal muscle
fibers.
Meissner's plexus is situated in the submucous coat of
the intestine.
Their function is to cause intestinal peristalsis.
8. The Malpighian bodies are found in the cortical
portion of the kidneys; their function is to excrete the
water, salts and urea which are eliminated in the urine.
Malpighian bodies are also found in the spleen; their
function is the formation of lymphocytes.
9. The organs of elimination are: (1) The skin,
which eliminates water and a slight quantity of carbon
dioxide, urea, and salts; (2) the lungs, which eliminate
water, carbon dioxide; (3) the intestines, which elimi-
nate the indigestible and unabsorbed substances from
the food, with secretions from liver and pancreas; (4)
the kidneys, which eliminate water, urea, and other
nitrogenous matter, and inorganic salts.
10. The cardioinhibitory and cardioaccelerator cen-
ters are situated in the floor of the fourth ventricle.
CHEMISTRY.
1. An element is a kind of substance which we can-
not, by any known means, split up into any two ot
more other kinds of substance; as oxygen.
745
MEDICAL RECORD.
A compound is a substance made up of two or more
elements, chemically united, in definite proportions; as
sulphuric acid.
2. A deliquescent salt is one that has a tendency to
unite with water which it absorbs from the air, be-
coming damp, and finally liquid.
An efflorescent salt is one which, on exposure to air,
loses its water of crystallization and becomes a powder.
3. The arsenical stain: (1) Volatilizes readily in an
atmosphere of hydrogen, and (2) the escaping gas has
the odor of garlic; (3) when heated in a current of
oxygen, octahedral crystals are formed; (4) it dissolves
promptly in a solution of sodium hypochlorite.
The antimonial stain: (1) Requires a much higher
temperature for its volatilization, and (2) the escaping
gas has not the odor of garlic; (3) when heated in a
current of oxygen, an amorphous powder is formed;
(4) it is insoluble in a solution of sodium hypochlorite.
4. Chlorine gas may be made by heating together
manganese dioxide and hydrochloric acid:
Mn0 2 -^ 4 HC1 = MnCL + 2 H 2 + Cl 2
Chlorine gas is a greenish yellow gas, with a pene-
trating and very irritating odor; in the presence of
moisture it is a bleaching agent; it combines readily
with other elements, and frequently combines with the
evolution of light and heat; it is a disinfectant. Its
value lies in its bleaching and disinfecting properties.
5. An acid is a compound of an electronegative ele-
ment or residue with hydrogen, part or all of which
hydrogen it can part with in exchange for an electro-
positive element, without the formation of a base.
A base is a ternary compound which is capable of
entering into double decomposition with an acid, to
form a salt and water.
2 NaCl + H 2 SO* = Na 2 S0 4 + 2 HC1
6. A normal salt is one in which all the replaceable
hydrogen of the acid has been replaced.
A basic salt is a compound made up of a normal salt
and the hydroxide or oxide of a metal.
An acid salt is one in which only a part of the re-
placeable hydrogen of the acid has been replaced.
7. Iodine is a bluish-gray solid, in crystalline scales,
with a metallic luster; it is volatile, and has a peculiar
odor; it is very slightly soluble in water.
Free iodine colors starch paste a dark violet-blue.
8. Chloral hydrate is prepared by mixing together
equivalent parts of chloral and water.
It is a colorless, transparent, crystalline solid, with
a penetrating and aromatic odor, and a caustic taste;
746
TEXAS.
it slowly volatilizes when exposed to the air, and is
freely soluble.
9. Salicylic acid is obtained synthetically from
phenol; it exists naturally, in combination, in oil of
wintergreen.
10. Solution of neutral ferric chloride gives a blue
color with morphine.
HISTOLOGY.
1. The Membranes of the Brain, — "The Dura is a
tough membrane composed of interlacing bundles of
white fibrous and yellow elastic tissues that contain
lymph spaces between them. Within the skull, it forms
the inner periosteum of the cranium, which relation
ceases at the foramen magnum, the entrance into the
vertebral canal. This membrane is lined by endothelial
cells, and forms the outer boundary of the subdura]
lymph space. It is quite vascular, and a few nerves,
that pass to the blood spaces are found. The Arachnoid
is a thin, delicate, weblike membrane composed of
loosely interwoven bundles of white fibrous tissue. It
lies closely applied to the dura, and is separated from
the pia by the subarachnoidean lymph space. This is
also lined by endothelial cells. It forms the Pacchionian
bodies and villi, but contains neither blood vessels nor
nerves. The Pia is the vascular membrane. Its outer
portion contains the bulk of the vessels, while the inner
enters into close relation with the nerve tissue. Its
blood vessels lie in the fibro-elastic network, surrounded
by perivascular lymphatics. Its arachnoidean surface
is covered by endothelial cells. Only a few nerve fibers
are present. The pia is the only one of these mem-
branes that follows the fissures and depressions of the
nerve system." — (Radasch's Histology,)
2. "The skin is composed of two parts, the epidermis
and cutis vera. The Epidermis consists of stratified
squamous epithelium, the cutis vera of fibrous tissue.
Processes of these interdigitate. The deeper layers of
the epidermis are soft, and constitute the rete mucosum.
or stratum Malpighii. The cells of the deepest layer
are columnar in shape, and in dark races they contain
pigment. In the layers above the cells become polyg-
onal or rounded. Narrow clefts between the cells are
bridged by fine protoplasmic processes (prickle cells).
The superficial layers are horny. In the layers of cells
(stratum granulosum) next the stratum Malpighii
granules of a substance called "eleidin" accumulate. In
the layers superficial to this (stratum lucidum) the
cells contain large droplets of a similar substance
(kerato-kyalin) , which tend to run together and obscure
747
MEDICAL RECORD.
the characters of the cells and render their outline
indistinct, giving the layers a clear appearance. The
surface layers take the form of long, thin, flat cells,
whose nuclei have been obscured by kerato-hyalin.
These constitute the stratum corneum. Cells of the
surface layer are always being lost, and are replen-
ished from the cells of the deeper layers. The young
cells formed in the deep layers push the older cells
toward the surface, and as they pass outward the
cells begin to accumulate granules, and then become
transformed to the type found in the stratum corneum.
The Cutis . Vera is composed of dense fibrous tissue,
which rises up into papillae, indenting the epithelium.
In the deeper part the fibrous tissue becomes looser,
and merges indefinitely into the reticular tissue of the
subcutaneous layer. In the papillae are loops of capil-
lary vessels, and in the palm and sole there are tactile
corpuscles. Bloodvessels form a capillary network
near the surface of the true skin, and send up
loops into the papillae and supply branches to the
hairs, sweat glands, etc.; but vessels do not pass into
the epidermis. Nerves pass into the Malpighian layer,
and some of the varicose branches form flattened
menisci between the layer of cells. Medullated nerves
end in touch-corpuscles in the fibrous papillae." — (Aids
to Histology.)
3. Peyer^s patches are aggregations of solitary
glands, measuring from about half an inch to three
inches in length; they are found mainly in the ileum,
but also occur in the duodenum, and jejunum; they are
situated lengthwise in the intestine, and are located
opposite to the mesenteric attachment. Each patch is
surrounded by a group of the crypts of Lieberkuhn.
There are said to be from SO to 50 of these patches
in the human intestine. As a rule, they have no villi
on their surface.
4. The thyroid gland "is surrounded by a capsule that
sends in trabeculae, which divide the gland into lobes
and lobules. These divisions are irregular, and the
lobules are composed of a number of short tubules,
sometimes called follicles. Each tubule is lined by
cuboidal epithelial cells that rest upon a basement mem-
brane ; outside of this is the intralobular, or inter-
tubular, connective tissue that supports the blood-ves-
sels. In the tubules is seen a peculiar, homogeneous
substance, the colloid substance, that is supposedly the
result of the activity of the cells. It has a yellowish
color, and as blood cells are frequently seen in it, the
748
TEXAS.
color may be due to the hemoglobin from these." —
(Radasch's Compend of Histology.)
5. "The chief difference between the pyloric and
cardiac regions of the stomach is found in the mucosa.
(1) The crypts in the cardiac end are shallow, while
in the pyloric end the crypts frequently extend half
way through the thickness of the mucosa. (2) The
gastric glands are longer than the crypts in the cardiac
end; toward the pyloric end the glands become
shorter, tortuous, and pressed closely against the mus-
cularis mucosa. Many of the pyloric glands are
branched. (3) The parietal cells are numerous in the
cardiac region and practically absent in the pyloric.
The pyloric mucosa, in this way, comes to resemble
that of the small intestine. In addition, an occasional
villus or Brunner's gland may be found in the pyloric
end."— (Hill's Histology.)
6. Development of Bone. — "The development of bone
is either intramembranous or endochondral. In the
latter a cartilage stage intervenes, otherwise the his-
tory in each case is the same. A synopsis of endo-
chondral development is as follows: (1) A solid shaft
of hyaline cartilage, non-vascular and without any
marrow cavity. (2) In the center of this shaft the
cartilage cells enlarge, their lacunae enlarge and
coalesce, particularly along lines extending toward the
ends of the bone. The rosette produced by this excava-
tion is called the primary areola of Sharpey. (3) Lime
salts are deposited in the thin walls of these spaces,
making calcined cartilage. (4) Osteogenetic cells and
blood vessels from the periosteum enter the cartilage
spaces. The cartilage cells disappear with this in-
vasion and the excavation, begun by the cartilage cells,
is further enlarged by the bone cells. The excavated
areas are now called the secondary areolae of Sharpey,
the cavities having a rich blood supply quite in contrast
with the primary areolae. The marrow cavity is exca-
vated and the shaft becomes longitudinally porous.
Endochondral bone, therefore, develops in cartilage, not
from cartilage. (5) Osteogenetic cells attach them-
selves to the wall of these enlarged Haversian canals
and become enclosed in lime deposits, forming thus
the outer lamellae and outer row of bone cells of each
Haversian system. Cells with lamellae are added cen-
tripetally to this outer row and thus ultimately com-
plete the Haversian system, leaving a small central
canal containing vessels and a nerve. Ossification be-
gins in the center of the cartilage shaft and proceeds
gradually toward each end, so that all the above changes
749
MEDICAL RECORD.
occur at one and the same time. After birth these
changes go on at the ends of the bone, so long as it
keeps growing. During this period the bone is made
thicker by deposits from the periosteum forming the
circumferential lamellae of bony shafts. These lamel-
lae are added without the intervention of a cartilage
stage and therefore represent intramembranous devel-
opment." — (Hill's Histology.)
7. A cross section of the spinal cord at the tenth
dorsal vertebra will show that the outline of the cord
is almost circular, with the transverse diameter a little
larger than the antero-posterior; the posterior median
cleft extends beyond the center of the cord; the gray
matter is in considerable quantity, both horns being
somewhat thick and approaching the type of the lumbar
cord; there is little or none of the formatio reticularis;
there is no posterior paramedian groove or septum;
and the central canal is nearer to the anterior than to
the posterior surface of the cord.
8. Arteries and veins resemble each other, generally,
in structure; they both have three coats, with the same
general arrangement, but in the veins the walls are
thinner in proportion to the size of the lumen of the
vessel. Further, in the veins the internal coat has less
elastic tissue and the endothelium cells are shorter; the
middle coat has less muscle and elastic tissue and more
fibrous tissue; many of the veins are provided with
valves.
9. Lymph glands are small, bean-shaped organs,
from a few millimeters to several centimeters in size.
Each is surrounded by a capsule, and composed of
cortex, medulla, and hilus. The capsule consists of
white fibrous tissue and contains some yellow elastic
and smooth muscle tissues; beneath is a lymph space
exhibiting a network of reticulum and called the sinus.
From the inner surface of the capsule, trabeculae are
sent into the cortex, and these divide the latter into
a number of masses called secondary nodules. The
lymph space continues along the trabeculae. The cortex
contains the secondary nodules and trabeculae. The
former consist of dense lymphoid tissue, and contain
a germinal center. The cells are chiefly lymphocytes,
which are arranged in concentric layers around the
periphery. Other cells of the hyaline variety are found
in the central portion. The nodules continue into the
center of the node as the medullary cords. The tra-
beculae separate the nodules from one another, and
pass into the medulla surrounded by the lymph space.
The medulla consists of the medullary cords and tra-
750
TEXAS.
beculse. The cords are the band-like continuations of
the secondary follicles, and are separated from the
trabecule by the lymph spaces that accompany the
latter. They consist of dense lymphoid tissue, support-
ed by reticulum. At the hilus, the medulla comes to
the surface. The hilus is a scar-like depression at
one side, where the vessels enter and leave. At this
place, the secondary nodules are wanting, and the
medulla comes to the surface." — (Radasch's Histology.)
BACTERIOLOGY.
1. "The Wassermann reaction for the diagnosis of
syphilis. — If the inactivated serum from a suspected
luetic is mixed with organ extract (luetic liver or
guinea pig heart macerated, extracted with alcohol and
inactivated) and complement (fresh guinea pig serum)
added, the complement is bound if the antigen finds an
homologous antibody in the serum, that is, if the
serum is genuinely syphilitic. To determine whether
this anchoring of the complement has taken place, the
mixture, after standing for a time, is brought in con-
tact with another mixture (of washed sheep's corpus-
cles and inactivated specific hemolytic serum obtained
by injecting a rabbit with sheep corpuscles), which
consists of red corpuscles and their specific amboceptor.
Should the complement in the first mixture not be
anchored, the "hemolytic system" will be complete and
hemolysis will occur. The reaction is a complicated
one, and it is necessary to control it carefully. A com-
mon source of error has been the use of too large a
quantity of organ extract, which has the effect of
bringing about an anchoring of the complement even
in the absence of the specific antibody in the serum.
Noguchi has devised a modification of the Wassermann
method which is simple and exceedingly delicate." —
(Jordan's Bacteriology.)
2. Alexins are defensive bodies which exist normally
in the blood serum.
Agglutinin is something in the blood serum of an
animal affected with a bacterial disease which is
capable of causing the clumping of the bacteria which
cause the disease.
Precipitin is a substance in the immune blood serum
which causes precipitation of an albuminous body which
has been injected into the body.
3. Diapedesis is the passage of the blood or the red
corpuscles through the unruptured walls of the blood
vessels.
Phagocytsis is the faculty of certain cells (notably
751
MEDICAL RECORD.
the mononuclear and polynuclear leucocytes) to take
up and destroy bacteria. Hence it is a protective
process, and has been claimed to be an essential process
in immunity.
4. Staphylococcus is stained with aqueous solutions
of the anilin dyes, and also by Gram's method.
Streptococcus is stained with aqueous solutions of
the anilin dyes, and also by Gram's method.
Negri bodies are stained by methyelene blue and
eosin, also by Giemsa's method.
5. The diphtheria bacillus grows readily upon all
the ordinary media, and is very easy to obtain in pure
culture, plates not being necessary. Material from
the infected throat can be taken with a swab or plat-
inum loop and spread upon the surface of several suc-
cessive tubes of Loeffler's blood serum media (which
consists of three parts of blood serum with one part
of ordinary bouillon to which has been added one per
cent, of glucose).
6. Toxins are poisonous products of bacteria or of
ptomaines or leucomaines.
Endotoxins are toxins which are not secreted into
the culture medium by the bacteria, but are rather at-
tached to the bodies of the bacteria.
Autotoxins are toxins which originate within the
body upon which they act.
7. The pneumococcus (of Friedlander) is an encap-
sulated bacillus of variable length, non-motile, non-
flagellated, aerobic and optionally anaerobic, non-lique-
fying, and pathogenic; it stains with the ordinary
anilin dyes, but does not retain the color when stained
by Gram's method. Its form is so variable that it
has been described by different writers as a coccus or
a bacterium.
The parasite of tertian malarial fever is about one
and a half times the diameter of a red corpuscle, and
is mulberry shaped; by the process of segmentation,
from 12 to 24 young parasites are formed; the male
gametocyte is smaller than the female gametocyte;
there are no crescents.
8. The Widal test for typhoid fever "depends upon
the fact that serum from the blood of one ill with
typhoid fever, mixed with a recent culture, will cause
the typhoid bacilli to lose their motility and gather
in groups, the whole called •'clumping.' Three drops of
blood are taken from the well-washed aseptic finger
tip or lobe of the ear, and each lies by itself on a
sterile slide, passed through a flame and cooled just
before use; this slide may be wrapped in cotton and
752
TEXAS.
transported for examination at the laboratory. Here
one drop is mixed with a large drop of sterile water
to redissolve it. A drop from the summit of this is
then mixed with six drops of fresh broth culture of
the bacillus (not over twenty-four hours old) on a
sterile slide. From this a small drop of mingled cul-
ture and blood is placed in the middle of a sterile cover-
glass, and this is inverted over a sterile hollow-ground
slide and examined. . . .A positive reaction is ob-
tained when all the bacilli present gather in one or
two masses or clumps, and cease their rapid movement
inside of twenty minutes." (From Thayer's Pathology.)
Von Pirquet's method of cutaneous diagnosis of
tuberculosis. — "Two small drops of old tuberculin are
placed on the skin of the front of the forearm, about
2 inches apart, and the skin is slightly scarified, first
at a point midway between them, and then through
each of the drops. A convenient scarifier is a piece of
heavy platinum wire, the end of which is hammered to
a chisel edge. This is held at right angles to the skin,
and rotated six to twelve times with just sufficient pres-
sure to remove the epidermis without drawing blood.
In about ten minutes the excess of tuberculin is gently
wiped away with cotton. No bandage is necessary. A
positive reaction is shown by the appearance in twenty-
four to forty-eight hours of a papule with red areola,
which contrasts markedly with the small red spot left
by the control scarification." — (Todd's Clinical Diag-
nosis.)
9. The Staphylococcus pyogenes aureus and the Strep-
tococcus pyogenes are the pus-producing organisms
which cause the greatest mortality. The Staphylococcus
pyogenes aureus may be found in boils, carbuncles,
abscesses, endocarditis, various skin lesions, diseases of
lungs, spleen, and kidneys, osteomyelitis. The Strepto-
coccus pyogenes may be found in erysipelas, endocar-
ditis, meningitis, periostitis, otitis, emphysema, pneu-
monia, lymphangitis, sepsis, puerperal endometritis,
scarlet fever.
10. Flagellated bacteria are bacteria which have
flagella or long filaments or hair-like structures, which
are undulating and may cause the motility of the bac-
teria to which they are attached. Flagellated patho-
genic organisms: Bacillus pyocyaneus y Bacillus tetani,
Spirillum cholerse Asiatics, Bacillus typhosus , Bacillus
colt communis, Bacillus enteritidis, Bacillus dysenterise,
Bacillus icteroides, Bacillus cedematis maligm, Bacillus
anthracis symptomatici.
753
MEDICAL RECORD.
OBSTETRICS.
1. Puerperal septicemia is septic intoxication with
the presence of living pyogenic bacteria in the blood
occurring during the puerperium. Symptoms: Chill;
rapid rise in temperature, to about 103° or 104°, higher
in the evening than in the morning; sweats; rapid
pulse; depression; dry tongue; anorexia; carphologia;
scanty, high-colored, albuminous urine ; restlessness ;
sometimes delirium or coma. The uterus is large, and
tender; the lochia are diminished or suppressed; the
milk secretion is often suppressed; pain in the abdo-
men; peritonitis may develop. Treatment: Prophy-
laxis is of the greatest importance. Purgatives; vagi-
nal douches; some recommend curettage, others decry
it; the introduction of antiseptics into the uterus; sup-
portive and general treatment are indicated; specific
sera and vaccines have been recommended by some.
2. The uterus is supplied by the uterine and ovarian
arteries; the veins correspond to the arteries.
3. Changes that take place in the circulatory appar-
atus at birth: The hypogastric arteries dwindle and
become impervious; the Eustachian valve atrophies; the
foramen ovale closes; the ductus arteriosus and ductus
venosus become obliterated; the umbilical vein becomes
obliterated and is afterward known as the round liga-
ment of the liver.
4. Pregnancy : The tumor is hard and does not fluc-
tuate, is situated in the median line, and may give fetal
heart sounds and movements; the cervix is soft, and
the other signs of pregnancy are present. The rate of
growth of the tumor and the general condition of the
patient's health may also help in arriving at a diag-
nosis.
Uterine fibroma: Menstruation is irregular and
sometimes very profuse; absence of the signs of preg-
nancy; the tumor is nodular, firm, irregular in outline,
and while generally placed somewhat centrally is not
in the median line, and is not symmetrical; the rate of
growth is irregular, being, as a rule, slow, and some-
times extending over years.
5. Indications for the use of forceps are: (1) Forces
at fault: Inertia uteri in the presence of conditions
likely to jeopardize the interests of mother or child,
(a) Impending exhaustion; (b) arrest of head, from
feeble pains. (2) Passages at fault: Moderate nar-
rowing, 3% to 3% inches, true conjugate; moderate ob-
struction in the soft parts. (3) Passenger at fault:
A. Dystocia due to (a) occipito-posterior, (6) mento-
anterior face, (c) breech arrested in cavity. B. Evi-
754
TEXAS.
dence of fetal exhaustion (pulse above 160 or below
100 per minute). (4) Accidental complications:
Hemorrhage; prolapsed funis; eclampsia. All acute or
chronic diseases or complications in which immediate
delivery is required in the interest of mother or child, or
both (Jewett). Conditions necessary for the use of
forceps are: (1) The rectum and bladder must be
empty; (2) the os uteri must be fully dilated; (3) the
membranes must be ruptured; (4) the pelvis must be
of sufficient size.
Cesarean section (conservative). <( Indications: The
cases in which it is performed are: (1) Extreme de-
formity of the pelvis, in which delivery by forceps and
version is excluded, and in which craniotomy is either
impossible or would be more dangerous to the mother
than cutting into the abdomen and uterus; and in
which there is not room for a successful symphyse-
otomy. Such cases present the 'positive' indication for
cesarean section; there is nothing else to be done. Flat
pelves having a conjugata vera of 2% inches or less,
and justo-minor pelves with a conjugata vera of 2%
inches or less, present this positive indication; (2) cases
of more moderate pelvic contraction in which crani-
otomy is possible, but cesarean section is agreed upon
to save the life of the child; (3) mechanical obstruction
in the pelvis from fibroid, cancerous, bony, or other
tumors which cannot be pushed up out of the way or be
safely removed; (4) irreducible impaction of a living
child in transverse presentations; (5) in women dying
near the end of pregnancy the child, if alive, is rapidly
delivered by post-mortem cesarean section; (6) various
other obstructions from inflammatory adhesions,
atresia, constrictions, etc., of the vagina, and uterine
displacements, may rarely require the operation; (7)
recently the operation has been done in eclampsia cases,
where more conservative methods of rapid delivery were
impracticable; and (8) in placenta praevia, chiefly with
a view to lessen the infant mortality attending the
usual treatment of this complication." — King's
Obstet?*ics.)
6. By the hygiene of pregnancy is meant the care
which should be observed by the pregnant woman for
the preservation of health and strength both of herself
and of the fetus. The pregnant woman should take
moderate exercise in the open air; in the last month
massage may take the place of exercise. Daily bathing
in tepid water, care of the teeth, regularity of the bow-
els, ample sleep in a well- ventilated room, plenty (but
not too much) of simple, nourishing and easily digested
755
MEDICAL RECORD.
food, at regular hours, clothing not too tight, espe-
cially about the abdomen and breasts; attention to the
nipples, regular examination of the urine, and the re-
striction of marital relations are the main points to
which advice should be directed.
7. Three diseases to which pregnancy may predis-
pose: Pernicious vomiting, eclampsia, varicose veins.
Symptoms of eclampsia: Headache, nausea, and vomit-
ing, epigastric pain, vertigo, ringing in the ears, flashes
of light or darkness, double vision, blindness, deafness,
mental disturbance, defective memory, somnolence ;
symptoms easily explained by the circulation of toxic
blood through the nerve centers. These may be pre-
ceded by lassitude, and accompanied by constipation, or
by diarrhea. Headache is perhaps the most significant
and common warning symptom. In bad cases the urine
is reduced in quantity (almost suppressed), very dark
in color, its albumin greatly increased, so that it be-
comes solid on boiling. Next comes the final catastro-
phe of convulsions. The convulsive fit begins with
twitching of the facial muscles, rolling and fixation of
the eyeballs, puckering of the lips, fixation of the jaws,
protrusion of the tongue, etc., soon followed by violent
spasms of the muscles of the trunk and limbs, including
those of respiration ; hence lividity of the face and ster-
torous breathing, biting of the tongue, opisthotonus,
etc. The fit lasts fifteen or twenty seconds, ending in
partial or complete coma, possibly death; or conscious-
ness may return, to be followed by other convulsions. —
(King.)
8. Conditions that justify the induction of premature
labor: (1) Certain pelvic deformities; (2) placenta
prsevia; (3) pernicious anemia; (4) toxemia of preg-
nancy; (5) habitual death of a fetus toward the end
of pregnancy; (6) hydatiform mole; (7) habitually
large fetal head.
Method of performing premature labor: "Catheteri-
zation of the uterus: The first step consists in separa-
tion of the membranes from the lower uterine segment
by means of a uterine sound or with the finger. The
operation must be aseptic. Detachment of the mem-
branes with the sound may be done with the woman in
either the left lateral or dorsal recumbent position. For
the use of the hand the dorsal position is best. The
second step consists in the insertion of one or more
No. 12 English bougies, or a sterile rectal tube, between
the membranes and the uterus. No anesthetic is re-
quired. Usually the bougie or rectal tube is most read-
ily passed with the aid of the Sims position, the Sims
756
TEXAS.
speculum exposing the cervix, which is drawn forward
and held with a volsella. The bougie is sterilized by
boiling or steaming, the proximal end is cut off, and a
stylet inserted. To facilitate introduction the bougie is
bent to nearly a right angle at about three inches from
the distal end, giving it a large curve. Great care must
be used to avoid rupturing the membranes. The in-
strument is then pushed up gently and in the direction
in which it passes most easily. After it has entered
between the membranes and the uterine wall, the stylet
is drawn down about one inch. The flexible tip of the
bougie finds its way readily with little risk of per-
forating the membranes. The bougie fully in place,
the stylet is withdrawn. A second bougie may be in-
serted if it can be pushed into place without too much
difficulty. Bleeding is probable evidence that the in-
strument has passed behind the placenta. The hemor-
rhage may occasionally be excessive. It is then best
to withdraw the instrument and pass it in another
direction. A light tampon of gauze may be packed in
the vagina, but it is not required to support the bougie.
The instrument is left to be expelled with the child.
Labor usually is established within twenty-four hours.
This method is not suited to cases in which immediate
delivery is called for." — (Polak's Obstetrics.)
9. Ophthalmia neonatorum. Prophylaxis: When-
ever there is the possibility of infection, or in every
case, wash the eyelids of the newborn child with clean
warm water, and drop on the cornea of each eye one
drop of a 1 per cent, solution of nitrate of silver, im-
mediately after birth. Treatment: Wash the eyes
carefully every half hour with a saturated solution of
boric acid; pus must not be allowed to accumulate.
Two drops of a 2 per cent, solution of nitrate of silver
must also be dropped on to the cornea every night and
morning. The eyes must be covered with a light, cold,
wet compress. The patient must be isolated, and all
cloths and compresses used must be burnt.
10. Abortion is expulsion or delivery of the fetus be-
fore it is viable, that is up to about the twenty-eighth
week. Premature labor is expulsion or delivery of the
fetus between the twenty-eighth week and term.
GYNECOLOGY.
1. A complete gynecological examination would in-
clude (1) anamnesis, including family history; personal
history, with special reference to menstruation, labors,
and miscarriages, and present illness. (2) Examina-
tion of the abdomen (and breasts), including inspec-
757
MEDICAL RECORD.
tion, palpation, percussion, auscultation, and mensura-
tion. (3) Inspection of the external genitals. (4)
Vaginal examination, digital, bimanual, and with spec-
ulum. (5) Bimanual examination of uterus and ap-
pendages. (6) Sometimes the sound, or curette, may
be required. (7) Chemical and microscopical examin-
ation of the urine. (8) Microscopical examination of
discharges or uterine scrapings. (9) Rectal examina-
tion. (10) Cystoscopic examination and perhaps ure-
teral catheterization. (11) In case of phantom tumor
or pseudocyesis, anesthetization would be required.
2. PfannenstieVs incision avoids a median incision,
the transverse scar is partly hidden by the pubic hair,
hernia is said to be less liable to follow. The disad-
vantage is that it is only available for limited opera-
tions on the tubes, ovaries, uterus, bladder, and pelvic
cavity.
Metrorrhagia: Causes: Salpingitis, ovaritis, ovarian
tumors, endometritis, endocervicitis, metritis; fibroids,
sarcoma, carcinoma or polyps of uterus; prolapsed,
retroflexed, or retroverted uterus; subinvolution; and
general diseases (such as scorbutus, purpura, hemo-
philia, acute fevers, nephritis, hepatic cirrhosis).
3. Perineorrhapy : "The labia are seized with Allis'
forceps at the level of the lowest carunculae myrti-
formes. A guide stitch is placed in the posterior vagi-
nal wall directly under the external urinary meatus.
By pulling one Allis forceps and the guide stitch in
opposite directions outward and downward, the pos-
terior sulcus is exposed; denudation is required, even
in a recent tear, for a part of it is always submucous.
The other sulcus is exposed and denuded. Then by
holding the guide stitch upward in the middle line and
pulling the forceps apart the mucous membrane be-
tween the sulci is denuded or freshly torn surfaces
covered with granulation-tissue are scraped with the
edge of a knife. The ruptured levator ani muscle in
the posterior sulci is united with a double tier suture
of chromic gut, two half hitches being taken in the
stitch as it turns upward after coming down from the
apex of the wound, in its deeper portion to the base.
One knot at the apex of the sulcal denudation secures
the stitch. The retracted ends of the transversus perinei
and bulbocavernosus muscles are brought together
by silk-worm sutures. Finally, a single stitch at the
top of the perineal wound unites the posterior com-
missure of the vulva, restoring the fossa navicularis.
The perineal stitches are knotted; they are removed on
the twelfth day. "—(Hirst's Obstetrics,)
758
TEXAS.
4. Vaginal examination of a virgin should not be un-
dertaken unless absolutely necessary, an anesthetic
should be employed if possible, and only one finger
should be used.
5. Ectopic gestation, and ovarian cyst, with twisted
pedicle.
6. Ventrofixation and ventrosuspension : Hermann
(Students' Handbook of Gynecology) states objections
to this operation as follows : "(1) Its risk. Oversights
will occur in the practice even of the most careful; but
the risk is very small. (2) Adhesions within the peri-
toneum are sometimes absorbed. They are absorbed
often enough to make stitching of peritoneum to peri-
toneum unsatisfactory. After abdominal section ven-
tral hernia may first develop after the scar has held
firm for twelve years; and possibly the new attach-
ment of the uterus may also, after many years, give
way. (3) The operation lifts up the uterus. If the
vulval orifice is very large there may still be a pro-
trusion of the vaginal mucous membrane. It is well,
therefore, to precede ventral fixation in women past
child bearing by posterior colporrhapy. (4) It is said
to cause difficulty in labor, should the patient become
pregnant. It does not always do so; and in many cases
reported as illustrating such difficulty, the ventral fixa-
tion was not the cause of the difficulty. Ventral fixa-
tion after colporrhaphy, if the result be permanent,
relieves the patient of any necessity for the continual
readjustment of a pessary, and lifts the uterus up ef-
fectually. Ventral fixation is not advised in cases in
which the womb can be comfortably kept up by a
pessary."
7. "The indications for oophorectomy are chiefly in-
fections of the ovaries; inflammations and their conse-
quences; certain rare and otherwise incurable cases of
dysmenorrhea; certain otherwise incurable cases of
ovarian pain, independent of the periods, and making
the patient an incurable invalid; clear cases of men-
strual epilepsy; menstrual insanity, when the attacks
occur only during the menstrual week, the patient be-
ing free from them during the interval; osteomalacia;
and bleeding uterine fibromata, of small size, where
the patient declines hysterectomy and other means
fail." — (Reed's Gynecology.)
8. The perineum should be repaired; and colpor-
rhapy (anterior and posterior) be done for the cystocele
and rectocele; ventrosuspension or ventrofixation may
be done for the procidentia, though this last procedure
is not as imperative in the case of a woman of 50
759
MEDICAL RECORD.
years of age as it would be in a much younger woman.
9. Contraindications to uterine curettage: The least
suspicion of even the possibility of pregnancy; menstru-
ation; acute endometritis; malignant disease of the
uterus or vagina; acute pelvic inflammation.
10. If there is nothing the matter with the appendix,
there can be no necessity for its removal; but some
surgeons believe that in case of any abdominal opera-
tion it is well to remove the appendix in order that it
may not cause trouble later on. It may be well, before
an abdominal operation, to consult the wishes of the
patient as to the removal of a healthy organ.
PATHOLOGY.
1. A tumor is a pathological new growth which tends
to persist independently of the structures in which it
lies, and which performs no physiological function.
Tumors may be classified as follows:
1. Those derived from the mesoblast:
(a) Benign: Lipoma (from fat tissue), fibroma
(from fibrous tissue), chondroma (from
cartilage), osteoma (from bone), myoma
(from muscle), neuroma (from nerve tis-
sue), glioma (from neuroglia), angioma
(from vessels).
(6) Malignant: Sarcoma (from connective tis-
sues) .
11. Those derived from the epiblast or hypoblast:
(a) Benign: Adenoma (from gland tissue),
papilloma (from papillae of skin or mucous
membrane) .
(b) Malignant: Carcinoma (from epithelial tis-
sues).
2. Malignant tumors are not encapsulated, tend to in-
filtrate the surrounding tissues, give rise to metastatic
growths, have a tendency to recur after removal, give
a cachexia, have a fatal tendency.
Metastases are carried by the lymphatics and by the
blood vessels.
3. The phenomena of inflammation are dilatation of
the arterioles, capillaries, and small veins. At first
the blood current is quickened, then retardation occurs,
and may progress to stasis and thrombosis. During
this time exudation of plasma and white corpuscles
from the small veins, and perhaps the capillaries, is
going on. The fate of the white cell may be either to
break up and set free prothrombin, or to act as food
for connective tissue cells, or to act as a phagocyte and
be transformed into a pus corpuscle. Red corpuscles
760
TEXAS.
may be exuded and broken up, setting free their color-
ing matter. The prothrombin of the white cells unites
with the calcium chloride of the plasma and forms
thrombin, or fibrin ferment, which acts upon the fibrin-
ogen of plasma to form fibrin.
The tissues are thus invaded with numbers of leuco-
cytes. In bacterial inflammation a varying portion of
the tissues is killed by the toxins produced, and is
either replaced by a mass of small round cells, or lique-
fied into pus. In the latter case it is surrounded by a
ring of small round cells. The connective tissue cells
absorb the leucocytes, and new vessels are formed, thus
constitutirg repair. In nonbacterial inflammation, ex-
udation may Q parate layers of cells to a large extent
and form blebs. In chronic inflammation the forma-
tion of new fibrous tissue is the chief part of the
process. — (From Aids to Surgery.)
4. Pathological processes leading to destruction of
valve in mitral insufficiency: "In those cases not di-
rectly attributable to acute endocarditis, the changes
briefly are: (1) Formation of small nodular promi-
nences, with thickening of the valve. (2) Formation
of yellowish, opaque, fatty patches. (3) Great in-
crease of fibrous tissue, which subsequently contracts,
producing much deformity. The cusps become rigid,
curled, and may cause great obstruction to the onward
flow of blood, and at the same time fail accurately
to close together when required. (4) Great narrow-
ing of the valvular orifice. (5) Shortening of the
chordse tendineae and papillary muscles. Frequently
fusion of the chordae tendineas (adhesions). (6) Cal-
cification of the fibrosed portion." — (Wheeler & Jack's
Handbook of Medicine.)
5. In pernicious anemia the blood would show: (1) A
diminution in the number of red corpuscles; (2) a
relative increase in the amount of hemoglobin; (3)
poikilocytosis ; (4) the presence of nucleated red cells;
(5) variation in the size of the red cells ; (6) the leuco-
cytes may be diminished.
6. The systemic pathological changes usually asso-
ciated with contracted kidney are: "The left side of
the heart is hypertrophied, and there is also hyper-
trophy of the muscular fiber of the arterioles through-
out the body; if the case is protracted, the hyper-
trophied tissues undergo fatty degeneration. Cardiac
degeneration with arteriocapillary sclerosis or fibrosis
is associated with advanced nephritis. The changes in
the arterial walls lead to apoplexy, albuminuric re-
tinitis, and fatty degeneration and atrophy of the
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MEDICAL RECORD.
ganglionic centers." — (Hughes' Practice of Medicine.)
7. In the first stage of typhoid fever Peyer's patches
become swollen, hyperemic, and reddened; a few days
later they appear as whitish or gray elevations, and
the hyperemia has disappeared; the surface of the
patch is smooth and its edge is sharply defined; after
the first week necrosis may occur; the center of the
patch becomes softer, more yellow, or sometimes even
red from the absorption of blood pigment. The necrotic
portion falls off, leaving an irregular ulcer, with ne-
crotic and undermined edges. These ulcers are elon-
gated, with the long axis parallel with that of the in-
testine, and a smooth floor. The ulcers may heal or go
on to perforation.
8. Gumma of the liver: "The gummata range in
size from a pea to an orange. When small they are
pale and gray; the larger ones present yellowish cen-
ters; but later there is a 'pale, yellowish, cheese-like
nodule of irregular outline, surrounded by a fibrous
zone, the outer edge of which loses itself in the lobular
tissue, the lobules dwindling gradually in its grasp.
This fibrous zone is never very broad, the cheesy cen-
ter varies in consistence from a gristle-like toughness
to a pulpy softness; it is sometimes mortar-like, from
cretaceous change' (Wilks). They may be felt as
large as an orange beneath the skin in the epigastrium
and they may disappear with the same extraordinary
rapidity as the subcutaneous or periosteal gumma.
Microscopically they may indeed at first look like mas-
sive cancer. Extensive caseation, softening, and calci-
fication may occur. The syphilitic scars are usually
linear or star shaped. They may be very numerous
and divide the liver into small sections. The syphilitic
cirrhosis is usually combined with gummata, or with
marked scarring in the portal canal, leading to lobula-
tion of the organ, but the ordinary multilobular cir-
rhosis is not common." — (Osiers Practice of Medicine.)
9. Acute lobar pneumonia. "It is convenient to de-
scribe four stages, those, namely, of (1) hyperemia or
engorgement, (2) red hepatization, (3) gray hepatiza-
tion, and (4) resolution. First stage or splenization. —
The lung is injected, dark red, and heavy, and pits
under the finger; on pressure, there exudes a frothy
serum tinged with blood and slightly aerated. The
lung still floats in water. Second stage or red hepatiza-
tion. — The part involved is solid and friable, presents
a granular or red granite appearance, and sinks in
water. The alveoli are filled with a coagulated exuda-
tion, which shows under the microscope fibrin, leuco-
762
TEXAS.
cytes, red corpuscles, proliferated alveolar epithelium,
and pneumococci. Third stage or gray hepatization, —
The lobe has now the appearance of gray granite, the
lung substance is softer and more friable; on pressure,
a dirty purulent fluid exudes. The gray appearance is
due to four factors: (1) Decolorization of the red blood
corpuscles; (2) obliteration of the alveolar blood ves-
sels from pressure; (3) fatty degeneration of the
coagulated material; (4) great infiltration of leuco-
cytes. A more advanced stage, in which the lung tissue
is bathed in purulent fluid, is known as purulent in-
filtration. It is probably inconsistent with life. Fourth
stage or resolution. — Resolution of the inflammatory
exudation is brought about principally by absorption
(autolysis), but partly by liquefaction and expectora-
tion. Pneumonia may affect a lobe, or the whole of a
lung, or it may attack both lungs. Double pneumonia
occurs in about 10 per cent, of cases. Different parts
of the same lung may at the same time show different
stages. There is always some degree of pleural in-
flammation over the affected area. Modern enlarge-
ment of the spleen is very common." — (Wheeler and
Jack's Practice of Medicine.)
10. "In amebic dysentery the lesions are situated in
the colon, but may be found in the ileum. Ulceration,
involving the mucosa and submucosa, is the character-
istic structural change. This process is preceded by
the infiltration of the mucous and submucous coats with
a grayish, gelatinous substance, the exfoliation of
which produces the ulcer. In the early stages these
local infiltrations appear as hemispherical elevations,
the mucous membrane covering which is soon cast off
to be followed by sloughing of the submucous coat and
its infiltrate. The microorganisms are present in the
necrotic tissue and by their migration not infrequently
(20 per cent.) produce abscess of the liver. " — (Hughes'
Practice of Medicine.)
PHYSICAL DIAGNOSIS.
1. Methods of physical diagnosis are: Inspection,
palpation, percussion, auscultation, mensuration, and
weighing. Inspection shows the shape, size, symmetry,
movements, and color of the chest. Palpation confirms
and adds to what is learned by inspection, shows areas
of tenderness, condition of chest walls, presence of
tumors, action of heart, and the existence and character
of fremitus. Percussion shows the composition of
structures or tissues, the resistance or elasticity of
certain organs, and resonance of lungs. Auscultation
763
MEDICAL RECORD.
enables one to study the condition of the heart and
lungs.
2. Pott's disease of the spine may be diagnosed by:
The local pain or ache at the site of the disease; it is
made worse by jarring, or pressure on the head; gir-
dle-pain or stomach-ache may be present; muscular
rigidity; angular displacement at the site of the dis-
ease; abscess; and, sometimes, paraplegia.
3. The use of the sphygmomanometer is to estimate
the blood pressure of a patient. Blood pressure is the
pressure exerted by the blood against the wall of the
vessel in which it is contained.
4. Hypertension may be observed in : Chronic inter-
stitial nephritis, arteriosclerosis, uremia, gout, lead
poisoning, cerebral hemorrhage.
Hypotension may be observed in: Shock, collapse,
concealed hemorrhage, anemia, acute infectious dis-
eases.
5. (1) Frequent pulse: In fevers, exophthalmic
goiter, early phthisis, heart disease, anemia, chlorosis,
locomotor ataxia, abuse of alcohol, tea, coffee. (2)
Slow pulse : In cardiac disease, cerebral tumor or hem-
orrhage, meningitis, myxedema, epilepsy, some poisons,
digestive disorders. (3) Intermittent pulse: In car-
diac disease, fevers, poisons, neurasthenia, cerebral
troubles, digestive disturbances. (4) High tension
pulse: In arteriosclerosis, gout, diabetes, contracted
kidney. (5) Low tension pulse: In fevers, anemia.
6. Organic murmurs are due to stenosis or incom-
petency of one or more of the valves of the heart.
Functional murmurs are not due to valvular disease.
Organic murmurs may be systolic or diastolic; may
be accompanied by marked dilatation or hypertrophy,
and there will probably be a history of rheumatism or
of some other disease capable of producing endocar-
ditis. Whereas a murmur, usually systolic, soft, and
blowing, heard best over the pulmonic area, associated
with evidences of chlorosis or anemia, and affected by
the position of the patient, is a hemic or functional
murmur, and denotes as a rule an impoverished condi-
tion of the blood.
7. Normal percussion notes: "The apices yield nor-
mally a resonant note, clear but not intense and tend-
ing to rise in pitch (dullness) as the pleximeter finger
approaches the vertebral line posteriorly, or the
trachea, anteriorly* The infraclavicular space is
typically resonant, and the pitch of the percussion note
is slightly higher upon the right than upon the left
side. Any tendency to approach the region of a
764
TEXAS.
primary bronchus results in a note of heightened pitch,
increased resistance, and shortened duration (dull-
ness). Below the right second rib anteriorly there is
increased resonance until the fifth rib is reached, when
the pitch rises because of the underlying solid tissue
of the liver. At the sixth rib resonance ceases and a
line of absolute dullness marks the lower limit of the
lung and the upper border of the uncovered surface
of the liver. In the axillary region typical pulmonary
resonance persists until the eighth rib is reached. The
cardiac area markedly modifies the percussion note of
the left chest anteriorly from the lower border of the
third rib downward within the nipple line; anteriorly
along the whole internal boundary of the lung the
note rises jas one approaches the sternum." — (Greene's
Medical Diagnosis.)
8. The microscope may be employed as an aid to
diagnosis in : Typhoid fever, malaria, cholera, tubercu-
losis, amebic dysentery, diphtheria, anemia, chlorosis,
leukemia, various forms of intestinal parasites, gonor-
rhea, influenza, tetanus, asthma, pneumonia, trichino-
sis, anthrax, actinomycosis, Bright's disease, syphilis.
9. Symptoms of sciatica: "Onset usually sudden,
with pain in the back of the thigh, running down the
course of the nerve. It may extend up into the lumbar
region, but is most marked in the thigh. Motion in-
creases it, and consequently the pelvis tilts up toward
the sound side and the trunk leans over toward the
affected side (sciatic scoliosis). The pain is dull and
almost continuous, with paroxysms in which it is
sharp, lancinating, burning, and of great severity.
There may be sensations of tingling, numbness, and a
sense of weight and coldness in the affected limb. There
are tender points at the sciatic notch, the middle of the
hip, behind the knee, in the middle of the calf, behind
the external malleolus, and on the back of the foot.
Rarely there is anesthesia along the course of the
nerve. There may be weakness and muscular atrophy
in chronic cases, and occasionally a partial De R. The
duration of the disease is usually 2 or 3 months, al-
though it may last for a year or more." — (Butler's
Diagnostics of Internal Medicine.)
10. In pellagra "the symptoms develop insidiously,
the earliest manifestations usually being gastroin-
testinal — anorexia, stomatitis, salivation, epigastric
pain or distress, diarrhea, and a gradually increasing
anemia, disinclination to exertion, and psychic depres-
sion. The fully developed disease is characterized by
cutaneous, digestive, and nervous symptoms. There is
765
MEDICAL RECORD.
at first a characteristic pellagrous erythema that
usually comes on first in the spring, tends to subside
and recur (in the fall and spring). It develops bilat-
erally especially on the exposed surfaces, the hands,
arms, face, and neck; that is, it seems to be related to
the action of the actinic rays of the sun ; it may be dry
(usually early) or wet; the lesions become pigmented
(liver yellow or chocolate color) and usually progress
to desquamation, exfoliation, and gangrene of the skin,
which are followed by cicatrization. The character-
istic digestive symptoms consist of stomatitis, the car-
dinal red tongue, the bald tongue, or the stippled, bluish
black tongue; salivation, pyrosis, and diarrhea (fetid,
slimy, greenish stools), sometimes bloody stools, may
occur. The nervous symptoms consist of neuromuscu-
lar pains in the back and legs, spinal tenderness, head-
ache, vertigo, unilateral or bilateral mydriasis, muscu-
lar spasms, exaggerated reflexes, later paralysis with
lessened or absent reflexes, mental depression, delu-
sions, hallucinations, melancholia, and insanity. Mild
cases may be afebrile, but fever (102° to 105° or more)
is not uncommon. Improvement may occur after the
lapse of several months, but recurrences especially in
the fall and spring are common." — (Kelly's Practice of
Medicine.)
SURGERY.
1. "A carbuncle is a localized inflammation of the sub-
cutaneous tissue, which goes on to sloughing, and is of
a more extensive character than a boil. Staphylococci
are the common exciting cause, while the predisposing
causes are lowered vitality from diabetes, albuminuria,
or after infective fevers. Inoculation is by autoinfec-
tion or directly from the surface. Signs: The disease
begins as an infiltration of a patch of subcutaneous
tissue, which is hard, painful, and tender, and the skin
over it is red and hot. The infiltration may extend till
it is the size of a dinner-plate, and the inflammation
ends in sloughing and suppuration, not only of the
subcutaneous tissues, but of small areas of the skin
over it, so that openings develop in the skin, and allow
of the exit of pus and sloughs. The openings extend,
the sloughs separate, and the wound heals by granula-
tion. The back is a common situation. Sometimes the
face is affected, and there is then a danger of throm-
bosis extending to the cavernous sinus and producing
pyemia." — (Aids to Surgery.)
An abscess is a localized collection of pus in a cavity
of new formation. It is, therefore, walled off; if near
the surface it fluctuates; it may occur at any period
766
TEXAS.
of life, whereas the carbuncle commonly occurs after
forty years of age; the abscess may be caused by
staphylococci, streptococci, or any other pus-producing
organism; abscess does not cause the severe constitu-
tional symptoms which may be observed in carbuncle.
2. Preparation of patient for abdominal section. —
"If possible, the patient should be under observation
for at least 24 hours prior to the operation. During
this time a careful study is made of the urine and the
condition of the heart and lungs, and necessary treat-
ment instituted. The diet should be restricted, and a
purgative given the night before, followed by an enema
on the morning of the operation. No breakfast, or
merely a cup of beef -tea, should be given on the day of
the op. ration. The abdomen should be shaved and
scrubbed thoroughly with tincture of green soap and
sterile water for at least 10 minutes on the night before
the operation. A general bath should then be taken,
giving special attention to the inside surfaces of the
thighs and to the umbilicus. A soap poultice is ap-
plied to the abdomen and allowed to remain for several
hours; this is removed, and the abdomen is scrubbed
with alcohol and washed with mercuric chloride solu-
tion (1:1000). A towel wet with this solution is placed
over the abdomen, and a binder is applied.
"If any operation is to be done that will involve open-
ing the vagina — such as total extirpation of uterus —
the patient, after being anesthetized, should be placed
upon the perineal pad, and the vagina should be thor-
oughly scrubbed with a piece of gauze held in a dress-
ing forceps, previously dipped in green soap. After
the scrubbing the soap should be washed out and the
vagina syringed with a 1:2000 sublimate solution. If
there is any septic material coming from the uterus,
as in cancer of the body, the uterus should be first
thoroughly curetted and packed with iodoform gauze.
A cancerous cervix should also be curetted, disinfected,
and the vagina lightly packed with iodoform gauze.
"All water, basins, trays, aprons, gowns, sheets,
sponges, pads, drains, dressings, and everything with
which the abdominal wall or the surgeon comes in con-
tact should be carefully sterilized."
After-treatment: "The patient is placed in bed, and
care is taken to prevent shock by the application of ar-
tificial heat. Nothing but water should be given by
the mouth for 24 hours. Pain is relieved by morphine,
gr. *4, hypodermically. Liquid diet is preferred for the
first week, at the end of which the stitches are re-
moved. The bowels are opened upon the third day by
767
MEDICAL RECORD.
fractional doses of calomel, followed in 12 hours by a
saline laxative and an enema. The patient should re-
main in bed for from 2 to 3 weeks. — (Pocket Cyclo-
pedia.)
3. Osteomyelitis is inflammation of the bone and mar-
row; the term is often used now for inflammation of
bone. The treatment consists in relieving the consti-
tutional symptoms and preventing the bone from ne-
crosing. An incision down to the bone is made; if pus
is beneath the periosteum, the latter is also incised; a
piece of bone is removed by chisel or trephine, pus is
removed, the endosteum is hurt as little as possible, the
wound is irrigated with hot bichloride solution and
packed with gauze; the soft parts are closed and the
wound well drained. In case this fails, amputation may
be necessary.
Symptoms: Sudden onset; pain, tenderness, fever,
chills, swelling of soft parts; sometimes the joint can
be moved gently without pain; septicemia or pyemia
may be present.
It is to be diagnosed from Rheumatism, in which
more than one joint is affected and the tenderness is
in the joint, and not near it.
4. Treatment of simple fracture at junction of upper
with middle third of femur; First of all, prevent the
fracture from becoming compound; then reduce it;
coapt the edges of the broken bone; immobilize the
parts, and attend to the general condition of the
patient. Splints and weight extensions may be re-
quired.
5. In ulcer of the duodenum the symptoms are very
similar to those found in ulcer of the stomach; but in
the former condition there is less tendency to vomit,
the pain does not come on till some time after food
has been swallowed (and has had time to pass the
pylorus), and blood in the stools is more common. All
of these points are due to physiological and anatomical
reasons based on the relative position of the stomach
and duodenum. A special sign of duodenal ulceration
is the so-called "hunger pain" which occurs at the end
of digestion, when the unmixed acid of the gastric juice
is passing into the duodenum. This pain is relieved by
taking food, for when this occurs the pylorus closes,
and the gastric juice is for the time retained in the
stomach to be mixed with the food, while the alkaline
duodenal and pancreatic secretions are stimulated.
6. The surgical complications which may arise in
typhoid fever, are: Perforation of the intestine, in-
ternal hemorrhage, peritonitis, and cholecystitis.
768
TEXAS.
y: _ Frequent micturition, with pns , „, d someti2es
en larger
-uvMmuwi, wicn pus, and sometimes
1 t^-temcss oTer the kMnejs,
bercle "bacilli 7::avTe"' lou-lV tlf .^ /T^LI^
'<■/■;:; sh;w a rc::':j-, ; ..,._.-,:;.;■ ^;:;;:v, ;;; e ~%?\*y
: ec te i s •' d e • t "~ e > — — -"-• ~ .T „ T \. *! \Z\ T r '"' " *° ° :* v :: e a ' *
'_'";;.;;?..;--•- * ~- c ?-" worse oy move
L y-TC :v re s:„
s~-.- v :■•-. ' ^,. . _
loir.?; '~^\ e -V" "'V-'^V:;' ^;;v i: 0I ? ai: ; A- : - be
cy e.\ercise, especially or:
jeltin
or :.e:
often
kidne
larce
The :
:•: ex
loin (
panic
effort
1HMMH
1 He
re: vis
S. "I
• to the thigh, groin
with hematuria^ and
.c: micturition. The
:er on pressure. .A
symptom whatever,
The
three or'fonr days before
should be cre~e-i "d*'"v~ «~d
r* e -V ** ^ -*- c opcr-t.o:
M :u::c empty. Any brortc'
sh :■'.:' " ~ -a o - - *~ * ~ ■>' - 1 .„ : „
call urgently rVr^relie-'" ^ : e
cases c: cystitis, the bladder
W a s h e i c u : once e v e ~ v ; ■-- \ ■ '
nitrate 1:5'.* >„" . f o 1 1 o w ed b v
::" the -->••—■ -h w t- "V
: si
.cord
n g c, (.
)WT:
.H.-4C.A
the
e i
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"• k i s
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om-
CO .
aps.
?.. F
recr.
lent
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on
lv a
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nty
"oai
.sed..
" Tc
a c s i
e t
1 3 j r
t "•' r
^s b
"''-
n to
the
be
kept at rest
for
r a *
ion,
the
bowels
*P %
en early
on
t n e
rec t u
n a v
je a e-
d. Ir.
dru ;
alia!
the bladder less s*otiV»_fJ*
at-
^ + >,^ -.- - ^ sr-s-er:, .a vase i>
m necessary nor wise. For cystitis, certain
^of lessening the
. K:r: > the interior or
«ne Bladder .ess sen"; — i J'-,\^^ ( ^,^ ,7,. .,„.,-.;,. j
ment in the absence of serious homnrrliso*
todproent of a foreign bodv is disinfection^ ^ri "™+ZZ
:: th, - '. . ^ ■• " - - ■ ;.■
side ;: the :h-;st. He:n ?rrh:t ce' tro^:' '-e : — I--^ : "--V^
•■•-'-ry ;:■ ntt-:-;;st:.'. ;.::--•; - ■- v *'-*e :'^- ""■'"' ^V'V,h " ; .\^".
i--::-' -.'■:•; ^---•-'■.-: * cn-:e"sa: Vet^-*^th7 ribs' a"d
ihng tne inner enn ;t the sa: vrith gat:.- s: that v,h-
drawn upon it will make pressure from within out-
MEDICAL RECORD.
ward. Excepting extensive wounds, bleeding from the
lung is rarely fatal, as the bleeding is checked by
collapse of the lung. In the absence of external hem-
orrhage serious loss of blood is diagnosticated by the
constitutional signs of acute anemia and a rapidly ac-
cumulating hemothorax. Cases of this sort have been
treated by the introduction of a drainage tube in order
to admit air and favor collapse of the lung, but in the
presence of serious symptoms one or more ribs should
be resected, and the wounded lung dealt with directly
by sutures or gauze packing. Hemothorax of lesser de-
gree, or that form due to hemorrhagic pleurisy or
tumors of the lung or pleura, does not require special
surgical treatment unless it causes pressure symptoms
or becomes infected; in the former case aspiration, and
in the latter resection of a rib and drainage would be
indicated. Foreign bodies should be removed if easily
accessible, and the same rules as to the examination
of the vulnerating instrument, the clothing, etc., apply
here as elsewhere. If the foreign body is not easily
found, it should be allowed to remain, unless it gives
rise to subsequent trouble, when it may be definitely
localized by the #-ray and its removal effected, if such
be deemed advisable. With the exception of pneumo-
cele, the complications of injuries to the chest are in-
flammatory in nature, viz., cellulitis, pleurisy, empyema,
pneumonia, abscess or gangrene of the lung, mediastinal
abscess, and peri-, myo-, or endocarditis." — (Stewart's
Manual of Surgery,)
10. "The treatment during the stage of collapse is the
application of external heat and the administration
of stimulants as in shock. Alcohol, however, should
not be given, because of its exciting effect on the brain,
and care should be taken not to overstimulate. When
reaction has been obtained, the patient should be kept
in bed in a quiet room, an ice bag placed on the head,
the bowels opened with a purge, and the catheter used
if there is retention of urine. The diet should be fluid,
and sedatives used if necessary. If unconsciousness is
prolonged, a suspicion of greater injury than concus-
sion should always be entertained. After severe con-
cussion the patient should avoid mental exertion for a
number of weeks or months." — (Stewart's Manual
of Surgery.)
MEDICAL JURISPRUDENCE.
1. Rigor mortis is the condition of rigidity or con-
traction into which the muscles of the body pass after
death. It begins at a period varying from about fifteen
minutes to about six hours. It usually begins in the
770
TEXAS.
muscles of the eye, neck, and jaw; then the muscles of
the chest and upper extremity, and last of all those of
the abdomen and lower extremity are affected. It
passes off in the same order in about twenty-four
hours. It is said to be due to the coagulation of the
muscle plasma.
Medicole gaily, it is a sign of death, and an indica-
tion of the length of time that has elapsed since death
occurred.
2. The features of the bony skeleton which charac-
ize sex, are: (1) In the male the bones are, as a rule,
stronger, larger and heavier, and the prominences,
ridges, and lines are more distinct; (2) the skull in the
male looks more mature, and less like that of a child,
and the glabella is more prominent; (3) in the female
the sternum is shorter, the capacity of the thorax is
less, and the upper ribs are more movable; (4) in the
female the clavicle is shorter, thinner, smoother, and
less curved; (5) in the female the sacrum is relatively
wider, less curved, and is directed more obliquely back-
wards; (6) in the female the pelvis is wider, shallower,
has an oval inlet, has a larger subpubic angle, the ob-
turator foramen is triangular (oval, in the male), the
tuberosities of the ischia are everted; (7) the inclina-
tion of the shafts of the femora from the pelvis to the
knee is greater in the female.
3. In a stab wound inflicted before death, there will
be retraction of the skin and muscles, arterial hemor-
rhage; the wound will have everted edges; large blood
clots may be present; signs of repair or of inflamma-
tion may be present.
In a stab wound inflicted after death, there will be no
retraction of skin or muscles, and no eversion of the
edges (unless from putrefaction) ; the hemorrhage will
be venous; blood clots are small; and there are no
signs of repair or inflammation.
4. Points which help to determine whether a gunshot
wound was self-inflicted: The location of the wound;
the distance at which the shot was fired; the charac-
ter of the wound; the burning of clothing, skin or
hair; the embedding of grains of gunpowder; the pres-
ence or absence of the weapon; the position of the
body when the wound was received; and certain, sur-
rounding circumstances which may have a bearing on
the case.
5. "The occasions in which pregnancy becomes the
subject of medico-legal inquiry are the following:
(1) A woman may declare herself pregnant with an
heir to an estate, for the purpose of defrauding other
771
MEDICAL RECORD.
heirs at law; (2) for the purpose of extorting money
from a seducer or paramour; (3) to stay the infliction
of capital punishment until after delivery; (4) the
plea of pregnancy may be set up as an excuse for non-
attendance at a trial, to awaken sympathy, etc.; (5) an
accusation of pregnancy may be made against a single
woman, or one living apart from her husband, which
may result in an action for damages for slander; (6)
accusations of malpractice may be made against a medi-
cal man for error in diagnosis of pregnancy, or an at-
tempt to bring on an abortion. On the other hand,
pregnancy may be concealed (1) in order to procure
abortion or infanticide; (2) in order to avoid dis-
grace." — (Reese's Medical Jurisprudence,)
6. When abortion is undertaken by properly qualified
physicians after due consultation with other physi-
cians, and for the purpose of saving the life or health
of the mother, it is justifiable; under all other circum-
stances it is criminal. The former is a perfectly law-
ful medical procedure; the latter is illegal.
7. Insanity is "that state of disordered mind in which
a person loses the power of regulating his actions or
conduct according to the ordinary rules of society." —
(Taylor.)
"The best classification for legal purposes 9 *; (1)
Idiocy; (2) imbecility; (3) mania; (4) melancholia;
(5) monomania; (6) general paralysis of the insane;
(7) dementia; 8) certain forms of mania without dis-
tinct etiological relations. — (Dwight's Medical Juris-
prudence.)
8. Application of hydrostatic < test, to determine
whether a dead infant was born alive :■ "Having opened
chest, note position of lungs (before respiration they
occupy a small space at upper and posterior parts of
thorax); their volume (of course increased after
breathing) ; their shape (before respiration, borders
sharp or pointed; after it, rounded) ; their cploY (be-
fore breathing, brownish-red; after it, pale, red or
pink); their appearance as regards disease . and* putre-
faction; and whether they crepitate on. -pressure (as
they will after respiration). Take out lungs with heart
attached, and place them in pure water having tem-
perature of surrounding air. Note whether they float
(high or low), or sink (slowly or rapidly). Separate
them from the heart and weigh them accurately; then
place them in water again, and note sinking or floating,
as before. Subject each lung to pressure with the hand,
and note sinking or floating again. Cut each lung ip
pieces arid test floating again. Tak6 out each pfecfe,
772
TEXAS.
wrap it in a cloth, and compress with fingers as hard
as possible, and test floating, etc., as before. The
crucial test of perfect respiration is each piece floating
after the most vigorous compression." — (King's Man-
ual of Obstetrics.)
9. In case of doubtful maternity, the following points
might help to fix the responsibility: Resemblance of
face, features, voice, gesture, attitude, habits, de-
formities; absence of one of the "claimants" beyond
the seas for a much longer period than that of the par-
ticular gestation.
10. It may be impossible to prove the fact of an
abortion. The evidence will depend on the signs of a
recent delivery and examination of the product of con-
ception. If the case is a criminal one, and was care-
lessly performed, there may be evidence of the use of
instruments, sepsis, etc.
Signs of recent delivery. — In the living : Woman is
more or less weak, and incapable of exertion; pallor;
soft abdomen with relaxed skin, and lineae albicantes;
breasts, full, tumid, and secreting milk; presence of
colostrum corpuscles in the milk; secondary areola;
external genitals relaxed and tumefied ; os uteri swollen
and dilated; fundus hard and globular; lochial dis-
charge; absence of fourchette; lacerated cervix. In the
dead: Uterus enlarged, thick and soft; uterus contains
blood, clots, and debris of decidua; tubes and ovaries
congested.
HYGIENE.
1. Diseases believed to be acquired by inhalation of
microorganisms from the air: Tuberculosis, pneu-
monia, diphtheria, measles, scarlet fever, whooping
cough, erysipelas, influenza.
2. An adult, at rest, takes about sixteen respirations
a minute; the tidal air is about 500 c.c. Therefore 500
X 16 = 8000 c.c. of air are respired in a minute. In-
spired air contains 21 per cent, of oxygen; therefore
80 X 21 = 1680 c.c. inspired per minute, or 1680 X 60
X 24, or 2,419,200 c.c. inspired per day. By the same
method it may be calculated that an adult expires 352
X 60 X 24, or 5,068,800 c.c. of carbon dioxide a day
(4.4 per cent, of expired air being carbon dioxide).
Ventilation: "The principal means of ventilation
are the windows, doors, and the artificial openings es-
pecially made for the purpose. The occasional opening
of doors and the opening of windows greatly assist the
exchange of air in ordinary dwellings, with not too
many persons in the rooms and with but ordinary
illumination and heating. When the number of per-
773
MEDICAL RECORD.
sons in rooms is large and the number of lights in-
creased, the windows and doors may not be sufficient
for adequate ventilation, and special artificial open-
ings may be needed. The number and character of
such openings vary in size, location, shape, character,
etc. The openings may be in the shape of tubes or
boxes placed within the windows, the sashes, the panes,
the walls at different points, the ceilings, or the floors.
All such openings communicate with the external air,
and serve as air inlets, or outlets, and may also be
provided with adjustable gates, so that they may be
closed up when not wanted. The number of ventilating
devices is very large; their value depends on their lo-
cation and size and character. Where local heating is
used within the house, ventilation is aided by the neces-
sary chimney and fire openings, and by the use of
grates and stoves. The advantages of mechanical ven-
tilation are the constancy of the exchange of air, the
independence from any other means, the perfect con-
trol of the velocity and volume of the supplied air, the
possibility to accurately regulate the temperature,
quantity, moisture, and purity of the incoming air.
Mechanical ventilation is, as a rule, carried on from a
central point, and is of three kinds: plenum, or pro-
pulsion method, in which pure air is driven into the
house from outside; vacuum, or exhaustion method, in
which the impure air is withdrawn from the house;
and the combined vacuum and plenum methods." —
(Price's Hygiene and Public Health.)
3. "Fifty gallons of water per day is a safe average
minimum, while in large cities and civilized communi-
ties a supply of 300 gallons and more per person is not
excessive." — (Price.)
Diseases caused by the use of impure water are:
Typhoid, cholera, dysentery, diarrhea, goiter, intestinal
parasites, metallic poisoning, vesical calculi.
4. The mere presence of nitrites in * water is sus-
picious, while the amount of nitrates must be marked
before the water containing the same is regarded as
suspicious. The presence of these salts in water in-
dicates organic nitrogenous matter which has under-
gone chemical changes.
5. Milk may be sophisticated or adulterated by: (1)
Skimming; (2) the addition of water; (3) the addition
of coloring matter, such as caramel, annatto, or methyl
orange; (4) the addition of preservatives, as boric acid,
formaldehyde, salicylic acid, or salicylates; (5) the
addition of arrowroot, flour, sugar, glycerine, chalk, or
sodium carbonate.
774
TEXAS.
The greatest danger in such adulteration is in the
transmission of the microorganisms of infectious dis-
eases which may be present in the dirty water with
which the milk is diluted.
6. Meat may be unfit for food owing to: Disease of
the animal; unfit condition and surroundings of living
animals; post-mortem changes; infection of the meat
by persons or places of manufacture, sale, etc.; and by
adulteration. This last may consist in: "(1) Addi-
tion of foreign substances reducing, lowering, or injur-
ing the quality of the food. (2) Partial or entire sub-
stitution of an inferior substance. (3) Extraction of
some of the valuable substance from the meat. (4) Col-
oring, coating, or otherwise changing the appearance
of the food, whereby poor quality is concealed, or it is
made to look better than it is. (5) Addition of some
foreign substance to 'preserve* it." — (Price's Epitome
of Hygiene.)
7. Diseases transmitted by flies: Typhoid, cholera,
plague, tuberculosis, dysentery, anthrax, and intestinal
parasites.
8. In locating a well for drinking water on a farm,
care should be taken that it is so situated that no water
can flow into it from stables, manure pits, privies, cess-
pools, cattle-pens, etc. Further, the well must be well
covered; and all around its opening should be a prop-
erly cemented border.
9. To prevent the spread of typhoid fever: Flies
should be kept out of the house as far as possible, by
means of screens or otherwise; all discharges from the
sick person must be disinfected; all utensils, dishes,
etc., used by the patient must be thoroughly cleansed
and boiled every day; soiled linen must be soaked in a
disinfectant solution before being washed; after each
attendance on a patient, physicians, nurses, and others
should wash their hands in a disinfectant; thorough
sterilization of all bedding, etc., must be performed
after the disease is over. Further, each household
should boil all water that is to be used for drinking or
for washing dishes, etc.; milk should be boiled also;
and no ice should be put in water or other drink or
food.
"When the patient has recovered from an infectious
disease, he should be given a general bath with soap
and water. In addition to this, he may be bathed with
chlorinated soda solution, and in the exanthemata it
may be advisable to anoint his body again unless all
desquamation has ceased. After a general bath has
been given the patient may be allowed to mingle with
775
MEDICAL RECORD.
the well. In most localities the convalescent from cer-
tain diseases, especially smallpox, is washed with
1:2000 bichloride of mercury solution, clothed with
clean clothing, and then transferred to a disinfected
room.
"The clothing and bedding which are to be disinfected
by means of steam should be carefully wrapped in
cloths saturated with 1 per cent, carbolic solution,
placed in a wagon, and taken to the disinfecting station.
After the bed has been stripped, all refuse matter,
paper, and articles of little value are wrapped in cloths
saturated with carbolic acid and burned in a stove or
furnace. The floor, doors, windows, furniture, and the
walls for a distance of \ x k meters from the floor should
be washed with 5 per cent, carbolic acid solution. The
walls and ceiling of the room should subsequently be
sprayed with 1:1000 bichloride of mercury solution. If
the walls are papered, it is advisable to remove care-
fully the paper before beginning the disinfection. The
room is then closed as tightly as possible and disinfected
by means of formaldehyde." — (Bergey's Hygiene.)
10. To fumigate by sulphur dioxide: For each 1,000
cubic feet of space, three pounds of sulphur are burned,
care being taken to prevent accidents. In every case all
apertures and crevices of the room should be closed, all
closets, drawers, or other receptacles opened; and after
the fumigation the room should be well ventilated and
thoroughly cleansed with a solution of corrosive sub-
limate.
STATE EOARD EXAMINATION QUESTIONS.
Medical Examining Board of Virginia.
anatomy.
1. Name and describe the nerves which supply the eye.
2. Describe the aorta and name its branches.
3* Locate and give description of the kidney.
4. Give common characters of ribs — name and tell in
what way the peculiar ribs differ from the others.
5. Name and describe the adductor muscles of the thigh.
6. Describe the ureter.
HISTOLOGY.
1. Name the elementary tissues of the body.
2. Name the forms of muscle and state principal loca-
tion of each.
3. Give principal sources of white and red blood cor-
puscles.
• 4. Give histological structure of spleen.
lie
VIRGINIA.
PHYSIOLOGY.
1. Describe normal urine; giving color, specific gravity,
reaction, visible contents and amount daily secreted.
2. Give amount of solids secreted daily by a healthy
man. Of what do these solids mainly consist?
3. Under what conditions does albumin appear in urine?
4. Give methods of stimulating muscles to contraction.
5. What is meant by clonic and tonic contraction of
muscles?
6. Name the ductless glands, giving location of each.
7. What substances must be taken into the body in order
to afford proper nutrition to the cells and in what forms
are these substances excreted from body after being util-
ized by cells?
8. Give function and location of gall-bladder and its
connections with other organs.
9. What condition of the blood causes the phenomena
known as dyspnea, apnea, and asphyxia?
10. As regards respiration, what is meant by tidal air?
Reserved air? Residual air?
EMBRYOLOGY.
1. Name different types of embryonic cells. In what
structures of body is each type chiefly concerned? ^
2. From what sources does the placenta derive its
structure and what are the three functions of placenta
in fetal life?
CHEMISTRY.
1. Name four classes of the compounds of C.
2. Tell something of Bi., naming its medicinal salts,
and the preparation of the subnitrate.
3. What do you mean by proteolytic changes, and give
an example.
4. Name a source of the following: (1) Myronic Acid.
(2) C,N,. (3) Dextrin. (4) Paraffin.
5. Name five substances obtained from the destructive
distillation of crude petroleum.
6. What are the amido acids and what is their impor-
tance ?
7. In a case of infantile diarrhea how could you de-
termine if (1) protein, (2) fats, or (3) starch were un-
digested by an examination of feces?
8. Give a test for (1) acetone, (2) bile pigments in
urine.
9. Give the solubility or the reverse of following; (j)
Ag NO«. (2) Cas (PO<),. (3) PbSO,. (4) Ca CO,. (5)
NaCl. (6) MgCl 2 . (7) FeS. (8) N,S0 4 . (9; I\aAU 8 .
(10) ZnO.
777
MEDICAL RECORD.
io. Give the chemical composition of average atmo-
spheric air.
ii. Name chemical constituents of urinary calculi.
12. Give chemical test for presence of morphine.
MATERIA MEDIC A.
i. State difference between a tonic and a stimulant, giv-
ing an example of each.
2. What are the preparations and doses of arsenic?
3. What is alcohol and what its medicinal uses?
4. Give doses of following: Creosote, sulphate of spar-
tein, phenacetine, caffeine citrate, atropine, potassium io-
dide.
5 : Give the classification of gentian, chloroform, mag-
nesium sulphate, strophantus, santonine, viburnum pruni-
folium.
6. What are the principal medicinal uses of digitalis?
7. What are (1) antiseptics, (2) germicides* (3) deo-
dorants? Giving an example of each.
TOXICOLOGY.
1. Give symptoms, minimum fatal dose, and treatment
of poisoning by arsenic.
2. When lucifer match heads are taken into stomach
what is best treatment and what should be especially
avoided?
3. Give chemical and physiological antidotes for opium,
strychnine, and carbolic acid.
THERAPEUTICS.
1. Classify emetics and give two examples in each class.
2. Give therapeutic uses of digitalis and the objections
to its long continued use.
3. Give uses of iodine and name preparations most pre-
scribed internally.
4. Name the urinary acidifiers and state whether the
bicarbonates should be given before or after meals for
such effect.
5. Give the leading action of each of the three principal
mineral acids.
PATHOLOGY AND BACTERIOLOGY.
1. What is meant by the term "compensation" as used
in heart diseases? Trace the course of events due to
broken compensation.
2. Give the etiology and pathology of erysipelas.
Through what channels does it spread?
3. Discuss syncope, shock, and collapse, and state what
features are common to all three conditions.
4. Distinguish between hemoptysis and hematemesis.
778
VIRGINIA.
Name the diseases of the organs that may produce the
latter.
5. Describe the phenomenon known as Cheyne-Stokes
respiration. State some of the conditions in which these
respirations appear, and give the prognosis of same.
6. Give the pathology of nephrolithiasis.
7. The power to induce (by biological reaction) the for-
mation of what distinguishes toxins from other poisons —
such as alkaloids?
Of what disease is the Spirocheta pallida the exciting
agent ?
8. How do bacteria multiply? Mention three pathogenic
bacteria that may be conveyed from the soil. Describe
the Bacillus tetani.
9. How does an antitoxin differ from a vaccine?
10. How would you prepare and stain a specimen of
sputum to examine for the baccilli of tuberculosis?
PRACTICE OF MEDICINE.
1. Differentiate from one another — apoplexy, epilepsy,
alcoholic intoxication, and uremia.
2. Give the etiology and clinical symptoms of catarrhal
(broncho or lobular) pneumonia.
3. Differentiate cardiac hypertrophy from cardiac dila-
tation.
4. Define : urticaria ; herpes zoster ; astigmatism ; am-
nesia; aphasia.
5. Give the clinical symptoms and treatment of acute
nephritis.
6. Describe a typical case of measles from the time of
infection to its close.
7/ Give the clinical symptoms of eczema and its treat-
ment, including diet.
8. Give the principal measures for protection against
malarial, typhoid, and yellow fever.
9. Give the treatment for f olHcular tonsillitis.
10. What factors determine normal blood^pressure and
what is the normal pressure for an adult?
OBSTETRICS AND PEDIATRICS.
1. Diagnosis of pregnancy at third month.
2. Diagnosis of extrauterine pregnancy.
3. (a) Dangers of the use of chloroform during preg-
nancy and labor, (b) Indications for use of an anesthetic
during labor.
4. What constitutes morbidity during the puerperium
and mention most important means of preventing same.
5. Management of the third stage of labor.
6. Mention the indications for the induction of labor.
779
MEDICAL RECORD.
7. Management of a case of pharyngeal diphtheria.
8. Causes and diagnosis of a case of empyema.
9. Differentiate between subacute cervical adenitis, tu-
berculous adenitis of bovine type, and tuberculous adenitis
of human type.
10. Give the number of calories and the percentage of
fat, sugar, proteid, and lime water in the following milk
mixture :
Milk, 4 per cent 15 ounces
Sugar of milk. 1*/% "
Lime water V/2 "
Plain water 1354 "
3<>~ "
SURGERY AND GYNECOLOGY.
i. Describe operation for removal of the glands of the
neck; what vessels and nerves would likely be injured,
and how avoided?
2. Give diagnosis and treatment of synovitis of knee-
• joint (non-tubercular).
3. Diagnosis and treatment of fracture of neck of the
femur.^
4. Give the operation for radical cure of umbilical her-
nia; name tissues that are brought together.
5. Differential diagnosis between congenital and ac-
quired talipes.
6. Etiology and treatment of osteomyelitis; what part
of the bone does it usually attack?
7. Give diagnosis between hematocele and hydrocele of
tunica vaginalis, with treatment of each.
8. Etiology, diagnosis j and treatment of pyelonephritis.
9. What relative position to each other do the ends of
the bone occupy in a Colles fracture? Give method- of
reductional treatment.
10. Diagnosis and treatment of acute anterior; acute
posterior urethritis.
11. Describe in detail operation ior. complete rupture
of perineum.
12. Give treatment of retroversio "uteri.
HYGIENE AND PREVENTIVE MEDICINE.
1. What is the safest disposal of public sewage? De-
scribe the process.
2. Briefly outline the precautions to be taken in a com-
munity where typhoid fever has developed.
3. (a) For the purification of large quantities of water,
such as is needed for large cities, what is the most avail-
able, satisfactory, and elficiertt method? (b) Construct a
rou^h outline of the general arrangement of a filter plant.
780
VIRGINIA.
4. (a) What is the difference in antitoxins and bac-
terial vaccines? (b) Give example of each, (c) How
should they be used?
5. Give prophylaxis of hook worm disease.
MEDICAL JURISPRUDENCE.
i. Give proper manner of making post-mortem exam-
inations.
2. What would be the appearance of a body that had
been drowned, and not to have been in the water more
than two or three hours?
3. What constitutes a "Live Birth ?"
4. What is th-e appearance of an infant born alive at full
term?
5. What do civil and criminal responsibility imply?
ANSWERS TO STATE BOARD EXAMINATION
QUESTIONS.
Medical Examining Board of Virginia.
ANATOMY.
I. The nerves which supply the eye are the second
cranial, or optic nerve; the third cranial, or motor oculi;
the fourth cranial, or trochlear ; the sixth cranial, or
abducens.
Second or Optic. "Origin: from optic tract, which arises
by two roots : Outer, from external geniculate body, optic
thalmus, and brachium of superior quadrigeminal body.
Inner, from internal geniculate body. Course, — Winds
across outer and anterior surfaces of crus cerebri, uniting
with fellow to form optic commissure, which is bounded
in front by the lamina cinerea and behind by the tuber
cinereum; the nerves separate at fore part of commissure,
get ensheathed in arachnoid, and pass into orbit through
optic foramen above and internal to ophthalmic artery ;
while passing through, each receives a tube of dura mater,
which divides into two, the outer piece becoming orbital
periosteum, and the inner, ensheathing the nerve, joins
the sclerotic in front. The nerve pierces sclerotic and
choroid coats of eyeball. Distribution. — Expands to form
retina. Special function. — Nerve of sight."
Third or Motor Oculi. "Superficial origin: inner side
of crus cerebri, just in front of pons. Deep origin: floor
of aqueduct of Sylvius. Course. — Pierces dura mater to
enter canal in outer wall of cavernous sinus near posterior
clinoid process, lying above and internal to fourth nerve.
As it passes forward to enter orbit through sphenoidal
fissure, the fourth nerve and frontal branch of fifth cross
781
MEDICAL RECORD.
and become superior to it It divides into two branches
in the fissure, which enter orbit between the heads of the
external rectus, the nasal branch of the fifth lying between
the two; while in cavernous sinus it communicates with
cavernous plexus. Distribution. — Superior branch sup-
plies superior rectus and levator palpebral Inferior
divides into three for internal rectus, for inferior rectus,
and for inferior oblique, which latter gives off short or
motor root to the lenticular ganglion. Special function. —
Motor nerve of eyeball."
Fourth or Trochlear. "Origin — Superficial: valve of
Vieussens, just behind corpora quadrigemina. Deep: floor
of aqueduct of Sylvius. Course. — Winds round outer sur-
face of crus cerebri and pierces free border of tentorium ;
passes forward in outer wall of cavernous sinus below
third, but enters orbit through sphenoidal fissure above
and internal to the other nerves and external rectus.
Distribution. — Enters orbital surface of superior oblique.
Special function. — Motor nerve of superior oblique/'
The sixth or Abducens Oculi. "Origin — Superficial:
from the sulcus between the pons and medulla, anterior to
the anterior pyramid. Deep: floor of fourth ventricle
beneath fasciculus teres. Course. — Pierces dura mater
on basilar process and grooves side of dorsum ephipii
to reach cavernous sinus; lies to outer side of internal
carotid, and below the other nerves. Enters orbit by
sphenoidal fissure, between the heads of the external
rectus, lying above ophthalmic vein. Distribution. — Ex-
ternal rectus (ocular surface.)" (Aids to Anatomy.)
2. The aorta commences at the upper part of the left
ventricle of the heart, ascends for a short distance, then
arches backward and to the left, passes over the root of
the left lung, then down the left side of the spinal column,
passing through the aortic opening in the diaphragm, and
terminating opposite the fourth lumbar vertebra, where
it divides into the right and left common iliac arteries.
Branches of ascending aorta. — Right coronary and left
coronary; of arch of aorta: innominate, left common
cartoid and left subclavian ; of descending aorta
(thoracic) : bronchial, esophageal, pericardial, mediastinal,
intercostal, subcostal, and superior phrenic; of descending
aorta (abdominal) : celiac axis, inferior phrenic, supra-
renal, renal, spermatic (or ovarian), superior mesenteric,
inferior mesenteric, lumbar, middle sacral, and common
iliacs.
3. The kidneys are situated in the back of the abdom-
inal cavity, one on each side of the vertebral column, be-
hind the peritoneum, and extending from the eleventh rib
to the second or third lumbar vertebra. The right kidney is
782
VIRGINIA.
about half an inch lower than the left one. Each kidney
is about four inches long, two inches broad, and one inch
thick, and weighs about four and a half ounces. The kid-
neys are kept in place by their vessels, fatty tissue, and
the peritoneum. The shape is characteristic. Each kidney
is surmounted by the suprarenal gland, is surrounded by a
capsule, and consists of a cortical and medullary portion.
In the cortical portion are found the Malpighian corpuscles,
which are tufts of capillaries, and are surrounded by a
capsule which is continuous with the uriniferous tubule
which ends in the renal papilla.
4. Each typical rib has a head, body, neck, angle, tuber-
osity, and sternal end.
The peculiar ribs are the first, second, tenth, eleventh,
and twelfth.
The first rib has only a single facet for articulation with
the first dorsal vertebra; and the tuberosity and angle are
blended.
The second rib has the tuberosity and angle very close
together, and the shaft is not twisted.
The tenth rib has only a single articular facet upon its
heads.
The eleventh rib has no neck, no tuberosity, and but a
single articular facet upon its head.
The twelfth rib has a single articular facet upon its
head, and no neck, no angle, no groove, and no tuberosity.
5. The adductor muscles of the thigh are : Gracilis, Pec-
tineus, Adductor longus, Adductor brevis, and Adductor
magnus.
The Gracilis arises from the symphysis pubis and the
pubic arch, and is inserted into the inner surface of the
shaft of the tibia, just below the tuberosity.
The Pectineus arises from the iliopectineal line and is
inserted into a line leading from the lesser trochanter of
the femur to the linea aspera.
The Adductor longus arises from the junction^ of the
crest with the symphysis of the pubic bone, and is inserted
into the inner lip of the linea aspera. It is generally
blended with the Vastus Internus and the Adductor
magnus.
The Adductor brevis arises from the body and descend-
ing ramus of the os pubis, and is inserted into the line
leading from the lesser trochanter of the femur to the
linea aspera.
The Adductor magnus arises from ramus of pubic bone,
ramus of ischium, and from tuberosity of ischium, and is
inserted into the line leading from the great trochanter
of the femur to the linea aspera.
6. The ureter is a tube about twelve inches long, con-
783
MEDICAL RECORD.
netting the kidney with the bladder. It enters the latter
very obliquely, about an inch and a half from its fellow
of the opposite side and the same distance from the be-
ginning of the urethra. Behind the ureter are the Psoas
magnus, common iliac artery and vein, sacroiliac sychron-
drosis, and Obturator internus. In front are the spermatic
vessels and the vessels of the colon (ascending or de-
scending). The right ureter has the inferior vena cava
at its inner side.
HISTOLOGY.
1. The elementary tissues of the body are: Epithelial,
connective, muscular, and nervous tissues.
2. Striated muscles are found attached to bones. All
the muscles under the control of the will are of this
variety.
Utistriated muscles are found in the esophagus, stomach,
intestines, trachea, bronchi, ducts of glands, blood-vessels,
ureter, bladder.
Cardiac muscle is found in the heart.
3. White blood cells are derived from the spleen, lymph
glands, lymph tissues, and bone marrow.
Red blood corpuscles are derived from the bone marrow
and the spleen.
4. "The spleen is invested by a thick capsule, consisting
of fibro-elastic tissue and a large proportion of visceral
muscle fibres. The capsule sends trabecule into the inte-
rior of the organ. These are thick, and the nuclei of the
muscle fibres in them stand out conspicuously in stained
specimens. The bulk of the organ is deep red in color,
and js called the spleen pulp. In the pulp are numerous
whitish nodules, about the size of a pin's head. These
nodules are composed of lymphoid tissue surrounding
small arteries, and are called Malpighian corpuscles. The
pulp consists of a network of fine fibres, with a number of
flattened and branched cells situated on the fibres and at
their crossings. In the spaces between the fibres are nu-
merous red corpuscles, large lymphocytes, and other blood
cells. Many of the red corpuscles undergo disintegration
in the large lymphocytes, so that pigment, both intracel-
lular and free, is present. An occasional giant cell of
bone-marrow type is seen in the spleen pulp. The splenic
artery breaks up at the hilus, and the branches pass into
the interior of the organ along the trabecule. Passing
away from the trabeculae, their outer coat becomes sur-
rounded at intervals by nodules of lymphoid tissue — the
Malpighian corpuscles. Each corpuscle ^usually shows a
germ center. The arteries open into capillaries, which, in
turn, open into the interstices of the pulp. From the pulp
784
VIRGINIA.
spaces there open wide venous sinuses, which are encircled
by fibres of the reticulum, and are lined by a very prom-
inent endothelium. These sinuses open into the radicles
of the splenic vein." (Aids to Histology.)
PHYSIOLOGY.
i and 2. The urine is a fluid, of pale yellow color, acid
reaction, characteristic odor, specific gravity about 1015 to
1025, and contains water and solids. The amount excreted
daily is about 50 ounces ; of this quantity, between 900 and
iood grains are solids.
SOLIDS IN THE URINE.
VOIDED PER DAY.
Organic —
Urea
about 500 grains.
Uric acid
about 10 grains,
about 6 grains.
Hippuric acid
Creatinin
about 12 grains.
Extractives
about 150 grains.
Inorganic —
Sodium chloride
about 150 grains.
Phosphates
about 37 grains.
Sulphates
about 24 grains.
Oxides of calcium,
magnesium, sodium,
and potassium
about 20 grains.
3. Albumin appears in the urine in: Inflammation and
degeneration of the kidneys; increased blood pressure in
the kidneys ; certain exanthemata, such as scarlet fever ;
following drugs, such as mercury, cantharides; pregnancy,
purpura, scurvy, leukemia, anemia, and other diseases; dis-
eases of the heart and coronary arteries.
4. Muscles may be stimulated to contraction by various
stimuli : Chemical, mechanical, thermic, electric, and
nervous. N
5. In tonic muscular contraction the muscle remains for
some time in a state of rigid contraction; in clonic con-
traction, the muscle alternately contracts and relaxes/
6. Ductless glands: (i) The spleen; situated in the
back part of the left hypochondriac and epigastric regions,
being covered by the ninth, tenth, and eleventh ribs on the
left side. (2) The thyroid; situated on the sides and in
front of the upper part of the trachea, and extending up-
ward on each side of the larynx. (3) The suprarenals;
situated in the back part of the abdominal cavity, behind
the peritoneum, one .on the upper extremity of each kidney,
and slightly also on the inner and anterior surfaces. (4)
The carotid gland; situated generally in the carotid bifur-
785
MEDICAL RECORD.
cation. (5) The thymus; situated in neck, and superior
mediastinum, up to lower border of thyroid. (6) The
coccygeal gland, at the tip of the coccyx. (7) The para-
thyroids; situated near the thyroid, on the posterior sur-
face, near the junction of the pharynx and esophagus; but
they are variable in position.
7. The cells of the body require: Water, inorganic salts,
proteids, fats, and carbohydrates. Water leaves the body
in the urine, perspiration, feces, and expired air. Sodium
chloride leaves the body in the urine and perspiration. So-
dium phosphate leaves the body in the urine, perspiration,
and mucus. Sulphates leave the body in the urine, saliva,
feces, mucus, and perspiration. Carbonates leave the body
in the urine. Calcium phosphate leaves the body in the
urine, feces, and perspiration. Magnesium and ammonium
salts leave the body in the urine. Nitrogen leaves the body
in the urine and feces. Carbon leaves the body in the
urine, feces, and expired air.
8. The gall bladder is a reservoir for the bile. It is
situated on the under surface of the right lobe of the liver,
to which it is connected by vessels and connective tissue.
It is also in relation with the transverse colon, the duo-
denum, and sometimes with the pyloric end of the stomach.
9. Asphyxia is due to lack of oxygen in the blood.
Apnea may be due to excess of any gas in the blood, or
to lack of oxygen.
Dyspnea is due to lack of oxygen or excess of carbon
dioxide in the blood.
10. Tidal air is the air which is inspired and expired dur-
ing ordinary respiration.
Reserve air is the extra air which can be expelled by a
forcible expiration.
Residual air is the air which cannot be expelled from
the lungs, even by a forcible expiration.
EMBRYOLOGY.
I. The different types of embryonic cells are the epi-
blastic, hypoblastic, and mesoblastic.
"From the epiblast are developed : The epithelium of the
niouth and salivary glands and the enamel of the teeth ;
parts of the nose, eye and ear; the nervous system, the
pituitary and pineal bodies, the medulla of the suprarenal
gland. From the hypoblast are developed : The epithelium
of the alimentary canal between the pharynx and the anal
canal, and of the liver and pancreas; the epithelium of
the respiratory passages and lungs ; the epithelium of the
Eustachian tube and tympanium ; the thyroid gland ; the
epithelium of the bladder and parts of the genitourinary
tract. From the mesoblast are developed: The connect-
786
VIRGINIA.
ive tissues; the muscles; the blood vessels, blood cells,
spleen, and lymph nodes ; the epithelium of the kidney, the
cortex of the suprarenal, the epithelium of the reproductive
organs, and of part of the genitourinary tract." (Aids to
Histology.)
2. *The placenta is developed from the decidua serotina
and chorionic villi. The placenta serves as: (i) a respira-
tory organ, (2) an excretory organ, and (3) a means of
nutrition to the fetus.
CHEMISTRY.
1. Saturated aliphatic compounds, unsaturated aliphatic
compounds, carbocyclic compounds, and heterocyclic com-
pounds.
2. Bismuth is a trivalent element, with atomic weight of
208. It is classed by some writers with antimony, by others
with phosphorus, and by others again with the metals, and
sometimes it is placed in a class by itself. It is found free,
also as the trioxide and trisulphide. It is usually contam-
inated with arsenic. The medicinal salts are: Citrate, bis-
muth and ammonium citrate, subcarbonate, subgallate, sub-
nitrate, subsalicylate.
Bismuth subnitrate is made by the action of water on
bismuth nitrate:
Bi(N0 3 ) 3 + H 2 = BiONOs + 2HN0 8
3. Proteolytic changes are changes effected in proteins
during their digestion, and are caused by the action of
proteolytic enzymes. Thus pepsin splits up proteins into
proteoses and peptones. The change is probably associated
with the addition of some molecules of water to the pro-
tein group.
4. Myronic acid exists in the seeds of black mustard.
Dicyanogen is prepared from mercuric cyanide.
Dextrin is derived from starch.
Paraffin is derived from petroleum.
5. From petroleum may be obtained : Cymogene, rhigo-
lene, gasolene, naphtha, and benzine.
6. Amido acids are derived from aliphatic acids by the
substitution of one NH 2 group for one atom of hydrogen
in the hydrocarbon group. They are basic on account of
the presence of the NH 2 group, they are also acid, because
they retain the COOH group. Their importance is due
to the number of physiological compounds which belong to
this class; such are leucin, tyrosin, tryptophan, lysin,
alanin, and ornithin.
7. If the proteid is undigested, casein may be present in
the stools, or the latter may be excessive, formed, with a
pale or white color. If fat is undigested, the stools may
be oily or glistening, whitish or grayish in color, and fat
787
MEDICAL RECORD.
globules or crystals may be detected. If starch is undi-
gested, starch granules may be seen, and a blue reaction
obtained with iodine.
8. Test for acetone in urine. Add a few drops of a
freshly prepared solution of sodium nitroprusside, and then
KOH solution; in the presence of acetone the liquid is
colored ruby-red, and becomes purple if acetic acid is added
in excess. . .
Test for bile pigments in urine: Put 3 ex. of nitric acid
in a test tube, add a piece of wood, and heat until the acid
is yellow ; cool. When cold, float some of the urine to be
tested upon the surface of the acid. A green band is
formed at the junction of the liquids, which gradually rises,
and is succeeded from below by blue, reddish- violet, and
yellow.
9. AgN0 8 is soluble in water. Ca 3 (P0 4 ) 2 is sparingly
soluble in water, but is soluble in acids. PbSCX is insoluble
in water, but sparingly soluble in acids. CaCC>3 is insoluble
in water, but soluble in hydrochloric or nitric or nitro-
hydrochloric acid. NaCl is soluble in water. MgCU is
soluble in water. FeS is insoluble in water, but soluble
in hydrochloric or nitric or nitrohydrochloric acid. NaaSCh
is soluble in water. NaNOs is soluble in water. ZnO is
insoluble in water, but soluble in hydrochloric or nitric or
nitrohydrochloric acid.
10. Average atmospheric air consists of oxygen 20.9,
nitrogen 79.0, and carbon dioxide 0.04 per cent.
11. Urinary calculi may consist of: (1) Uric acid, so-
dium urate, ammonium urate, calcium oxalate, calcium
phosphate, ariimonio-magnesium phosphate. (2) Cystin,
xanthin, urates of potassium, calcium and magnesium, cal-
cium carbonate.
12. Test for morphine: Add to the suspected substance
a solution of neutral ferric chloride; the presence of mor-
phine is indicated by the appearance of a blue color.
MATERIA MEDICA.
i. The terms stimulant and tonic are both used laxly. In
Foster's Dictionary of Practical Therapeutics stimulants
are defined as "agents whose influence is to augment the
vital activity or function of an organ or to increase the
vital energy of the entire system. ,, Tonics are said to be
"measures which are employed for the purpose of re-
storing permanent energy or tone to weakened, impaired,
or diseased organs or systems of organs or the organism
at large." Alcohol is an example of a stimulant; strych-
nine, of a tonic.
2. Arsenic trioxide, gr. 1/20; solution of arsenous acid.
TTjviij ; solution of potassium arsenite, ■ tipvii j ; sodium ar-
788
VIRGINIA.
senate, gr. i/io; exsiccated sodium arsenate, gr. 1/20; solu-
tion of sodium arsenate, n^iij ; arsenic iodide, gr. 1/10;
solution of arsenic and mercuric iodide, H£jss.
3. Alcohol is a liquid containing about 93 per cent, of
ethyl alcohol and about 7 per cent, of water. It is used
medicinally as an antiseptic, astringent, and refrigerant;
for bruises and sprains; in headaches, in fevers; to check
sweating; in diphtheria, pneumonia, snake-bite; as a
stimulant, a food, and as a diuretic.
4. Dose of creosote, l^iij ; sulphate of sparteine, gr. 1/5;
phenacetine, gr. vijss; citrated caffeine, gr. ij ; atropine,
gr. 1/160; potassium iodide, gr. vijss.
5. Gentian is a stomachic; chloroform, an anesthetic;
magnesium sulphate a cathartic; strophanthus, a circula-
tory stimulant; santonin, an anthelmintic; viburnum pru-
ni folium, an antispasmodic.
6. Therapy of digitalis: Digitalis is indicated in /dis-
eases, of the heart, (1) when the heart action is rapid
and feeble, with low arterial tension; (2) in mitral le-
sions when compensation has begun to fail; (3) in non-
valvular cardiac affections; (4) in irritable heart, due to
nerve exhaustion. Digitalis is also a diuretic ; and it is
also used in some forms of nephritis, exopthalmic goitre,
pneumonia, chronic bronchitis, etc.
7. An antiseptic is a substance which prevents or re-
strains putrefaction ; example, cold. A germicide is a
substance or agent which destroys bacteria and their
germs ; example, mercuric chloride. A deodorant is a
substance or agent which destroys foul odors; example,
sulphur dioxide.
TOXICOLOGY.
1. Symptoms of arsenic poisoning: Nausea, faintness
pain in stomach, vomiting, purging, and pain in extrem-
ities; the vomitus is blood-streaked. Minimum fatal dose
is probably between two and four grains. Treatment con-
sists in the administration, of freshly prepared solution
of ferric hydroxide. '
.2. Give an emetic (copper sulphate or apomdrplaineX
or wash out the stomach with a" 6.2 per cent, solution of
potassium permanganate, and then with warm water. Old
French oil of turpentine is said to be the physiological
antidote. Fats and oils are not to be administered. (Note
that Old French, oil of turpentine is not an oil chemically.)
; 3. Opium. Potassium permanganate is a chemical anti-
dote; caffeine, strong coffee, strychnine, nitroglycerin, and
cocaine are said to ne physiological antidotes,
. Strychnine, /Tannin is the chemical -antidote; chloral
and chloroform are physiological antidotes."
78'9
MEDICAL RECORD.
Carbolic acid. Alcohol and sodium sulphate are said to
be antidotes.
THERAPEUTICS.
1. Emetics are: (i) local (which act directly on the
nerve filament in the stomach or pharynx), such as alum
and copper sulphate; and (2) general or systemic (which
act through the circulation), such as apomorphine and
ipecac.
2. See above, Materia Medica, 6, The objection to the
long continued use of digitalis is its cumulative action;
the heart may be so strained by overstimulation that some
slight but sudden exertion may cause cardiac failure.
3. Iodine is an irritant, vesicant; it is used as a counter
irritant in glandular tumors, cysts, hydrocele, skin dis-
eases, fissures. It is an antiseptic and disinfectant. Iodine
is but little used internally. The preparations are: Tinc-
ture of iodine, n#iss; compound solution of iodine,
tt#iij, well diluted; and ointment of iodine.
4. The urinary acidifiers are: Acid sodium phosphate,
benzoic acid, salicylic acid, vegetable acids, salol, and
potassium bitartrate. The bicarbonates are not urinary
acidifiers.
5. Hydrochloric, sulphuric, and nitric acids are all
escharotic. /Further, hydrochloric acid is a bleaching,
deodorizing, and disinfecting agent. Nitric acid is a good
local escharotic because its action is limited to the spot
where it is applied. Sulphuric acid, on the other hand,
has an escharotic action which spreads ; this is owing to
the strong tendency of this acid to unite with water.
, , pathology and bacteriology.
I. Compensation. "The alterations in the systemic
blood supply caused by the valvular defects of chronic
endocardial inflammation are such that, If continued, the
integrity of the body is threatened. To overcome the
impaired functions of the valves and to maintain the
general circulation, the heart increases in size and strength
{compensatory hypertrophy). The period in which this
occurs is called the period of compensation; its duration
is , indefinite. It may be recognized by the physical signs
of valvular disease without any symptoms of disturbed
circulation. Anything which disturbs the . equilibrium as
it how exists, such as acute diseases and excessive work,
leads to ruptured compensation, a condition attended by
cyanosis, dyspnea, . edema, gastric, hepatic, and renal dis-
turbances, and often death. " (Hughes' : Practice of Med-
icine.}
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VIRGINIA.
2. Erysipelas is caused by the streptococcus erysipelatis,
which enters through a wound or abrasion. The skin and
subcutaneous connective tissue are inflamed, and the
lymphatic vessels are also involved; there is little or no
pus formation, but leucocytosis is present, and the strep-
tococci are found in and around the lymphatic channels.
Round cell infiltration is common. The disease spreads
by the lymphatics, and possibly also by direct continuity
3. Syncope is a state of suspended animation due to sud-
den failure of the action of the heart. Shock is a condi-
tion of general depression of vital activity due to a vio-
lent stimulation of the peripheral nerves or nerve end-
ings of the sensory or sympathetic system; it may also
be produced by a sudden or severe emotion. "Collapse
is a condition of extreme depression of the nervous sys-
tem, especially of the cardiac and respiratory centers.
It is usually due to powerful afferent stimuli, but may
be produced by slighter impulses, if preceded by condi-
tions tending to exhaustion. Its chief manifestations are
those of mental and physical prostration. The terms
collapse and shock are often used indiscriminately in
reference to conditions of sudden prostration due to in-
jury of any kind. They are not, however, synonymous
terms. Shock is essentially a reflex vasomotor paralysis
with cardiac inhibition, the effect being produced through
the vagi, depressor, and other nerves. The venous sys-
tem thus becomes intensely congested, the condition being
virtually equivalent to the occurrence of an internal
hemorrhage. The output of blood from the heart is
diminished, and the resulting diminution of arterial
pressure causes acute arterial anemia, in which the brain,
muscles, skin, etc., partake. Combined with this anemia
is inhibition (i.e. slowing) of the heart's action, and les-
sened frequency of the pulse. But the flow of blood from
the veins into the heart being deficient the pulse, instead
of being infrequent and full, becomes infrequent and
weak. Thus the heart has less work to perform as meas-
ured by output, and its pause or recuperative period is
longer; hence it does not become exhausted. In collapse,
failure of the heart and respiration of central origin is
the essential feature, as shown by the frequent weak
pulse and shallow breathing. Shock may precede, merge
into, and terminate in collapse, or the latter may result
directly from the cause of the shock if it is prolonged;
but the shock is neither a necessary antecedent nor an
invariable accompaniment of collapse." (From Quaim's
Dictionary of Medicine.)
Pallor and a weak or imperceptible pulse are found in
all three conditions.
791
MEDICAL RECORD.
HEMATEMESIS.
1. Previous history of gas-
tric, hepatic, or splenic
disease.
2. Blood is vomited.
3. Blood is dark colored and
not frothy.
4. Blood may be mixed with
food.
5. Giddiness or fainlness
usually precede vomiting.
6. Nawsea and weight in
epigastrium.
7. Often followed by me-
lena (black tarry stools).
HEMOPTYSIS.
i. Previous history of pul-
monary troubles.
2. Blood is coughed up.
3. Blood is frothy and
bright red.
4. Blood may be mixed
with sputa.
5. Sensation of tickling in
the throat usually pre-
cedes.
6. Dyspnea and pains in
the chest.
7. Is not usually succeeded
by melena.
"Hematetnesis may be due to ulcer, cancer, cirrhosis,
or congestion of the liver, scurvy, purpura, hemophilia,
malaria, congestion of the spleen, chronic heart disease,
vicarious menstruation, traumatism, yellow fever, toxic
gastritis, or rupture of an aneurysm into the stomach."
(Hughes' Practice of Medicine.)
5. In Cheyne-Stokes respiration the respirations grad-
ually become deeper and more rapid, then they become
shallower and slower, and after a pause of several seconds
this cycle is repeated. It is found in apoplexy, uremia,
chronic nephritis, tuberculous meningitis, fatty degenera-
tion of the heart. The prognosis is grave.
6. Nephrolithiasis. "In the absence of septic infection,
the changes in the kidney are the result of mechanical
irritation, with or without retention of urine according
to the situation of the stone. The irritation induces an
increase in the interstitial connective tissue, whereby the
organ becomes tougher and harder, and the fatty and
fibrous capsules become thickened and fused with one an-
other, and firmly adherent to the parenchyma. The
mucous membrane of the pelvis is injected and swollen,
and the stone tends to become buried in it. If the stone
hinders the outflow from the pelvis, hydronephrotic
changes result. In some cases there is a remarkable over-
growth of fat, which originates at the hilum, surrounds
the calyces, and finally replaces the parenchyma, the kidney
being ultimately transformed into a solid lipoma enclosing
a cavity — the pelvis-— in which the stone is lodged. When
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VIRGINIA.
infective processes are superadded, pyelonephritis and
pyonephrosis ensue. The perinephric cellular tissue also
may become the seat of suppuration and of abscess. The
addition of sepsis may result in the deposition of phos-
phates upon the existing stone/which may thereby be
greatly increased in size. The opposite kidney may re-
main healthy, and may even undergo hypertrophy to com-
pensate for the loss of function in the diseased organ, but
it also is liable to become the seat of stone formation and
of infection and suppuration." (Thomson and Miles'
Surgery.)
J. Toxins are capable of producing antibodies or anti-
toxins ; other poisons, such as alkaloids, cannot do this.
8. The Spirochceta pallida is the exciting agent of syph-
ilis. Bacteria multiply by cell-division. A bacterium about
to divide seems to; be larger than normal, and if it is a
coccus it becomes more ovoid; changes occur first in the
nucleus, and the bacterium just falls in two. Cocci may
divide in one, two, or three directions of space; bacilli
divide transversely to their long axis, and spirilla divide
transversely to their long diameter. Three pathogenic
bacterid that may be conveyed from the soil: Bacillus
tetani, bacillus edematis, and bacillus aerogenes capsulatus.
The bacillus of tetanus is characterized by its peculiar
spore, formed at one end of the bacillus and giving it the
appearance of a pin; it is purely anaerobic, and cannot be
developed at all in the presence of oxygen. It generally
comes from the soil and is found in penetrating wounds.
It appears in two forms, the spore-bearing form, as de-
scribed above, and the vegetative form, which is a short
bacillus with rounded ends, and which may occur singly or
in pairs, or may form long filaments. It grows in gelatin
stab cultures in the middle of the medium and the colonies
look something like a fir tree; its growth is slow, and a
disagreeable odor is at the same time emitted. In bouillon,
it grows near the bottom of the tube, and produces gases.
9. Differences between an antitoxin and a bacterial vac-
cine: 'The antitoxic sera act directly upon the poison
secreted by the living bacterial cell and neutralize its toxic
property, while the bacteriolytic sera affect the bacteria
themselves and destroy them or paralyze their action.
Since the antibacterial sera are without effect upon the
formed toxin, they are mainly useful in practice as a
means of protecting against the bacterial invasion, while
the antitoxic sera (e.g. diphtheria) may be employed to
combat an infection already in progress! Broadly speak-
ing, the latter are curative, the former protective." (Jor-
dan's Bacteriology.)
10. To demonstrate the existence of tubercle bacilli in
798
MEDICAL RECORD.
the sputum: The sputum must be recent, free from par-
ticles of food or other foreign matter ; select a cheesy-
looking nodule and smear it on a slide, making the smear
as thin as possible. Then cover it with some carbol-
fuchsin and let it steam over a small flame for about two
minutes, care being taken that it does not boil. Wash it
thoroughly in water and then decolorize by immersing it
in a solution of any dilute mineral acid for about a
minute. Then make a contrast stain with solution of
Loeffler's methylene blue for about a minute; wash it
again and examine with oil immersion lens. The tubercle
bacilli will appear as thin red rods, while all other bac-
teria will appear blue.
PRACTICE OF MEDICINE.
1. In alcoholic coma the coma is not usually absolute;
there may be an odor of alcohol on the breath, the patient
can generally be aroused by shouting in his ear; there is
no paralysis; the pupils are normal or dilated; respiration
is practically normal; the pulse is first rapid and later
feeble, and the skin cool.
In uremic coma the coma is deep; there may be a
urinous odor to the breath; the urine is scanty and con-
tains albumin; there is slow pulse, with high arterial ten-
sion ; the pupils are usually small and equal ; respiration
is deep and may be quickened; the body temperature may
be above normal, or subnormal.
In cerebral apoplexy there is generally paralysis of the
head and upper limbs, and in left-sided lesions there may
be aphasia; the pulse is slow and full; the respirations are
at first slow, regular, and stertorous, later on becoming of
the Cheyne-Stokes type.
In coma of epilepsy: History of attack, with previous
convulsion ; the coma is of brief duration, and the uncon-
sciousness gradually becomes less ; there may be a bitten
tongue or other scars.
2. Catarrhal pneumonia \s generally secondary to some
other disease such as diphtheria, whooping cough, or
measles ; but it may be primary. It is most frequent in
childhood and old age; in the latter condition it is often
secondary to some exhausting disease. It generally begins
as a bronchial catarrh, the temperature becomes high,
dyspnea and cough are present, the sputum may be bloody
but it is never rusty, and is quite different from that of
lobar pneumonia. Vocal resonance and fremitus may be
increased, and subcrepitant rales may be present.
3. Cardiac hypertrophy: "Inspection reveals fullness
or prominence of the precordium with a distinct impulse.
Palpation detects the impulse one or two intercostal
794
VIRGINIA.
spaces lower down and to the left. It is stronger and more
or less diffused — the heaving iifipulse. Percussion deter-
mines an increase in the area of cardiac dullness vertically
and transversely on the left side of the sternum, unless
the right ventricle is also hypertrophied, when the cardiac
dullness is increased to the right of the sternum. Auscul-
tation in simple hypertrophy without any valvular changes
detects a loud first sound of a somewhat metallic quality,
the second sound being strongly accentuated. In the pres-
ence of valvular disease the characteristic murmurs are
heard in addition." (Hughes' Practice of Medicine.)
Cardiac dilatation : "Inspection detects enlargement
and distention of the superficial veins and an indistinct,
often wavy and diffused, cardiac impulse. If tricuspid
regurgitation is present jugular pulsation will be observed.
Palpation confirms inspection; the impulse is feeble, ir-
regular, and heaving. Percussion serves to determine ex-
tension of the area of cardiac dullness transversely and
especially toward the right side. Auscultation in the pres-
ence of valvular lesions reveals characteristic murmurs.
If there are no valvular lesions the cardiac sounds are
weaker than normal and the first sound is sharper in
quality than usual." (Hughes' Practice of Medicine.)
4. Urticaria is an inflammatory condition of the skin
with development of wheals, and accompanied by itching
and often associated with fever and gastric disturbances.
Herpes zoster is an inflammatory disease with formation
of vesicles along the line of a cutaneous nerve, and accom-
panied by neuralgic pains.
Astigmatism is a condition of the eye in which rays of
a light from a point do not converge on the retina.
Amnesia is loss of memory, especially of the ideas pre-
sented by words.
Aphasia is inability to express ideas in speech or writing.
5. Acute nephritis. Symptoms: The first evidence of
the affection is the edematous condition of the face. This
edema may extend and produce general anasarca. The
urine is scanty, smoky in color, and of a high specific
gravity. It usually contains albumin, blood-cells, blood
casts, epithelial casts, hyaline casts, and free renal epithe-
lium. Retention of urine, uremia, intense itching of the
skin, dyspnea, delusional insanity, and palsies occur.
The treatment consists largely in rest in bed, warmth,
milk diet, and attempts at elimination of waste products.
Free purgation should be secured by means of the salines,
calomel, or compound jalap powder. Diaphoresis may be
favored by the administration of sweet spirits of niter,
and in severe cases pilocarpin, and by the use of warm
baths, warm applications, or the vapor bath. Tincture of
795
MEDICAL RECORD.
digitalis . (tig 5-20 every 4 hours), tincture of strophantus,
or spartein (gr. J4-J4) may be given as diuretics. The
occurrence of uremia will require prompt and energetic
measures. (Pocket Cyclopedia.)
6. Measles. The incubation period is from nine to four-
teen days and the disease is attended by a more or less
extensive catarrhal inflammation of the various mucous
surfaces of the body. The prodromes are coryza, lacrima-
tion, photophobia, hard bronchial or croupy cough, som-
nolence, irritability of temper, and sometimes convulsions.
The temperature rises to ioo° or 104 F., and increases
until the rash is fully developed. On the second day, hard
papules of a. dark purplish color may be seen on the palate,
and on the fourth day an eruption made up of crescentic
patches of small papules upon a slightly reddened base
appears on the neck, forehead, trunk, and extremities.
The rash remains for from one to six days, after which
the symptoms subside and a branny desquamation occurs.
Extension of the catarrhal inflammation may result in
complications such as bronchopneumonia, laryngitis, otitis
media, enteritis, tuberculosis, etc. In healthy children and
in uncomplicated cases recovery is the rule. The treat-
ment consists in rest in bed in a darkened, well ventilated
room, liquid diet, isolation, and the administration of water
or acidulated drinks. In the early stages an enema or mild
laxative is very beneficial. (Pocket Cyclopedia.)
j. Eczema. The skin is red, swollen, hot; a discharge
is present, which leads to crust formation; itching or burn-
ing is always present. The disease is often intractable.
The general health must be attended to; tea, coffee, alcohol,
pastry, sugar, fried meat, starches, should be reduced to a
minimum or prohibited. Cathartics and diuretics are in-
dicated, as are proper hygienic surroundings and suitable
exercise. Soap should not be used over the affected part,
but water containing boric acid may be employed. The
crust and scales must be removed with some oily prepara-
tion, and a dusting powder of bismuth subnitrate, boric
acid, or zinc oxide used. Lassar's paste has also been
recommended. Tar preparations or phenol may relieve
the itching, but care must be taken to use only such
strengths as will not increase the irritation.
8. Malaria is spread by the anopheles mosquito; yellow
fever, by the stegomyia. These mosquitoes should be
kept out of the dwellings, and away from the houses.
Mosquito netting should be used, swarnps and weeds re-
moved, and a general destruction of mosquitoes instituted.
For typhoid, see Hygiene and Preventive Medicine, 5.
9. Follicular tonsillitis requires cold compresses to the
796
VIRGINIA.
neck; and potassium chlorate and iron should be adminis-
tered internally.
10. The factors which influence normal blood-pressure
are : Age, posture, altitude, exercise, excitement and emo-
tion, food, alcohol, tobacco, diseases, and quantity of the
blood. The normal pressure for an adult is about 120 to
130 millimeters of mercury; a more liberal limit places it
at from 100 to 145 for young, healthy adults.
OBSTETRICS AND PEDIATRICS.
1. Pregnancy at the third month should show: Absence
of menstruation, changes in the mammary glands, morning
vomiting, purplish hue of the vagina, the os is soft and
is low in the vagina, and the abdomen is flat
2. "When extrauterine pregnancy exists there are: (1)
The general and reflex 5 symptoms of pregnancy; they have
often come on after an uncertain period of sterility;
nausea and vomiting appear aggravated. (2) Then comes
a disordered menstruation, especially metrorrhagia, ac-
companied with gushes of blood, and with pelvic pain co-
incident with the above symptoms of pregnancy; pains are
often very severe, with marked tenderness within the pel-
vis; such symptoms are highly suggestive. (3) There is
the presence of a pelvic tumor characterized as a tense
cyst, sensitive to the touch, actively pulsating; this tumor
has a steady and progressive growth. In the first two
months it has the size of a pigeon's egg; in the third month
it has the size of a hen's tgg; in the fourth month it has
the size of two fists. (4) The os uteri is patulous; the
uterus is displaced, but is slightly enlarged and empty. (5)
Symptoms No. 2 may be absent until the end of the third
month, when suddenly they become severe, with spasmodic
pains, followed by the general symptoms of collapse. • (6)
Expulsion of the decidua, in part or whole. Nos. 1 and 2
are presumptive signs; Nos. 3 and 4 are probable signs;
Nos. 5 and 6 are positive signs* 3 (American Textbook of
Obstetrics.)
3. Anesthetics are used in~ labor to lessen suffering
produced -by labor pains; to lessen the pain attending ob-
stetric operations;- to Felax the uterus- when its rigid con-
traction interferes/ with ver^^ to promote dilatation of
the os uteri; to reduce excessive nervous excitement which
may interfere with progress of early stage of labor; to
relieve eclamptic convulsions and mania; in cases of
uterine inversion to relax the constricting cervix and so
facilitate replacement; in bipolar version to lessen pain of
introducing the hand into vagina; in precipitate labor to
suspend action of voluntary muscles and retard delivery;
in all cutting operations upon the abdomen; and sometimes
""797
MEDICAL RECORD.
in sewing up a lacerated perineum when many sutures are
required. (From King's Obstetrics.)
Dangers: It lessens the efficiency of the uterine con-
tractions; it predisposes to postpartum hemorrhage; and,
if given too freely, may be followed by headache, nausea,
and vomiting.
4. Morbidity during the puerperium is anything in addi-
tion to the normal accompaniments of an average or
normal labor. Prolonged labor, shock, hemorrhages, mal-
presentation, or malposition, the use of instruments, abnor-
malities of the fetus, and sepsis are the main factors. The
patient should be put in the best possible condition before
labor, all abnormalities should be corrected where possi-
ble, and examinations should only be made when necessary
and always with aseptic precautions.
5. During the third stage of labor, one dram of fluid-
extract of ergot is administered and irritation of the
uterus by friction through the abdominal wall is practised
for ten or fifteen minutes. If the placenta is not expelled
by this time, the uterus is firmly grasped between the
thumb and four fingers and compressed. Firm pressure
is then made from above downward and backward in the
direction of the pelvic canal. This usually causes de-
livery of the placenta. A vulvar pad of salicylated cotton
and carbolized gauze and an abdominal pad and binder are
then applied. (Pocket Cyclopedia.)
6. Conditions that justify the induction of premature
labor: (1) Certain pelvic deformities; (2) placenta praevia;
(3) pernicious anemia; (4) toxemia of pregnancy; (5)
habitual death of a fetus toward the end of pregnancy;
(6) hydatidiform mole; (7) habitually large fetal head.
7. In pharyngeal diphtheria, the patient should be iso-
lated and put to bed, and kept on a milk diet. The room
should be well ventilated, the air kept warm and moist;
mild antiseptic solutions may be used for nose and throat ;
the bowels should be kept open with small doses of calo-
mel; diphtheria antitoxin should be administered as early
$s possible, and in a sufficiently large dose ; tonics and
stimulants should be given as required. The rest of the
family must be kept away from the patient, and all in-
fected articles should be soaked in a solution of corrosive
sublimate or carbolic acid.
8. Empyema is generally secondary to pneumonia, tuber-
culosis, scarlet fever, or other exanthem, suppurative in-
flammations, or traumatism. The pneumococcus, strepto-
coccus, and staphylococcus are the bacteria most frequently
found. The condition is diagnosed by finding the symp-
toms of fluid in the pleural cavity; this is withdrawn by
VIRGINIA.
a needle and on examination is found to be pus; a leuco-
cytosis is also present.
9. In subacute cervical adenitis, the patients are generally
under three years of age, there is no suppuration or casea-
tion, the glands do not adhere to skin or deeper tissues,
and the condition responds to constitutional treatment.
In the tuberculous adenitis, the patients are generally
from three to ten years of age, caseation and suppuration
generally occur, and the tubercle bacilli can be found in
the pus.
To differentiate between tuberculosis of bovine type and
that of human type is difficult. "There are certain slight
but constant differences between the bacilli isolated from
human tissue lesions and those of bovine origin. The
bacilli obtained from cattle are shorter, straighter, and
thicker than those obtained from man; they are cultivated
less readily, as a rule, on artificial media, and they are uni-
formly much more virulent for rabbits. In glycerin broth
2 per cent, acid to phenolphthalein, and containing at least
3 per cent, of glycerin, the reaction produced by human
cultures remains permanently acid to phenolphthalein, while
with bovine cultures the originally acid reaction diminishes
and when the conditions for the multiplication of the
bacilli are favorable a feebly alkaline reaction is eventually
reached." (Jordan's Bacteriology.)
10. Milk, 4 per cent, contains .04 ounces of fat, .04 ounces
of sugar, and .04 ounces of proteids.
As the 15 ounces of milk is diluted to 30 ounces, these
quantities will be .02 ounces.
Sugar, 2 per cent, of 30 ounces =0.6 ounces
Add 1% ounces (in the mixture) =1.125 ounces
Total. . . . 1.725 ounces of su
gar, which is 5K per cent, of 30 ounces.
Lime water, i l / 2 ounces = 5 per cent, of 30 ounces.
Percentages are, therefore : Fat. 2 per cent.
Sugar of milk sH "
Proteids 2 "
Lime water. ..5 "
In 30 ounces: Fat 2 per cent. =0.6 ounces = 18 gram-
Sugar 5J4 " = 1725" =5175"
Proteids 2 " =0.6 " =18
The calorie coefficients (of Atwater) are:
Fats, 8.9; Sugar, 4; and Proteids, 4.
Hence Fat = iS X 8.9 cal. = 160.2 calories
Sugar =51.75 X 4 " =207.0 "
Proteid=i8 X4 " = 72.0 "
Total = 439-2 calories.
799
MEDICAL RECORD.
SURGERY AND GYNECOLOGY.
1. "The excision of tuberculous glands is often an ex-
tensive and difficult operation because of the number and
deep situation of the glands to be removed, and of the
adhesions to surrounding structures. The skin incision
must be sufficiently extensive to give access to the whole of
the affected area, and to avoid disfigurement should, when-
ever possible, be made in the line of the natural creases of
the skin. When glands are to be removed from both
anterior and posterior triangles, the best access is obtained
by a Z-shaped incision, the upper limb running parallel
with the lower jaw, the vertical limb along the sterno-
mastoid, and the lower limb parallel with the clavicle. In
exposing the glands the common facial and other venous
trunks may require to be clamped and tied. Care must be
taken not to injure the important nerves, particularly the
spinal accessory, the vagus, and the phrenic. The infra-
maxillary branches of the facial, hypoglossal and its de-
scending branches, and the motor branches of the deep
cervical plexus are liable to be injured, and should, if
possible, be conserved. The dissection is rendered easier
and is attended with less risk of injury to the nerves if,
instead of a knife, the conical scissors of Mayo are em-
ployed. In the removal of matted glands beneath the
sterno-mastoid, it may be necessary to cut this muscle
across and to reflect the divided ends upwards and down-
wards; if the muscle itself is infiltrated with tubercle, the
affected portion is removed along with the glands. When
the glandular mass is closely adherent to the internal
jugular vein, the operation is rendered easier by ligating
the vein at the root of the neck and removing it from
below upwards along with the glands (Watson-Cheyne).
When the glands are extensively affected on both sides of
the neck, it may be advisable to allow an interval to elapse
rather than to operate on both sides at one sitting. In
closing the wound, the platysma and cervical fascia should
be reunited by means of a fine catgut suture and the skin
edges brought together by Michel's clips; if drainage is
called for, a very fine glass tube should be introduced
through* the skin and fascia at a little distance from the
main wound." (Thomson and Miles' Surgery.)
2. In non-tubercular synovitis of the knee-joint, the knee
is held in a semiflexed position, the joint is hot and painful,
there is a swelling on each side of the patella and also
above that bone, fluctuation may be obtained. ^ Treatment
consists in immobilization of the joint, bandaging, applica-
tion of lead and laudanum lotion, ice is of use in the very
early stages, later on (if pain is present) hot applications
800
VIRGINIA.
arc of service; if the tension is very great leeches or aspi-
ration may be of benefit. Later on, massage and passive
movements are serviceable.
3. Extracapsular fracture of neck of femur. There are :
History of injury; pain, bruising, and swelling; crepitus
(in unimpacted fractures) ; loss of power of walking (as
a rule) Reversion; shortening of the limb; the great tro-
chanter is raised, everted, and is nearer to the mid line.
Treatment : Unless there is great deformity, it is not
advisable to break up impaction. Bony union always
occurs. The patient should be anaesthetized, and traction
kept upon the leg during fixation. A stirrup extension is
first put on, and then the leg is firmly bandaged to a long
Liston splint, with the eversion corrected. The chest is
fixed to the splint by a binder; the foot of the bed is
raised, and a weight of 8 or 10 pounds is put on to the
cord of the stirrup extension. Hodgen's splint may also
be used. Union occurs in six weeks. (From Aids to
Surgery.)
4. Operation for radical cure of umbilical hernia. "(1)
Incise at first through skin and fascia only; the incision
is elliptical, with upper and lower ends in the median line,
and widest part opposite the greatest width of the hernia.
(2) Carefully deepen the wound on one side until the
abdominal aponeurosis (sheath of the recti) is reached,
aiming to come down upon it a short distance to the outer
side of the hernial neck. (3) Having once reached the
rectal aponeurosis, similarly expose this aponeurosis and
the neck of the hernial sac all around the outline of the
ellipse. All bleeding is controlled by clamp and ligature.
(4) The hernial sac is now incised and its contents dealt
with as indicated. Adhesions are separated. Excess of
omentum is ligated and excised. All remaining contents
of the sac are returned to the abdomen — and kept in place
by a large, anchored gauze pad — which is removed just
before closure of the abdomen. (5) The entire sac, with
the umbilicus and the coverings included in the ellipse, is
now excised — dividing the peritoneum in an elliptical man-
ner about the neck of the sac. (6) The peritoneum — or
the peritoneum and transversalis fascia together — is su-
tured with interrupted or continuous gut sutures. (7) The
borders of the abdominal ring — formed by the sheaths and
margins of the recti muscles — are freshened with curved
scissors. The edges of the ring are then brought together
with interrupted sutures of kangaroo tendon or chromic
gut — using either the plain interrupted suture, or the mat-
tress type. (8) The skin and fascia (unless the fascia be
thick enough to require separate gut suturing) are sutured
with interrupted silkworm-gut sutures. (9) The part is
801
MEDICAL RECORD.
then well supported by an abdominal dressing." (Bick-
ham's Operative Surgery.)
5. Points of distinction between Congenital and Acquired
Talipes Equino-varus :
CONGENITAL.
History :
Feet affected:
Circulation :
Muscles :
Electrical reac-
tions :
Growth of bones
Affection has ex-
isted from birth.
Bilateral.
Good.
Little wasting.
Not much im-
paired
Unimpaired
PARALYTIC.
Not developed till
second or third
year.
Generally uni-
lateral.
Limb cold and blue.
Marked wasting.
Absent in paralyzed
muscles.
Impaired.
(Aids to Surgery.)
6. Acute infective osteomyelitis. Causes: "The gen-
eral vitality is lowered, and there is some focus of ulcera-
tion in the mouth or throat, by which organisms enter and
circulate in the blood. All that is now necessary is that
some part of a bone should have its vitality depressed by
a blow, strain, or exposure to cold, and the organisms then
attack it. The bacteria most commonly found are the
staphylococci, but streptococci are present occasionally.
The disease usually begins in the new growing bone at
the end of the diaphysis, rarely in the epiphysis. The
lower ends of the femur and radius, the upper ends of
the tibia and humerus, are the commonest seats.
"Treatment must be very prompt. A free incision must
be made through the periosteum and the pus evacuated.
In any case, whether pus is found or not, the surface of
bone must be gouged away to expose the medulla freely,
and any gangrenous tissue scraped out. The cavity must
then be washed out and freely drained. The wound in the
soft structures is not closed in any part. If symptoms of
pyemia occur, it may be necessary to amputate the limb
through the joint or bone above, so as to cut off the source
of emboli. When a large portion of, or the whole dia-
physis is necrosed, there are two courses: either to cut
short the disease by removing the dead portion at once, or
to leave the sequestrum to stimulate the formation of an
involucrum. Where there is a single bone, as in the arm
and thigh, the sequestrum is left; where there is a double
set of bones, as in the forearm and leg, the sequestrum is
removed at once. Celluloid, zinc, and ivory rods have been
inserted to stimulate osteogenesis. In most cases it is
802
VIRGINIA.
doubtful how much bone is actually dead, so that it is
better to open up the cloacae in the newly-formed involu-
crum to remove the sequestrum. The cavity heals by gran-
ulation." (Aids to Surgery.)
y. In hematocele: The tumor is solid, opaque, tense or
doughy, globular in outline, the onset is generally sudden
with history of an injury; the scrotum may be ecchymosed.
In hydrocele : The tumor is elastic or fluctuating, trans-
lucent, pyriform in shape, and is chronic.
Treatment of hematocele: Rest in bed, with the parts
elevated; application of evaporating lotions; if there is
much effusion, paracentesis may be indicated. Radical
treatment includes excision of the sac, with turning out of
the clot; sometimes castration is necessary, particularly in
old people, or where the pain is very severe.
Treatment of hydrocele: Tap the cavity, and remove
the fluid; radical treatment includes injecting the cavity
(after tapping) with tincture of iodine, or excision (partial
or complete) of the tunica vaginalis.
8. Pyelonephritis "is usually due to extension of sepsis
from the bladder in cases of stricture, enlarged prostate,
and spinal injuries. It may be due to calculus in the kidney
or ureter, or stricture of the ureter. Organisms spread
upwards along the mucous membrane or lymphatics of the
ureter or along strings of mucus, and cause pyletitis. The
bacteria further invade the lymphatics around the renal
tubules and give rise to abscesses. Acute inflammation
causes death from uremia, but if the process is chronic
pyonephrosis is the result. In acute cases a rigor follows
an operation on the urinary passages, associated with fever
and vomiting. The patient gets into a typhoid condition,
and dies in two or three weeks from uremia. In chronic
cases the onset is insidious. There is some pain in the
loin and an irregular intermittent temperature. The urine
is alkaline and contains pus and casts. The case terminates
in death from toxemia. Treatment. — The cause must be
attended to and the bladder regularly washed out, while a
large quantity of fluids should be drunk. Hot fomentations
and cuppings over the loins relieve the pain, and urotropin
is the best internal antiseptic." (Aids to Surgery.)
g. In Colics' fracture, the lower fragment forms a promi-
nence on the dorsal aspect; above the lower fragment is a
well defined hollow. On the palmar aspect, just above the
wrist is a projection formed by the end of the upper frag-
ment. Reduction is effected by extension with the hand
supinated and adducted, combined with manipulation of
the fragments.
10. The symptoms of acute anterior urethritis are: An
incubation period of 24 hours, a tickling or an itching
803
MEDICAL RECORD.
sensation of the meatus, which is red, glazed, and often
colored with grayish, opaline mucus; the discharge is
scanty at first, but gradually increases. At the end of 3
or 4 days the redness and congestion about the meatus
increase and may cause edema, phimosis, and paraphimosis.
Lymphangitis is present. The discharge becomes thick and
purulent. Ardor urinae, chordee, and frequent urination
are now present. At this stage, when the urine is passed
into two glasses, in the first glass the urine will be cloudy ;
in the second, clear. The symptoms just mentioned usually
last for about 4 weeks, when they gradually abate.
Symptoms of Acute Posterior Urethritis. — The discharge
decreases; the: frequency of urination increases; vesical
tenesmus may be present; there is considerable pain;
hematuria, albuminuria, and retention of urine are also
symptoms. When the urine is passed into two glasses,
both specimens will be cloudy.
Treatment of acute anterior urethritis consists in rest,
light diet, cleanliness, laxatives, irrigation with hot solution
or permanganate of potassium (1:2,000) ; a one per cent,
solution of protargol is also used; internally, urinary anti-
septics, such as salol or methylene blue, are used. In acute
posterior urethritis, in addition to the general treatment
mentioned above, opium in suppository may be given;
copaiba or salol may be administered; irrigations are dis-
continued ; complications may require treatment.
11. Operation for lacerated perineum: "The labia are
seized with Allis' forceps at the level of the lowest carun-
culae mytiformes. A guide stitch is placed in the posterior
vaginal wall directly under the external urinary meatus.
By pulling one Allis forceps and the guide stitch in oppo-
site directions outward and downward, the posterior sulcus
is exposed; denudation is required, even in a recent tear,
for a part of it is always submucous. The other sulcus is
exposed and denuded. Then by holding the guide stitch
upward in the middle line and pulling the forceps apart,
the mucous membrane between the sulci is denuded or
freshly tbrn surfaces covered with granulation-tissue are
scraped with the edge of a knife. The ruptured levator
ani muscle iri the posterior sulci is united with a; double
tier suture of chromic gut, two half-hitches being taken
in the stitch as it turns upward after coming down from
the apex of the wound, in its deeper portion to the base.
One knot at the apex of the sulcal denudation secures the
stitch. The retracted ends of the transversus perinei and
bulbocarvernosus muscles are brought together by silk-
worm sutures. Finally, a single stitch at the top of the
perineal wound unites the posterior commissure of the
vulva, restoring the fossa navicularis. The perineal stitches
804
VIRGINIA.
are knotted; they are removed on the twelfth day."
(Hirst's Obstetrics.)
12. Treatment of retroversio uteri: Remove the cause,
if possible; replace the uterus and keep it in position by
pessaries, tampons, and knee-chest position; pelvic mas-
sage and vaginal douches ; proper hygiene, particular atten-
tion being paid to the bowels, clothing, and exercise.
Curative treatment: The choice lies between ventral sus-
pension of the uterus and shortening of the round ligament.
HYGIENE AND PREVENTIVE MEDICINE.
i. The biological (or bacterial) process of sewage dis-
posal is probably the best and safest.
"The actual changes which take place in sewage, as
the result of bacterial action, are somewhat complex and
obscure, but they have been aptly described by Rideal as
consisting mainly of three stages. In the first stage, or
that of anaerobic liquefaction and preparation by hydrol-
ysis, the albuminous matters, cellulose, and fats are broken
up into soluble nitrogenous compounds, fatty acids, phenol
derivatives, gases, and ammonia. In the second stage, or
that of semi-anaerobic disintegration of the intermediate
dissolved bodies, a further formation of ammonia, nitrites
and gases takes place. In the third stage, or that of
aeration and nitrification, ammonia and carbon residues
are changed into water, carbon dioxide, and nitrates."
A septic tank is a specially constructed tank for the
treatment of sewage ; in it the sewage as such is destroyed,
and new substances are built up in its place. In Cameron's
septic tank system "the sewage is first led into a tank
from which air and light are excluded. Digestive changes
take place in the sewage within this tank as the result of
anaerobic bacterial action, which is favored by the dark-
ness, the absence of air, and the perfect stillness at which
the sewage is maintained. Under these circumstances
much of the solid matter is rendered soluble and dissolved."
(Notter and Firth's Hygiene.)
2. The entrance of typhoid fever into the human organ-
ism may be prevented by boiling all water that is to be
used for drinking or for washing dishes, etc. ; milk should
be boiled also ; and no ice should be put in water or other
drink or food; flies should be kept out of the house as far
as possible, by means of screens or otherwise; all dis-
charges from the sick person must be disinfected; all
utensils, dishes, etc., used by the patient must be thoroughly
cleansed, and boiled every day ; soiled linen must be soaked
in a disinfectant solution before being washed ; after each
attendance on a patient, physicians, nurses, and others
should wash their hands in a disinfectant; thorough sterili-
805
MEDICAL RECORD.
zation of all bedding, etc., must be performed after the
disease is over.
3. Filtration is an efficient method of water purification.
Ordinary filter beds for the purification of water are
tanks of varying size, shape, and construction; the walls
may be vertical or sloping; upon the paved bottom are
pipes to carry off the filtered water. Above these pipes are
successive layers of coarse gravel, fine gravel, coarse sand,
and at the top fine sand about four feet deep. Through
these layers the water passes. Dibdin's bacteria beds are
based on "the idea that purification in a filter bed is not
brought about wholly at the surface, but that the whole
bulk of the filter is concerned therein, and experiments
were made to determine the results of filling a bed and
restraining the outflow for different periods, thus giving
the organisms throughout the bed the same opportunity for
action." (Harrington's Hygiene.)
4. See Pathology and Bacteriology, 9.
5. Prophylaxis of hook-worm disease: Children and
adults should be made to wear shoes ; proper toilet facilities
should be provided, and their use enforced; bathing or
wading in shallow water should be forbidden; a proper
water supply should be available for drinking purposes ;
and prompt recognition and treatment of all cases should
be encouraged.
medical jurisprudence.
1. Reference must be made to a large textbook on
Pathology or Medical Jurisprudence; the answer is too
long for insertion here.
2. "Supposing the immersion not to have been over two
or three hours, and the inspection to be made immediately,
the face will be found to be pale, the expression placid,
the eyes half open, the eyelids livid, and the pupils dilated,
the mouth half closed or open, the tongue swollen and
congested, often indented by the teeth, and perhaps
lacerated; the lips and nostrils covered with a mucous
froth, which issues from them. The skin is cold and pale,
and generally contracted so as to present the appearance
called 'gooseskin.' This, being a vital act, is a pretty
sure sign that the body was living when immersed in the
water. It is not dependent on cold, as was at one time
supposed. Cadaveric rigidity usually comes on early in the
drowned, hence the body is often found with the limbs
stiffened. (Reese's Medical Jurisprudence.)
3. To constitute a "live birth," there must be (1) com-
plete extrusion of the child from its mother's body, and
(2) some certain sign of life. The latter would be estab-
lished by one or more of the following: pulsation of the
806
WASHINGTON.
cord, beating of the child's heart, motions of the limbs,
twitchings of the muscles, wrinkling of the brows, pucker-
ing of the face, opening of the eyes, even if respiration
does not take place. (From Witthaus and Becker's Med-
ical Jurisprudence, etc.")
4. "The general appearance of a child that has been bom
alive at full term and respired is something like the fol-
lowing: The remains of the vernix caseosa are usually
seen under the axilla, and behind the ears. The eyes re-
main partly open, and cannot be permanently closed. The
ears are not so close to the sides of the head as is the
case in children born dead. The hair is perfectly dry and
clean, and the swelling at the back of the head (caput
succedaneum) is more prominent \han in the still-born.
In the dead-born infant who has died immediately before
its birth the vernix caseosa will be found, more or less,
over its entire body. The eyes are closed and the ears are
in close apposition to the head. The eyelids when raised
close again. The mouth is closed, and from the nostrils
is often observed exudation of watery blood. The hair is
glued to the head. The thorax is unexpanded and flat-
tened, and the lungs are situated at the posterior part of
the thoracic cavity; they are greater in length than in
breadth, and their margins are rounded; upon pressure
no crepitation is elicited. Within the trachea, which is
flattened, may be found a viscid mucous secretion. The
remnant of the umbilical cord appears fresher looking than
that of a child that has survived its birth a few hours."
(Her old's Legal Medicine.)
5. Civil responsibility refers to the responsibility which
an individual has in reference to such actions as witnessing
or making a will or contract, or marrying. Criminal re-
sponsibility refers to the responsibility which an individual
has to the State for the commission of a criminal act.
STATE BOARD EXAMINATION QUESTIONS.
Washington State Board of Medical Examiners.
[Answer ten (10) questions only in each paper.]
anatomy.
1. Describe the sacro iliac articulation, giving liga-
mentous attachment and nerve supply.
2. Describe the knee joint, giving ligamentous attach-
ments, nerve and blood supply.
3. Describe the heart and its position. Give size and
weight of same, with blood supply.
4. Describe the femoral artery, and give its relation
to anterior crural nerve and femoral vein.
807
MEDICAL RECORD.
5. Describe the collateral circulation after ligature of
axillary artery.
6. Name the cranial nerves in the order of their pas-
sage through cranial foramina.
7. Describe the brachial plexus.
8. What are ductless glands? Name them.
9. Describe the lungs, giving nerve and blood supply.
10. Where is the prostate gland situated? Describe
its form and size.
11. Name the muscles of the eyeball and give nerve
supply.
12. What is the inguinal canal? Describe the in-
ternal and external abdominal ring. Give boundaries
of the canal.
PHYSIOLOGY.
1. Define human physiology.
2. Define protoplasm, and give the characteristic
properties of living protoplasm.
3. Describe in detail how the placenta performs its
functions.
4. Name the nerves concerned in the constriction, and
in the dilatation of the pupil of the eye.
5. What is the function of the cerebellum?
6. Describe the phenomena of (a) asphyxia, (b)
syncope, (c) sleep.
7. What is the order of occurrence of rigor mortis
in the different parts of the body?
8. State the manner in which the blood circulates
through the heart, and the lungs, beginning at the right
auricle.
9. What would be the effect of a transverse section of
(a) the anterior root of a spinal nerve, (6) the pos-
terior root of a spinal nerve?
10. Describe (a) chyme; (b) chyle.
11. Why does the blood remain fluid in the body in
life and coagulate when shed?
12. What effect is produced on the heart action by
stimulation of the cardio inhibitory center?
HISTOLOGY,
1. Describe an erythrocyte. Tell how a normal cell
differs in an adult human being from that found in
early fetal life.
2. Define anabolism; catabolism. Discuss the vital
properties of cells.
3. What layers constitute the blastoderm? (a)
Name the structures developed from the mesothelium ;
(b) the structures developed from the mesenchyme
group of cells.
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WASHINGTON.
4. Name the five groups of adult tissues.' Describe
adipose tissue. ^ :
5. Make a diagram of a cross section of the humerus,
and then describe the development of the Haversian
system of canals.
6. Name the histological characteristics of the cardiac
muscle.
7. Describe the Peyer's patches (agminated follicles).
8. Describe a section of the human cornea.
9. Differentiate between a section of the thymus
gland, and a like section of a small lymph gland.
10. Describe the structural differences between the
Malpighian corpuscles of the spleen and those of the
kidneys — make drawing.
11. Describe the histological structure of the lungs.
12. Describe, histologically, tactile corpuscles, where
found; Pacinian bodies, where found.
GYNECOLOGY.
1. What is gynecology?
2. Name the external genital organs.
3. Define amenorrhea, dysmenorrhea, menorrhagia.
4. Give the forms of vaginitis: Give the symptoms of
senile vaginitis.
5. Give causes and symptoms of endometritis.
6. Give the varieties of pelvic hematocele.
7. Differentiate: fibroid tumor, gravid uterus, and
ovarian cyst.
8. Give symptoms and prognosis of carcinoma of the
uterus.
9. Give symptoms and diagnosis of uterine polypi.
10. Differentiate: prolapsus uteri, rectocele, and
cystocele.
11. Give varieties, causes, and symptoms of uterine
displacement.
12. What are the symptoms of pelvic abscess? What
the prognosis?
PATHOLOGY.
1. Mention the different kinds of tumor of the uterus,
with short history of each.
2. Describe progressive changes in acute yellow
atrophy of the liver.
3. Discuss hydrocephalus.
4. Give short definition of the following terms: Cys-
tocele, embolus, keloid, lipoma, sycosis, variocele, mas-
titis, cholemia, apoplexy and clavus.
5. Describe leukemia; what other disease does it
closely resemble and how differentiate.
6. Discuss epithelioma.
809
MEDICAL RECORD.
7. Give macroscopical pathology of small intestines
in typhoid fever.
8. What are the findings in mitral regurgitation.
9. Give pathological anatomy in chronic parenchy-
matous nephritis.
10. Describe fully the progressive changes in gonor-
rheal rheumatism.
11. What is the pathology of locomotor ataxia.
12. Describe the pathogenesis of renal calculi.
GENERAL DIAGNOSIS.
1. How would you diagnose an acute attack of ap-
pendictis? Differentiate between an acute attack and
an un-ruptured ectopic gestation.
2. Describe the cardinal symptoms of exophthalmic
goitre. When should you operate and what are the
dangers in operating?
3. Describe burns of the first, second and third degree.
What complications are likely to arise in the latter
class?
4. Describe the symptoms of intestinal obstruction
and differentiate from stone in the ureter?
5. Give differential diagnosis between concussion and
compression of brain.
6. What sequel frequently follows depressed fracture
of skull? How would you locate such by symptoms in
the superior parietal region?
7. Differentiate between tabes dorsalis and multiple
sclerosis.
8. Differentiate between pleuritic effusion and gan-
grene of lungs.
9. Differentiate between acute albuminuria and in-
terstitial nephritis.
10. Describe acute otitis media, and what complica-
tions are likely to arise?
11. Give diagnosis between Landry's paralysis and
rabies?
12. Describe symptoms and name causes of sacroiliac
disease. Differentiate from sciatica.
BACTERIOLOGY.
1. Give four methods by which microorganisms gain
entrance to the body and name two diseases of each
class.
2. Name the pathogenic agents in the following dis-
eases: diphtheria, uncinariasis, syphilis, erysipelas,
malaria (estivoautumnal), abscess, acute osteomyelitis,
purulent salpingitis.
3. What is meant by infection? Give the usual symp-
toms.
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WASHINGTON.
4. Define following terms: chemotaxis, strict para-
site, saphrophyte, opsonins, agglutinin, antiseptic, disin-
fectant.
5. Describe and give the characteristics of pneumo-
coccus.
6. In a case of suspected diphtheria how would you
arrive at a positive diagnosis? Describe process.
7. Differentiate between: vaccines and antitoxins;
sapremia and septicemia; septicemia and pyemia.
8. What bacteria most frequently cause puerperal
fever?
9. Give short description of Gram's method of stain-
ing and state which of following bacteria are "Gram
positive" : tubercle bacillus, typhoid bacillus, gonococcus,
diphtheria bacillus, anthrax bacillus.
10. Describe the bacillus of typhoid fever and give
characteristics.
11. What is a pure culture? Name five culture media
in common use.
12. Give characteristics of the tubercle bacillus.
CHEMISTRY.
1. Define chemistry, atom; molecule; density.
2. Define carbon. Illustrate, (a) Free; (6) In com-
bination.
3. What are hydrocarbons? Illustrate.
4. What gaseous matters are found in the body during
health?
5. What is sodium chloride and daily amount elimi-
nated?
6. What are curative sera and how prepared?
7. Give pigments of bile, blood, urine.
8. What is the caloric value of food? How serviceable
in the dietaries of (a) Infancy; (6) adult; (c) old age.
9. Give quantitative estimation of total acidity of gas-
tric contents.
10. Give four abnormal constituents of urine and
method of determining same.
11. Give ferments of pancreatic fluid and their func-
tion.
12. Essential differences between human and cow'g
milk.
OBSTETRICS.
1. (a) What is placenta prsevia? (b) What is its
frequency? (c) Symptoms? (d) Diagnosis? (e) What
would you do if you had a case?
2. (a) What is prolapse of the funis? (b) What is
its cause? (c) Diagnosis? (d) Danger? (e) How
would you manage a case?
811 A
MEDICAL RECORD.
3. (a) What is the placenta? (b) At what time does
it assume its functions? (c) From what is it formed?
(d) What are its functions? (e) What is the channel
of communication between placenta and foetus?
4. How would you deliver a brow presentation?
5. (a) What is ophthalmia neonatorum? (b) What is
its cause? (c) Symptoms? (d) What are the means
of prevention?
6. (a) What is the vitellus? (b) Allantois? (c) ■
Amnion? (d) Chorion?
7. (a) What is eclampsia? (b) What per cent of
cases occur in primiparae? (c) What is the prognosis
to mother and child? (d) What is the condition of the
urine? (e) What is its frequency? (/) If it occurs
at eighth month of pregnancy, how should it be man-
aged?
8. (a) What is eutocia? (b) What is dystocia?
(c) Name varieties of dystocia?
9. (a) What is hydatid pregnancy? (b) What is
its frequency? (c) What are its symptoms?
10. (a) What is ectopic pregnancy? (6) Give the
varieties? (c) What is the cause? (d) Between what
ages does it usually occur? (e) What are the symp-
toms? (/) What are its terminations?
11. Differentiate an ovarian cyst, a uterine fibroid
and pregnancy at the fifth month.
12. Tell what you know about pelvimetry.
TOXICOLOGY.
1. Mention five (5) emetic poisons.
2. Method of conducting autopsy in death from
arsenic poisoning.
3. Give one test for discovery of a mineral poison.
4. Differentiate tissue change in poisoning from
hydrochloric, sulphuric, nitric and carbolic acid.
5. Give symptoms of acute arsenical poisoning.
6. Give symptoms of mercurial poisoning.
7. Method of examining dead caused by gunshot
wounds.
8. Infanticide* — (a) How determine if child born
alive? (6) How long did it live after birth? (c) How
determine criminal violence?
9. What signs manifest on pelvic organs in case of
criminal abortion?
10. Post-mortem appearances in death from hanging,
(a) External; (b) Internal.
11. What are the signs of recent delivery (par-
turition) ?
12. Source of meat and fish poisoning.
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WASHINGTON.
HYGIENE.
1. What are ptomaines. Give usual symptoms of
ptomaine poisoning and the most common source.
2. In treating a case of scarlet fever what precau-
tions should be taken to prevent spread of the con-
tagion — by attendants? by yourself?
3. What is sewer gas and how is it objectionable.
4. State period of incubation, date of eruption and
limit of quarantine in the following diseases: measles,
variola, scarlet fever?
5. Give sanitary methods for the production and
marketing of pure milk. Name five diseases that may
be caused by impure milk.
6. What is Pasteurized milk? Give some advantages
and disadvantages.
7. What do you understand by natural immunity?
What is acquired immunity? Give examples.
8. Describe fully the precautions necessary in the
care of a typhoid fever patient.
9. Describe two methods of disinfecting a room
20 x 15 x 10 feet, giving the amount of materials
necessary.
10. Name the requisites of a successful house water
filter.
11. Name six diseases to which the habitual alcohol
drinker is predisposed.
12. How is malaria communicated? How may ma-
larial districts be made healthy?
ANSWERS TO STATE BOARD EXAMINATION
QUESTIONS.
Washington State Board of Medical Examiners,
anatomy.
1. The Sacroiliac articulation is an amphiarthrodial
joint formed between the lateral surfaces of the sacrum
and ilium. The ligaments are: (1) The anterior sacro-
iliac, connecting the anterior surfaces of the sacrum and
ilium; (2) the posterior sacroiliac passing chiefly down-
ward and inward from the rough part of the ilium to
the posterior part of the sacrum; three of the fasciculi
are of large size, two of them constitute the short sacro-
iliac ligament and one of them is the long or oblique
sacroiliac ligament; (3) the inter osseus ligaments
which fill up the hollow existing in the posterior of the
joint, and are completely covered by the posterior sacro-
iliac ligament. The nerve supply is from the superior
gluteal, and sacral plexus.
813
MEDICAL RECORD.
2. The knee joint is a ginglymus, and is formed by
the condyles of the femur, the head of the tibia, and
the patellae. . "The external ligaments: ^ The anterior
or ligamentum patellae is the continuation of the ten-
don of the triceps extensor. Above it occupies the apex
and rough marking, on the lower and posterior surface
of the patella ; below it is attached to the lower part of
the tubercle of the tibia. There is a bursa between the
upper part of the tubercle and the ligament. The poste-
rior ligament (ligamentum posticum Winslowii), broad
and thin, covers the back of the joint. It consists of a
central and two lateral parts. The lateral parts spring
above from the femur above the condyles and are at-
tached below to the head of the tibia. The central part
is derived from an expansion of the semi-membranosus
tendon, and passes from the inner tuberosity of the
tibia to the inner side of the upper part of the outer
condyle of the femur. The internal lateral ligament,
broad and flat, is attached above to the inner condyle
of the femur; below, to the margin of the inner tuber-
osity, to the internal fibrocartilage, and to the inner sur-
face of the shaft of the tibia for iy 2 inches. The long
external lateral ligament, a rounded cord, is attached
above to the external condyle of the femur, and below
to the external part of the head of the fibula, dividing
the biceps tendon into two parts, a bursa intervening.
The short external lateral ligament, very indistinct, lies
parallel and behind the preceding, attached above to the
outer condyle of the femur, and below to the styloid
process of the fibula. The capsular ligament, thin, fills
up the intervals between the special ligaments; it is at-
tached to the margins of the articular surfaces of the
bones, and blends with the fascia lata of the thigh:
above it receives expansions from the vasti (lateral
patellar ligaments).
"The Internal Ligaments: The anterior or exter-
nal crucial ligament is attached to the depression in
front of the spine of the tibia and to the external semi-
lunar fibrocartilage; it passes upwards, backwards,
and outwards to the posterior part of the inner side of
the external condyle of the femur. The posterior or in-
ternal crucial ligament is attached to a depression be-
hind the spine of the tibia, to the popliteal notch, and
the posterior border of external semilunar fibrocarti-
lage, this latter slip being sometimes called the ligament
of Wrisberg; it passes upwards, forwards, and inwards,
the posterior fibers attached by side of oblique curve of
inner condyle, the anterior ones to the fore part of inter-
condylar fossa and to the anterior part of the outer
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WASHINGTON.
surface of the inner condyle. The semilunar cartilages
are thicker at the circumferences than at the central
margins, and serve to deepen the cavities for the head
of the femur. The internal semilunar cartilage is oval
in shape, the anteroposterior diameter being the longer.
Its anterior extremity is attached to the tibia in front
of the anterior crucial ligament, and the posterior ex-
tremity in front of the posterior crucial ligament. The
external semilunar cartilage is nearly circular; its an-
terior extremity is attached to the tibia in front of the
spine, the posterior extremity to the back of the spine."
(Aids to Anatomy.)
3. A line from the lower border of the second left
costal cartilage (one inch from sternum) to upper
border of third right costal cartilage (half inch from
sternum) represents the base line; the right side will
be a line drawn from right side of upper limit to sev-
enth right chondrosternal articulation; the lower limit
is a line from this last point to the apex (in fifth
intercostal space, three and one-half inches from mid-
line) ; the left side, from left end of upper border to
left of apex. The valves are: Aortic, mitral, tri-
cuspid, pulmonary (and Eustachian and coronary.)
The aortic valves are behind the third intercostal
space, close to the left side of the sternum. Pulmonary
valves, in front of the aortic, behind the junction of the
third rib, on the left side, with the sternum. Tricuspid
valves, behind the middle of the sternum, about the level
of the fourth costal cartilage. Mitral valves behind the
third intercostal space, about one inch to the left of the
sternum.
In the right auricle are the Eustachian and coronary
valves ; the former is situated between the anterior mar-
gin of the inferior vena cava and the auriculo-ventricu-
lar orifice; in the fetus it directs the blood from the in-
ferior vena cava through the foramen ovale into the
left auricle; the coronary valve prevents the regurgita-
tion of blood into the coronary sinus during the auricu-
lar contraction. In the right ventricle are the tricuspid
and semilunar valves; the former prevents the blood in
the right ventricle from flowing back into the right
auricle during ventricular systole; the latter guards the
orifice of the pulmonary artery. In the left ventricle
are the mitral and semilunar valves; the former acts
similarly to the tricuspid; the latter guards the orifice
of the aorta. The heart is about 5 x 2% x SV2 inches,
and weighs about ten ounces. It is supplied with blood
by the right and left coronary arteries.
4. The femoral artery begins at Poupart's ligament;
815
MEDICAL RECORD.
it is the continuation of the external iliac, and passes
down the fore part and inner side of the thigh, to ter-
minate at the opening in the adductor magnus at the
junction of the middle with the lower third of the thigh,
where it becomes the popliteal artery.
In the upper part of its course, the anterior crural
nerve is on the outer side of the artery, and the femoral
vein is to the inner side; lower down the vein passes
behind the artery.
5. If the axiliary artery is ligated (below its sub-
scapular branch), the collateral circulation will take
place by : ( 1 ) Anastomoses between the branches of
the posterior circumflex and the superior profunda;
(2) anastomoses between the branches of the subscapu-
lar and the superior profunda; (3) anastomoses
through various muscular branches of the artery.
6. Cranial nerves: I. Olfactory; II. Optic; III. Mo-
tor oculi; IV. Pathetic or Trochlear; V. Trifacial; VI.
Abducens; VII. Facial; VIII. Auditory; IX. Glosso-
pharyngeal; X. Pneumogastric ; XI. Spinal accessory;
XII. Hypoglossal.
7. The brachial plexus is formed by the union and
subsequent division of the anterior divisions of the fifth,
sixth, seventh, and eighth cervical and the first dorsal
nerves. The union of the fifth and sixth makes the up-
per trunk; the seventh forms the middle trunk, and the
eighth cervical and first dorsal make the lower trunk.
Each of these trunks is divided into an anterior and a
posterior branch. The anterior branches, from the up-
per and middle trunks, make the upper or outer cord of
the plexus; the anterior branch of the lower trunk be-
comes the lower or inner cord; the three posterior
branches unite to form the posterior or middle cord.
The plexus lies between the Scalenus anticus and me-
dius. The branches are: (1) Above the clavicle; com-
municating, muscular, posterior thoracic, and supra-
scapular. (2) From outer cord: External anterior
thoracic, musculocutaneous, and outer head of median.
(3) From inner cord: Internal anterior thoracic, lesser
internal cutaneous, ulnar, and inner head of median.
(4) From posterior cord: Subscapular, circumflex, and
musculospiral.
8. The ductless glands are glands which do not pos-
sess excretory ducts. They are the spleen, thyroid
parathyroids, thymus, suprarenals, carotid, coccygeal
pineal, and pituitary body.
9. "The lungs are two in number, occupying the lat-
eral cavities of the chest, separated from each other by
the heart and structures within the mediastinum. They
816
WASHINGTON.
accurately fill the cavity of the chest at all times, and
are covered by the pleura. They are conical in shape,
presenting each a base, apex, two borders, and two sur-
faces. The apex extends upward above the level of the
first rib; the base occupies the convex surface of the
diaphragm; the external, or thoracic surface is ac-
curately applied to the wall of the thorax; the inner
surface is in contact with the pericardium, and is
marked by a depression, the hilum pulmonis, at the root
of the lungs. The posterior border rests on either side
of the spinal column, and the anterior border is thin
and overlaps the pericardium. The root of each lung,
situated near its middle, is composed of the following
structures, surrounded by a reflection of pleura : Bron-
chus, pulmonary artery, pulmonary veins, bronchial
glands, bronchial vessels, posterior and anterior pul-
monary plexuses of nerves, connective tissue. The
right lung has three lobes; the left but two, of which
the lower is the larger. The nerves are derived from
the anterior and posterior pulmonary plexuses of the
pneumogastric and sympathetic; ganglia are found up-
on these nerves. The blood supply is from the bronchial
arteries." (Young's Handbook of Anatomy).
10. Prostate gland is about 1^ x % x V2 inches, and
weighs about three-quarters of an ounce. It resembles
a chestnut in size and form. It is situated at the neck
of the bladder, and surrounds the first part of the
urethra. It consists of fibromuscular (unstriated) tis-
sue with imbedded follicular pouches, the whole enclosed
in a firm fibrous capsule, continuous in front with the
triangular ligament, and behind with the posterior
layer of the deep perineal fascia.
11. Muscles of the eyeball: Rectus superior, rectus
inferior, rectus externus, rectus internus, obliquus supe-
rior, and obliquus inferior; the rectus externus is sup-
plied by the abducens nerve, the superior oblique by the
trochlear, and the others by the motor oculi.
12. The inguinal canal is an oblique canal situated a
nine auove and running parallel with Poupart's liga-
ment. It is from an inch and a half to two inches in
length, runs downward and inward, and extends from
the internal abdominal ring to the external abdominal
ring.
Its boundaries are: In front: the skin, superficial
fascia, aponeurosis of the external oblique, and (for its
outer third) the internal oblique. Behind: the con-
jointed tendon, the triangular fascia, the transversalis
fascia, subperitoneal fat, and peritoneum. Above: the
fibers of the internal oblique and transversalis.
817
MEDICAL RECORD.
Below: Poupart's ligament and the transversalis fascia.
Contents: The spermatic cord in the male, and the
round ligament in the female.
Internal abdominal ring: "An oval opening lying
in the transversalis facia, half way between the ante-
rior superior iliac spine and symphysis pubis, and about
1.3 cm. {y 2 inch) above Poupart's ligament. Superior
and external boundary — curved fibers of transversalis.
Inferior and internal boundaries — deep epigastric ves-
sels. Transmits spermatic cord in male — and round
ligament in female. Infundibuliform process of fascia
transversalis strengthens its opening."
External abdominal ring: "A triangular opening in
aponeurosis of external oblique immediately above and
just external to crest of os pubis. Bounded, inferiorly,
by crest of os pubis — superiorly by intercolumnar fibers,
strengthened by intercolumnar fascia; internally by in-
ner or superior pillar; externally by outer or inferior
pillar. Transmits spermatic cord in male and round
ligament in female." — (Bickham's Operative Surgery.)
PHYSIOLOGY.
1. Human physiology is that branch of science which
deals with the functions of the human body in a state of
health.
2. Protoplasm is the matter of which cells are made ;
it is the physiological basis of life, and consists of
water, protein, lecithin, cholesterin, phosphates, chlo-
rides, and other substances. Its constitution is un-
known. Properties of living protoplasm: Irritability,
or power of responding to a stimulus; power of move-
ment; power of assimilation; power of growth; power
of excretion; power of reproduction.
3. "As a separate organ, the placenta dates from the
third month of pregnancy, and from that time gradu-
ally increases in size until the termination of preg-
nancy. The chorionic villi lose Langhans' layer of
cells, and embed themselves into the interglandular
stroma of the decidua basalis, and sometimes penetrate
the mouths of the small veins. The syncytium also pen-
etrates the endothelium of the decidual arterioles, and
large blood sinuses are thus formed. By this arrange-
ment, the fetal and maternal blood, while kept separate,
are brought into such close contact that osmosis may
readily occur between them, thus permitting the absorp-
tion of nutritive material from the maternal into the
fetal circulation, the excretion of urea and other waste
products of fetal metabolism, the passage of oxygen to
the fetus, and the excretion of carbon dioxide from it.
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WASHINGTON.
The functions of the placenta may be summed up as fol-
lows : 1. It is nutritive, allowing of the passage of nu-
tritive material to the fetus. 2. It is respiratory. Oxy-
gen passes to, and carbon dioxide from, the fetus. 3. It
is excretory, allowing the escape of urea and other
products of fetal metabolism. 4. It has a glycogenic
function. Glycogen is stored in its cells for the future
use of the fetus. 5. It is iron storing, by which iron in
organic combination is passed from the maternal cir-
culation into the fetal circulation to be stored in the
liver cells of the fetus, in order to aid in the formation
of new colored blood corpuscles." — (Lyle's Physiology.)
4. Constriction of the pupil is caused by the motor
oculi; dilatation, by the cervical sympathetic.
5. Functions of cerebellum: (1) Coordination of
muscular movements; (2) it is concerned in maintain-
ing the equilibrium of the body.
6. Asphyxia. "In considering the phenomena of as-
phyxia, it is necessary to distinguish between rapid
asphyxia, produced by complete obstruction to the en-
trance of air, and slow asphyxia, which is gradually
established. The phenomena of asphyxia are divisible
into three stages, which are easily observed in animals,
especially in the dog. In the first stage, called the stage
of exaggerated breathing, hyperpnea, the respiration is
more rapid and deeper, due to the C0 2 ; then the phe-
nomena of dyspnea appear, the extraordinary muscles
of inspiration and expiration are called into play, the
abdominal muscles contract forcibly, the pupils are
small. This stage lasts about a minute. Second stage,
convulsive stage. Here the inspiratory muscles lose
their force, while the expiratory movements become
more active; next all the muscles of the body, including
the expiratory ones, become convulsed, due to the car-
bon dioxide stimulating the central nervous system.
This stage lasts about a minute. Third stage, or stage
of exhaustion. This usually comes on suddenly, the car-
bon dioxide paralyzing the center of respiration; the
pupils dilate, the eyelids do not close when the cornea
is touched; a state of general calm ensues, which is in
marked contrast with the previous agitation ; conscious-
ness is abolished; the animal lies motionless and seems
dead; occasional inspiratory acts take place, then they
become feebler and of a gasping character; finally, the
nostrils dilate, the limbs of the animal are extended,
opisthotonos ensues, the pulse disappears, and death
closes the scene. This state lasts about three minutes.
This pulseless condition is properly denominated as-
phyxia. The phenomena of slow asphyxiation follows
819
MEDICAL RECORD.
the same course, but less rapidly." (Ott's Physiology.)
Syncope is the complete, and often sudden, loss of
motion and sensation with diminution or suspension of
heart pulsations and respiratory movements; it may
indicate cardiac disease.
Sleep. — "This phenomenon is one of many instances
of the rhythmic activities of the central nervous system.
From time to time all animals with a well-developed
nervous system go to sleep, during which psychical ac-
tivity is at its lowest point. To reach this condition the
most important favoring factor is an exclusion of all
or most of the impulses from the central nervous sys-
tem. In a well-known case of Strumpell, in which, from
a complicated anesthesia, all sensory impulses were
limited in their entrance to a single eye and a single
ear, the patient could be put to sleep at will by closing
the eye and stopping the ear. In addition, sleep has
been attributed to the following influences: 1. Chemical
influences. 2. Circulatory influences. 3. Histological
influences. Those who hold to chemical influences in
the nroduction of sleep maintain that during normal
activity of the body various substances are formed
which are circulated in the blood and directly lessen the
activity of the nerve cells or indirectly diminish the
supply of blood in the brain. In the theories of circu-
latory influences a fatigue of the vasomotor center is
looked upon as the cause of the anemia of the brain
resulting in sleep. In the third set of theories sleep is
supposed to be due to a separation of the dendrites of
the brain cells due to an active contraction or to an
intrusion of neuroglia cells between them. During
sleep the capability of the nervous system to transmit
impulses is not entirely lost. The cerebral cortex is
most affected, the spinal cord least. The close relation
between dreams and external stimuli is well known and
it has been proved experimentally that vasomotor
changes induced by external stimuli may take place
without awakening the sleeper. The period of deep
sleep is short and falls within the first two hours after
its onset. During this time the pulse and breathing
are slower, the intestines and bladder are at rest, the
output of carbon dioxide is lessened, and the consump-
tion of oxygen still more so ; metabolism is less vigorous
and the temperature falls. The respiration is said to
become thoracic in type and to take on a more or less
pronounced Cheyne-Stokes rhythm. The visual axes
are directed upward and inward, but the pupils are
contracted. The latter is peculiar, since an absence of
light should bring about dilatation. This is connected
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perhaps with important actions taking place in lower
levels of the brain." (Guenther's Physiology.)
7. Rigor mortis first appears in the muscles of the
lower jaw, then spreads to the muscles of the face and
neck, then to the muscles of the thorax and abdomen,
then to those of the upper extremity, and finally to those
of the lower extremity.
8. "The left ventricle pumps the arterial blood
through the large arteries, the small arteries, and the
arterioles into the systemic capillaries. For the most
part between the capillaries and the tissues is the tissue
fluid, and across this the tissues acquire the oxygen
from the arterial blood and return carbon dioxide to
the blood in the capillaries. The blood which leaves the
tissues is venous. The venous blood returns from the
capillaries through the small veins into the larger veins,
and the largest veins pour the blood back into the right
auricle. It will thus be seen that the right side of the
heart is occupied with the pulmonary circulation and
the left side of the heart with the systemic circulation.
The right auricle receives the venous blood as it re-
turns from the tissues, arid transmits it to the right
ventricle. The function of the right ventricle is to
pump the venous blood through the pulmonary arteries
into the lung capillaries, where the venous blood becomes
oxygenated. The oxygenated blood returns by the pul-
monary veins to the left auricle, and the arterial blood
is then received into the left ventricle." — (Lyle's Physi-
ology.)
9. Transverse section of the anterior root of a spinal
nerve causes loss of motion and degeneration of the
peripheral portion of the anterior root fibers; the sen-
sory fibers of the posterior root are not affected.
Transverse section of the posterior root of a spinal
nerve causes loss of sensation and degeneration, which
latter differs according as the section is made on the
proximal or peripheral side of the ganglion. If the sec-
tion is made between the cord and the ganglion, degen-
eration only occurs in the piece severed from the gang-
lion, but connected with the cord. If the section is made
beyond the ganglion, degeneration occurs in the fibers
peripheral to the lesion.
10. Chyme is a thick, acid liquid, which is the result
of gastric digestion; it consists of proteids, salts, lique-
fied fat, and undigested matter. It is passed forward
into the duodenum.
Chyle is that portion of the lymph which is found in
the small intestine during the period of digestion; it is
mainly composed of water, proteids, and fats, the latter
giving it a milky appearance.
821
MEDICAL RECORD.
11. The reason why the blood remains fluid in the
body during life and coagulates when shed, is because
during life the blood is kept moving and because the
fibrin enzyme which normally exists in the blood plasma
is neutralized by the antithrombin which is secreted by
the liver cells.
12. Stimulation of the cardioinhibitory center inhibits
or restrains the action of the heart; the frequency of
the heart's action is diminished, and the strength of its
contractions is lessened.
HISTOLOGY.
1. An erythrocyte is a non-nucleated, circular, con-
cave disc; it contains red coloring matter, hemoglobin;
and is about 1/3200 inch in diameter. In adult life it
is non-nucleated; in fetal life it is nucleated.
2. Metabolism is the entire series of changes that
occur in a cell or organism during the processes of nu-
trition. It is of two kinds: (1) Assimilative or con-
structive (anabolism), and (2) destructive (catabol-
ism).
The manifestations of cell life are: Movement, inges-
tion, assimilation, excretion, growth, irritability, and
reproduction.
3. The blastoderm has three layers — the ectoderm,
mesoderm, and entoderm.
From the mesothelium are derived the flattened epi-
thelioid cells which line the various serous cavities of
the body.
From the mesenchyme are derived the various con-
nective tissue cells such as bone, dentine, cartilage,
fibrous and areolar tissue, lymph, and blood.
4. The five groups of adult tissue are: (1) Epithelial
tissues, (2) connective tissues, (3) blood, (4) muscle
tissue, and (5) nerve tissue.
Adipose tissue is a form of connective tissue and con-
sists of vesicles filled with fat; these vesicles are col-
lected into lobules, and vary in shape, being round or
oval when not subjected to pressure, but polyhedral
when compressed. The cell has an oval flattened
nucleus situated just within the thin membrane which
surrounds the cell.
5. For illustration, see Bailey's Histology, 3d Edition,
1910, fig. 102, p. 167.
Transverse section of compact bone from shaft of
humerus (From Bailey's Histology) :
"All bone is at first of the spongy variety. When this
is to be converted into compact bone, there is first ab-
sorption of bone by osteoblasts, with increase in size
822
WASHINGTON.
of the marrow spaces and reduction of their walls to
thin plates. These spaces are now known as Haversian
spaces. Within these new bone is deposited. This is
done by osteoblasts which lay down layer within layer
of bone until the Haversian space is reduced to a mere
channel, the Haversian canal. In this way are formed
the Haversian canals and the Haversian systems of
lamellae. Some of the interstitial lamellae are the re-
mains of the spongy bone which was not quite removed
in the enlargement of the primary marrow spaces to
form the Haversian spaces; other interstitial lamellae
appear to be early formed Haversian lamellae which
have been more or less replaced by Haversian lamellae
formed later." •
6. Cardiac muscle consists of fibers of short, stubby
cylindrical form, possessing striations and a delicate
sheath, but no regular sarcolemma. There is a single,
oval nucleus to each cell; this nucleus is centrally situ-
ated and is surrounded by pigment granules.
7. Peyer^s patches are aggregations of solitary
glands, measuring from about half an inch to three
inches in length; they are found mainly in the ileum,
but also occur in the duodenum, and jejunum; they are
situated lengthwise in the intestine, and are located
opposite to the mesenteric attachment. Each patch is
surrounded by a group of the crypts of Lieberkuhn.
There are said to be from 30 to 50 of these patches
in the human intestine. As a rule, they have no villi
on their surface.
8. The cornea consists of five layers: (1) An anterior
layer of stratified squamous epithelium; (2) an an-
terior elastic membrane, also known as Bowman's
membrane; (3) the substantia propria consisting of
connective tissue fibrils which are cemented together
to form bundles and lamellae; (4) the posterior elastic
membrane of Descemet, similar to the anterior elastic
membrane, but thinner; (5) the posterior endothelium
of Descemet, consisting of one layer of flat hexagonal
cells.
9. The thymus contains spherical or oval bodies of
concentrically arranged epithelial cells known as Has-
salPs corpuscles; nucleated red blood corpuscles may
be seen in the thymus; and the lymph nodules contain
no germinal centers. The lymph glomd does not con-
tain Hassall's corpuscles and it has no nucleated red
corpuscles; furthermore the lymph nodules contain ger-
minal centers.
10. The Malplghian corpuscles of the spleen "are
distributed throughout the splenic pulp. Each splenic
823
MEDICAL RECORD.
corpuscle contains one or more small arteries. These
usually run near the periphery of the corpuscle; more
rarely they lie at the center. Except for its relation to
the blood-vessels, the splenic corpuscle is quite similar
in structure to a lymph nodule. It consists of lymphoid
cells so closely packed as completely to obscure the
underlying reticulum. In a child's spleen the center of
each corpuscle shows a distinct germinal center. In
the adult human spleen germ centers are rarely seen."
(Bailey's Histology).
The Malpighian corpuscle of the kidney "is spher-
oidal, and has a diameter of from 120 to 200m. The
structure of the Malpighian body can be best under-
stood by reference to its development. During the de-
velopment of the uriniferous tubules and of the blood-
vessels of the kidney, the growing end of a vessel meets
the growing end of a tubule in such a way that there
is an invagination of the tubule by the blood-vessel.
The result is that the end of the vessel which develops
a tuft-like network of capillaries — the glomerulus —
comes to lie within the expanded end of the tubule,
which thus forms a two layered capsule for the glom-
erulus. One layer of the capsule closely invests the
tuft of capillaries, dipping down into it and separating
the groups of capillaries. This layer by modification
of the original epithelium of the tubule is finally com-
posed of a single layer of flat epithelial cells with pro-
jecting nuclei. The outer layer of the capsule lies
against the delicate connective tissue which surrounds
the Malpighian body. This layer consists of a similar
though slightly higher epithelium and is known as
Bowman's capsule. Between the glomerular layer of
the capsule and Bowman's capsule proper is a space
which represents the beginning of the lumen of the
uriniferous tubule, the epithelium of Bowman's capsule
being directly continuous with that of the neck of the
tubule." (Bailey's Histology).
For illustrations see Bailey's Histology 3d Edition,
1910, figs. 95 and 198, pp. 159 and 289.
11. The structure of the lungs. — "In the lungs the
bronchi branch in a tree-like manner, the final ramifi-
cations opening into the pulmonary cells. The larger
intrapulmonary bronchi are lined by columnar ciliated
epithelium resting on a basement membrane. Lying
under this basement membrane are longitudinally dis-
posed elastic fibers with loose connective tissue. More
externally is a layer of smooth muscle fibers arranged
circularly, the bronchial muscle. External to the bron-
chial muscle is a fibrous coat containing scattered, ir-
824
WASHINGTON.
regular plates of hyaline cartilage. The smaller
bronchi (bronchioles) have no cartilaginous plates, but
their muscular coat is well marked. Each bronchiole
leads into a small number (three or four) of wider
thin-walled spaces, lined by flattened epithelium, and
called atria. Out of each atrium open two or three
blind diverticula, each of which is called an inf undibu-
lum. The walls of the infundibula are studded with
hemispherical sacs known as alveoli, which are lined
by flattened, non-nucleated,, epithelial cells. Between
adjacent alveoli there is a dense network of capillaries,
supported by a small amount of fine connective and
elastic tissue; the network of capillaries is thus com-
mon to the two adjacent air cells, and the blood in the
capillaries is separated from the air in the alveoli
merely by two thin layers of epithelium. In birds, even
the alveolar epithelium appears to be absent, the blood
and air being separated solely by the capillary wall."
(From Bainbridge and Menzies', Essentials of Physi-
ology.)
12. "Tactile corpuscles. — These consist of connective
tissue which forms a capsule, from which are given off
membranous partitions or septa. After winding around
the corpuscle the axis-cylinder enters it, and terminates
in an enlargement. Tactile corpuscles occur in the
papillae of the skin of the hand, foot, front of the fore-
arm, lips, and nipple; also in the mucous membrane of
the tip of the tongue and the conjunctiva lining the eye-
lids.
"Pacinian corpuscles. — These are also called corpus-
cles of Vater. Each corpuscle consists of concentrically
arranged layers of connective tissue, with nucleated
cells. A medullary nerve-fiber enters at one end and
passes into an interior space which contains a trans-
parent substance; here only the axis-cylinder is present.
This terminates at the end of the corpuscles in an
enlargement or in minute branches, an arborization.
These corpuscles exist in the subcutaneous tissue of the
palm of the hand and sole of the foot, and in the penis.
Observers have also found them in the pancreas,
lymphatic glands, and thyroid." (Raymond's Physi-
ology.)
GYNECOLOGY.
1. Gynecology is that branch of medicine and surgery
which deals with the diseases peculiar to women.
2. The external genital organs are: Labia majora,
labia minora, clitoris, mons Veneris, and the orifice of
the vagina; the external urinary meatus is generally
included, though it is not a genital organ.
R25
MEDICAL RECORD.
3. Amenorrha is absence of menstruation during the
period of sexual activity.
Dysmenorrhea is unduly painful menstruation.
Menorrhagia is a condition characterized by exces-
sive loss of blood at the menstrual period.
4. Forms of vaginitis : Acute, chronic, primary, sec-
ondary, catarrhal, membranous, diphtheritic, gonor-
rheal, tuberculous, senile, emphysematous, granular,
superficial (there is no recognized classification).
Symptoms of senile vaginitis: "The subjective symp-
toms are not in any way characteristic and all the
patient usually complains of is a thin, serous, leucor-
rheal discharge which is not profuse or constant and
which is at times streaked with blood. In some cases
there may be a burning sensation in the vagina, a feel-
ing of weight in the pelvis, and a distressing irritation
of the external organs of generation. Sexual inter-
course is either impossible or very painful. The ob-
jective symptoms, on the other hand, are marked. The
mucous membrane is found to be smooth, atrophied, and
covered with a scanty serous secretion, while various
sized spots of ecchymosis and superficial ulceration are
observed scattered over its surface. Adhesions result-
ing from contact between the ulcerated surfaces are
common, and in some cases the vaginal vault as well as
other parts of the canal may be obliterated or greatly
distorted." — ( Ashton's Gynecology.)
5. "Acute endometritis is the result of the introduc-
tion into the uterus of septic microorganisms. This
usually occurs during labor or miscarriage, or it may
result from operations, such as dilatation, or from the
introduction of an unclean sound. It sometimes occurs
as a complication of the exanthems. If the process is
severe enough, it may involve the muscular tissue un-
derneath the mucous membrane, when it is called
metritis; or the peritoneal covering of the uterus may
be invaded, when it is called perimetritis. Symptoms. —
Acute corporeal endometritis is usually attended by
considerable pain, of a dull, aching character. There
are constipation and vesical irritability. The pulse is
rapid and temperature in some cases is very high —
from 104° to 106° F. Vaginal examination reveals a
patulous cervical canal with a profuse purulent dis-
charge escaping from it. The uterus is enlarged,
boggy, and tender.
"Chronic endometritis may result from an acute at-
tack or it may be chronic from the beginning. One of
the most frequent causes of this condition is gonorrheal
infection. Chronic endometritis accompanies a variety
826
WASHINGTON.
of pathological conditions of the uterus, such as dis-
placements, subinvolution, laceration of the cervix, and
fibroid tumors. Two varieties of chronic endometritis
have been described — glandular and interstitial. The
symptoms of chronic endometritis are usually well
marked. There is pain, of a dull, aching character,
most evident in the back and extending down the
thighs. Leucorrhea is constant, and is quite charac-
teristic. The discharge is thin, purulent, and blood-
streaked. Menstruation is profuse, and lasts usually
from 5 to 7 days. The patient's general health suffers ;
she loses weight and becomes anemic, there is a sense
of great reduction in physical strength. Headache is a
very common symptom. Nervous, digestive, and cir-
culatory disturbances appear sooner or later. Physical
examination reveals an enlarged, tender uterus. The
cervical canal is patulous ; the external os is eroded. The
characteristic discharge can be seen escaping from the
cervix." — (Cyclopedia of Medicine and Surgery.)
6. There are two varieties of pelvic hematocele: (1)
due to rupture of an organ, (2) due to the entrance of
menstrual blood into the peritoneal cavity. The most
common cause is rupture of a tubal pregnancy.
7. Pregnancy : The tumor is hard and does not fluc-
tuate, is situated in the median line, and may give fetal
heart sounds and movements ; the cervix is soft, and the
other signs of pregnancy are present. The rate of
growth of the tumor, and the general condition of the
patient's health may also help in arriving at a diag-
nosis.
Uterine fibroid: Menstruation is irregular and some-
times very profuse; absence of the signs of pregnancy;
the tumor is nodular, firm, irregular in outline, and
while generally placed somewhat centrally is not in the
median line, and is not symmetrical; the rate of growth
is irregular, being, as a rule, slow, and sometimes ex-
tending over years.
Ovarian cyst: Absence of the chief signs of preg-
nancy; there may be the characteristic facies, the tu-
mor is soft, fluctuating, is more to one side, and does
not show fetal signs.
8. Symptoms of carcinoma of the uterus: Presence
of a tumor, pain, offensive discharge, hemorrhage, and
cachexia. Prognosis is unfavorable, particularly after
glands are involved.
9. In the case of polypus, the body and fundus of the
uterus are in their normal position in the abdomen, a
sound can be passed into the uterus, the uterine and
cervical canals are not obliterated, the polypus does
827
MEDICAL RECORD.
not bleed easily, and is not particularly sensible to pain.
The inverted uterus shows: Absence of body and fun-
dus from normal position, will not permit passage of
a sound into uterine cavity, the uterine and cervical
canals are absent, the inverted uterus tends to bleed
easily, and is very sensible to pain. In prolapse the
largest part of the tumor is above; the opening of the
Fallopian tubes cannot be seen; a sound can be passed
into the uterine cavity.
Polypi of cervix. "Polypoid tumors are found grow-
ing from the mucous membrane of the cervical canal,
projecting into the canal or protruding from the ex-
ternal os. The mucous polypus is the most usual form,
and is caused by cystic degeneration of the Nabothian
glands of the cervical mucous membrane. Sometimes
such polypi protrude from the ostium vaginae. Less
often a papillary or warty growth is found on the
mucous membrane of the cervical canal, in the neigh-
borhood of the external os. There is usually present
dilatation of the external os and cervical canal. The
symptoms of cervical polypi are not characteristic. In-
flammation of the cervical mucous membrane and cervi-
cal catarrh may result. There may be slight, and rarely
profuse, bleeding from the externl os. The bleeding
may follow efforts at straining, sexual connection, long
standing, or exercise. Occurring at the time of the
menopause or later, this symptom would excite the sus-
picion of beginning cancer of the cervix."
10. For prolapse, see Question 9. In rectocele, the
posterior wall of the vagina is bulged forward and
downward. In cystocele, the anterior wall of the vagina
is bulged backward and downward.
11. The varieties of displacement of the uterus are:
Retroversion, retroflexion, anteversion, anteflexion, lat-
eral version, lateral flexion, descent or prolapse, ascent,
and mallocation (to front, back, or one side) .
The following symptoms may follow displacements of
the uterus : Backache, bearing-down pains, a feeling of
pressure in the pelvis, constipation, hemorrhoids, fre-
quent or painful urination, leucorrhea, menstrual dis-
turbances, as dysmenorrhea or menorrhagia, sterility;
there may also be general symptoms, as headache, in-
digestion, nausea, anorexia, neurasthenia, and general
malaise.
Causes of downward displacements of the uterus :
(1) Pressure from above (pelvic or abdominal tumors,
ascites, tight or heavy clothing, straining at stool, mus-
cular exertion, fecal accumulations, habitual overdis-
tention of the bladder) ; (2) weakening and relaxation
828
WASHINGTON.
of the uterine supports (subinvolution, senile atrophy
of pelvic floor, abnormally large pelvis, increased weight
of uterus, puerperal traumatisms, pressure from above,
traction from below) ; (3) increased weight of uterus
(congestion, subinvolution, metritis, pregnancy, fluid in
the endometrium, uterine tumors) ; (4) traction from
below (vaginal cicatrices, falling of pelvic floor, con-
traction and congenital shortening of vagina, tumors
of cervix or vagina.) — (From Dudley's Gynecology,)
12. "The onset of pelvic cellulitis is usually marked
by a rigor, followed by pain in one or both flanks;
febrile symptoms supervene, and, as the exudation in-
creases, troubles during micturition or defecation are
experienced. These signs are of greater significance
when they follow within twenty-four or thirty-six hours
an abortion, delivery, or an operation on the uterus.
On examining through the vagina, a hard mass will be
found on one or both sides of the cervix; in many cases
the hard masses are conjoined by a ring of hard tissue
surrounding the neck of the uterus. When the whole
extent of the ligaments is infiltrated the swelling is per-
ceptible at the brim of the pelvis and in the hypogas-
trium. When suppuration occurs, the temperature,
pulse, and general condition of the patient are those ac-
companying large collections of pus. The local signs
are as follows: the previously hard masses become
softer, fluctuation is detected, or the overlying skin is
edematous and perhaps red. The abscess is then said
to point." (Sutton and Giles' Diseases of Women.)
The prognosis is favorable, if proper treatment is in-
stituted.
PATHOLOGY.
1. Tumors of the uterus may be: Fibroma, fibro-
myoma, myofibroma, adenoma, sarcoma, carcinoma, pap-
illoma, and syncytioma malignum.
"Fibroids. — These tumors are the most common of
those of the uterus. Although spoken of as fibroma,
they nearly always contain a large amount of involun-
tary muscle, so the term fibromyoma is the more cor-
rect. They are classified according to their situation
into: mural, intramural, or interstitial, when occurring
within the muscular body of the uterus; submucous,
when beneath the endometrium; and superitoneal, when
beneath the peritoneal covering. The tumors may be
single or multiple, and their size varies from a pea to
one weighing fifty pounds. The largest are the sub-
peritoneal, as their growth is practically unlimited. The
density of the tumors depends upon the amount of
fibrous tissue present. They are generally encapsu-
829
MEDICAL RECORD.
lated. The blood-supply is poor, so degenerations are
common. These usually begin in the center of the
tumor, and the most frequent form is calcification. If
the tumor has been a pedunculated one, the pedicle may
become twisted and necrosis set in. Fibromata may be
associated with lipoma, myxoma, or sarcoma.
"Sarcoma, of the uterus usually originates within the
connective tissue between the muscle-fibers and about
the vessels or occasionally from the muscle cells. I_i
may also arise within the submucous tissue. The my-
ometrial sarcoma is generally spindle-cell in character;
is grayish-white and soft; the endometrial is commonly
round celled. Angiosarcoma is rare, and the so-called
adenosarcoma is probably nothing more than an in-
clusion of the pre-existing endometrial glands.
"Papilloma appears on the cervix as rather small,
cauliflower-like growths, composed of connective-tissue
villi covered by many layers of squamous epithelium.
Venereal warts are sometimes found upon the cervix.
"Adenomata as such occur as polypoid projections
from the mucous membrane, or as a glandular hyper-
plasia of the endometrium. They are benign.
"Malignant adenoma, or adenocarcinoma, usually
arises in the fundus of the uterus, upon the posterior
wall. It is characterized by the tendency of the glands
to invade the uterine muscle and by the epithelium
breaking through the basement membrane. Quite fre-
quently the epithelium proliferates so rapidly that the
acini become completely filled with cells, the glandular
character is lost, and the tumor assumes a typical car-
cinomatous structure. Metastasis is unusual; the
destruction is mainly local.
"Carcinoma is usually an adenocarcinoma and the
progress is practically similar. There is rapid infiltra-
tion with extensive ulceration. The vaginal walls and
the tissues in the neighborhood of the cervix become in-
volved. The neighboring lymphatic nodes are fre-
quently the seat of metastases.
"Squamous epithelioma of the cervix is the common-
est type of malignant tumor. In many cases it prob-
ably begins as a papilloma. There is soon developed a
tendency of the cells to infiltrate the surrounding tissues
and to grow superficially as a cauliflower-like mass. The
growth extends downward, involving the vagina; ex-
tensive ulceration, accompanied at times by severe
hemorrhage, occurs, and there is an extremely foul dis-
charge. The tumor extends in all directions, and may
perforate into the bladder or rectum or into the peri-
toneal cavity, giving rise to fatal peritonitis.
830
WASHINGTON.
"Syncytioma malignum, or chorio-epithelioma, is a pe-
culiar malignant tumor developing from embryonal tis-
sue. The greater part of the cells are supposed to be
derived from the syncytium. Is a rare form of growth."
(McConnell's Manual of Pathology.)
2. Acute yellow atrophy of the liver. "At a very
early stage the liver may be a little enlarged, but it
rapidly diminishes in size, and the disease may run a
fatal course in ten to fourteen days. The liver is re-
duced to one-half its normal size or less, the capsule is
wrinkled, the consistence tough, and the color usually
yellow. The outline of the lobules is not recognizable;
here and there patches of liver-cells may have escaped
destruction, but for the most part they are converted
into a granular and fatty detritus. Numerous hemor-
rhages may be found in the skin, serous and mucous
membranes; the urine is almost destitute of urea but
contains leucin and tyrosin. The etiology of the condi-
tion, which bears considerable resemblance to phos-
phorus poisoning, is unknown, but it is probably in-
fective." — ( Hewlett's Pathology. )
3. "Hydrocephalus is a condition characterized by
the accumulation of an increased, and often very large,
amount of serous fluid within the ventricles of the
brain. This condition is sometimes spoken of as in-
ternal hydrocephalus, to distinguish it from external
hydrocephalus, a collection of fluid between the brain
and the dura mater. This occurs in atrophy of the
brain (hydrocephalus ex vacuo), in advanced life, and
after hemorrhages, softenings, etc.
"Internal hydrocephalus may be congenital or ac-
quired. The congenital case may be observed at birth,
when the enlarged head may interfere with parturition,
or it may not become apparent until the child is some
months or a year old. The condition may occur in sev-
eral members of the same family. The real cause is not
known, although it is likely some vice of development
or a fetal meningitis obstructing the foramen of Ma-
gendie and leading to the intraventricular accumulation
of fluid. The acquired cases may result from an
ependymitis with marked serous exudation, a condition
which Quincke believes to be angioneurotic in nature
(Quincke's angioneurotic hydrocephalus) ; or they may
be due to inflammatory (meningitis) or pressure
(tumor) obstruction of the passage from the third to
the fourth ventricle or of the foramen of Magendie.
"In the congenital cases and those developing in
early life the head may be slightly or enormously dis-
tended. The bones of the skull are separated and the
831
MEDICAL RECORD.
fontanelles widened; the forehead overhangs the face,
the eyes are recessed, and the bones of the face seem
small (ony relatively small in comparison with those of
the skull). The brain is enlarged, the ventricles more
or less distended, and the cortex, as a rule, correspond-
ingly atrophied. Although rarely considerable intel-
lectual development occurs, the mentality, as a rule, is
variously impaired up to complete idiocy. Death usu-
ally occurs in childhood, but the patient may reach adult
life. The cases developing in adult life can scarcely be
recognized with certainty; the hydrocephalus is usually
only an incident in the course of the disease to which
it is due." — (Kelly's Practice of Medicine.)
4. Cystocele is a protrusion of the bladder into the
anterior wall of the vagina.
Embolus is a plug of some substance blocking up a
blood vessel.
Keloid is a growth occurring in scar tissue.
Lipoma is a tumor composed of fat.
Sycosis is a skin eruption involving the hair follicles,
especially those of the beard.
Varicocele is a varicose condition of the veins of the
spermatic cord.
Mastitis is inflammation of the breast.
Cholemia is the presence of bile in the blood.
Apoplexy is a condition resulting from hemorrhage
or embolism of a cerebral vessel.
Clavus is a corn.
5. Leukemia is a condition in which there is a great
and persistent increase in the number of white blood
corpuscles. There are two varieties of the disease: (1)
Splenomedullary in which the chief changes are found
in the spleen and bone marrow; and (2) lymphatic, in
which the chief changes occur in the lymphatic glands.
It is possible for leukemia to be confounded with
splenic anema and Hodgkin's disease. The diagnosis is
made by an examination of the blood. In Hodgkin's dis-
ease there is either no increase in the number of the
leucocytes, or a very slight increase. In anemia, there
is a marked diminution in the number of the red blood
corpuscles and there is no leucocytosis. In spleno-
medullary leukemia, there is an enormous leucocytosis,
and myelocytes are present. In lymphatic leukemia, the
lymphocytes form the main part of the leucocytosis,
and there are no myelocytes.
6. Epithelioma, or squamous-celled carcinoma, may
arise on any surface covered with stratified epithelium.
It usually arises in the middle-aged or elderly, but may
also occur in the young. It often results from long-
832
WASHINGTON.
'continued irritation, and may arise in old scars or ul-
cers. It may appear in one of three forms: (1) A wart-
like growth with an indurated base; (2) a small cir-
cular ulcer with raised, rampart-like edges; (3) an in-
durated fissure. The growth extends to the deeper
structures; the surface ulcerates and becomes foul from
contamination with putrefactive organisms. The near-
est lymphatic glands always become infected sooner or
later, and a fatal termination occurs rapidly unless
treatment is early and thorough. Secondary deposits,
except in the glands, are rarer than in glandular car-
cinoma. The glands sometimes undergo cystic change,
invade the skin, ulcerate, become foul, and may cause
death by secondary hemorrhage from ulceration into
large bloodvessels.
Microscopically, columns of cells are seen extending
from the epithelium into the underlying tissues, and
interlacing with one another. In some of the columns
concentrically arranged masses of flattened, cornified
cells occur, called 'cell nests.' The tissues immediately
surrounding the growth are infiltrated with small
round cells. — (Aids to Surgery,)
7. Pathology of typhoid fever. — "Principally inflam-
mation of the lymphoid tissue of the lower portion of
the ileum, with more or less catarrh throughout the
bowels. Peyer's Patches — first week. — Are swollen
through infiltration of leucocytes, the surfaces raised
and fawn-colored — the infiltration involves the submu-
cous coat. The lesions are most numerous at the lower
end of the ileum. Second week. — The surface becomes
abraded; sloughs form which are often bile-stained.
Third week. — Sloughs come away, leaving ulcerating
surfaces. Typical typhoid ulcers are thus formed. A
few solitary glands undergo the same process. At the
end of the week the ulcers begin to granulate, but heal-
ing is usually slow. Mesenteric glands may undergo the
same changes, but more often become swollen, red, and
tender only, or break down into cheesy masses. Other
organs. — Spleen and liver are enlarged; heart is soft
and flabby. The voluntary muscles undergo granular
degeneration; in fact, similar changes to those found
after death from high temperature." — (Wheeler and
Jack's Practice of Medicine.)
S. In mitral regurgitation, "the most common condi-
tions observed are more or less contraction and narrow-
ing of the tongues of the valves, with irregular thick-
ening and rigidity; atheroma or calcification of the seg-
ments; laceration of one or more segments; adhesion
of one or more segments to the inner surface of the
833
MEDICAL RECORD.
ventricle; thickened and stiffened, or ruptured, chordae
tendineae, and also contraction and hardening of the
musculi papillares. As a result of the regurgitation
or leakage of the blood back into the left auricle, there
is a dilatation of the auricle, followed by slight cardiac
hypertrophy. Ventricular hypertrophy occurs after a
time from the increased number of the cardiac contrac-
tions. If, as is eventually the case the left auricle is
unable to overcome the backward flow of blood, it
dilates and the lungs become congested. The right ven-
tricle is then forced to perform more work and hyper-
trophies. Hypertrophy of the right ventricle is fol-
lowed by that of the left ventricle. In the event of its
failure to overcome the backward flow, it (right ven-
tricle) also dilates and the tricuspid valve becomes in-
sufficient." — (Hughes' Practice of Medicine.)
9. In chronic parenchymatous nephritis "the kidney
is larger and paler than normal. The capsule strips
easily and the stellate veins are injected. On section,
the cortex is larger than normal and pale ; the pyramids
are often conspicuous by their engorgement. The pelvis
shows no increase of fat. On microscopic section, the
tubules are dilated, their epithelium shows fatty
changes, and they contain fatty and granular casts.
The epithelium lining Bowman's capsules may be pro-
liferated, and the capillaries and epithelium of the tuft
show hyaline changes. Changes in the interstitial tis-
sue are present, such as edema and increase of fibrous
tissue." — (Woodwark's Manual of Medicine.)
10. Progressive changes in gonorrheal rheumatism.
"In recent cases of this disease the structures connected
with one or more of the articulations are acutely in-
flamed. The cavity contains a variable amount of
serous effusion according to its form and size; the
knee, for example, being considerably distended, while
the digital joints are more moderately enlarged. The
various component parts are hyperemic and swollen;
and the peri-articular structures full or even edematous.
In more advanced cases the joints are found to contain
either sero-purulent or purulent material; the carti-
lages may be eroded ; and finally the articulations may
become completely disorganized or ankylosed. The
gonococcus has been found in the intra-articular effu-
sion. The cardiac structures are very rarely affected.
The eye may present the ordinary appearances # of
catarrhal (not gonorrheal) conjunctivitis." — (Quain's
Dictionary of Medicine.)
11. In locomotor ataxia the posterior columns of the
spinal cord and the posterior nerve roots are involved.
834
WASHINGTON.
The posterior columns of the spinal cord are gray and
shrunken, and show considerable overgrowth of con-
nective tissue in the columns of Goll, Burdach, and Lis-
sauer; this process extends upwards from the lumbo-
sacral region; the posterior nerve roots degenerate and
become atrophic. The meninges over the affected parts
become opaque and adherent. Some of " the cranial
nerves may also atrophy, notably the optic, but also
the motor oculi and vagus.
The process is destructive and progressive; it is not
a simple wasting, although the nerve fibers are atro-
phied, but it is characterized by irritation, changes in
the axis cylinders, overgrowth of the connective tissue,
and sometimes congestion; the spinal ganglia may be
affected.
12. "The mode of formation of calculi has been much
discussed. They may be produced by an excess of a
sparingly soluble abnormal ingredient, such as cystine
or xanthine; more frequently by the presence of uric
acid in a very acid urine which favors its deposition.
Sir William Roberts thus briefly states the conditions
which lead to the formation of the uric-acid concre-
tions; high acidity, poverty in salines, low pigmentation,
and high percentage of uric acid. Ord suggests that
albumin, mucus, blood, and epithelial threads may be
the starting-point of stone. The demonstration of or-
ganisms in the center of renal calculi renders it prob-
ably that in many cases the nucleus of the stone is an
agglutinated mass of bacteria." — (Osier's Practice of
Medicine.)
GENERAL DIAGNOSIS.
1. Acute appendicitis is characterized by sudden on-
set of pain, at first general over the abdomen, but later
localized in the right iliac fossa; tenderness, most
marked at McBurney's point; rigidity of the right rec-
tus abdominis muscle; fever; vomiting and constipa-
tion; the patient generally lies on his back with the
right thigh drawn up.
In unruptured ectopic gestation, there is a history of
irregular menstruation, morning nausea, and breast
signs; the pain is of a colicky character and may cause
faintness; vaginal examination shows a movable mass
on one side of the uterus.
2. The cardinal symptoms of exophthalmic goiter
are: Exophthalmus, enlargement of the thyroid gland,
tachycardia and tremor. Operation should be^ under-
taken when the disease continues to progress in spite
of proper medical treatment. The dangers in operating
are: Hemorrhage, sudden death from dyspnea, injury
835
MEDICAL RECORD.
to the recurrent laryngeal or pneumogastric nerve, and
tetany.
3. Burns of the first degree are characterized by
erythema, and local congestion of the skin ; burns of the
second degree, by vesication; and burns of the third
degree by destruction of the skin. The possible com-
plication of this last class are: Shock, sepsis, and ul-
ceration of the duodenum (which may cause death from
hemorrhage or perforation).
4. Symptoms of intestinal obstruction: Abdominal
pain of an acute and severe type, constipation, vomit-
ing which may become fecal, prostration, pallor, thirst.
In renal colic, the pain is agonizing, and is located
in the kidney and radiates down the ureter, and may be
felt in the testicle, glans penis, or inner side of the
thigh; a chill is usually present; and the urine is
bloody.
5. Differential diagnosis of concussion and compres-
sion of the brain:
Concussion.
Compression.
Onset
Sudden.
Gradual.
General condition
Can be roused.
Cannot be roused.
Pupils
Equal, react.
Dilated, immo-
bile, perhaps
unequal.
Pulse
Slow and weak.
Slow, full, heav-
Respirations ....
Slow, shallow, ir-
ing.
Slow, deep, ster-
regular.
torous.
Muscular system.
Relaxed (func-
Organic paraly-
tional paraly-
sis.
sis).
Reflexes
Present.
Absent.
Rectum
Incontinence of
Incontinence of
feces.
feces.
Bladder
Incontinence of
False inconti-
urine.
nence.
Temperature
Subnormal, equal
Subnormal, ris-
on the two
ing in late
sides.
stages; may be
unequal on the
two sides.
— (Aids to Surgical Diagnosis.)
6. Depressed fracture of the skull is frequently fol-
lowed by compression of the brain.
The symptom locating it in the superior parietal re-
gion is paralysis of the muscles of the lower extremity
on the opposite side of the body.
836
WASHINGTON.
7. In tabes dorsalis the cardinal symptoms are: Loss
of knee-jerks, lightning pains, Romberg symptom and
ataxic gait, Argyll-Robertson pupil, numbness of the
feet, a history of syphilis, and the slow onset of the
disease.
In multiple sclei*osis, the cardinal symptoms are: In-
tention tremor, nystagmus, scanning speech, exagger-
ated knee-jerks, ankle clonus, ataxia, rigidity in the
legs, attacks of vertigo and apoplectiform and epilepti-
form seizures. — From Butler's Diagnostics.)
8. In gangrene of the lung, the offensive odor of the
breath and the presence of lung tissue in the sputum
are quite sufficient to differentiate this condition from
pleuritic effusion (or anything else) .
9. In acute albuminuria there is albumin in the urine,
but none of the other symptoms of interstitial nephritis.
In interstitial nephritis the symptoms may be latent,
but as a rule the general health is disturbed; headache,
defective vision, lassitude, insomnia, dyspnea on exertion
may be present. The urine may contain a little albumin
or none at all, blood pressure is increased, the pulse is
hard and incomprehensible, and the second aortic sound
is accentuated.
10. In acute otitis media there is tinnitus, impaired
hearing, pain (which may become intense), and fever.
Possible complications are: Inflammation of the mastoid
cells, caries and necrosis, phlebitis, meningitis, and cere-
bral abscess.
11. In rabies "the wound by which the poison was
introduced, as a rule, rapidly heals, and for a time noth-
ing happens to attract the patient's attention to the
scar. In about six to eight weeks or so the scar may
become painful and nervous disturbances manifest
themselves. The patient becomes sleepless, peevish, ir-
ritable, and experiences a choking sensation about the
throat. When the disease is fully developed there are
intense muscular spasms, the respiratory muscles and
those of deglutition being specially involved; but a more
or less tetanoid condition may be observed in nearly all
the muscles. There may be opisthotonos. The features
may be horribly contorted or wear an aspect of extreme
terror; the saliva is not swallowed, and as it collects in
the mouth along with thick mucus from the congested
fauces it causes noisy attempts at ejection, attended
with great difficulty. The face is usually flushed or
livid during the attacks and there may be raving delir-
ium, delusions, and hallucinations. It should be noted
that, though the patient is very thirsty, he is afraid to
drink, as any attempt at swallowing brings on the
837
MEDICAL RECORD.
spasms at once; even the sound of running water will
excite the attacks. There is generally fever, the tem-
perature ranging from 100° to 103° F. After from
two to three days the patient may pass into the "paraly-
tic stage," which, however, is more common in animals.
He generally dies of exhaustion in from two to ten days
after the development of the characteristic symptoms."
Landry's paralysis "is an acute ascending paralysis
beginning in the legs, rapidly involving the trunk, dia-
phragm, and arms, ending fatally, and probably due to
a toxic affection of the lower motor neurone." —
(Wheeler and Jack's Handbook of Medicine.)
12. Sacro-iliac disease is of tuberculous origin. The
symptoms consist of pain over the joint, increased by
movement or standing. From pressure on the lumbo-
sacral cord, pain may be referred to the leg. The leg
can be moved without pain or limitation if gentleness is
exercised; but pain is produced by compressing or for-
cibly separating the crests of the iliac bones. There
may be apparent lengthening on the diseased side from
pushing downward of the iliac bone on that side. Ten-
derness and swelling, or even an abscess, may be felt
over the joint posteriorly, or the abscess may burrow
and point in the lumbar region, groin, or ischiorectal
fossa.
The diagnosis from sciatica is made by the absence of
pain on compressing the pelvis in sciatica. — (Aids to
Surgery.)
BACTERIOLOGY.
1. Microorganisms may enter the body: (1) By the
respiratory tract, as in pulmonary tuberculosis and
whooping cough; (2) by the digestive tract, as in ty-
phoid fever and cholera; (3) by the mucous membrane
of the genital tract, as in gonorrhea and syphilis, and
(4) by the bite of an insect (transferred to the blood)
as in malaria and yellow fever.
2. Diphtheria is caused by the Klebs-Loeffler bacillus ;
uncinariasis, by the Ankylostomum duodenale and the
Necator americanus; syphilis, by the Treponema palli-
dum; erysipelas, by the Streptococcus erysipelatis ;
malaria (estiv o -autumnal) , by Plasmodium prsecox;
abscess, by Staphylococcus pyogenes aureus, Staphylo-
coccus pyogenes citreus, Staphylococcus pyogenes albus,
Streptococcus pyogenes, Bacillus tuberculosis, and
others; acute osteomyelitis, same as abscess; purulent
salpingitis, same as abscess, with Micrococcus gonor-
rhea, and Bacillus coli communis.
3. Infection is the morbid process caused by the suc-
cessful invasion of the organism by pathogenic micro-
838
WASHINGTON.
organisms. The usual symptoms are: Malaise, chill,
fever, prostration, headache, rapid pulse; other symp-
toms vary according to the infection.
4. Chemotaxis is the property by virtue of which cer-
tain living cells approach or move away from certain
other living cells or substances.
Strict parasite is a parasite which cannot lead an
existence independent of its host.
Saprophyte is a microorganism which grows on dead
matter.
Opsonin is that quality of a serum which makes a
microorganism more susceptible to phagocytosis.
Agglutinin is something in the blood serum of an ani-
mal affected with a bacterial disease which causes the
clumping of the pathogenic bacteria.
Antiseptics are agents which prevent or restrain
putrefaction.
Disinfectants are agents which restrain infectious
diseases by destroying or removing their specific poi-
sons.
5. Pneumococcus is a spherical or oval coccus, encap-
sulated, non-mobile, non-flagellated, non-sporogenous,
non-liquefying, often occurring in pairs, non-chromo-
genie, aerobic and optionally anaerobic, staining readily
with aniline dyes and by Gram's method; its cultural
characteristics are variable, some strains growing read-
ily on ordinary media, some with difficulty, and some
not at all.
6. A sterile swab is rubbed over any visible mem-
brane on the tonsils or throat and is then immediately
passed over the surface of the serum in a culture tube.
The tube of culture, thus inoculated, is placed in an
incubator at 37° C. for about twelve hours, when it is
ready for examination. A sterile platinum wire is in-
serted into the culture tube, and a number of colonies of
a whitish color are removed by it and placed on a clean
cover slip and smeared over its surface. The smear is
allowed to dry, is passed two or three times through a
flame to fix the bacteria, and is then covered for about
five or six minutes with a Loeffler's methylene-blue solu-
tion. The cover slip is then rinsed in clean water,
dried, and mounted. The bacilli of diphtheria appears
as short thick rods with rounded ends; irregular forms
are characteristic of this bacillus, and the staining will
appear pronounced in some parts of the bacilli and defi-
cient in other parts. Methods of culture: The bacillus
of diphtheria grows upon all the ordinary culture media,
and can be readily obtained in pure culture. Loeffler's
blood serum, particularly with the addition of a little
839
MEDICAL RECORD.
glucose, is an admirable medium for the rapid growth
of this bacillus. The medium should be alkaline and
not less than 20° C.
The characteristics of the bacillus of diphtheria: The
bacilli are from 2 to 6 mikrons in length and from
0.2 to 1.0 mikron in breadth; are slightly curved, and
often have clubbed and rounded ends; occur either
singly or in pairs, or in irregular groups, but do not
form chains; they have no flagella, are nonmotile, and
aerobic ; they are noted for their pleomorphism ; they do
not stain uniformly, but stain well by Gram's method
and very beautifully with Loeffler's alkaline-methylene
blue.
7. Difference between an antitoxin and a bacterial
vaccine: "The antitoxic sera act directly upon the
poison secreted by the living bacterial cell and neutra-
lize its toxic property, while the bacteriolytic sera
affect the bacteria themselves and destroy them or
paralyze their action. Since the antibacterial sera are
without effect upon the formed toxin, they are mainly
useful in practice as a means of protecting against the
bacterial invasion, while the antitoxic sera (e.g. diph-
theria) may be employed to combat an infection al-
ready in progress. Broadly speaking, the latter are
curative, the former protective." — (Jordan's Bacteri-
ology.)
Sapremia is due to absorption of toxins only, and is
characterized by a persistent high temperature, re-
lieved at once by removing the source of the poison.
Septicemia is due to organisms multiplying in the
blood, and characterized by a maintained high tempera-
ture, but not relieved by getting rid of the original
source.
Pyemia is due to particles of blood-clot carrying or-
ganisms to parts distant from the original source, and
there setting up abscesses. It is characterized by rig-
ors, very high temperature, sweatings, and big remis-
sions of temperature.
8. Bacteria which most frequently cause puerperal
fever, are: Streptococcus pyogenes, Staphylococcus
pyogenes aureus, gonococcus, Bacillus coli communis,
Bacillus aerogenes capsulatus.
9. Gram's method of staining: Stain a cover glass
preparation for two or three minutes in anilin gentian-
violet. Wash in water. Treat with Gram's solution
(iodine, 1 gram; potassium iodide, 2 grams; water, 300
c.c.) for a minute and a half, when the preparation be-
comes nearly black. Decolorize with strong or abso-
lute alcohol for at least five minutes, wash, dry, and
840
WASHINGTON.
mount. Sometimes a contrast stain of Bismarck brown
or eosin is used.
Tubercle bacillus, diphtheria bacillus, and anthrax
bacillus are Gram positive; typhoid bacillus, and gono-
coccus are Gram negative.
10. The bacillus of typhoid fever is a short bacillus,
with rounded ends, about 1 to 3 microns long by 0.5 to
0.8 micron wide, motile, flagellated, non-sporogenous,
aerobic and optionally anaerobic, stains by carbol-
fuchsin but not by Gram's method. The Widal reac-
tion is obtained with the typhoid bacillus, a culture of
which shows the phenomenon of agglutination or clump-
ing upon the addition of dilute serum from a patient
with typhoid fever.
11. A pure culture is one that contains only one kind
of microorganism.
Five culture media: Gelatin, bouillon, blood serum,
agar, and potato.
12. The tubercle bacillus is a small slender rod, about
3 or 4 microns long by 0.2 to 0.5 micron wide; it is non-
motile, has no flagella, no spores, is aerobic, and resists
acids; stains well by Ehrlich's method or by carbol-
fuchsin method. The bacilli grow well on blood serum
and in glycerin bouillon.
CHEMISTRY.
1. Chemistry is that branch of science which treats
of the composition of substances, their changes in com-
position, and the laws governing these changes.
An atom is the smallest particle of an element that
can enter into chemical action.
A molecule is the smallest quantity of any substance
that can exist in a free state.
Density of a substance is the weight of a given vol-
ume of that substance as compared with the weight of
an equal volume of some other substance accepted as a
standard of comparison, under like conditions of tem-
perature and pressure.
2. Carbon is a chemical element, with atomic weight
12, valence 4, and symbol C. It exists free in three
allotropic forms, diamond, graphite, and coal; in Com-
bination it is found in every organic compound, such
as ether, chloroform, chloral, phenol, carbohydrates.
3. Hydrocarbons are substances which contain car-
bon and hydrogen only, as methane CH 4 ; ethane C 2 H 6 .
4. Gaseous matters found in the body during health:
Hydrogen, oxygen, nitrogen, carbon, dioxide, methane.
5. Sodium chloride is a compound whose molecule
841
MEDICAL RECORD.
contains one atom of sodium and one atom of chlorine,
NaCl. Abut fifteen grams are eliminated daily.
6. "Serum-therapy proper is the prophylactic and
curative treatment of certain infectious diseases by the
subcutaneous or intravenous administration of a blood-
serum containing an antibody (antitoxic, bactericidal,
etc.) which is specific to the particular disease. As
generally used, however, the term includes also the
treatment of some of these affections by vaccines and
by the toxic products (toxins) of attenuated cultures
of their respective microbes; but these toxins, though
sometimes grown on blood-serum, may be produced on
other media, and are never administered in a blood-
serum, as the antibodies invariably are.
"An Antitoxic Serum is prepared as follows: A
highly virulent culture of the specific microorganism of
the particular disease, or still better, a strong toxin of
tested strength prepared therefrom, is injected into
the cellular tissue of a suitable animal, generally a
horse, at first in very small quantity. The effect is
soon shown by the onset of fever and other symptoms
of acute disease, which are known as the 'reaction.' Af-
ter an interval of time sufficient for recovery from
these symptoms, the injection is repeated with a
stronger toxin or with a culture of greater virulence,
or with a larger quantity of the original toxin. This
process is continued for several months, or until the
animal no longer 'reacts' to the poison, and then suffi-
cient antitoxin is presumed to exist in its blood to ren-
der it immune to the toxin and to the disease. After
each inoculation the animaPs blood serum is tested as
to its value by experiment on guinea-pigs of definite
weights. When the desired degree of immunity is
reached the animal is bled from the jugular vein un-
der strict aseptic precautions, from 6 to 12 pints be-
ing taken from a horse, according to his size and gen-
eral condition. The blood is received in sterilized flasks,
which are carefully stoppered and stored on ice until
the clot has separated from the serum. The latter is
tested to determine its value in antitoxin, has phenol
added to it in the proportion of 0.5 per cent, and is
bottled in vials which contain in each the dose for one
patient. The vials are labeled with a statement of the
number of normal antitoxin units per c.c. of the con-
tents, expressed in multiples of a standard normal
serum." — (Potter's Materia Medica.)
7. Pigments. Of bile: Bilirubin, biliverdin, bili-
fuscin, biliprasin, bilihumin. Of blood: Hemoglobin,
842
WASHINGTON.
oxyhemoglobin, hematin. Of urine: Urochrome, uro-
bilin, uroerythrin, uroxanthin.
8. "In order to supply the requirements of the or-
ganism a certain amount of potential energy is needed
to over-balance the amount dissipated in waste and in
the production of body-heat. More potential energy is
consumed during work than when the individual is at
rest. The following table, computed by Rubner, shows
the daily heat consumption, in units of heat (calories) ,
in an adult, weighing 65 kilograms:
During rest in bed 1800 calories or 28 calories per kilo.
In repose 2100 calories or 32 calories per kilo.
In light work 2300 calories or 33 calories per kilo.
In moderate work 2600 calories or 40 calories per kilo.
In hard work 3100 calories or 48 calories per kilo.
From Rubner's investigations we learn that:
1 gm. of protein =4.1 calories .
1 gm. of fat =9.3 calories
1 gm. of carbohydrates = 4.1 calories
It has also been determined that 1 gram of alcohol
equals 7 calories. In other words, the number of grams
of proteins, fats, and carbohydrates required daily can
be converted into their calorimetric equivalents, and
inasmuch as the alimentary principles can in a degree
be substituted for one another (law of isodynamics),
the daily food requirements can be easily estimated in
calories of heat. Thus, in order to calculate the caloric
value of any food in preparing a dietary, the number
of grams of proteins contained are multiplied by 4.1;
the number of grams of fat by 9.3; and the number
of grams of carbohydrates by 4.1; the total is then
ascertained by adding. Bearing the weight of the in-
dividual in mind, a dietary can easily be constructed
according to the following method:
The quantity of protein consumed daily is
100 gm. X 4.1 == 410
The quantity of carbohydrates consumed daily is
500 gm. X 4.1 = 2050
The quantity of fats consumed daily is 50 gm. X 9.3 = 465
2925
The average number of calories required daily in an
individual, according to this calculation, is therefore
3000." — (Friedenwald and Ruhrah's Dietetics for
Nurses.)
9. Estimation of total acidity of gastric contents:
"To lOc.c. of the filtered fluid, accurately measured into
a beaker, three drops of a 1 per cent solution of phenol-
N
phthalein is added, and enough — NaOH solution,
10
843
MEDICAL RECORD.
accurately measured from a burette, to produce a per-
manent pink color. After the addition of a few cubic
centimeters of the decinormal soda solution, a light
rose color appears, which should not be mistaken for
the end reaction. The final change of color is produced
by a single drop of the alkali, and hence the addition
should be made drop by drop near the end. Near the
completion of the test, each drop will produce a pink-
red cloud as it falls into the liquid, which will disap-
pear on gently mixing the contents of the beaker. This
is best done by giving the beaker a rotary motion." —
(Bartley's Chemistry.)
10. First of all, test for the albumin, as follows: The
urine must be perfectly clear. If not so, it is to be fil-
tered, and, if this does not render it transparent, it is
to be treated with a few drops of magnesia mixture,
and again filtered. The reaction is then observed. If
it be acid the urine is simply heated to near the boil-
ing point. If the urine be neutral or alkaline it is
rendered faintly acid by the addition of dilute acetic
acid, and heated. If albumin be present a coagulum is
formed, varying in quantity from a faint cloudiness
to entire solidification, according to the quantity of al-
bumin present. The coagulum is not redissolved upon
the addition of HINKV
If albumin is present it should be removed. The urine
is then tested for sugar as follows: Render the urine
strongly alkaline by addition of Na 2 C0 3 . Divide about
6 c.c. of the alkaline liquid in two test tubes. To one
test tube add a very minute quantity of powdered sub-
nitrate of bismuth, to the other as much powdered
litharge. Boil the contents of both tubes. The presence
of glucose is indicated by a dark or black color of the
bismuth powder, the litharge retaining its natural color.
Test for bile: Put 3 c.c. HN0 3 in a test tube, add a
piece of wood, and heat until the acid is yellow; cool.
When cold, float some of the urine to be tested upon the
surface of the acid. A green band is formed at the
junction of the liquids, which gradually rises, and is
succeeded from below by blue, reddish-violet, and yellow.
Test for Blood: To the urine add a solution of potas-
sium hydroxide to distinct alkaline reaction; Iheat
nearly to boiling (do not boil). A red precipitate is
produced.
11. Ferments of the pancreatic fluid: Trypsin, which
splits up proteins into proteoses, peptones, and amino-
acids: Steapsin, which emulsifies and saponifies fats:
and Amylopsin, which converts starches into erythro-
dextrin, achroodextrin and maltose.
844
WASHINGTON.
12. Normal human milk consists of about 88 per cent
of water and about 12 per cent of solids. These latter
are approximately: proteins, 2 per cent; fats, 3 to 4
per cent; sugar, 6 per cent; and inorganic salts, about
0.3 per cent.
Cow's milk has approximately: proteins, 4 per cent;
fats, 4 per cent; sugar, 4 per cent; and inorganic salts,
about 0.7 per cent.
OBSTETRICS.
1. Placenta prsevia is the condition in which the
placenta is attached in the lower uterine segment, and
may be near or over (partially or completely) the in-
ternal os. Frequency: About once in 1200 to 1300
pregnancies. Symtoms: Sudden hemorrhage, accom-
panied by syncope, vertigo, restlessness, and feeble
pulse. Treatment: Stop the hemorrhage by vaginal
tampon; this must be tight and thorough. Accouche-
ment force is indicated; this consists of dilatation of
cervix, version, and immediate extraction of the child.
Treatment before term: Rest in bed, with or with-
out a tampon, will arrest hemorrhage for the time; the
sinuses are closed by thrombi, and the case may go on
to term or another hemorrhage. The patient should
be allowed cold drinks; opium may be used where pain
is present. If the hemorrhage is great, it is safer to
induce labor at once than to wait. Occasionally no hem-
orrhage occurs during pregnancy, not even in labor.
Treatment at term: (1) Introduce one or two fingers
within the os (the hand being in the vagina) and dissect
the placenta from the uterine wall for about three
inches from the os uteri in all directions, pushing it to
one side if necessary. (2) Rupture the membranes,
and if there is an unfavorable presentation, turn the
child and make the breech engage in the os; or, if the
head presents, the forceps may be used, if speedy de-
livery is necessary. The strength of the woman is then
the main point to be cared for, and if in a reasonable
time the uterus seems to be incompetent, the child may
be delivered by art. In some cases of central placenta
praevia, where rapid delivery is required, cesarean
section may give good results for mother and child. —
(Landis* Obstetrics.)
2. Prolapse of the funis is the condition in which the
umbilical cord hangs down alongside of or in front of
the presenting part of the fetus. Causes: Malpositions
and malpresentations, multiple pregnancy, sudden es-
cape of liquor amnii, too small fetal head, too large
pelvis or abdomen of mother. Diagnosis is made by
feeling the cord through the membranes; it feels like a
845
MEDICAL RECORD.
soft, compressible body with pulsations which are syn-
chronous with the fetal heart. Danger: Compression
causes death of the fetus. Treatment of prolapsed
funis consists in: (1) Not rupturing the membranes
prematurely unless there is some positive indication;
(2) postural treatment, in which the woman is placed
on her back or on the opposite side to that on which
the cord lies, with hips and pelvis elevated, or the knee-
chest position may be adopted; (3) reposition of the
cord, either manually or with some form of repositor;
(4) speedy delivery, by forceps or podalic version.
3. The Placenta, — "The placenta is formed by the
fusion and intergrowth of the decidua basalis, which
forms the maternal portion of the placenta, and the
chorion frondosum, which forms the fetal part of the
placenta. As a separate organ, the placenta dates
from the third month of pregnancy, and from that time
gradually increases in size until the termination of
pregnancy. The chorionic villi lose Langhans' layer
of cells, and embed themselves into the interglandular
stroma of the decidua basalis, and sometimes penetrate
the mouths of the small veins. The syncytium also
penetrates the endothelium of the decidual arterioles,
and large blood sinuses are thus formed. By this ar-
rangement, the fetal and maternal blood, while kept
separate, are brought into such close contact that
osmosis may readily occur between them, thus permit-
ting the absorption of nutritive material from the
maternal into the fetal circulation, the excretion of urea
and other waste products of fetal metabolism, the pas-
sage of oxygen to the fetus, and the excretion of car-
bon dioxide from it.
"The functions of the placenta may be summed up as
follows: (1) It is nutritive, allowing of the passage of
nutritive material to the fetus. (2) It is respiratory.
Oxygen passes to, and carbon dioxide from, the fetus.
(3) It is excretory, allowing the escape of urea and
other products of fetal metabolism. (4) It has a
glycogenic function. Glycogen is stored in its cells for
the future use of the fetus. (5) It is iron storing, by
which iron in organic combination is passed from the
maternal circulation into the fetal circulation to be
stored in the liver cells of the fetus, in order to aid in
the formation of new colored blood corpuscles.
"At full term the placenta is a discoidal mass about
7 inches in diameter, two-thirds of an inch in thickness,
and weighs about 16 oz. Its fetal surface is smooth
and covered by the amnion, and its maternal surface
is divided by sulci into a number of irregular areas
846
WASHINGTON.
termed cotyledons. The fetus is attached to it by the
umbilical cord or funis, which averages 20 inches in
length and half an inch in thickness. It consists of a
stroma of Wharton's jelly, embedding the two umbilical
arteries and a single umbilical vein. It is covered by
the amnion. " — (Lyle's Physiology.)
4. Management of brow presentation: If recognized
before the onset of labor, postural treatment may be
tried. This consists in placing the woman on that side
toward which the fetal face is directed, so as to secure
flexion of the fetal head. Failing in this, or if only
recognized too late for the above to be tried, cephalic or
podalic version may be attempted; or forceps may be
applied, chiefly to act as a rotator. If the above do not
succeed, symphyseotomy may be performed, and the
child delivered by forceps. When all other methods fail,
if the child is dead craniotomy is indicated.
5. Ophthalmia neonatorum. Causes: The gonococ-
cus or some other pyogenic microorganism; the secre-
tions of the mother contain the infecting agent, and
transmission may occur directly during parturition, or
indirectly by the fingers of physician or nurse, cloths,
instruments, etc. Symptoms: Swollen eyelids, wtth
copious purulent discharge; ulceration of the cornea
may ensue. Prophylaxis: Whenever there is the possi-
bility of infection, or in every case, wash the eyelids of
the newborn child with clean warm water, and drop on
the cornea of each eye one drop of a 1 per cent solution
of nitrate of silver, immediately after birth.
6. Vitellus is the germinal portion of the ovum with
the substance which nourishes the embryo.
Allantois is a fetal membrane; it enters into the for-
mation of the bladder, placenta, and umbilical cord.
Amnion is the inner of the fetal membranes.
Chorion is the outer of the fetal membranes.
7. Eclampsia is an acute morbid condition, occurring
during pregnancy, labor, or the puerperal state, and is
characterized by tonic and clonic convulsions, which
affect first the voluntary and then the involuntary mus-
cles; there is total loss of consciousness, which tends
either to coma or to sleep, and the condition may ter-
minate in recovery or death. About 75 per cent of the
cases occur in primiparse. Prognosis is bad, the ma-
ternal mortality being about 30 per cent and the fetal
mortality from 50 to 75 per cent. The urine contains
albumin, is reduced in quantity, and is more toxic than
normal. Frequency^ about once in from 350 to 500
pregnancies. "The treatment of the attack consists of
the administration of chloroform by inhalation, chloral
847
MEDICAL RECORD.
hydrate (gr. 60) by enema, and the fluidextract of vera-
trum viride hypodermically (gtt. 15 followed by gtt. 5,
repeated frequently enough to keep the pulse at about
60 beats a minute), to control the convulsions, and free
purgation by croton oil (gtt. 2, or 3, in sweet oil or
glycerine), free sweating by the hot pack, and some-
times depletion by venesection to eliminate the poison.
The after treatment consists of free purgation by the
salines, restriction of diet, and later the administration
of tonics and stimulants. The obstetric treatment is
usually noninterference." (Pocket Cyclopedia.) Some-
times accouchment force is indicated.
8. Eutocia is normal labor, or one in which there is a
vertex presentation and no complications.
Dystocia is difficult or abnormal labor, and includes
all cases not carried in the term eutocia.
Varieties of dystocia: These may be classified, accord-
ing to causation, as follows:
(1) Anomalies of the expellent forces: (a) Excess —
precipitate labor; (b) deficiency — delayed or protracted
labor and inertia uteri; (c) spasm and irregularity —
rigid os and cervix, and tetanus uteri.
,(2) Anomalies of the passages: Pelvic deformities;
uterus, developmental anomalies of, atresia of cervix,
rigidity of cervix, impaction of cervix, malposition, sac-
culation, and new growths; stenosis and rigidity of
vulva and vagina; hematoma or edema of the vulva;
latral abscesses and cysts; conditions of intestines or
bladder; tumors and swellings of various tissues.
(3) Anomalies of the fetus: Malposition of the head;
occipito-posterior cases; malpresentations — face, brow,
pelvic, and transverse; prolapse of limbs; anomalies of
fetal development — shortness of cord, unduly ossified
skull, large size of fetus, death of fetus, and enlarge-
ment of head or body by disease; plural births, and
monstrosities (modified from Jewett's Practice of Ob-
stetrics) .
9. Hydatid pregnancy is a pregnancy in which the
chorionic villi undergo a proliferating degeneration with
the production of a mass of cysts attached to the pla-
centa. These cysts look like bunches of grapes. It
occurs once in about 2,000 cases of pregnancy.
The pregnancy begins as in normal cases, but about
the third month the uterus becomes suddenly and rap-
idly enlarged; irregular uterine hemorrhages occur;
and there is a discharge of fluid containing the vesicular
growths ; labor occurs and the mass of cysts is expelled.
10. Ectopic pregnancy is a pregnancy where the fetus
is being developed outside of the uterine cavity. Varie-
848
WASHINGTON.
ties: It may be interstitial, tubal, ovarian, or abdominal.
Probable cause: Some pathological condition in the Fal-
lopian tube which obstructs the passage of the fecun-
dated ovum. The most common condition is salpingitis,
especially of the gonorrheal variety. The age at which
it commonly occurs is not known. King says, "It is
more apt to occur after than before thirty years of
age"; Dorland says, "It is generally encountered in
women who are between twenty and thirty years of
age." Symptoms of tubal pregnancy will be signs of
early pregnancy, hypogastric or inguinal pains, prob-
able history of a previous sterility, probable expulsion
of decidual membrane or shreds, softening of the cervix,
enlargement of the uterus, presence of a distended tube,
contractions of the wall of the gestation sac ; if rupture
occurs, there will be sudden, excruciating pains over the
lower abdomen and on the affected side, shock, collapse,
and symptoms of internal hemorrhage.
The possible terminations are: Rupture of the tube,
followed by hemorrhage, shock, peritonitis, and perhaps
death ; tubal abortion, and continuance of the pregnancy
to term.
11. Pregnancy : The tumor is hard and does not fluc-
tuate, is situated in the median line, and may give fetal
heart sounds and movements; the cervix is soft, and the
other signs of pregnancy are present. The rate of
growth of the tumor, and the general condition of the
patient's health may also help in arriving at a diag-
nosis.
Uterine fibroid: Menstruation is irregular and some-
times very profuse; absence of the signs of pregnancy;
the tumor is nodular, firm, irregular in outline, and
while generally placed somewhat centrally is not in the
median line, and is not symmetrical ; the rate of growth
is irregular, being, as a rule, slow, and sometimes ex-
tending over years.
Ovarian cyst: Absence of the chief signs of preg-
nancy ; there may be the characteristic f acies, the tumor
is soft, fluctuating, is more to one side, and does not
show fetal signs.
12. External pelvimetry: "The measurements are
made with a pair of calipers. Interspinous diameter:
The points of the calipers are held in the two hands so
that the point of the forefinger rests alongside the point
of the instrument. The two anterior superior spines
are located, and the points placed on them. The cali-
pers are then screwed tight by an assistant or nurse,
and the measurement read off. Normally it is 9% to
10 inches. Intercristal diameter: The instrument is
849
MEDICAL RECORD.
held as before and the points passed slowly round the
iliac crests until the points of greatest separation are
found, when the measurement is made. Normally it is
10% to 11 inches. The external conjugate diameter is
measured by placing the one point of the calipers over
the tip of the last lumbar spine, and the other over the
front of the symphysis pubis. This is most easily done
with the patient standing, and the tip of the last lumbar
spine can be found by counting downward from above.
It is, however, usually marked by a slight dimple due to
fascial attachments. In fat persons it suffices to make
a point in the mid line 2% inches above the line joining
the posterior superior iliac spines. The external con-
jugate usually measures about IV2 to 8 inches; 3%
inches at the very least must be allowed for the thick-
ness of the bony and soft tissues. Therefore, while a
large reading may not necessarily mean a large conju-
gate, a reading under IV2 inches, and more especially
under 7 inches, indicates that the conjugate is dimin-
ished proportionately.
"Internal pelvimetry: The diagonal conjugate from
the promontory of the sacrum to the under margin of
the symphysis may be measured by the fingers. The
diagonal conjugate measures 4% to 4% inches, and Vz
to % of an inch must be subtracted to give the length
of the conjugate vera. The actual amount to be sub-
tracted varies with the depth of the pubic bone and its
inclination toward the sacrum, so that at the best this
method of estimation is but approximately correct. In
practice, however, these methods are found to be suffi-
ciently accurate in the vast majority of cases. It should
be remembered that in a normal pelvis it is impossible
to touch the promontory of the sacrum by vaginal ex-
amination without forcing the fingers so far in as to
hurt the patient. Therefore if the promontory can be
felt readily it indicates a small pelvis and the desira-
bility of more careful investigation. The outlet of the
pelvis can be directly measured in both its anteropos-
terior and transverse diameters by means of the fingers
and a measuring tape, or more conveniently by means
of a pair of calipers with the points crossed." — (John-
stoned Textbook of Midwifery.)
TOXICOLOGY.
1. Five emetic poisons: Arsenic, antimony, croton oil,
mercuric salts, and ptomaines.
2. The following portions of the cadaver should be
preserved for analysis in cases of suspected homicide
by poison: "The alimentary canal from the cardia to
850
WASHINGTON.
the middle of the rectum, unopened, and the contents
enclosed by ligatures at the esophagus, duodenum, and
lower end of gut; the liver, including the gall bladder;
one kidney; the spleen; a piece of muscular tissue from
the leg; the bram, and any urine which may remain in
the bladder. Any suspected food articles, and any ob-
tainable vomited matter, are to be also preserved. They
are to be placed in clean and new glass jars, closed with
glass or cork covers or stoppers. Jars with metallic
caps should never be used. Tapes or cords should be
tied about the jar and cap, to which they should be at-
tached by sealing wax bearing impressions of a seal,
in such a manner that access can be had to the interior
only after breaking the seals or cutting the tapes or
cords. Great care must be exercised that no sealing
wax can get into the jars. Each portion should be
placed in a jar by itself.
"The post-mortem appearance in acute arsenical pois-
oning are confined to the stomach and intestines. The
stomach is inflamed, whether arsenic has been taken by
the mouth or by other channels of absorption. The
mucous surface is coated with a layer of mucus, tinged
with blood or bile, and sometimes containing white crys-
tals of As 2 3 or green particles of Paris green. The
color of the mucous membrane is brownish red, inter-
spersed wtih darker streaks or patches between the
rugae. The small intestines are sometimes inflamed
throughout their length, but more usually the inflamma-
tion is limited to the duodenum." — (Witthaus' Essen-
tials of Chemistry and Toxicology."
3. A reliable test for arsenic: Reinsch's test is as fol-
lows: To the suspected fluid add a little pure HC1; sus-
pend in the fluid a small strip of bright copper foil, and
boil. If a deposit forms on the copper, remove the cop-
per, wash it with pure water, dry on filter paper, but be
careful not to rub off the deposit. Coil up the copper,
and put it into a clean dry glass tube, open at both ends,
and apply heat at the part where the copper is. If
arsenic is present there will appear in the cold part of
the tube a mirrqr, which will be found on microscopical
examination to consist of octahedral crystals of arsenic
trioxide.
4. The tissue changes in poisoning by the acids men-
tioned are as follows :
"In poisoning by sulphuric acid, the postmortem ap-
pearances correspond with the amount of local injury,
and this depends upon the size of the dose, state of con-
centration and length of time after the poison has been
swallowed. Spots on the skin are white at first, but
851
MEDICAL RECORD.
soon become brown. The mucous membrane is white
and leathery and friable. The heart is generally empty
and the venous system engorged with cherry red, thick,
ropy, acid blood. The stomach is generally corroded,
but may only show indications of severe irritation."
"In poisoning by nitric acid the mucous membrane of
the mouth and throat is yellow. The stomach is distend-
ed with gas, if not perforated, and patches of yellow,
brown or green are seen on its internal surface. Per-
foration is not common."
"In poisoning by hydrochloric acid the appearances
are much , the same as from the preceding acids, but
there is not so much disorganization of tissue."
"In poisoning by carbolic acid the mouth and throat
show corrosive effects. The mucous membrane is gen-
erally white or gray and pultaceous, or it may be har-
dened and corrugated. The stomach usually shows rela-
tively little corrosion. The blood is dark and fluid." —
(Riley's Toxicology.)
5. The symptoms of acute arsenical poisoning: "In
acute cases the symptoms usually begin in from twenty
to forty-five minutes. Nausea and faintness. Violent,
burning pain in the stomach, which becomes more and
more intense, and increases on pressure. Persisting and
distressing vomiting of matters, sometimes brown or
gray, or streaked with blood, or green (Paris green).
Purging. More or less severe cramps in the lower ex-
tremities." (Witthaus' Essentials of Chemistry.)
6. Symptoms of acute mercurial (corrosive subli-
mate) poisoning: "The nauseous, metallic taste is ex-
perienced during the act of swallowing. Within a few
moments this is followed by an intense, burning pain
in the mouth, throat and stomach, the mouth and tongue
are whitened and shriveled. There are vomitings of a
white material, containing shreds of mucous membrane
and tinged with blood, and bloody stools. Salivation
occurs if life be sufficiently prolonged. Death sometimes
occurs early from collapse, accompanied by convulsions,
or in the deep coma; but in most fatal cases life is pro-
longed for from three to six days." (Witthaus* Essen-
tials of Chemistry.)
7. Points to be considered in the investigation of gun-
shot wounds, are: "(1) the position of the weapon,
whether within the hand of the deceased, or whether it
has been so placed by another; (2) the presence or ab-
sence of blood upon it; (3) the indication or not of the
recent discharge of the weapon; (4) the number of car-
tridges or bullets discharged; (5) the caliber of the wea-
pon; (6) the weight and dimensions of the ball dis-
852
WASHINGTON.
charged; (7) the number, size, and direction of the
wounds; (8) the presence or not of marks of violence
and of blood-stains; (9) the amount of blood lost,
whether clotted or not; (10) the presence or not of
stains upon the clothing; (11) the direction of the
effused blood; (12) the course of the wounds in the
body; the presence or not of foreign substances (splin-
ters of bone, fibers of tendon or aponeurosis) in the
course of the missile; (13) the condition of the lips of
the wound, whether there be inversion of the wound of
entrance and eversion of the corresponding one of exit,
or not; (14) the condition of the weapon, of its bar-
rel; or if a revolver, of its different chambers; note
whether they are clean or not, etc.; (15) the peculiari-
ties, if any, of the cartridges; whether the primer is
marked by the hammer, and the name of the maker, etc. ;
(16) the size and weight of the bullets used; (17) the
weight and number, if shot were employed; (18) the
condition of the sights of the weapon, whether dis-
placed or loosened, etc.; also note the "trigger-pull,"
and (19) the places of impact of the various bullets,
as upon the wall, etc." (Herold's Legal Medicine.)
8. "In addition to the hydrostatic test, live birth may
be deduced from the following conditions : The stomach
may contain milk or food, recognized by the microscope
and by Trommer's test for sugar; the large intestines
in still-born children are filled with meconium; in those
born alive they are usually empty; the bladder is gen-
erally emptied soon after birth; the skin is in a condi-
tion of exfoliation soon after birth. The organs of cir-
culation undergo the following changes after birth, and
the extent to which these changes have advanced will
give an idea of how long the child has lived : The ductus
arteriosus begins to contract within a few seconds
of birth; at the end of a week it is about the size of a
crowquill, and about the tenth day is obliterated. The
umbilical arteries and vein: The arteries are remark-
ably diminished in caliber at the end of twenty-four
hours, and oblterated almost up to the iliacs in three
days; the umbilical vein and the ductus venosus are
generally completely contracted by the fifth day. The
foramen ovale becomes obliterated at extremely variable
periods, and may continue open even in the adult."
(MurrelPs Aids to Forensic Medicine.)
"The criminal modes for the purpose of destroying
the life of the newborn child are suffocation, drowning,
cold and exposure, starvation, wounds, fractures, and
other injuries, luxation and fracture of the neck, pois-
oning, intentional neglect to ligate the umbilical cord,
853
MEDICAL RECORD.
causing the infant to inhale noxious gases, the introduc-
tion of instruments into various parts of the body, etc."
9. There may be marks of violence or injury on the
uterus or vagina, such as perforation or tears ; but there
may be very few signs after the lapse of a very few
days. There may be the signs of a recent delivery.
10. Postmortem appearances in death by hanging:
"In the main they resemble those attending death from
strangulation. Externally, swelling and lividity of the
face, congestion of the eyelids, dilated pupils, eyes red
and protruding, tongue swollen, livid, often protruded,
or compressed between the teeth, lower jaw retracted;
often a bloody froth escaping from the mouth and nos-
trils. There are frequently petechial effusions on the
neck, shoulders, arms, and hands. In many cases, how-
ever, especially in suicides, the countenance is calm, the
face pale, the eyes and tongue natural. Sometimes there
is turgescence of the genital organs, and an involun-
tary escape of the urine, feces, and semen, but these
signs are by no means peculiar to death by hanging.
The position of the head varies according to the part
of the neck where the knot was placed. As the latter
is usually behind the neck, the head is generally flexed
forward. If the knot were in front, the head would be
found extended backward (Tardieu). The hands are
generally closed, often tightly; the legs extended, and
often livid. The neck is nearly always stretched, owing
to the weight of the body, and it presents very decided
marks of the cord, varying, however, somewhat accord-
ing to the nature of the latter and its mode of appli-
cation. Thus, the mark may be deep or superficial, sin-
gle or double, according to the strain made upon it, and
the thickness, roughness, or duplication of the cord. The
skin under this mark becomes very dense and tough, and
of a yellowish-brown color, and has been aptly com-
pared to old parchment. This appearance is more
marked if the body has remained suspended for some
hours or days ; and the cellular tissue underneath is also
condensed, and has a silvery appearance. Besides the
above, there is often a livid mark (ecchymosis) , where
great violence has been used, as in executions; but the
latter is quite distinct from the true mark of the cord,
with which it has been confounded. The livid line is
much less frequently met with than was formerly sup-
posed. The groove or furrow in the neck is oblique
(which distinguishes it from strangulation) ; it may
also be double (arising from a double fold of the cord),
and irregular or interrupted. It is more marked in
front, less so at the sides and below the ears, and ceases
854
WASHINGTON.
behind. In general, the narrower the ligature, and the
longer the suspension, the deeper the furrow. A broad
leather thong, pressing only by its borders, might pro-
duce a double mark.
"Internally the appearances usually accompanying as-
phyxia are met with, such as engorgement of the lungs,
right side of the heart, and venous system, with dark
fluid blood. Both ventricles of the heart contain blood,
if the death has been caused by apoplexy; if by as-
phyxia, the left cavities are found empty, while the right
side of the heart and the large vessels are engorged
with blood. The lining membrane of the larynx and
trachea is deeply congested, as in strangulation, and is
sometimes coated with a bloody froth, though less so
than in strangulation and suffocation. The vessels of
the brain are generally congested, but extravasation of
blood into the brain or upon its membranes is extremely
rare. The brain itself when cut into presents numer-
ous bloody points. The kidneys are usually congested;
the stomach frequently presents evidences of such deep
congestion as to suggest the idea of an irritant poison.
The same is true also of the intestines." (Reese's Medi-
cal Jurisprudence.)
11. The signs of recent delivery: "If the woman is
examined within three days of her delivery, the follow-
ings signs will be shown : pallor of the face and general
weakness will be apparent; the skin will be moist, re-
laxed, and soft; the eyes somewhat sunken, with a dark-
ening beneath or surrounding them; the pulse will be
soft and slightly quickened, and the breasts are knotty
to the feel, and full and enlarged; the nipples are en-
larged, and often exude a watery-like milk. In addition
to these signs the abdomen feels soft and relaxed to
the touch, and is thrown into folds; it shows on its
surface numerous transverse lines, the lineae albicantes.
The uterus is readily appreciated, between the abdomi-
nal walls, being situated low down within the pelvis;
it appears like a large ball. The external genitals are
swollen, moist and relaxed. The vagina is rather ca-
pacious, and there is a mucopurulent discharge from
the uterus. The os uteri is patulous and low, the lips
thereof being somewhat soft and relaxed, and perhaps
lacerated. These signs singly afford no proof of de-
livery, but when taken together they form conclusive
evidence of the recent delivery of the woman/' (Her-
old's Legal Medicine.)
12. "The kinds of food which most frequently pro-
duce symptoms of poisoning are pork, veal, beef, meat-
pies, potted and tinned meats, sausages and brawn. It is
855
MEDICAL RECORD.
not necessary that the food should be "high" to give
rise to poisoning. It may arise from the use of the
flesh of an animal suffering from some disease, from
inoculation with microorganisms, or from the presence
of toxalbumoses or ptomaines. Many diseases such as
diarrhea, enteric fever, and cholera, and perhaps tuber-
culosis, may be caused by eating infected foods. Trich-
uriasis may also be mentioned. Tinned fish often gives
rise to symptoms of poisoning, and shell fish are not
uncommonly contaminated with pathogenic microorgan-
isms. Mussel poisoning was formerly supposed to be
due to the copper in them derived from ships' bottoms,
but it is more probably the result of the formation of a
toxin during life, and not after decomposition has set
in." (MurrelPs Aids to Forensic Medicine.)
HYGIENE.
1. Ptomaines are basic, nitrogenous, organic com-
pounds produced from protein material by the bacteria
which cause putrefaction.
Symptoms of ptomaine poisoning: Nausea, pain in
abdomen, vomiting, purging, chilliness, headache, thirst,
weak and rapid pulse, anorexia, impairment of vision,
muscular weakness, collapse.
The most common source is decomposed or infected
food (meat, sausage, fish).
2. The patient must be isolated; no one but the phy-
sician and nurse must enter the room; the physician
should put on a large washable gown when he goes in,
and remove it on leaving, at the same time washing his
hands in a disinfectant; the nurse, when she leaves the
sick room should also remove her clothes and put on
others, at the same time disinfecting herself. Special
care must be taken during the period of desquamation.
At the termination of the disease everything should be
disinfected; toys, and books, etc., are better burned.
And see answer to question 8.
3. The air of sewers ("sewer gas") has no constant
composition, and if the sewer be properly constructed,
well ventilated, and sufficiently flushed, may differ but
little from outside air. Much depends upon the sewage
being removed quickly, or, on the other hand, being al-
lowed to stagnate and undergo decomposition. In the
latter case the air of the sewer becomes foul ; oxygen is
lessened, carbonic acid increased, and there is much or-
ganic matter, together with variable quantities of marsh
gas, sulphuretted hydrogen, and ammonium sulphide.
The exact composition of the organic matter varies, but
its properties are similar to those of the organic matter
856
WASHINGTON.
in respired air. Micro-organisms adhere to moist sur-
faces, and hence the air of well-constructed sewers is, on
the whole, remarkably free from them, except near
fresh air inlets and at junctions, where splashing oc-
curs. Neither bacteria nor other solid particulate mat-
ters are, under ordinary circumstances, given off from
quiescent liquid surfaces ; but if putrefaction be allowed
to occur the bursting of bubbles may recharge the air
with them. ... It is probable that pathogenic or-
ganisms are but rarely conveyed by sewer gas. Air
contaminted by sewage emanations may, however, be a
cause of diarrhea and other gastrointestinal disturb-
ances, and of certain forms of sore throat. Anemia,
depression, and general ill-health may result from pro-
tracted exposure to such an atmosphere. Cholera,
enteric fever, pneumonia, erysipelas, puerperal fever,
and diphtheria. Cholera, enteric fever, pneumonia, ery-
sipelas, puerperal fever, and diphtheria have a much
heavier incidence, both in numbers and severity, upon
persons exposed to these conditions. It is not necessary
to assume an origin de novo in such cases, or even in the
case of diarrhea and sore throat, the evidence being con-
sistent with the supposition either that the specific poi-
son is sometimes carried by such emanations, or that
their effect is merely to predispose to the disease. There
is no evidence of any specific relation between sewer
gas and small-pox, measles, or whooping-cough."
(Whitelegge and Newman's Hygiene and Public
Health.)
4. Measles. Period of incubation: From 7 to 18
days, oftenest 14. Date of eruption, third or fourth
day. Quarantine. In contacts, 18 days; for the sick,
at least that length of time, and as much longer as for
the entire completion of desquamation and the subsid-
ence of the catarrhal conditions. After release from
quarantine the child should not be allowed to re-enter
school for at least 5 days longer.
Variola. Period of incubation, 9 to 15 days; most
often 12 days. Date of eruption, usually on the fourth
day. Quarantine. For the sick, until desquamation is
complete and the skin thoroughly healed, not less than
21 days. For contacts, 14 days.
Scarlet Fever. Period of incubation, usually from
2 to 4 days; occasionally 24 hours and sometimes as
long as 12 days. Date of eruption, first or second day.
Quarantine. For contacts, 12 days, if possible non-im-
munes should be isolated in another house. For conva-
lescents, until desquamation is absolutely complete, a
minimum of 21 days and a maximum of 8 weeks; with a
857
MEDICAL RECORD.
running ear, the child should be excluded from school
much longer than 8 weeks and should under no circum-
stances return to school under 5 weeks. (From Gardner
and Simonds' Practical Sanitation,)
5. Essentials for the production and preservation of
pure dairy milk: Vaughan's rules are as follows: "(1)
The cows should be healthy, and the milk of any animal
which seems indisposed should not be mixed with that
from the healthy animals. (2) Cows must not be fed
upon swill or the refuse from breweries or glucose fac-
tories, or upon any other fermented food. (3) Milch
cows must not be allowed to drink from stagnant pools,
but must have access to fresh, pure water. (4) The past-
ure must be freed from noxious weeds, and the barn and
yard must be kept clean. (5) The udders should be
washed and then wiped dry before each milking. (6)
The milk must be at once thoroughly cooled. This is
best done in the summer by placing the milk can in a
tank of cold water or ice water, the water being of the
same depth as the milk in the can. It would be well if
the water in the tank could be kept flowing, and this
will be necessary unless ice water is used. The tank
should be thoroughly cleaned each day to prevent bad
odors. The can should remain uncovered during the
cooling, and the milk should be gently stirred. The
temperature should be reduced to 60 deg. Fahr., or
lower, within an hour. The can should remain in cold
water till ready for delivery. (7) Milk should be de-
livered, during the summer, in refrigerated cans or in
bottles about which ice is packed during transporta-
tion. (8) When received by the consumer it must be
kept in a clean place, and at a temperature some degrees
below 60 deg. Fahr."
Diseases specially liable to he conveyed by the in-
gestion of milk: Tuberculosis, typhoid fever, scarlet
fever, diphtheria, tonsilitis, cholera, and gastrointesti-
nal disorders.
6. Pasteurization of milk consists in heating the milk
for twenty minutes at a temperature of 140 deg. Fahr.
"Advantages of pasteurization milk: (1) That most,
if not all, of the common bacteria and their toxins are
killed. (2) That the ordinary ferments and germicidal
properties of the milk are not destroyed. (3) That the
process may be accomplished on a large scale, and fur-
nish a commercially safe milk. (4) That the taste, ap-
pearance, odor, and cream separation quality of the
milk are not altered. (5) That pasteurized milk, if
kept cold, furnishes a clean, healthy milk, safe for in-
fant food and other uses.
858
WASHINGTON.
"Disadvantages of the pasteurization of milk: The
following are some of the objections which are urged
by the opponents of pasteurization upon a large and
commercial basis: (1) That the spore-bearing bacteria
and bacterial toxins are not destroyed, and the milk is
therefore not wholly safe. (2) That pasteurization
stops lactic-acid fermentation, and thus destroys the
only 'nature's danger signal/ and the first symptom by
which aged milk is known. (3) That unless pasteur-
ized milk is rapidly cooled and kept under 50 deg. Fahr.,
certain fermentative changes which are ordinarily
stopped by lactic-acid fermentation increase in activity,
owing to the destruction of lactic-acid bacilli by the
pasteurization. (4) That pasteurization, by preserv-
ing unclean milk for some time, may induce the pro-
ducers to furnish dirty milk, discourage rigid cleanli-
ness, and promote carelessness on the part of the pro-
ducer who relies entirely on the pasteurization- to pre-
serve the milk. (5) That the pasteurization furnishes
a 'purified' milk instead of a 'pure milk.'" — (Price's
Hygiene and Sanitation.)
7. Immunity is the power of resistance of cells and
tissues to the action of pathogenic microorganisms.
Immunity may be either natural or acquired.
Natural immunity is that power of resistance, natural
and inherited, and peculiar to certain groups of animals,
but common to every individual of these groups.
Acquired immunity is this resistance acquired (1) by
a previous attack of the disease, or (2) by the person
being made artificially insusceptible. The conditions
which give immunity are: (1) a previous attack of the
disease; (2) inoculation with the specific microorgan-
isms in small numbers or of diminished virulence, so as
to produce a mild attack of the disease; (3) vaccina-
tion; (4) the introduction of antitoxins; (5) the intro-
duction of the toxins of the bacteria.
Examples: The rat is naturally immune to anthrax;
the white mouse is naturally immune to infection with
Bacillus mallei. Acquired immunity is seen in the im-
munity from smallpox after vaccination, or after hav-
ing suffered from an attack of the disease.
8. To prevent the spread of typhoid fever: Flies
should be kept out of the house as far as possible, by
means of screens or otherwise; all discharges from the
sick person must be disinfected; all utensils, dishes, etc.,
used by the patient must be thoroughly cleansed and
boiled every day; soiled linen must be soaked in a dis-
infectant solution before being washed; after each at-
tendance on a patient, physicians, nurses, and others
859
MEDICAL RECORD.
should wash their hands in a disinfectant; thorough
sterilization of all bedding, etc., must be performed
after the disease is over. Further, each household
should boil all water that is to be used for drinking or
for washing dishes, etc. ; milk should be boiled also ;
and no ice should be put in water or other drink or food.
"When the patient has recovered from an infectious
disease, he should be given a general bath with soap
and water. In addition to this, he may be bathed with
chlorinated soda solution, and in the exanthemata it
may be advisable to anoint his body again unless all
desquamation has ceased. After a general bath has
been given the patient may be allowed to mingle with
the well. In most localities the convalescent from cer-
tain diseases, especially smallpox, is washed with
1:2000 bichloride of mercury solution, clothed with
clean clothing, and then transferred to a disinfected
room.
"The clothing and bedding which are to be disinfected
by means of steam should be carefully wrapped in
cloths saturated with 1 per cent carbolic solution,
placed in a wagon, and taken to the disinfecting station.
After the bed has been stripped, all refuse matter,
paper, and articles of little value are wrapped in cloths
saturated with carbolic acid and burned in a stove or
furnace. The floor, doors, windows, furniture, and the
walls for a distance of W2 meters from the floor should
be washed with 5 per cent carbolic acid solution. The
walls and ceiling of the room should subsequently be
sprayed with 1:1000 bichloride of mercury solution. If
the walls are papered, it is advisable to remove care-
fully the paper before beginning the disinfection. The
room is then closed as tightly as possible and disinfected
by means of formaldehyde. " (Bergey's Hygiene.)
9. To fumigate by chlorine: For 1000 cu. ft. of space
pour two ounces of H 2 S0 4 , and three ounces of water,
previously mixed and cooled, upon eight ounces of NaCl
and two ounces of Mn0 2 . The fluids must be mixed
slowly and with care, and the salts should be in an
earthen vessel upon a bed of sand. The generating
apparatus should be as high in the room as possible,
because chlorine gas is very heavy.
To fumigate by sulphur dioxide: For each 1000 cu.
ft. of space, five pounds of sulphur are burned, care
being taken to prevent accidents. In all cases, all aper-
tures and crevices of the room should be closed, all
closets, drawers, or other receptacles opened; and after
the fumigation the room should be well ventilated and
thoroughly cleansed with a solution of corrosive subli-
mate.
860
WEST VIRGINIA.
The room in question contains 3000 cu. ft.
10. The requisites of a good filter are (according
to Parkes) : (1) That every part shall be accessible for
cleansing or renewing the medium. (2) That the filter-
ing medium shall have a sufficient purifying power and
be present in sufficient quantity. (3) That the medium
gives nothing to the water favoring the growth of low
forms of life. (4) That the purifying power be rea-
sonably lasting. (5) That there be nothing in the con-
struction of the filter itself capable of undergoing putre-
faction or of yielding metallic or other impurities to the
water. (6) That the filtering material shall not clog,
and that the flow of water be reasonably rapid; to
which may be added: 7. That the filtering medium be
such that it can be readily cleansed and sterilized, or
else so cheap that the removal and replenishing may
not be neglected when necessary on account of the ex-
pense.
11. The habitual use of alcohol predisposes to: Arte-
riosclerosis, chronic nephritis, cirrhosis of liver and
kidneys; it lowers the resisting power against bacterial
invasion, hence pneumonia, tuberculosis, etc., may be
included in this list. The excessive use of alcohol
shortens life; the moderate use probably has no effect
on longevity, but much depends on the constitution and
habits of the individual.
12. Malaria is transmitted through the bite of an in-
fected mosquito {anopheles). Individuals should use
mosquito netting round their beds and wire gauze in
doors and windows, so as to keep out the mosquitos as
much as possible. All pools, stagnant water, etc., where
mosquitos may breed, should be removed. All mosquitos,
larvae, etc., should be destroyed as far as possible. By
staying indoors during dusk and darkness, opportuni-
ties for infection may be avoided. Occasional fumaga-
tion with formaldehyde or sulphur is also efficacious.
STATE BOARD EXAMINATION QUESTIONS.
West Virginia State Board of Health.
anatomy.
1. Describe the structures of the index finger and
their relation to bone tissue.
2. Give the anatomy of the kidneys.
3. Describe the portal circulation.
4. Describe the spinal cord and give its relation to
other tissues.
861
MEDICAL RECORD.
5. Describe Scarpa's triangle, naming the most im-
portant structures nearest it.
6. What is meant by the circle of Willis?
7. Describe fully the stomach.
8. Describe the peritoneum and name structures to
which it is attached.
9. Name and give insertions and attachments of the
muscles of the forearm.
10. Describe the bones of the foot and give their
articulation.
PHYSIOLOGY AND HISTOLOGY.
1. Give the principal forms in which connective tissue
occurs.
2. Give the histology of the spleen.
3. Describe in brief the histology of the kidney.
4. Give a brief description of the capillaries.
5. What are the fundamental groups of elementary
tissue?
6. Give the function of the lymph glands.
7. What is the effect of respiration upon pulse and
blood pressure?
8. Name and give function of the ferments of pan-
creatic juice.
9. Give function of the liver.
10. Give the conditions affecting body temperature.
CHEMISTRY AND MEDICAL JURISPRUDENCE.
1. Define chemistry, element, and molecular weight.
2. What is an acid, a base, a salt, a radical?
3. From what is iodine derived? Give symbol and
atomic weight.
4. State difference between quantitative and qualita-
tive analysis.
5. Describe the chemical changes in olive oil in the
alimentary canal.
6. What is your opinion of the physician's legal re-
sponsibility?
7. What is an ordinary witness? An expert witness?
8. What is molecular death? Somatic death?
9. Name some of the ways of identifying a dead
body.
10. Under what conditions would a physician be
justified in producing abortion? What precautions for
self protection?
MATERIA MEDICA.
1. Give rules for giving medicine to children.
2. Salol — give composition, dose, and physiological
action.
3. Name three hypnotics, give doses, and state which
hypnotic is safest and why.
862
WEST VIRGINIA.
4. Salvarsan — give method of administration and
name some of its dangers.
5. Serums and vaccines — name two of each, give
doses and method of use.
6. Oleum ricini- — give therapy.
7. Hydrotherapy — give indications.
8. Urotropin — give therapy.
9. Mercury — give preparations and therapy.
10. Cocaine — give therapy.
• PRACTICE OF MEDICINE AND PEDIATRICS.
1. Give treatment of scarlet fever and its complica-
tions.
2. Give treatment of typhoid fever and principal
complications.
3. Diphtheria, diagnosis, and treatment.
4. Give the cause, symptoms, and treatment of cere-
brospinal meningitis; the symptoms of tuberculous
meningitis.
5. What diseases may cause occlusion of the common
bile-duct?
6. Describe the normal heart sounds and state the
points on the chest where each is heard with greatest
distinctness.
7. Describe briefly the following diagnostic signs or
tests and name the disease or diseases in which they
may be found, Koplik's spots; Romberg's symptoms;
Argyll-Robertson pupil; Babinski's reflex; Kernig's
sign; Stokes-Adams syndrome.
8. Give cause and treatment of "summer diarrhea"
in children.
9. Describe the varieties of stomatitis, giving cause
and treatment.
10. What diseases are most commonly found in the
right iliac region?
SURGERY.
1. Give the morphological and clinical characteristics
of sarcoma and its varieties.
2. Give the differential diagnosis between a sub-
coracoid dislocation and a fracture of the surgical neck
of the humerus.
3. Give the symptoms and treatment of a fracture of
the femur, about the middle, in a young child.
4. Give the clinical history of a typical case of
osteomyelitis of the tibia in a child.
5. Give the differential diagnosis of a duodenal ulcer.
6. What must the surgeon do to prevent infection in
his operative work in addition to careful aseptic pre-
cautions?
863
MEDICAL RECORD.
7. Give the varieties and discuss the etiology of
ileus.
8. Describe in detail two methods of skin disinfec-
tion, and give the reasons for each step.
9. Give the treatment of burns.
10. What wounds are likely to become infected with
the tetanus bacillus, and what prophylaxis is to be
practised in the treatment of such wounds?
OBSTETRICS AND GYNECOLOGY.
1. What is the etiology of eclampsia? Discuss treat-
ment.
2. Describe method by which the diagnosis of presen-
tation and position can be made?
3. What is the treatment of threatened, and of in-
evitable, abortion?
4. Describe the changes in the mucous membrane of
the uterus incident to pregnancy.
5. What are the rules governing the introduction of
the blades of forceps?
6. Describe phantom tumor and give treatment.
7. What is the mesosalpinx and what* does it contain?
8. What is the relation of the pubococcygeus muscles
to prolapsus uteri?
9. Name the organs or parts composing the vulva
and give functions of each.
10. Discuss the theories of menstruation.
SPECIAL MEDICINE.
1. Conjunctivitis — give two varieties and treatment
of each.
2. Glaucoma — describe and give treatment.
3. Otitis media — give causes and treatment.
4. Eustachian tube — name some of the diseases af-
fecting it and the treatment.
5. Epistaxis — give causes and treatment.
6. Nasal catarrh ( cor yza)— treatment.
7. Give points at which principal heart murmurs
are heard.
8. Hemorrhage from the lungs — give cause and treat-
ment.
9. Name three curable forms of insanity and give
general treatment.
10. Describe the S. Weir Mitchell rest cure.
BACTERIOLOGY AND HYGIENE.
1. Name several non-pathogenic bacteria which are
useful to human life and health.
2. Name the two methods by which bacteria multiply,
864
WEST VIRGINIA.
and state what bearing the knowledge of this has upon
the methods of surgical sterilization.
3. Name five bacteria which are or may be pyogenic,
and state their relative virulence.
4. Define the following: Obligate, facultative, toxin,
and chemotaxis.
5. State Koch's four laws.
6. Describe a sanitary privy.
7. Give detailed directions how to rid a town of the
house-fly.
8. Enumerate the important points in school hygiene,
and discuss one of them in detail.
9. What is social hygiene, and what can the physi-
cian do in the course of his professional duties to pro-
mote it?
10. Discuss oral hygiene, and give the pros and cons
concerning the use of the toothbrush.
ANSWERS TO STATE BOARD EXAMINATION
QUESTIONS.
West Virginia State Board of Health.
ANATOMY.
1. The index finger consists of the following struc-
tures, beginning with the skin on the palmar surface:
Skin, subcutaneous tissue and fat, the sheath of the
flexor sublimis digitorum, flexor sublimis digitorum,
and flexor profundus digitorum, branches of the digital
arteries and nerves (from radial artery and median
nerves), and the three phalanges. Behind, will be
found the extensor communis digitorum and tlfe ex-
tensor indicis, with expansions of the first lumbrical
and first dorsal interosseous muscles, branches of the
second and third digital nerves (from the radial), sub-
cutaneous tissue, and skin. The tendon of the flexor
sublimis digitorum divides into two slips opposite the
base of the first phalanx to allow of the passage of the
flexor profundus digitorum. The joints between the
phalanges are provided with a capsule and anterior
and two lateral ligaments; these are found next to the
bones.
2. The kidneys are situated in the back of the abdom-
inal cavity, one on each side of the vertebral column, be-
hind the peritoneum, and extending from the eleventh
rib to the second or third lumbar vertebra. The right
kidney is about half an inch lower than the left one.
Each kidney is about four inches long, two inches broad,
and one inch thick, and weighs about four and a half
865
MEDICAL RECORD.
ounces. The kidneys are kept in place by their vessels,
fatty tissue, and the peritoneum. The shape is charac-
teristic. Each kidney is surmounted by the suprarenal
gland, is surrounded by a capsule, and consists of a
cortical and medullary portion. In the cortical portion
are found the Malpighian corpuscles, which are tufts
of capillaries, and are surrounded by a capsule which
is continuous with the uriniferous tubule which ends in
the renal papilla.
Relations of the right kidney. In front : Right lobe of
liver, second part of duodenum, hepatic flexure of colon
(of which the last two areas are nonperitoneal). Be-
hind. - Diaphragm, quadratus lumborum, psoas, fascia
covering these muscles, anterior lamella of lumbar
aponeurosis, ilio-hypogastric ilio-inguinal, nerves, last
dorsal; first lumbar artery, pleura, last intercostal
space, and twelfth rib.
Relations of the left kidney. In front: Fundus of
stomach, postero-internal surface of spleen, tail of pan-
creas, descending colon (of which last two are non-
peritoneal). Behind: As on right, except that left kid-
ney, lying rather higher, lies over 11th rib.
Above each kidney is the suprarenal body.
Below each kidney is the iliac crest.
3. By the portal circulation is meant the capillary
circulation of venous blood in the liver, between the
portal and hepatic veins.
Portal circulation: "The hepatic artery and the portal
vein convey blood to the liver. The artery carries
arterial blood, and the vein food-laden venous blood
from the walls of the alimentary canal, and from the
splefn and pancreas. Both vessels enter the liver at
the transverse fissure, and they ramify in its interior,
breaking up into small terminal branches which run
between the lobules and send fine capillary branches
into their substance; from these latter branches the
blood passes into the capillary tributaries of the intra-
lobular veins, thence to the sublobular veins, and from
the sublobular veins to the hepatic veins, which termi-
nate on the posterior surface of the liver in the in-
ferior vena cava." (Bain's Medical Practice.)
4. "The spinal cord is the elongated portion of the
cerebrospinal axis contained in the spinal canal. Its
length is about sixteen to eighteen inches, extending
from the medulla above to the lower border of the first
lumbar vertebra below, where it terminates in the
cauda equina by a slender prolongation of gray sub-
stance, called the conus medullaris. It presents two
enlargements, the upper or cervical, extending from
866
WEST VIRGINIA.
the third cervical to the second dorsal vertebra, and
the lower about the position of the second or third
dorsal vertebra. It is divided into two lateral halves
by the anterior and posterior median fissures, united
in the center by the commissure. The lateral portions
are again subdivided by the antero-lateral and postero-
lateral fissures into the anterior lateral and posterior
lateral columns, and posteriorly a narrow fissure sep-
arates the posterior median column from the posterior
median fissure. The gray substance occupies the center
of the cord, and is arranged into two crescentic masses
connected together by the gray commissure. The pos-
terior horn forms the apex cornu, from which arises
the posterior root of the spinal nerves. The anterior
horn is thick and short, and affords origin to the an-
terior root of the nerves. The gray commissure con-
tains throughout its whole length a minute canal the
central canal, or ventricle of the cord, continuous above
with the fourth ventricle." (Young's Handbook of
Anatomy) .
The relation of the structures in the vertebral col-
umn is (from without inward), the vertebra; venous
plexus between the bone and the dura; the dura,
arachnoid and pia with ligamenta denticulata; the cere-
brospinal fluid; the spinal arteries and veins; the
spinal cord.
5. Scarpa's triangle is a triangular area or depres-
sion situated just below the fold of the groin. It is
bounded above by Poupart's ligament, externally by the
Sartorius, and internally by the inner margin of the
• Adductor longus ; its apex is formed by the junction of
the Adductor longus and Sartorious. The floor is
formed, from without inward, by the Iliacus, Psoas,
Pectineus, Adductor brevis, and Adductor longus. Con-
tents: The femoral vessels pass from about the center
of the base to the apex, the artery being on the outer
side of the vein ; the artery gives off the superficial and
profunda branches, and the vein receives the deep
femoral and internal saphenous; the anterior crural
nerve lies to the outer side of the femoral artery; the
external cutaneous nerve is still further external, lying
in the outer corner of the space; just to the outer side
of the femoral artery, and in the sheath with it is the
crural^ branch of the genitocrural nerve. At the apex,
the vein (which at the base was internal to the artery)
lies behind the artery. The triangle also contains fat
and lymphatics.
6. The circle of Willis is an arterial anastomosis
situated at the base of the brain. It is formed: In
867
MEDICAL RECORD.
front by the two anterior cerebral arteries (branches
of the internal carotid), which are connected by the
anterior communicating artery; behind, by the two
posterior cerebrals (branches of the basilar artery),
which are connected to the internal carotid on each
side by the posterior communicating artery.
7. The stomach is that pouch-like portion of the ali-
mentary canal which is situated between the esophagus
and the small intestine. It is conical, with base to left
side; the upper border is concave, and is called the
lesser curvature; the lower border is convex, and is
named the greater curvature. The left extremity is
known as the fundus, above and to the right of which is
the cardiac orifice, and the right or small end is termed
the pyloric extremity. It occupies left hypochrondriac
and epigastric regions. Its orifices are cardiac, above,
communicating with the esophagus ; pyloric, at the right
extremity, passing into the duodenum. It is 10 to 12
inches long, 4 to 5 inches in diameter at widest part.
Its left or cardiac end is fixed by esophagus and gastro-
phrenic ligament to diaphragm, " lying beneath the
seventh left costal cartilage, one inch from sternum; it
is connected with the spleen by the gastrosplenic omen-
tum. The right or pyloric end reaches the .gall-bladder,
touching under part of quadrate lobe of liver; is very
movable; when stomach is empty is in midline four
inches below tip of gladiolus. Anterior surface, which
also looks upward, is in contact with, from left to right,
diaphragm, abdominal parietes (epigastric region),
under surface of liver. Posterior surface is separated
from pancreas, crura of diphragm, aorta, vena cava
inferior, and solar plexus, by lesser sac of peritoneum.
Superior border is attached to liver by small omentum.
Inferior border gives attachment to great omentum.
Coronary and pyloric arteries run along lesser curva-
ture; right and left gastroepiploic, along inferior or
greater curvature; vasa brevia, from the splenic to
fundus. Right pneumo gastric nerve supplies the pos-
terior surface; left pneumo gastric, the anterior sur-
face; sympathetic, from the solar plexus, both surfaces.
— (Aids to Anatomy.)
The Mucosa "is a pale, pinkish-ash color, thickened
toward the pylorus, where it presents numerous rugae, or
pleats, and at the pyloric end it helps to form the pyloric
valve. It is lined throughout with columnar epithelium,
and is studded with three kinds of minute tubes, the
gastric follicles, and lenticular glands. The gastric
follicles consist of two kinds, the pyloric and the peptic
glands, the former most abundant at the pyloric end
868
WEST VIRGINIA.
and the latter distributed all over the surface of the
stomach. The pyloric or mucous glands consist each
of from two to four blind tubes opening into a common
duct, and lined throughout by columnar epithelium.
The peptic glands are similar in structure, but have a
much shorter duct, and contain, in addition, peculiar
large, spheroidal, granular peptic cells. The lenticular
or simple solitary glands are small masses of lymphoid
tissue scattered throughout the connective tissue frame-
work of the stomach between the gastric follicles." —
(Young's Anatomy.)
8. Peritoneum. Course of, forming greater sac — in
longitudinal section. — -"Passing down from the umbili-
cus, the peritoneum lines the anterior abdominal wall
— covers the urachus and obliterated hypogastric ar-
teries — passes onto the bladder, from its upper aspect
to the trigone — is reflected onto the anterior and upper
part of the lateral aspects of the rectum, in the male,
forming the rectovesical pouch. In the female, the re-
flection is from the bladder onto the uterus (utero-
vesical fold) — extending thence over the upper portion
of the posterior vaginal wall — and thence to the rectum
(recto-vaginal pouch). From the rectum, the sigmoid
flexure of the colon is entirely covered (sigmoid meso-
colon) — the asgending and descending colons being cov-
ered, generally, only anteriorly and laterally — and
passing from the spine downward, the peritoneum
covers the small intestines, forming the lower leaf of
the mesentery — and thence back again, completing the
investment of the small bowel, forming the upper leaf
of the mesentery — and passes backward over the trans-
verse portion of the duodenum to the pancreas — thence
forward to form the inferior layer of the transverse
mesocolon — covers the inferior and part of the anterior
aspect of the transverse colon — thence runs downward
to form the posterior layer of the great omentum— re-
turning to form the anterior layer of the great omen-
tum — thence to the stomach, covering its antero-su-
perior aspect — thence to the under surface of the liver,
forming the anterior layer of the lesser or gastro-
hepatic omentum — thence covers the inferior surface
of the liver, from the transverse fissure to its anterior
border — whence it is reflected over the anterior border
to cover the superior surface of the liver to the pos-
terior peritoneal limit — thence it passes to the inferior
concave surface of the diaphragm (superior layer of
the coronary ligament) — thence over the anterior por-
tion of the concavity of the diaphragm to the anterior
abdominal wall — whence it passes down the anterior
S69
MEDICAL RECORD.
abdominal parietes to the umbilicus, to the place of be-
ginning.
Course of the Peritoneum Forming the Lesser Sac —
In Longitudinal Section, — "Beginning at the posterior
aspect of the stomach, which it covers, the peritoneum
of the lesser sac passes upward to the inferior surface
of the liver, behind the transverse fissure, forming the
posterior layer of the lesser or gastro-hepatic omen-
tum — and having covered the postero-inferior aspect of
the liver, it passes on to the under surface of the
diaphragm (inferior layer of the coronary ligament) —
thence passes downward over the posterior portion of
the concavity of the diaphragm to the spine, covering
the great vessels— thence to the pancreas — thence for-
ward, forming the upper layer of the transverse meso-
colon — covers the supero-anterior aspect of the trans-
verse colon — descends, forming the innermost layer of
the great omentum — then ascends to the greater curva-
ture of the stomach — and covers its posterior wall, to
the place of beginning. The lesser sac is in relation
with the inner aspect of the spleen, forming the inner
layer of the gastrosplenic omentum— and also in rela-
tion with the superior portion of the left kidney." —
(Bickham's Operative Surgery.)
9. Muscles of the forearm: Pronator radii teres.
Origin: Humerus, just above the internal condyle, and
inner side of coronoid process of ulna. Insertion:
Middle of outer surface of shaft of radius.
Flexor carpi radialis. Origin: Internal condyle of
humerus. Insertion: Base of metacarpal bone of index
and middle fingers.
Palmaris longus. Origin: Internal condyle of
humerus. Insertion: Palmar fascia.
Flexor carpi ulnaris. Origin: Internal condyle of
humerus, and olecranon and upper and posterior part
of ulna. Insertion: Pisiform bone and annular liga-
ment.
Flexor sublimis digitorum. Origin: Internal con-
dyle of. humerus, coronoid process of ulna, and oblique
line of radius. Insertion: Second phalanges of fingers.
Flexor profundus digitorum. Origin: Upper part
of anterior and inner surfaces of shaft of ulna, and
from coronoid process. Insertion: Last phalanges of
fingers.
Flexor longus pollicis. Origin: Anterior surface
of shaft of radius, and coronoid process of ulna. In-
sertion: Last phalanx of thumb.
Pronator Quadratus. Origin: Lower part of an-
terior surface of ulna. Insertion: Lower fourth of an-
terior part of radius.
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Supinator longus. Origin: Upper part of external
supracondylar ridge of humerus. Insertion: Styloid
process of radius.
Extensor carpi radialis longior. Origin: Lower
part of external supracondylar ridge of humerus. In-
sertion: Metacarpal bone of index finger.
Extensor carpi radialis brevior. Origin: External
condyle of humerus, external lateral ligament of elbow-
joint. Insertion: Metacarpal bone of middle finger.
Extensor communis digitorum. Origin: External
condyle of humerus. Insertion: Second and third
phalanges of fingers.
Extensor minimi digiti. Origin: External condyle
of humerus. Insertion: Second and third phalanges of
fingers.
Extensor carpi ulnaris. Origin: External condyle
of humerus, and posterior border of ulna. Insertion:
Metacarpal bone of little finger.
Anconeus. Origin: External condyle of humerus.
Insertion: Olecranon and upper and posterior part of
shaft of ulna.
Supinator radii brevis. Origin: External condyle
of humerus, external lateral ligament of elbow-joint,
orbicular ligament, and from ridge of ulna. Insertion:
Bicipital tuberosity and oblique line of radius.
Extensor ossis metacarpi pollicis. Origin: Outer
and posterior part of shaft of ulna, and middle of pos-
terior surface of shaft of radius. Insertion: Base of
metacarpal bone of thumb.
Extensor brevis pollicis. Origin: Posterior sur-
face of shaft of radius. Insertion: First phalanx of
thumb.
Extensor longus pollicis. Origin: Outer and pos-
terior part of shaft of ulna. Insertion: Last phalanx
of thumb.
Extensor indicis. Origin: Posterior surface of
shaft of ulna. Insertion: Second and third phalanges
of index finger.
10. Bones of foot. — Seven tarsal (os calcis, astraga-
lus, cuboid, scaphoid, and internal, middle, and external
cuneiform) ; five metatarsals; and fourteen phalanges.
Articulations. Os calcis: Astragalus and cuboid.
Astragalus : Tibia, fibula, os calcis and scaphoid.
Cuboid: Os calcis, external cuneiform, fourth and
fifth metatarsals, and (sometimes) scaphoid.
Scaphoid: Astragalus, three cuneiform, and (some-
times) cuboid.
Internal cuneiform: Scaphoid, middle cuneiform, first
and second metatarsals.
871
MEDICAL RECORD.
Middle cuneiform: Scaphoid, internal and external
cuneiform, and second metatarsal.
External cuneiform: Scaphoid, middle cuneiform,
cuboid, and second, third, and fourth metatarsals.
First metatarsal: Internal cuneiform, second meta-
tarsal, and first phalanx of great toe.
Second metatarsal: First metatarsal, internal cunei-
form, middle cuneiform, external cuneiform, third
metatarsal, and first phalanx of second toe.
Third metatarsal: Second metatarsal, external
cuneiform, fourth metatarsal, and first phalanx of third
toe.
Fourth metatarsal: Third metatarsal, external cunei-
form, cuboid, fifth metatarsal, and first phalanx of
fourth toe.
Fifth metatarsal: Fourth metatarsal, cuboid, and.
first phalanx of little toe.
Phalanges : The first row, with the metatarsals be-
hind, and the second row of phalanges in front; the
second row of the four outer toes, with the first and
third phalanges; of the great toe, with the first pha-
lanx; the third row of the four outer toes, with the
second phalanges.
PHYSIOLOGY AND HISTOLOGY.
1. The principal varieties of connective tissue are:
Areolar, adipose, elastic, fibrous, retiform, lymphoid,
cartilage, and bone. They all serve to connect and
support other tissues.
2. "The spleen is invested by a thick capsule, consist-
ing of fibroelastic tissue and a large proportion of
visceral muscle fibers. The capsule sends trabecular
into the interior of the organ. These are thick, and the
nuclei of the muscle fibers in them stand out con-
spicuously in stained specimens. The bulk of the organ
is deep red in color, and is called the spleen pulp.
In the pulp are numerous whitish nodules, about the
size of a pin's head. These nodules are composed of
lymphoid tissue surrounding small arteries, and are
called Malpighian corpuscles. The pulp consists of a
network of fine fibers, with a number of flattened and
branched cells situated on the fibers and at their cross-
ings. In the spaces between the fibers are numerous
red corpuscles, large lymphocytes, and other blood cells.
Many of the red corpuscles undergo disintegration in
the large lymphocytes, so that pigment, both intra-
cellular and free, is present. An occasional giant cell
of bone marrow type is seen in the spleen pulp. The
splenic artery breaks up at the hilus, and the branches
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pass into the interior of the organ along the trabecular.
Passing away from the trabecular, their outer coat
becomes surrounded at intervals by nodules of lymphoid
tissue — the Malpighian corpuscles. Each corpuscle
usually shows a germ center. The arteries open into
capillaries, which, in turn, open into the interstices of
the pulp. From the pulp spaces there open wide venous
sinuses, which are encircled by fibers of the reticulum,
and are lined by a very prominent endothelium. These
sinuses open into the radicles of the splenic vein."
(Aids to Histology.)
3. "The kidney is a compound, tubular gland com-
posed of microscopic tubules whose function it is to
secrete from the blood those waste products which col-
lectively constitute the urine. If the apex of each pyra-
mid be examined with a lens, it will present a number
of small orifices, which are the beginning of the urini-
ferous tubules. From this point the tubules pass out-
ward in a straight but somewhat divergent manner
toward the cortex, giving off at acute angles a number
of branches. From the apex to the base of the pyramids
they are known as the tubules of Bellini. In the cortical
portion of the kidney each tubule becomes enlarged and
twisted, and after pursuing an extremely convoluted
course, turns backward into the medullary portion for
some distance, forming the descending limb of Henle's
loop; it then turns upon itself, forming the ascending
limb of the loop, reenters the cortex, again expands, and
finally terminates in a spheric enlargement known as
Miiller's or Bowman's capsule. Within this capsule is
contained a small tuft of blood-vessels, constituting the
glomerulus, or Malpighian corpuscle. Each tubule con-
sists of a basement membrane lined by epithelium cells
throughout its entire extent. The tubule and its con-
tained epithelium vary in shape and size in different
parts of its course. The termination of the convoluted
tube consists of a little sac or capsule, which is ovoid
in shape and measures about 1/200 of an inch. This
capsule is lined by a layer of flattened epithelial cells,
which is also reflected aver the surface of the glomerulus.
During the periods of secretory activity the blood-ves-
sels of the glomerulus become filled with blood, so that
the cavity of the sac is almost obliterated; after secre-
tory activity the blood-vessels contract and the sac-
cavity becomes enlarged. In that portion of the tubule
lying between the capsule and Henle's loop the epithelial
cells are cuboid in shape; in Henle's loop they are flat-
tened, while in the remainder of the tubule they are
cuboid and columnar." (Brubaker's Physiology.)
873
MEDICAL RECORD.
4. "A capillary is a small vessel from 7 to 16 m
in diameter. Its wall consists of a single layer of
endothelial cells. The cells are somewhat elongated in
the long axis of the vessel. Their edges are serrated
and are united by a small amount of intercellular sub-
stance which can be demonstrated by the silver nitrate
stain. In certain capillaries those of the early embryo,
of the kidney glomeruli, of the chorioid coat of the
eye, of the liver, no cell boundaries can be made out.
In these capillaries the endothelium appears to be of
the nature of a syncytium. Capillaries branch with-
out diminution in caliber, and these branches anas-
tomose to form capillary networks, the meshes of which
differ in size and shape in different tissues and organs.
The largest meshed capillary networks are found in
the serous membranes and in the muscles, while the
smallest are found in the glands, as e. g. the liver. As
to caliber, the largest are found in the liver, the smallest
in muscles." (Bailey's Histology.)
5. The fundamental groups of elementary tissue are :
Epithelial, Connective, Muscle and Nerve.
6. The functions of the lymphatic glands and vessels
are: "(1) Mechanical, protective, or regulatory of the
circulation, the serous surfaces, bursae, tendon sheaths,
the cerebrospinal fluid. (2) The absorption of digested
products, the intestinal lymphatics or lacteals. (3) The
formation of the blood in the thymus, bone marrow,
spleen, and lymphatic glands. (4) The destruction of
injurious materials in the spleen, lymphatic glands, and
the lymphadenoid tissue of the respiratory tract, espe-
cially the nasopharyngeal section." — (Spencer and
Gask's Surgery.)
7. The pulse is more frequent during inspiration and
less frequent during expiration.
Blood-pressure rises a little with each inspiration and
falls during expiration.
8. Ferments of the pancreatic juice: (1) trypsin,
which changes proteids into proteoses and peptones,
and af terward decomposes them into leucin and tyrosin ;
(2) amylopsin, which converts starch into maltose; (3)
steapsin, which emulsifies and saponifies fats; and (4)
a milk-curdling ferment. All of these act in an alkaline
medium only.
9. The functions of the liver are: (1) the secretion of
bile; (2) the formation and storage of glycogen ; (3) the
formation of urea and uric acid; (4) the manufacture
of heat; (5) the formation of creatinine; (6) the pro-
duction of antithrombin ; (7) the conversion of poison-
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ous and harmful into inert material; (8) it is also a
reservoir for blood on its way to the heart.
10. The normal body temperature is regulated and
maintained by the thermotactic centers in the brain and
cord keeping an equilibrium between the heat gained
or produced in the body and the heat lost.
Heat is produced in the body by: (1) Muscular ac-
tion; (2) the action of the glands, chiefly of the liver;
(3) the food and drink ingested; (4) the brain; (5) the
heart; and (6) the thermogenetic centers in the brain,
pons, medulla and spinal cord.
Heat is given off from the body by: (1) The skin,
through evaporation, radiation, and conduction; (2) the
expired air; (3) the excretions — urine and feces.
CHEMISTRY AND MEDICAL JURISPRUDENCE.
1. Chemistry is that branch of science which treats
of the composition of bodies, their changes in composi-
tion, and the laws governing such changes. An element
is a substance which cannot, by any known means, be
split up into other, dissimilar, substances.
Molecular weight is the weight of a molecule of a
substance as compared with the weight of an atom of
hydrogen.
2. An acid is a compound of an electro-negative ele-
ment or radical with hydrogen, part or all of which
hydrogen it can part with in exchange for an electro-
positive element, without the formation of a base.
A base is a ternary compound capable of entering into
double decomposition with an acid to produce a salt and
water.
A salt is a substance formed by the substitution of
an electro-positive element for part or all of the replace-
able hydrogen of an acid.
A radical is a group of atoms which can enter or
leave a chemical reaction like a single atom.
3. Iodine is derived from sea-weed. Symbol, I ; atomic
weight, 127.
4. By qualitative analysis we determine what ele-
ments or groups of elements are present in a substance.
By quantitative analysis we determine also the exact
amounts of these elements or groups of elements.
5. Olive oil is partly emulsified, partly saponified in
the intestines, its glycerin being set free and its fatty
acids combining with the free alkalies to form soap,
which with. the emulsion forms the molecular basis of
the chyle, entering the blood through the lacteals and
being finally oxidized into carbon dioxide and water
though an excess will appear unchanged in the urine.
— (Potter's Materia Medica.)
875
MEDICAL RECORD.
6. A physician is not at all bound to accept a profes-
sional call; but if he accepts, he is bound to continue in
attendance until the patient no longer requires his
services, or he is discharged. He can leave during the
continuance of the condition for which he was called
only after giving ample notice of his intention to dis-
continue his services, and allowing a reasonable time
for the patient to obtain the services of another physi-
cian.
The physician undertakes to use proper skill, care,
and judgment in diagnosing and treating the case, and
also to give full instructions as to how the patient may
be best cared for. The physician is not allowed to
divulge anything that he learned while in professional
attendance, provided such knowledge was necessary
to the successful conduct of the case.
Malpractice is a failure on the part of a medical
practitioner to use such skill, care, and judgment in
the treatment of a patient as the law requires; and
thereby the patient suffers damage. If due to negli-
gence only, it is civil malpractice. But if done delib-
erately, or wrongfully, or if gross carelessness or neg-
lect have been shown, or if some illegal operation (such
as criminal abortion) be performed, it is criminal mal-
practice.
7. An expert witness may give his opinion on facts
or supposed facts as noted by himself or asserted by
others. Theoretically, this can only be done by one
perfectly familiar with the subject in question; but
practically any (or almost any) physician with a license
to practise is accepted as an expert witness. A non-
expert witness testifies only the facts which he has
seen, or heard, or with which he has become acquainted
by personal observation.
8. Molecular death is .caries, or death of some cells.
Somatic death is death of the entire body.
9. "When a body entirely unknown is found, the de-
cision as to identity may be simplified by exclusion, so
that such general questions as those of sex, race, age,
height, and weight, are first settled; then with the help
of the clothing, vocational stigmata, and the circum-
stances under which the body is found, much may be
learned as to the individual and the class of life from
which he came. The color, amount, and character of
hair, color of eyes, the condition and number of the
teeth, and general type of features, the presence of
deformities, tattoo marks, and cicatrices, will, in the
entire and fresh, unmutilated body, give us a basis on
which to rest a thorough and complete identification.
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It frequently happens, however, that bodies of unknown
dead are found after the lapse of days or weeks, or,
when found in water or in the woods, may be so^ dis-
figured as to make useless most of those means of iden-
tification which are most commonly used. In such in-
stances one makes the most of those points which are at
his command. When from decomposition, or for other
reasons, it becomes necessary to bury or in other ways
dispose of the body before identification is complete,
proper photographs should be taken, and the contents
of the pockets, and other possessions found on or about
the body, which may assist in identification, should be
retained for future reference." — (Dwight's Medical
Jurisprudence. )
10. Conditions that justify the induction of prema-
ture labor: (1) Certain pelvic deformities; (2) pla-
centa prasvia; (3) pernicious anemia; (4) toxemia of
pregnancy; (5) habitual death of a fetus toward the
end of pregnancy; (6) hydatidiform mole; (7) habitu-
ally large fetal head.
The physician should protect himself by calling in
consultation another reputable physician of recognized
standing.
MATERIA MEDICA.
1. Rules for giving medicine to children: "Never
prescribe a drug without a good and sufficient reason.
Prescribe so that the dose will be small in amount and
as agreeable as possible. Pills and capsules are not
intended for children who rarely can swallow them.
Prescriptions should be simple and if possible contain
but one or at most two drugs. Powders made up with
sugar of milk are mixed with water and given from the
teaspoon. Tablet triturates form an easy and accurate
method of giving drugs (except nitroglycerin). If the
child is unwilling, the medication on the spoon is quickly
slipped on to the tongue and the spoon held in position
well back until swallowing takes place. In this way
the child cannot regurgitate it. Begin with small doses
in early life and increase if the desired effect is not ob-
tained. Heroic doses, however, may be used in emer-
gencies where rapid and active stimulation is required.
Hypodermatic injection of the stimulant is often re-
quired to produce physiological effects. The rule that
an infant up to a year should receive one-twentieth of,
and at one year one-tenth of the adult dose, is to be
followed in the majority of cases. The stimulants,
however, are exceptions to this rule. At the fifth year
one-fifth, and about the tenth year one-half the adult
877
MEDICAL RECORD.
dosage is usually to be given." — (Chapin and Pisek's
Diseases of Children.)
To determine the proper dosage for a child: Let
x
x = the age of the patient; then = the frac-
x + 12
tion of the adult dose which the patient should re-
ceive. Thus, a patient four years old should receive
4 4 1
=± — = — of an adult dose.
4 + 12 16 4
2. Salol is phenyl salicylate; and is composed of 60
parts of salicylic acid, and 40 of carbolic acid. Dose,
gr. vijss. Its physiological action is: antiseptic, anti-
pyretic, and germicidal. Care should be exercised in
its administration, because in the small intestine it is
decomposed into its constituent parts, and symptoms
of carbolic acid poisoning may develop.
3. Three important hypnotics: (1) Chloral hydrate;
dose, gr. xv to xx. (2) Sulphonal; dose, gr. xv to xxv.
(3) Trional; dose, gr. xv to xxv.
Indications: They are all used to produce sleep
(when no pain is present).
Chloral hydrate produces a natural sleep, acts
promptly, but is of no service if pain is present; it also
lowers the body temperature. It can be given for a
long time without deleterious effect, but it may irritate
the tissues and weaken the heart.
Sulphonal produces a natural sleep, but is of slow
action, requiring 3 or 4 hours to take effect; it is of no
use if pain is present, does not irritate the tissues and
weaken the heart, but is probably not so good for con-
tinuous use as chloral hydrate, though the two may re-
place each other for a time.
Trional is very similar to sulphonal but is more solu-
ble, and acts quicker. Both sulphonal and trional are
supposed to be safer than chloral.
Sulphonal is said to be safer than trional because it
contains fewer ethyl groups than the latter does.
4. Salvarsan. "It has become the regular custom
to administer salvarsan intravenously , because in a
number of instances its intramuscular injection was
followed by necrosis and the formation of an abscess,
the arsenic remaining unabsorbed. A number of
deaths have occurred from its use. The untoward ef-
fects are: (1) The Jarisch-Herxheimer reaction, in
which the secondary eruption becomes darker and ap-
pears to spread for a number of hours. It is believed
to be the result of insufficient dosage at the outset.
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(2) Irritation of the tissues, with lymphangitis, from
leakage in the neighborhood of the vein.
After effects. — The usual ones are headache, nausea,
malaise, lasting from twelve to twenty-four hours. —
(Bastedo's Materia Medica.)
5. Antidiphtheritic serum, immunizing dose 500
units, curative dose 3,000 units; it is injected sub-
cutaneously.
Antiietanic semm, dose 2^ to 5 drams; it is in-
jected into the spinal cord.
Typhoid vaccine, dose 500 to 1,000 million for first
dose, double this amount for second, and third doses;
given hypodermatically.
Streptococcus vaccine, dose 10 to 25 million, hypo-
dermatically.
6. Cod liver oil is a demulcent and emollient; it is
a tissue food. It is used in tuberculosis, rheumatism,
strumous diseases, rickets, nervous diseases, and wast-
ing diseases of childhood.
7. Hydrotherapy. "Cold water or ice has many ex-
ternal applications of value in the treatment of dis-
ease. As a wet pack it is used in tonsillitis, diph-
theria, and croup. Cold baths are the most effective
antipyretic in the high temperature of fevers, and the
cold wet pack is used for the same purpose. Ice or
cold water is applied to the head in acute cerebral con-
gestion, and to the spine in chorea, etc.; also locally in
hemorrhoids, bubo, orchitis, and to the uterus in post-
partum hemorrhage. Cold effusion to the body is em-
ployed as a preventive of spasmodic croup, as well as
to lessen the tendency to taking cold.
"Hot water externally as fomentations, hot wet pack,
hot baths, etc., is most effective in reducing local con-
gestion and in setting up resolution of local inflamma-
tion. Hot fomentations to the renal region are useful
in functional inactivity of the kidneys. The hot spinal
douche is used in affections of the spinal cord and
meninges, and in the backache of women. The hot
wet pack is highly esteemed in inflammation of the
chest organs, and hot injections are useful in chronic
inflammation of the uterus. Hot water dressings for
wounds are strongly favored by many surgeons.
Vapor and Turkish baths are used as diaphoretics ir.
advanced kidney disease, in acute and chronic rheu-
matism, in mineral poisoning, and in syphilis. Warm
baths, with cold applications to the head, are of value
in infantile convulsions and chorea." — (Cyclopedia of
Medicine and Surgery.)
8. Urotropin, when taken, is decomposed in the body
879
MEDICAL RECORD.
and formaldehyde is liberated and eliminated in the
urine; hence it is used as a urinary (and intestinal)
antiseptic, dose gr. iv., administered in water.
9.
Official Preparations
of Mercury
Ammoniated mercury. . .
Bichloride of mercury. . .
Calomel
Red oxide of mercury . . .
Yellow oxide, of mercury.
Red iodide of mercury. .
Yellow iodide of mercury
Solution of mercuric ni-
trate
Ointment of mercuric
nitrate
Chiefly Indicated in :
Ozoena, psoriasis, tinea, and other
skin affections.
Syphilis, anemia, summer diarrhea.
Syphilis, biliousness, dropsy, dysen-
tery.
Syphilitic sores, chronic skin dis-
eases.
Indigestion, syphilitic sores, chron-
ic skin diseases.
Syphilis, acute tonsilitis.
Chronic Bright's disease, syphilis.
Epitheliomata, warts, lupus.
Chronic skin diseases.
10. Cocaine hydrochloride. Physiological action:
local anesthetic (externally) ; internally it is a mus-
cular, cerebral, circulatory, and respiratory stimulant,
also a mydriatic. Its principal uses are: As a local
anesthetic; also in paralysis agitans, chorea, and
alcoholic tremors.
PRACTICE OF MEDICINE AND PEDIATRICS.
1. Treatment of scarlet fever and its complications.
The treatment is that of infectious fevers in general,
and in addition: "1. Serum treatment. — Serum from
convalescents, injected in doses up to 20 c.c, has some-
times proved successful. Good results have also been
obtained with polyvalent antistreptococcic sera (i.e.
sera prepared from several different strains of cocci).
2. The danger of spreading the disease is greatest dur-
ing the desquamative period. Isolation must, there-
fore, be kept up for at least six weeks from the onset,
or till all desquamation and discharges (nasal, aural,
etc.) have ceased. 3. A minimum amount of nitro-
genous food, to avoid irritation of the kidneys. This
caution does not affect milk, which may be freely used.
4. Daily toilet, tepid sponging, or tepid baths. 5. In-
unction of oily antiseptic preparations into the skin,
to prevent dissemination of the desquamating scales.
6. Examine the urine daily for signs of nephritis. 7.
The condition of the ears must be carefully watched.
Complications. — Arthritis demands warm and sedative
applications. Wrap the joints in cotton wool; alkalies
are better than salicylates, as the latter tend to irri-
tate the kidneys. Throat. — Ice to suck; antiseptic
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sprays; glycerin of carbolic acid; warm applications
externally. For the severe types. — Avoid caustic ap-
plications; relieve pain by cocaine solutions; internally,
tincture of ferric chloride, with free administration of
ammonia; quinine, either alone or with ferric chloride.
Stimulants may also be required. Nasal feeding often
gives much relief. Nephritis. — Milk diet, hydragogue
purgatives (avoid mercurials), hot-air baths, hot
packs, etc., according to the severity of the dropsy."
— (Wheeler and Jack's Handbook of Medicine.)
2. Treatment of typhoid fever with its principal
complications: The patient must be in bed, and no
medicine given unless indicated. "Give no solid food,
or that which would not readily pass through a fine
sieve. Milk, if it agrees, albumin-water made from
white of egg, beef tea, and chicken broth are the prin-
cipal foods. Of late some authorities have advocated a
light solid diet throughout, but nothing must be given
that would increase the risk of perforation. The stools
should be daily inspected. If undigested curd is found,
milk is being given too often, or the gastric function
is impaired. It may then be given with lime water or
barley water. Beef tea should be sparingly used, lest
it excite diarrhea. Alcohol is required mainly in the
later stages, when the typhoid state has set in, and
the heart is weak. Many cases do well without it al-
together. Other stimulants are strychnine, ammonia,
ether, etc.
"If the diarrhea becomes excessive give bismuth and
opium, or lead acetate and morphia, or an enema of
starch and opium. When the motions are very offen-
sive intestinal antiseptics (calomel in small doses,
salol, etc.) , may be given. They are also useful in
meteorism. If constipation be troublesome, give
enemata. No purgatives should be given after the
first week. Hemorrhage — opium, lead acetate, or cal-
cium lactate gr. xv every four hours, hypodermic in-
jection of morphine or ergotin, ice-bag to the cecum.
Perforation. — The main chance of recovery lies in
early laparotomy and suture of the affected bowel.
Every hour lost after the diagnosis is made, and the
initial shock has passed off, increases the danger to
life. Cases operated on within twenty-four hours may
recover; later, recovery is very rare. In anticipation
of operation, morphine may be given to relieve pain
and diminish peristalsis. Bed sores — water-bed, clean-
liness, stimulant and antiseptic lotions, dry dressings
if the slough is large. High fever — quinine and cold
baths. The antipyrin group is dangerous to the heart.
881
MEDICAL RECORD.
The stools and urine must be carefully disinfected.
During convalescence the diet must be increased with
the utmost caution, and the possibility of relapse must
always be remembered." — (Wheeler and Jack's Hand-
book of Medicine.)
3. Diphtheria. Diagnosis is made by finding the
diphtheria bacilli in the exudate. A sterile swab is
rubbed over any visible membrane on the tonsils or
throat and is then immediately passed over the surface
of the serum in a culture tube. The tube of culture,
thus inoculated, is placed in an incubator at 37° C.
for about twelve hours:, when it is ready for examina-
tion. A sterile platinum wire is inserted into the cul-
ture tube, and a number of colonies of a whitish color
are removed by it and placed on a clean cover slip and
smeared over its surface. The smear is allowed to
dry, is passed two or three times through a flame to
fix the bacteria, and is then covered for about ^ve or
six minutes with a Loeffler's methylene-blue solution.
The cover slip is then rinsed in clean water, dried,
and mounted. The bacilli of diphtheria appears as
short thick rods with rounded ends; irregular forms
are characteristic of this bacillus, and the staining will
appear pronounced in some parts of the bacilli and
deficient in other parts.
Treatment includes isolation, rest in bed, liquid diet,
washing of the throat and nose with an antiseptic so-
lution, and injection of the antitoxic serum. About
5,000 units may be given at once, and another dose of
half this amount in from twelve to twenty-four hours
if necessary.
4. Cerebrospinal meningitis. Cause: the diplococ-
cus intracellulars meningitidis. Symptoms: Sudden
onset, pain in back of head and neck and down the
spine, opisthotonos, vomiting, convulsions, cutaneous
eruption, rise of temperature, and Kernig's sign.
Treatment: Rest in bed, quiet, warmth and stimula-
tion, withdrawal of cerebrospinal fluid by lumbar punc-
ture and injection of Flexner's antimeningococcic
serum.
Tuberculous Meningitis. — An inflammation of the
soft intracranial membranes due to the deposit of gray
miliary tubercles. It is usually secondary to tuber-
culosis elsewhere, and is seen most often in children.
The onset is usually attended with various prodromes,
such as irritability, anorexia, headache, insomnia, etc.
The stage of excitation is characterized by headache,
vomiting, convulsions, intermittent temperature, soft,
irregular, and compressible pulse, and a red line upon
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drawing the finger-nail over the skin. This stage lasts
for about two weeks and is followed by depression, in
which the pulse is slow and compressible, temperature
is depressed, and somnolence and stupor alternating
with delirium, convulsions, headache, and peculiar
shrieking are present. Collapse, coma, convulsions fol-
low, and death usually results in from one day to two
weeks." — {Pocket Encyclopedia.)
5. Occlusion of the common bile duct may be caused
by: Gallstones, ulcers, foreign bodies, parasites, tumors
in neighboring structures, aneurysms.
6. There are two normal heart sounds which follow
in quick succession, and are succeeded by a pause. The
first, or systolic, sound is dull and somewhat prolonged,
the second, or diastolic, sound is sharper and shorter.
The sounds may be expressed by the syllables lubb —
dup.
The first sound is heard best at the apex beat in the
fifth left intercostal space; the second sound is heard
best over the second right costal cartilage.
7. Koplik's spots are bluish-white spots on a reddish
base, found on the mucous membrane of the cheeks and
lips in the pre-eruptive stage of measles.
Romberg's symptom: An ataxic patient is unable to
stand steadily if his eyes are closed and his feet to-
gether; he will sway from side to side or backwards
and forwards and may even fall down.
Argyll-Robertson pupil : The pupil responds to accom-
modation, but not to light; found in locomotor ataxia,
general paralysis of the insane, cerebral syphilis.
Babinski's reflex: Irritation of the skin of the sole
of the foot causes extension instead of flexion of the
toes; found in lesions of the pyramidal tract, in organic
(but not hysterical) hemiplegia.
Kernig's sign: The patient lies with the thighs flexed
on the abdomen and the legs flexed on the thighs; if
cerebrospinal meningitis is present, extension of the legs
is impossible, being prevented by the contraction of the
hamstrings.
Stokes-Adams syndrome: A symptom complex con-
sisting of bradycardia, visible auricular pulsation in the
veins of the neck, and vertigo or syncope; it occurs
in heart-block.
8. "Summer diarrhea in children is a severe form of
gastro-intestinal infection, due to the toxins of the
bacteria in milk. It occurs in hot weather among the
poor in large cities. .Treatment. The stomach and
colon should be irrigated. From 2 to 4 ounces of water
at 100° F. should be allowed to flow into the stomach
883
MEDICAL RECORD.
through a soft rubber catheter and be siphoned out.
This should be done only once. For the colon, sodium
bicarbonate, 3J, should be added to the pint, and the
irrigation performed twice daily. If the rectal temper-
ature is very high, ice cold water should be used;
otherwise warm water. When symptoms of collapse
appear, hot pack is used. Ice water quenches the thirst,
even if it is vomited. Champagne and drop doses of
brandy may be given - if the stomach is tolerant.
Strychnine gr. 1/100-1/48, hypodermically, to a child
1 year old, is a valuable stimulant. Morphine, gr. 1/100,
and atropine, gr. 1/800, may be givevn in the same way
and repeated every hour until the child is quieted. —
(Pocket Cyclopedia of Medicine and Surgery.)
9. "Aphthous stomatitis is characterized by a hypere-
mia of the mucous membrane of the mouth, and by the
formation upon it of small, yellowish white vesicles of a
herpetic character. Children from 6 to 18 months of age
are the most commonly affected. It is due to unclean-
ness, improper feeding, bad hygiene, etc. The affection
is self limited, but proper feeding, regulation of the
bowels, and improved hygiene should be instituted, and
mouth washes containing boric acid or sodium salicylate
should be used.
"Catarrhal stomatitis is a simple catarrhal inflam-
mation of a portion or of the entire surface of the
mouth. It occurs most commonly during the period of
first dentition. It results from uncleanliness, the in-
gestion of irritating food, infectious fevers, gastrointes-
tinal disturbances, etc., the mouth is red, dry, and hot;
later, there is an increased flow of saliva ; coated tongue,
constipation, slight fever, thirst, etc., are present. The
affection lasts about one week, during which sucking is
painful. The treatment consist in cleansing the nipple
and the child's mouth frequently, the administration of
fractional doses of calomel, and the use of, mild alkaline
mouth washes.
"Gangrenous stomatitis is a rare affection, consist-
ing of a gangrenous destruction of the tissues of the
cheek, and possibly of the adjoining structures as well.
It occurs in debilitated children and follows the infec-
tious fevers. The disease progresses rapidly and termi-
nates in death in from a few days to two or three
weeks. In debilitating affections the treatment should
include strict cleanliness of the mouth to prevent this
condition. After it has occurred the affected areas
should be excised and tonics should be administered.
"Parasitic stomatitis is characterized by a catarrhal
condition and by the presence on the mucous mem-
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brane of white, flake like patches. It occurs usually
in young infants, and is caused by a vegetable parasite
(one of the mold fungi) variously known as Oidium
albicans or Saccharomyces albicans. It results from un-
cleanliness, and the treatment is similar to that of
catarrhal stomatitis.
"Ulcerative stomatitis is an inflammation and ulcera-
tion of the mucous membrane of the mouth, principally
of the gums. It results from infantile scorbutus, in-
fectious fevers, mercurial salivation, malnutrition, im-
proper hygiene, etc. The symptoms include slight con-
stitutional disturbances, reddened and swollen gums,
pain and salivation, acrid, irritating and offensive saliva,
foul breath, hemorrhages from the mucous membrane
on pressure, etc. The treatment should first be directed
toward the diet and hygiene of the patient. Salicylate
of sodium, borax, or hydrogen dioxide may be used in
mouth washes. Potassium chlorate should be adminis-
tered internally (gr. 10-20 in 24 hours to child one year
of age) and also should be used locally." — (Pocket Cy-
clopedia.)
10. Diseases most commonly found in the right iliac
region: Inguinal hernia, psoas abscess, appendicitis,
ovarian cyst or abscess, pyosalpinx, ruptured ectopic
pregnancy.
SURGERY.
1. Sarcoma. — "(1) Round-celled sarcomata consists
of a mass of round, nucleated cells with very little
intercellular substance. The tumors grow rapidly, in-
filtrate, and disseminate. There are three varieties:
(a) The small round-celled; (6) the large round-
celled; (c) the lympho-sarcoma, in which the cells are
small, but the intercellular substance consists of reti-
form tissue. They begin in lymphatic glands or lym-
phoid tissue. (2) Spindle-celled sarcomata. — The cells
vary in size, but they are all oat-shaped, or fusiform.
When much fibrous tissue is present, they are called
fibro-sarcomata. Frequently patches of immature
hyaline cartilage are present. (3) Myeloid sarcomata
consist of round or spindle cells with large multi-
nucleated cells scattered among them. The intercel-
lular substance is gelatinous. The nuclei of the giant
cells are scattered throughout, not arranged around
the periphery, as in the giant cells of tubercles. They
are very vascular, and may pulsate, or hemorrhage
may occur in them. No secondary deposits occur, and
they do not recur if completely removed. They always
grow from bones, and are the least malignant. (4)
Alveolar sarcomata are round-celled, but the cells are
885
MEDICAL RECORD.
grouped in alveoli by distinct stroma. (5) Melanotic
sarcomata are the most malignant. They originate
from pigmented structures, the skin, and the retina.
The tumor consists of round or spindle cells arranged
in alveoli, the cells containing a deposit of brown pig-
ment — melanin. The primary growth may be only
slightly pigmented, and either shaped as a flat plaque
or a papilloma; but the secondary deposits are of an
inky-black hue. Pigmented moles are the commonest
site of origin." (Aids to Surgery.)
2. In subcoracoid dislocation, the acromion process is
prominent,, and there is a flattening or depression be-
low it; the head of the humerus may be felt below the
coracoid process, and the glenoid cavity is empty;
crepitus cannot be elicited; the head of the bone is
fixed, and adduction is impossible; as a rule there is
preternatural immobility. In fracture of the surgical
neck of the humerus, the shoulder is somewhat flatter
than normal; the head of the bone is in the glenoid
cavity, and does not rotate with the shaft; crepitus
may be obtained unless the fracture is impacted; as a
rule there is preternatural mobility of the injured
limb.
3. Fracture of the middle of the shaft of the femur
in a young child. Symptoms: "As a rule, in fracture
of the shaft of ~the femur the lower fragment is drawn
upward and the upper end of the lower fragment is
found posterior and somewhat to the inside of the
lower end of the upper fragment, and the lower frag-
ment also undergoes external rotation (the drawing
up is due to the rectus and hamstrings; the passing
inward is due to the adductor muscles; the rotation
outward arises from the weight of the limb). There is
complete loss of function, the thigh and leg are
slightly flexed and usually everted. In some cases the
leg and lower fragment are inverted. There are
shortening, pain on movement, preternatural mobility,
crepitus, and obvious deformity, and the ends of the
fragments can be felt by the surgeon. In impaction
there is alteration of the axis of the limb and some
shortening. Always feel for the pulse below the frac-
ture to learn if the artery is damaged.
Treatment: "Fractures of the thigh in children are
reduced by extension and counter-extension; a well
padded splint reaching from the axilla to below the
sole of the foot may be applied to the outer side of the
limb and body. This splint is held in place by band-
ages which are overlaid with plaster of Paris. It is
worn for four weeks, at which time it is removed and
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a plaster bandage, applied so as to include the entire
limb, is worn for four weeks. Bryant's extension is
very satisfactory in treating a child. Both the in-
jured limb and the sound limb should be flexed to a
right angle with the pelvis, fixed by light splints, and
fastened to a bar above the bed. The weight of the
body produces counter-extension and the child can be
easily cleaned." — (Da Costa's Surgery.)
5. Osteomyelitis is inflammation of the bone and
marrow; the term is often used now for inflammation
of bone.
It is caused by infection, the bacteria gaining en-
trance either through a wound, or by extension fron
neighboring tissues, or they may be brought by the
blood.
Symptoms: Sudden onset; pain, tenderness, fever
chills, swelling of soft parts; sometimes the joint can
be moved gently without pain; septicemia or pyemia
may be present.
It is to be diagnosed from (1) Rheumatism, in which
more than one joint is affected and the tenderness is
in the joint, and not near it. (2) Tubercular arthritis,
in which the onset is slow and the trouble starts in
the epiphysis rather than in the diaphysis. (3) Cel-
lulitis in which the bone and periosteum are not af-
fected, and in which there is always a wound.
In osteomyelitis, the treatment consists in relieving
the constitutional symptoms and preventing the bone
from necrosing. An incision down to the bone is made;
if pus is beneath the periosteum, the latter is also in-
cised; a piece of bone is removed by chisel or trephine,
pus is removed, the endosteum is hurt as little as pos-
sible, the wound is irrigated with hot bichloride solu-
tion and packed with gauze; the soft parts are closed
and the wound well drained. In case this fails, ampu-
tation may be necessary.
6. In ulcer of the duodenum the symptoms are very
similar to those found in ulcer of the stomach; but in
the former condition there is less tendency to vomit,
the pain does not come on till some time after food
has been swallowed (and has had time to pass the
pylorus) , and blood in the stools is more common. All
of these points are due to physiological and anatom-
ical reasons based on the relative position of the stom-
ach and duodenum. A special sign of duodenal ulcera-
tion is the sorcalled "hunger pain" which occurs at the
end of digestion, when the unmixed acid of the gastric
juice is passing into the duodenum. This pain is re-
lieved by taking food, for when this occurs the pylorus
887
MEDICAL RECORD.
closes, and the gastric juice is for the time retained in
the stomach to be mixed with the food, while the alka-
line duodenal and pancreatic secretions are stimulated.
7. Intestinal obstruction may be caused by: Stran-
gulation, kinking, volvulus, foreign bodies, intussus-
ception, stricture, fecal accumulation, and tumors
either within or outside the bowel.
STRANGULATION
Subjective Symp-
toms.
1. Generally oc-
curs after age of
20.
2. Pain localized,
rapid collapse.
3. Pain intense,
paroxysmal in
character.
4. Constipation
complete.
Objective Symp-
toms.
1. Temperature
often subnormal.
2. Location in
small intestine.
INTUSSUSCEPTION TWISTS (VOLVULUS)
Subjective Symp-
toms.
1. Most frequent
in childhood.
2. Constant te-
nesmus.
3. Pain develops
suddenly and is
continuous.
4. Frequent di-
arrhea, passage of
bloody mucus.
Objective Symp-
toms.
1. Temperature
normal or subnor-
mal.
2. Localization in
small intestine ;
bowel frequently
protrudes at rec-
tum.
Subjective Symp-
toms.
1. Most frequent
after age of 30.
2. Pain diffuse.
3. Pain paroxys-
mal ; recurs less
often than in
strangulation.
4. Constipation
complete.
Objective Symp-
toms.
1. Temperature
slightly elevated.
2. Location,
small intestine ;
abdomen often
protrudes, in cer-
tain areas giving
dullness on percus-
sion.
— (Pocket Cyclopedia.)
8. Two methods of skin disinfection (hands ana
forearms) : "After mechanical cleansing a germicide
is employed to render the parts sterile. Whatever
method is adopted it is desirable that it shall not un-
duly irritate the skin." Fiirbringer's Method: After
washing off the soap in sterile water the hands are
dipped in 95 per cent, alcohol and held there for two
or three minutes while the forearms hands, fingers,
and nails are being rubbed with alcohol. Alcohol re-
moves the soap which has entered into follicles and
creases, removes desquamated epithelium, enters un-
der and about the nails, and favors the diffusion of
the corrosive sublimate under and about the nails and
into the follicles, when the hands are placed later in
the mercurial solution. Alcohol also hardens epithe-
lium and keeps it from desquamating into the wound.
After using the alcohol the hands are then dipped in
a hot solution of corrosive sublimate (1:1000), and
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WEST VIRGINIA.
with the forearms are scrubbed for at least a minute,
the nails receiving especial care.
The Sublimate Alcohol Method: It is as follows:
Cleanse the hands with soap and water as previously
directed. Use 95 per cent, alcohol as in Furbringer's
method. Dip the hands in 70 per cent, alcohol contain-
ing 1 part to 1000 of corrosive sublimate, and rub the
hands, forearms, and nails with a piece of sterile gauze
wet with this fluid for three minutes. Rinse these
parts in the fluid and then rinse in sterile water."
— (Da Costa's Surgery.)
9. Treatment of Burns. — General: If carbonic-
oxide-poisoning is present, artificial respiration and ad-
ministration of oxygen. For shock, opium and stimu-
lants. Local: For burns of the first degree, powder
with boracic acid. Puncture blisters, and cover the
part with an antiseptic dressing. Burns of deeper de-
grees than the second must be made aseptic with 1 in
1,000 perchloride of mercury. Carbolic acid is absorbed
readily, and must not be used. Antiseptic gauze dress-
ings should then be used. Picric acid (20 grains to 1
ounce of water) is used as a dressing. It lessens the
pain, and can be left on two or three days. The con-
tinuous bath may be used. If the burn be of any size,
it should be skin-grafted, as the scars of burns con-
tract very much, and may produce deformities. — (Aids
to Surgery.)
10. Punctured wounds, and those made with an im-
plement which is dirty or which is infected with the
tetanus bacillus are the most likely to result in tetanus.
Such wounds should be disinfected before being
dressed; and all wounds which have been exposed to
infection by earth, dust or stable refuse should be thor-
oughly purified. The use of Antitetanic Serum has
been recommended by some surgeons.
OBSTETRICS AND GYNECOLOGY.
1. Puerperal eclampsia. Etiology: Urema, albu-
minuria, imperfect elimination of carbon dioxide by the
lungs, medicinal poisons, septic infection; predisposing
causes are renal disease and imperfect elimination by
the skin, bowels, and kidneys.
u The prophylactic treatment consists in frequent and
regular examination of the urine. After the first ap-
pearance of albumin, daily quantitative examination of
the urine should be made. The diet should be milk;
the bowels should be kept freely open by means of
calomel and salines; the skin should be kept active by
hot baths, followed by vigorous rubbing. Diuretics,
889
MEDICAL RECORD.
such as Basham's mixture, digitalis, and caffein,
should be administered. During pregnancy, if the per-
centage of albumin increases in spite of the treatment,
abortion or induction of labor is indicated.
"The treatment of the attack consists of the admin-
istration of chloroform by inhalation, chloral hydrate
(gr. 60) by enema, and the fluidextract of veratrum
viride hypodermically (gtt. 15 followed by gtt. 5, re-
peated frequently enough to keep the pulse at about
60 beats a minute) , to control the convulsions, and free
purgation by croton oil (gtt. 2, or 3, in sweet oil or
glycerine), free sweating by the hot pack, and some-
times depletion by venesection to eliminate the poison.
The after-treatment consists of free purgation by the
salines, restriction of diet, and later the administration
of tonics and stimulants. The obstetric treatment is
usually noninterference." {Pocket Cyclopedia.) Some-
times accouchment force is indicated.
2. Methods of determining the position of the fetus
prior to labor: — "The examiner stands alongside the
patient, facing her head; the tips of the fingers of both
hands, moving together and at equal distances from the
middle line, are carried up the sides of the abdomen by
a series of tapping movements; and upon one side (for
example, the left, in the L. O. A. position) is noticed, a
firm, broad, even sense of resistance, contrasting with
the cystic, tumor-like sensation of the other side, with
the occasional encounter of firm, irregular bodies, — the
fetal extremities. This firm, broad, even resistance is
produced by the fetal back, and, to confirm this fact,
the extremities are felt for by a rubbing motion with
one outstretched hand on the opposite side. They are
felt as cylindrical, irregular bodies, slipping away from
the hand, and changing their position from time to
time. Having located the back and the extremities, the
portion of the fetal ellipse presenting at the superior
strait is next ascertained. The examiner now faces the
woman's feet, and, with the outstretched hands, the
fingers parallel with and the middle finger over the
center of Poupart's ligament, on either side, the fingers
dip down beneath the ligament into the pelvic cavity.
If the head is presenting, it is felt as a hard, regular,
round body, the greater mass of the occiput, the sharp
point of the chin, and the groove between occiput and
back being often distinguishable. At the same time,
the density of the head, its compressibility, its ap-
proximate size, and its relative size to the pelvis may
be learned. By auscultation the fetal heart-sounds are
located, and their rate and intensity are noted. The
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WEST VIRGINIA.
uterine bruit and the funic souffle are often heard. The
former is a low-pitched musical murmur synchronous
with the maternal heart-beat. The latter is a high-
pitched whistling murmur synchronous with the fetal
heart-beat. The position of the abdomen at which the
fetal heart-sounds are heard with greatest intensity is
of diagnostic value in confirming the find, by abdom-
inal palpation, as to position and presentation. By
vaginal examination the finger detects the varying
portions of the fetal body which may present at the
superior strait, as the cranium, the face, the shoulder,
the buttocks, the knees, feet, and, exceptionally, the el-
bow or hand." — (Hirst's Obstetrics.)
3. "Treatment of threatened abortion includes rest
in bed with absolute quiet; the administration of nerve
sedatives, preferably suppositories of opium, one grain
of the aqueous extract morning and evening; this may
be supplemented by teaspoonful doses of the fluid ex-
tract of viburnum prunifolium four times daily. If the
abortion is due to general disease, such as typhoid
fever, pneumonia, phthisis, or valvular heart disease,
no attempt should be made to prevent it."
Treatment of inevitable abortion: "If the preceding
plan of treatment fails and abortion seems inevitable,
the emptying of the uterus should be hastened.
Two methods of treatment have been advised for
these cases. The first is the expectant plan, which may
be described briefly as follows: Place the patient in
bed, and if the bleeding is profuse, insert a tampon of
iodoform gauze (1 yard) well up against the cervix.
If this fails to control the hemorrhage, reinforce it by
another yard or two of gauze and a perineal pad and
binder. Small doses (3% ) of the fluid extract of ergot
should now be given every 2 or 3 hours. At the end
of from 8 to 12 hours remove the tampon,' when the
ovum may be found extruded from the cervix; if not,
a vaginal douche of mercuric chlorid; (1:4000) must
be given, and another tampon introduced. If, upon tne
removal of this second tampon at the end of 10 or 12
hours, the ovum is not discharged, then more vigorous
methods to secure its expulsion must be adopted.
The active plan comprises the following: The phy-
sician's hands and instruments are sterilized; the
patient is etherized and placed on an appropriate table,
or across the edge of the bed, her buttocks resting upon
a Kelly pad; the genitalia are thoroughly cleansed and
a vaginal douche of mercuric chloride (1:4000) is
given; the anterior lip of the cervix is brought down
to the vulvar orifice; the cervix is dilated if necessary;
891
MEDICAL RECORD.
the placental forceps are introduced into the uterus,
and as much as possible of the ovum is removed; the
uterus is thoroughly cureted, and an intrauterine
douche of sterile water is given. A light tampon of
iodoform gauze is placed in the vagina; the patient is
then returned to bed.
A strip of gauze may be placed in the uterus in cases
of sharp retroflexion, to secure free drainage, and oc-
casionally an intrauterine tampon will be necessary
when the uterus refuses to contract and hemorrhage
persists after the use of the curette." — (Pocket Cyclo-
pedia.)
4. "As a result of impregnation the mucous mem-
brane of the uterus undergoes certain changes in
structure, and is henceforth known as the decidua. The
fertilized ovum may enter the uterus at any stage of
the menstriial cycle. The surface of the endometrium
may not be quite smooth, and the ovum may possibly
be arrested by some ridge or projection of the surface.
Here it embeds itself, and the destructive and invasive
action of the syncytium is soon followed by a reaction
on the part of the uterus. This reaction is character-
ized by a rapid transformation of the small, primitive,
connective tissue cells of the stroma of the endomet-
rium into large oval or polygonal 'epithelioid' cells with
large pale oval nuclei. These are the decidual cells,
and they are probably thrown out as a line of defence
against the advance of the syncytium (Turner). The
glands of the endometrium become enlarged and di-
lated, the capillaries distended with blood, and the
whole membrane becomes markedly thickened and soft
and edematous. Instead of being only about one-eighth
of an inch thick, it swells until it may even be as
much as half an inch in depth. In this growth the
glands take a very active share, and increase so much
in length that in order to accommodate themselves,
they become folded backwards and forwards in their
middle parts. The effect of this is to make the middle
portion of the decidua full of distended gland spaces,
whereas the more superficial portion contains only the
mouths and necks of the glands supported in a stroma
packed with the decidual cells. If a section be made
through the decidua, it thus appears to be divided into
three layers, the superficial part being compact in
structure, and hence known as the superficial compact
layer, while the deeper part is known as the spongy
layer. The deepest part of all, immediately next the
muscle wall, contains only the blind ends of the glands
(many of which actually penetrate the muscle) , and is
892
WEST VIRGINIA.
sometimes described as a third layer, the deep compact
layer. For purposes of description the decidua is di-
vided further into three parts according to its rela-
tionship to the ovum. The part on which the embedded
ovum rests is called the decidua serotina; the part su-
perficial to it is called the decidua reflexa, and the de-
cidua lining the rest of the cavity of the uterus is
called the decidua vera." — (Johnstone's Midwifery).
5. Manner of using forceps: "They should not be
used when the os is undilated, when the head is not en-
gaged, except in placenta praevia, when the membranes
are unruptured, when the disproportion between the
child's head and the parturient canal is too great, or
in impossible positions and presentations. Before ap-
plying the instruments they should be sterilized, pref-
erably by boiling; and the patient anesthetized and
placed in the lithotomy position. Two fingers of the
right hand are introduced into the vagina; the left
blade of the forceps is then held almost perpendicularly
by the left hand, with the tip of the blade opposite the
vulva; the tip is introduced into the vagina, passed
along the floor toward the sacrum. The blade is rotated
outward in its long axis in order to escape the pro-
montory of the sacrum. The right blade is introduced
in a similar manner. To facilitate locking, one of the
blades must be rotated forward. If the head occupies
the right oblique diameter, as in L. O. A. and R. O. P.
positions, the right blade must be rotated; if it occupies
the left oblique diameter, the left blade must be rotated.
Traction is made in the direction of the pelvic axis
until the perineum is well distended. The perineum is
then protected by one hand, while the face is swept over
it by an upward movement of the forceps. In posterior
positions it is necessary to remove the instruments
after the head is drawn down to the pelvic floor ; after
anterior rotation is secured they may be reapplied. If
the occiput rotates into the hollow of the sacrum the
hands should be depressed as the face is swept out
under the symphysis pubis." — (Pocket Cyclopedia.)
6. Phantom tumor may be a "pseudocyesis," a con-
dition in which the patient (erroneously, but honestly)
believes herself to be pregnant. She may present some
of the subjective signs of pregnancy, with increase in
the size of the adbomen; but the cervix is unaltered,
the uterus is not enlarged, and there are no fetal move-
ments. The diagnosis is made by giving an anesthetic
when the abdominal swelling diminishes in size. The
difficulty lies in getting the patient to believe that she
is not pregnant; perhaps the best method is for a
893
MEDICAL RECORD.
friend of the patient to be present during the exam-
ination under anesthesia and to witness the diminution
of the swelling. No treatment is indicated.
7. The mesosalpinx is that part of the broad ligament
beneath the Fallopian tube; it consists of two layers
of peritoneum with a little connective tissue, and con-
tains the organ of Rosenmueller.
8. It was formerly believed that a ruptured perin-
eum was the main, if not the only factor in causing
a prolapse of the uterus. This is no longer accepted
as true. Of course if the perineum is completely torn
prolapse is more likely to occur, but the perineum is
only one factor in the case. The levator ani is one
of the perineal muscles, and the pubo-coccygeus is one
of the divisions of the levator ani. In an ordinary
perineal laceration in the median line, even if it ex-
tends into the rectum, very few fibers of the pubo-
coccygeus are torn. Hence this muscle cannot be con-
sidered as having much of a causal relationship to
prolapse of the uterus.
9. The vulva consists of the labia majora, labia mi-
nora, clitoris, hymen, vestibule, fossa navicularis, and
mons Veneris. All these parts are endowed with great
sensibility, and are mainly concerned with the function
of coitus; in addition, the clitoris is regarded as being
the main seat of sexual sensation and pleasure; the
mons Veneris is said to prevent irritating secretions
from the skin trickling into the vulval cleft; the hymen
is a membrane closing (partially) the entrance into
the vagina.
10. Menstruation is a periodic discharge of blood
from the mucous membrane of the uterus, due to a
fatty degeneration of the small blood-vessels. Under
the pressure of an increased amount of blood in the
reproductive organs, attending the process of ovula-
tion, the blood-vessels rupture, and a hemorrhage takes
place into the uterine cavity; thence it passes into the
vagina. Menstruation lasts from five to six days, and
the average amount of blood is about five ounces. It
begins at puberty and occurs periodically at about 28
days interval, until the menopause; it is absent during
pregnancy and early lactation.
The relation existing between ovulation and men-
struation is not known. The two processes are usually
coexistent, but they may be independent of each other.
The following theories have been held: (1) Menstrua-
tion is dependent upon ovulation: (2) ovulation is de-
pendent upon menstruation; (3) they are independent
of each other; (4) they both depend upon some other
(at present unknown) cause.
894
WEST VIRGINIA.
Menstruation has been considered as being analogous
to the condition of "heat" or "rut" in the lower ani-
mals.
SPECIAL MEDICINE.
1. Acute conjunctivitis. Etiology: Irritation, a
foreign body, cold, exposure to strong light or heat,
eyestrain, disordered secretion of tears. Symptoms:
Hyperemia, lacrimation, epiphora, discharge, photo-
phobia, sensation of sand in the eye, symptoms are
worse in evening. Treatment: Remove cause if pos-
sible; use astringent and antiseptic washes; anoint
the lids with vaseline; alum, tannic acid, zinc sulphate,
or silver nitrate have all been recommended. When it
becomes contagious, its common name is "pink-eye."
Ophthalmia neonatorum. Causes: The gonococ-
cus or some other pyogenic microorganism; the secre-
tions of the mother contain the infecting agent, and
transmission may occur directly during parturition, or
indirectly by the fingers of physician or nurse, cloths,
instruments, etc. Symptoms: Swollen eyelids, with
copious purulent discharge; ulceration of the cornea
may ensue. Prophylaxis : Whenever there is the possi-
bility of infection, or in every case, wash the eyelids
of the newborn child with clean warm water, and drop
on the cornea of each eye one drop of a 1 per cent,
solution of nitrate of silver, immediately after birth.
Treatment: Wash the eyes carefully every half hour
with a saturated solution of boric acid; pus must not
be allowed to accumulate. Two drops of a 2 per cent,
solution of nitrate of silver must also be dropped on
to the cornea every night and morning. The eyes must
be covered with a light, cold, wet compress. The
patient must be isolated, and all cloths and compresses
used must be burnt.
2. Glaucoma is a diseased condition of the eye, pro-
duced by increased intraocular pressure, and resulting
in excavation and atrophy of the optic disc, and blind-
ness. It is due to increase of the contents of the eye,
hypersecretion, retention, old age, gout, rheumatism,
nephritis. Symptoms: Visual disturbances, increased
ocular tension, hazy and anesthetic cornea, sluggish
and dilated pupil, shallow anterior chamber, ciliary,
neuralgia, cupping of optic disc, blindness. Treatment :
Myotics, such as eserine or pilocarpine; massage of
the eyeball; mydriatics are contraindicated ; operative
treatment may include paracentesis, iridectomy, or
sclerotomy.
3. Acute catarrhal otitis media is frequently caused
by acute coryza and the infectious fevers. There is a
895
MEDICAL RECORD.
painless obstructed sensation in one or both ears, im-
pairment of hearing, and tinnitus. The inflammation
causes closure of the Eustachian tube. Inflation and
aspiration of the middle ear and syringing and
douching the nares and nasopharynx must be avoided.
A moderate spray of DobelPs solution may be used.
If pain is present, dry heat, in the form of hot-water
bottle, hot stone wrapped in flannel, etc., may be ap-
plied. A few drops (100), warmed, of a carbolic acid
solution (1:40), or one of formalin (1:2000), may be
instilled into the ear.
"Acute purulent otitis media: Acute catarrhal otitis
media, instead of undergoing resolution, may pass into
acute purulent otitis media (especially in exanthemata)
from the passage of pathogenic germs from the naso-
pharynx into the middle ear. The pain will become
more intense, the hearing dull; tinnitus will become
louder and more distressing, and fever usually sets in.
Dry heat allays the pain. Warmed water or warmed
carbolic acid solution (1:40) may be used. Inflations,
aspirations, etc., should be avoided. If the nares are
filled with tough secretions, a spray of DobelPs solution
may be used. If the pain continues over six hours in
a child or over twelve hours in an adult without spon-
taneous perforation of the tympanic membrane, para-
centesis of that structure should be performed. The
concha and meatus should be smeared with petrolatum
to avoid chapping, and the secretions should be gently
mopped off as they appear. Under this treatment the
ear usually returns to normal in two to three weeks."
— (Pocket Cyclopedia of Medicine and Surgery.)
4. Eustachian tube, diseases of: Catarrh (acute and
chronic) and obstruction. Cleanse the postnasal space,
and inflate the Politzer bag or bougie. Dover's powder
may be given at the commencement of an acute ca-
tarrhal condition.
5. Epistaxis. Causes: Ulceration, foreign bodies,
anemia, cardiac hypertrophy, fracture of nose, pur-
pura, hemorrhagic diathesis, nephritis, typhoid. Treat-
ment: (1) Try to cauterize the bleeding point; (2)
plug the nasal cavity with gauze soaked in adrenalin;
(3) inject into the nares a solution of peroxide of
hydrogen; (4) plugging the nares, anteriorly and
posteriorly; (5) an inflating plug may be used.
6. The treatment of nasal catarrh consists in rest
in bed, the administration of fractional doses of calo-
mel followed by a saline, hot foot baths, hot drinks,
quinine, Dover's powder, and a combination of bella-
donna, opium, and camphor water. The local treatment
896
WEST VIRGINIA.
consists in a gentle spray with an alkaline solution,
and the application of a mixture of one ounce of liquid
vaseline and four grains of menthol.
7. The mitral regurgitant murmur is heard best in
the center of the mitral area, above and to the left
of the apex.
The aortic obstructive murmur is heard best in the
midsternum or to the right of it; opposite the third rib
or second interspace.
The aortic regurgitant murmur is heard best in the
midsternum opposite the upper border of cartilage of
third rib.
The mitral obstructive murmur is heard best over
the mitral area around the apex.
The tricuspid regurgitant murmur is heard best in
the midsternum just above the ensiform cartilage.
The tricuspid obstructive murmur is heard best in
the midsternum opposite the cartilage of the fourth
rib.
The pulmonary obstructive murmur is heard best in
the second interspace to the left of the sternum or at
the level of the third rib.
The pulmonary regurgitant murmur is heard best in
the second left interspace.
8. Hemorrhage from the lungs may be caused by: —
Injury, severe coughing, purpura; it occurs in phthisis,
pneumonia, abscess or gangrene or cancer of the lung,
affections of the mitral valve, aneurysm. Treatment :
"Unless a large artery is opened, bleeding usually
ceases spontaneously, and the patient should be re-
assured. Absolute rest and quiet, light food given cold,
ice to suck and injections of morphine and atropine
suffice in the majority of cases. Inhalation of nitrite
of amyl is a valuable measure. Ergot raises the in-
trapulmonary blood pressure and may do harm. In
protracted cases, saline purgatives and aromatic
sulphuric acid are indicated. Adrenalin is useless."
— (Wheeler and Jack's Practice of Medicine.)
9. Three curable forms of insanity: Some forms of
mania, melancholia, and delusional insanity.
In a general way, rest and change of environment
are necessary; removal of constipation and dyspepsia
is essential; sleep is beneficial, frequent bathing with
friction of the skin is useful. In mania, a hot or
warm bath reduces the excitement; hyoscine or chloral
may quiet the patient and produce sleep; the food must
be nutritious and easily digested; and the patient must
be removed from his friends. A kind, but firm and
judicious nurse is invaluable.
897
MEDICAL RECORD.
10. "The 'Weir Mitchell 9 treatment is a systematized
plan by which the weakened body is placed in thorough
condition, by means of continuous rest, enforced feed-
ing, and regular muscular waste produced by massage,
which enables food to be taken and assimilated. The
essentials of this method are:
(1) Complete rest, the patient being placed in bed,
and kept there during treatment; and it should be a
sine qua non that this rest should not be in the patient's
own house, but in a medical home or in lodgings, the
friends and relatives, whose influence is often most
injurious, being strictly excluded.
(2) Regular muscular exercise to produce tissue
waste, by means of massage of the whole body, at first
for ten minutes or a quarter of an hour, twice daily,
soon increased to an hour or an hour and a half. The
influence of this is often misunderstood, and this treat-
ment is frequently erroneously talked of as a 'massage
treatment.' It should be borne in mind that massage
is nothing more than a remedial agent, used for a
specific purpose; that it is not the most important part
of the cure; and that, used alone, and without enforced
rest and over feeding, as is unfortunately so often
done, it cannot possibly be productive of any real good.
(3) Feeding is the most essential part of the treat-
ment. At first the patient should be placed on milk
alone, about five ounces every third hour. Within a
few days this is increased to ten ounces, so that at
least two quarts are taken in twenty-four hours. Then,
by degrees, solid food is added, so that within a fort-
night the patient should be taking three large mixed
solid meals daily, in addition to the milk, and often a
cup of strong soup, with two teaspoonfuls of beef
peptonoids added, twice daily as well. This exag-
gerated diet is continued for six weeks or two months,
when it is gradually lessened, the massage also being
discontinued, and the patient allowed to get up. In an
average case the patient should gain from fourteen to
twenty-three pounds during this time. It is strange to
see how, with returning health, all invalid habits are
lost, sleep becomes regular without drugs, the bowels
cease to require assistance, and the whole appearance,
and apparently even the nature, of the patient is
altered.
At the end of the treatment, in most cases, it is ad-
visable that the patient should go for a change, either
on a sea voyage or abroad, so as to complete the cure.
At any rate, she should not return to her family until
her health is re-established. The essential point to re-
898
WEST VIRGINIA.
member is that no half measures should be permitted:
if this treatment is not carried out thoroughly and
completely, it had much better not be tried at all." —
(Quain's Dictionary of Treatment.)
BACTERIOLOGY AND HYGIENE.
1. Clostridium pasteurianum ; Nitroso-bacteria; Ni-
trobacteria; various bacteria of the genera. Thiothrix,
Chromatium, Spirillum, Monas, Crenothrix, Cladothrix,
Leptothrix; Bacterium aceti; B. pasteurianum; Bacil-
lus chauvsei; Saccharomyces cerevisise.
2. Bacteria multiply by fission (or division), and
also by spore-formation. Spores are much more re-
sistant to heat than the bacteria without spores.
Hence the process of fractional sterilization is adopted
by the surgeon. Sterilization on the first day kills all
the non-spore forms, while the spores remain alive.
The next heating kills such spores as have assumed
the non-spore form. The third heating probably kills
the remainder.
3. Five pyogenic bacteria. — Streptococcus pyogenes,
Staphylococcus pyogenes aureus, Staphylococcus pyo-
genes citreus, Staphylococcus pyogenes albus, Micro-
coccus tetragenus.
4. An obligate aerobe is a bacterium that can only
exist in the presence of oxygen; an obligate anaerobe
is one that can only exist in the absence of oxygen.
A facultative aerobe or anaerobe is one that can ex-
ist either with or without oxygen.
A toxin is the poisonous product of bacteria.
Chemotaxis is the property by virtue of which cer-
tain living cells approach (positive chemotaxis) or
move away from (negative chemotaxis) certain other
cells or substances.
5. Koch's four laws. To prove that bacteria
causes disease it is essential: (1) That the micro-
organism be found in the tissues, blood, or secretions
of a person or animal sick or dead of the disease; (2)
the microorganism must be isolated and cultivated from
these same sources; it must also be grown for several
generations in artificial culture media; (3) the pure
cultures, when thus obtained, must, on inoculation into
a healthy and susceptible animal, produce the diseases
in question, and (4) the same microorganisms must
again be found in the tissues, blood, or secretions of
the inoculated animal.
6. A sanitary rural privy consists of a "small water-
tight pit, not drained but roofed over to exclude rain,
and so arranged that the excreta and ashes become
899
MEDICAL RECORD.
thoroughly mixed. For this purpose either the ashes
must be thrown in through the closet seat, which may
be hinged so as to be lifted en masse, or else a "shoot"
or sloping slab must conduct one and the other to a com-
mon point. The floor should be smooth, and raised a
few inches above the level of the adjoining ground.
"The contents ought to be removed at fixed short in-
tervals, and the work should be done at night or early
in the morning so as to minimize the nuisance." —
(Whitlegge and Newman.)
7. "Since flies breed only in filth, the first thing to
do is to render it impossible for the fly to reach any
of the accumulations unavoidable around habitations.
This is done: (1) By destroying filth wherever found.
(2) By rendering it distasteful or poisonous to flies
or their larvae by the use of lime, kerosene, oil of
pennyroyal or cresol. (3) By excluding light from the
receptacle or by screens which the flies cannot pass.
The most difficult part of an anti-fly campaign is
teaching the people to dispose of their garbage prop-
erly. No amount of screening, trapping or poisoning,
will make up for careless disposal of filth and waste.
All such materials must be promptly destroyed or
buried. If a really good suspension of milk of lime
(calcium hydrate) is mixed with the garbage or refuse,
the eggs and pupae or maggots of the fly are at once
destroyed, but it must be made to come in contact with
the eggs or maggots to do any good. Kerosene oil is
more effective, but more expensive. Where crude oil
or low grade distillates are procurable, the expense is
much lessened. Oil of pennyroyal, in the proportion of
1 ounce to 1 quart of kerosene, is very distasteful to
the adult fly, as well as fatal to the young, and a
small quantity sprinkled around the garbage can is
sufficient to keep away all flies. The greatest draw-
back is the expense. Cresol is not expensive, and may
be used freely in 2 per cent, emulsion. Privy vaults,
manure bins, and similar places must be made and
kept perfectly dark. Screens must be made auto-
matically self-closing, otherwise they are sure to be left
open and to fail of their object." — (Gardner and
Simond's Practical Sanitation). Fly poisons, flytraps
and fly papers may also be used. «
8. Concerning schools: The school building should be
as near as possible to the center of the area which it
is to serve; the site should be airy and open, of suffi-
cient size, free from swamps, and somewhat elevated;
it should not be too near factories, busy streets, or
railways; the soil should be as free as possible from
900
WEST VIRGINIA.
organic matter. The buildings should be so planned
that the corners look towards the four points of the
compass. In this way the sun will have access to each
side and to every room during some part of the day.
The building should have as few stories as possible.
The walls should be of brick or stone, and should be
pointed with cement; the inner surface of the wall
should be cemented smooth. The foundations must be
solid. The general arrangement will depend upon size
of site, number of scholars, and number of required
rooms. Fifteen square feet per child should be al-
lowed. Details will have to be considered on : plans,
accommodations to be provided, shape and size of class
rooms, distribution of rooms, teachers' rooms, corri-
dors, entrances and staircases, playground, ventilation,
heating, lighting, and placing of windows, sanitation,
lavatories, water supply, drinking water, sewage dis-
posal, removal of refuse, sanitary appliances, and
drainage. Special care must be given to the prevention
of contagious diseases and the exclusion of all possible
sources of infection or contagion; there should be
physical examination of children, also, for non-
contagious physical defects.
The principal means of preventing the spread of con-
tagious diseases in schools are: Regular and efficient
inspection by physicians; prompt exclusion and isola-
tion of any one suffering from a contagious disease,
or coming from a house where such disease is; com-
pulsory notification of all infectious and contagious
diseases; individual towels, drinking vessels, and other
implements; children w T ho have had a contagious or
infectious disease or who have come from a house
where such disease prevailed should not be readmitted
to school until sufficient time has elapsed since the
occurrence of the last case to insure safety.
9. Social hygiene is a term with no exact meaning,
but which is often euphemistically applied to venereal
prophylaxis — the prevention and control of venereal
diseases. The physician can advise parents about the
proper supervision of their children's leisure, amuse-
ments, companionships, and tendencies; he should urge
physical exercise upon such as need it, but are disin-
clined to take it. He can recommend the adaptation of
schooling and vocational training to the child's nervous
system. He can suggest to the parents instruction
in the basic facts of sex as the child attains to puberty,
and in the venereal perils thereafter. Upon request,
he should himself undertake this instruction. He
should employ every legitimate means to insure that
901
MEDICAL RECORD.
venereal patients under his care do not marry until they
are cured, impressing upon them the seriousness of the
consequences if they disregard this advice.
10. The mouth and teeth should receive* especial at-
tention in the way of cleanliness. The hygiene of the
mouth is of the first importance and may he a means
of preventing disease. The teeth should be cleansed
with a" brush of suitable size, having bristles neither
too hard nor too soft, and a handle bent at such an
angle with the bristles that the latter may be able to
reach all the surfaces of the teeth; the bristles should
be of unequal length, and the brush must be kept clean.
An improper brush, with bristles either too hard or
dirty, may do harm, and has been held responsible for
pyorrhoea alveolaris; but a suitable tooth-brush can ef-
fect nothing but good. The mouth and teeth should
be cleaned morning and night, and if possible, after
meals. In this way particles of food may be removed,
fermentation checked, decay prevented, bad breath
prevented or lessened, and dyspepsia warded off.
STATE BOARD EXAMINATION QUESTIONS.
College of Physicians and Surgeons op Ontario.
medicine.
1. Endocarditis. Discuss the types, etiology, morbid
anatomy, and clinical manifestations.
2. Cirrhosis of the liver. Enumerate varieties, and
discuss the pathology, symptoms and treatment.
3. Diabetes mellitus. Describe the mode of onset and
urinary findings, and discuss in detail your treatment.
4. Discuss the cause, and describe the prodromal
symptoms, course, and treatment of a case of typhoid
fever.
5. Discuss the etiology, and describe the lesions and
mode of treatment of: Impetigo contagiosa, Herpes
zoster, Alopecia areata.
surgery.
1. (a) What symptoms differentiate a malignant
from a non-malignant tumor of the breast? (6) What
course would you adopt in doubtful cases? (c) Describe
the operation for complete removal of the breast.
2. (a) How is intussusception produced? (6) Give
symptoms, (c) Give treatment.
3. (a) Describe a method for amputation in the
middle of the forearm, (b) Enumerate the structures
divided.
902
ONTARIO.
4. (a) Give the differential diagnosis between anal
fissure, hemorrhoids and carcinoma of the rectum.
(b) Give the treatment of each.
5. (a) Give the differential diagnosis between
malignant disease of the esophageal and pyloric ends of
the stomach, (b) Give treatment in each case.
OBSTETRICS AND GYNECOLOGY.
1. Give the management of a case of pregnancy up
to the advent of labor, and also from the delivery of
the placenta to the end of the puerperium, in a normal
case.
2. Pains: Define the following: — True, false, weak,
cutting, atonic, expulsive, after.
3. Forceps and pituitrin: What are the indications,
and the contraindications, for the use of each?
4. A woman's abdomen is enlarged from the pelvis to
the level of the umbilicus. Mention the conditions which
may produce such an enlargement. How would you
make a differential diagnosis of them?
5. Prolapsus uteri; give causes, symptoms, and treat-
ment, operative, and non-operative.
MEDICINE.
Answer five questions only.
1. Describe the clinical course of an average case of
acute lobar pneumonia terminating favorably, giving the
usual physical signs noted over affected lung at various
stages of progress.
2. Discuss the causation, symptoms, differential diag-
nosis and treatment of catarrhal jaundice.
3. Describe the causation, symptoms, differential diag-
nosis and treatment of epidemic cerebro-spinal menin-
gitis.
4. (a) Give the causation, diagnosis, course and
treatment of tinea tonsurans (ringworm of the scalp).
(6) Give the diagnostic features and detail treatment
of scabies.
5. What are the most common types of growth in
brain or brain membranes causing symptoms of cerebral
tumor? Discuss the general symptoms of such growths,
and give localizing features of a growth in any selected
area of cerebrum.
6. A business man, 48 years old, of sedentary habits,
with good appetite and using alcohol and tobacco mod-
erately, consults you for frequent headaches and
tendency to be forgetful. On examination you find a
high tension pulse, systolic blood pressure of 190 mm.,
while urine shows a trace of albumin and a few hyaline
903
MEDICAL RECORD.
casts. Describe further examinations you would think
necessary, and discuss diagnosis, prognosis, and treat-
ment.
SURGERY.
1. (a) Describe the symptoms of fracture of the
spine at lower dorsal region. (6) Give treatment,
(c) Give indication for operation, (d) Describe the
operation.
2. (a) In what diseases of the kidneys do you con-
sider its removal advisable? (b) Give differential diag-
nosis between any two of these diseases, (c) Describe
the operation for removal.
3. (a) Give symptoms of ulcer of the stomach. (6)
From what other diseases must it be differentiated?
(c) Under what conditions is operation necessary? (d)
Describe the operation.
4. (a) Describe the symptoms of a strangulated
hernia (inguinal), (b) Give methods of treatment.
(c) Describe the operation when the intestine is
gangrenous.
5. (a) Describe the symptoms of a fracture of the
middle of the femur. (6) Give treatment in detail in
an adult.
OBSTETRICS AND GYNECOLOGY.
1. Cystitis: give causes, course and treatment.
2. Describe the operation for (a) a recent laceration
of the perineum, (6) an old laceration, and (c) mention
the most important features of each case.
3. What conditions are often mistaken for pregnancy?
How would you establish a diagnosis?
4. Define accidental haemorrhage and give its prog-
nosis and treatment.
5. Give (a) the characters and duration of normal
lochia, (6) causes of suppression, (c) causes of pro-
longed continuance.
ANSWERS TO STATE BOARD EXAMINATION
QUESTIONS.
College of Physicians and Surgeons of Ontario.
medicine.
1. Endocarditis.
Types:-!. Acute{|™g ant or Ulcerative {|y$oid
II. Chronic.
The difference between simple and malignant endo-
904
ONTARIO.
carditis is probably one of degree rather than of kind.
Etiology: Simple endocarditis is associated with rheu-
matism or scarlet fever. Malignant endocarditis is
also associatedwith rheumatism, scarlet fever, and also
with pneumonia or septic processes. Micrococci are
often found. Chronic endocarditis may follow an acute
endocarditis, or may be the result of syphilis, old age,
high arterial tension, gout.
Morbid Anatomy: In the simple form there will be
found a cloudiness, followed by edematous thickening
of the valvular endocardium; superficial erosions, and
the formation of small granulations; deposits of layers
of fibrin and corpuscles from the blood, the whole proc-
ess resulting in the formation of small warty vegeta-
tions. These vegetations are most marked at a slight
distance from the free borders of the valves — i.e. those
parts which come into opposition during closure. In
course of time they are transformed into fibrous
tissue. According to Poynton and Paine the infective
organisms are conveyed to the base of the valves by the
capillaries, and thence pass to the subendothelial tis-
sues by the minute nutrient channels in the valvular
substance; others hold that the organisms are derived
from the blood circulating over the surface of the
valves. In the malignant form the initial changes are
similar, but there are some important differences, inas-
much as ulcerations may completely replace the vege-
tations. The differences are: (1) The vegetations when
present are larger and f ungating. (2) The underlying
tissues are necrotic and show loss of substance and
round-celled infiltration. (3) They contain masses of
micrococci, while in simple endocarditis the organisms
are scanty. The two forms cannot be distinguished by
the organisms producing them; either simple or malig-
nant endocarditis may arise from a pyogenic infection.
(4) When the vegetations become detached they form
septic emboli, giving rise to metastatic abscesses. (5)
The ulcerative process causes great destruction of the
valves, and may even lead to perforation of the curtains.
(6) The subsequent or permanent changes in the valves,
if the patient survive, are much more marked. (7)
If the vegetation touches the mural endocardium as it
flaps to and fro, the part touched becomes affected by
contact.
As regards the side of the heart most affected — Con-
genital endocarditis attacks the right side of the heart
(but note that many congenital cardiac lesions are due
not to endocarditis, but to developmental faults) ; simple
endocarditis attacks the left only; the malignant at-
905
MEDICAL RECORD.
tacks both sides, though the left is much more impli-
cated than the right side.
The vegetations are upon that side of the valve op-
posed to the blood-stream — viz., at the aortic valve the
vegetations project into the ventricle, at the mitral valve
into the auricle.
As in pericarditis, the myocardium almost always
shares in the inflammatory affection.
In chronic endocarditis, when not directly due to
acute endocarditis, the changes are : Formation of small
nodular prominences, with thickening of the valve. The
vegetations are much firmer than in the acute disease.
Formation of yellowish, opaque fatty patches. Great
increase of fibrous tissue, which subsequently contracts,
producing much deformity. The cusps become rigid,
curled, and may cause great destruction to the onward
flow of blood, and at the same time fail accurately to
close together when required. Great narrowing of the
valvular orifice. Shortening of the chordae tendineae
and papillary muscles. Frequently fusion of the chordae
tendineae (adhesions). Calcification of the fibrosed por-
tion. — (Wheeler and Jack.)
Clinical Manifestations : "Simple Endocarditis, — The
signs are extremely ill marked; possibly increased rap-
idity of pulse, dyspnea, precordial distress, etc., may
attract attention to the heart. On examination some
dilatation of the heart, from the accompanying myo-
carditis, may be found, and a recently developed mur-
mur of a soft blowing or bellows-like character may be
heard in the mitral or aortic areas. The commonest
murmurs are those of mitral regurgitation (systolic),
or mitral stenosis (presystolic).
"It should be remembered, however, that in most
fevers the heart is somewhat dilated, and a murmur,
not due to endocarditis, may be present. We must
therefore be cautious in coming to a too rapid conclu-
sion that a suddenly developed murmur is indicative of
endocarditis. An important distinction is that the on-
set of endocarditis is usually accompanied by a smart
rise in temperature above the previous level, while in
hemic murmurs, or those due to simple dilatation, this
is absent. A diastolic murmur in the aortic area is
likely to be organic (aortic regurgitation).
"Malignant Form, — Three types may be distinguished
— The Septic Type is characterized by the symptoms of
septic infection — viz., rigors, sweats, oscillating tem-
perature, emaciation and metastic abscesses. The symp-
toms may continue for months. The Typhoid Type is
characterized by irregular or intermittent temperature,
906
ONTARIO.
looseness of the bowels, petechial rashes, and a rapid
assumption of the typhoid state. Great difficulty may
be experienced in distinguishing this form from typhoid
fever or meningitis. The Cardiac Type is that in which
symptoms of acute endocarditis, with fever of a septic
type, appear in the course of a chronic valvular lesion.
In some of these cases death is rapid; others may re-
cover after a protracted illness.
"Along with these general symptoms there are usual-
ly definite cardiac signs — development of murmur, dila-
tation of the heart, cardiac irregularity, and so on.
But the cardiac symptoms may be altogether latent,
causing difficulty in diagnosis." — (Wheeler and Jack's
Handbook of Medicine.)
2. Cirrhosis of Liver. Varieties: Portal, or atrophic
or alcoholic; biliary or hypertrophic; also syphilitic or
pericellular.
Pathology. In atrophic cirrhosis the liver may be
very small, but is sometimes enormously enlarged. The
latter condition may be caused by congestion or fatty
changes. Generally, in the atrophic condition, the sur-
face of the liver is rough and nodular. The connective
tissue is increased in quantity, and the liver cells are
destroyed (probably by the poison which causes the
disease). The fibrous tissue in Glisson's capsule is in-
creased, the portal circulation is obstructed, and later
the bile ducts are obstructed and the hepatic cells be-
come obliterated. In the hypertrophic cirrhosis the
liver is always enlarged. The following table (from
Wheeler and Jack) gives the important features of
the morbid anatomy of the two varieties of cirrhosis,
together with the differences:
PORTAL OR MULTILOBULAR
CIRRHOSIS
1. The bile-ducts are not
involved, and jaundice is a
late sysmptom.
2. The new-formed con-
nective tissue compresses the
branches of the portal vein
3. In the earlier stages,
active congestion and pro-
liferation of connective tissue
£n the portal spaces may
cause increase in the size of
the liver ; later, there is usu-
ally contraction.
4. The capsule is much
thickened, and the surface is
rough and hob-nailed.
BILIARY OR UNILOBULAR
CIRRHOSIS
1. The smaller bile-ducts
are inflamed (cholangitis) ;
jaundice is early and severe.
2. The portal circulation is
not impeded.
3. The new tissue is dif-
fused throughout the organ,
and causes a great increase
in size.
4. The capsule is not
thickened, and the surface
is smooth (like morocco
leather).
907
MEDICAL RECORD.
PORTAL OR MULTILOBULAR
CIRRHOSIS
5. The masses of liver cells
vary in size, some consisting
of several lobules, others be-
ing smaller than a lobule.
Each mass forms a distinct
area with a rounded outline,
and is enclosed in a fibrous
girdle
6. On microscopic exam-
ination, the process is seen
to be going on chiefly at the
periphery of the lobules. The
fibrous tissue is very dense.
BILIARY OR UNILOBULAR
CIRRHOSIS
5. The masses of liver cells
consist of isolated lobules.
The cut surface has a uni-
form and finely-granulated
appearance.
6. The fibrous tissue is not
confined to the periphery, but
invades the substance of the
lobules. It is much more
open than that of portal cir-
rhosis.
Symptoms. Atrophic cirrhosis presents gastric
catarrh, with anorexia, dyspepsia, nausea, flatulence,
diarrhea and sometimes hematemesis. The liver is ten-
der and enlarged at the beginning of the disease. As
the disease progresses, and the pressure in the portal
system increases, the liver and spleen enlarge, the
superficial abdominal veins become prominent, ascites
and swelling of the feet are observed, hemorrhoids de-
velop and there may be hemorrhage from the stomach
or bowel. Later, the liver gets smaller, the patient
loses flesh and strength, slight jaundice may be present,
fever, headache, and nervous symptoms (stupor, de-
lirium, convulsions and coma) may appear. In the
hypertrophic cirrhosis the liver is much enlarged, the
spleen enlarged, jaundice is marked, there is pronounced
loss of flesh and strength, hemorrhages into the skin
and from the mucous membrane may occur, pain in the
hepatic region, fever and vomiting are of common oc-
currence. Ascites and dilated abdominal veins are ab-
sent.
Treatment. In atrophic cirrhosis, alcohol must be
forbidden ; for the gastric catarrh, bismuth and alkalies
may be adopted; the portal congestion is relieved by
salines and diuretics; Epsom salts, compound jalap
powder, claterium, squill, digitalis and calomel have
been recommended. Paracentesis is indicated for the
ascites; epiplopexy has also been suggested. In the
hypertrophic variety the treatment is symptomatic only,
and follows the lines laid down under atrophic cirrhosis.
The atrophic variety is amenable to treatment in the
early stages.
3. Diabetes Mellitus. The mode of onset is grad-
ual, and generally it is the frequency of urination or
the extreme thirst which attracts the patient's atten-
90?
ONTARIO.
tion. Occasionally the disease sets in somewhat rapidly,
following injury or a severe chill or intense and sudden
emotion.
The urinary findings are: Increased quantity voided,
from 3 or 4 quarts to 20 quarts or more in a day; the
specific gravity is generally high, 1020 to 1045; the
urine is pale in color and has a sweetish odor and taste ;
the reaction is acid; glucose is present in varying
amounts, from 10 to 20 or more ounces being excreted
in a day; the urea is increased, and so is the nitro-
genous output in general; acetone, diacetic acid, beta-
oxybutyric acid are often present; phosphates and
sodium chloride are often present in increased quanti-
ties ; fat and gas in the urine are sometimes met with ;
albumin may be present.
Treatment. The diet must be carefully regulated,
and explicit written directions must be given to the
patient. The carbohydrates must be limited, the diet
consisting of proteins and fat, the tolerance for carbo-
hydrates must be built up and increased, and a sufficient
number of calories must be supplied. With many pa-
tients the gradual withdrawal of carbohydrates is tol-
erated better than their sudden restriction. The per-
centage of sugar in the urine when the patient is on a
general diet is first to be calculated, then the amount on
a sugar-free diet, and then the quantity of carbohydrate
which can be given without glycosuria appearing. Re-
cently the starvation diet of Allen and Joslin has been
recommended, but the details of this method are too
lengthy for insertion here. Care must be taken lest
a diet which is too exclusively nitrogenous should throw
an excessive strain upon the liver and kidneys. As a
general rule, diabetics must not take: Liver, sugars,
sweets or starches of any kind, wheaten bread or bis-
cuits, corn bread, oatmeal, barley, rice, rye bread, arrow-
root, sago, macaroni, tapioca, vermicelli, potatoes, par-
snips, beets, turnips, peas, carrots, melons, fruits, pud-
dings, pastry, pies, ices, honey, jams, sweet or sparkling
wines, cordials, cider, porter, lager, chestnuts, peanuts.
They may, as a rule, be allowed a diet selected from the
following: Soups or broths of beef, chicken, mutton,
veal, oysters, clams, terrapin or turtle (not thickened
with any farinaceous substances), beef tea, shell fish
and all kinds of fish, fresh, salted, dried, pickled or
otherwise preserved (no dressing containing flour),
eggs, fat beef, mutton, ham or bacon, poultry, sweet-
breads, calf's head, sausage, kidneys, pig's feet, tongue.
tripe, game (all cooked free of flour, potatoes, bread or
crackers), gluten porridge, gluten bread, gluten gems,
909
MEDICAL RECORD.
gluten biscuits, gluten wafers, gluten griddle cakes,
almond bread or cakes, bran bread or cakes. String
beans, spinach, beet-tops, chicory, kale, lettuce plain or
dressed with oil and vinegar, cucumbers, onions, toma-
toes, mushrooms, asparagus, oyster plant, celery, dande-
lions, cresses, radishes, pickles, olives, custards, jellies,
creams (without sugar), walnuts, almonds, filberts,
Brazil nuts, cocoanuts, pecans, tea or coffee (without
sugar), pure water, peptonized milk.
In every case the diet list must be prepared for the
individual patient. The general health must also be
attended to. The patient should lead a quiet life, free
from worry, take gentle exercise, bathe daily in warm
water, and only take drugs when indicated. The most
commonly used drugs are codeine, morphine, strychnine,
arsenic and cod liver oil. For the extreme thirst citrate
of potassium or lemon juice with water may be given.
4. Typhoid Fever. Etiology. The exciting cause is
presence of the bacillus typhosus. It may be communi-
cated by contaminated food, milk, water, dust, soiled
hands, clothing, instruments or utensils, flies, "car-
riers," or anything that has become contaminated with
the feces, urine or vomitus of one affected with the
disease.
The prodromal symptoms are vague. There are pain
in the head or back or limbs, general depression, anor-
exia, nausea, chills, headache, epigastric oppression,
diarrhea or constipation, disturbed sleep, cough, nose-
bleed.
Course of the disease. After the prodromal symp-
toms the patient takes to his bed, and from this the
definite onset is generally dated. "During the first
tveek there is, in some cases (but by no means in all,
as has long been taught) , a steady rise in the fever, the
evening record rising a degree or a degree and a half
higher each day, reaching 103° or 104°. The pulse is
rapid, from 100 to 110, full in volume, but of low ten-
sion and often dicrotic ; the tongue is coated and white ;
the abdomen is slightly distended and tender. Unless
the fever is high there is no delirium, but the patient
complains of headache, and there may be mental con-
fusion and wandering at night. The bowels may be
constipated, or there may be two or three loose move-
ments daily. Toward the end of the week the spleen
becomes enlarged and the rash appears in the form of
rose-colored spots, seen first on the skin of the abdo-
men. Cough and bronchitic symptoms are not uncom-
mon at the outset. In the second week, in cases of
moderate severity, the symptoms become aggravated;
910
ONTARIO.
the fever remains high and the morning remission is
slight. The pulse is rapid and loses its dicrotic character.
There is no longer headache, but there are mental tor-
por and dulness. The face looks heavy; the lips are
dry; the tongue, in severe cases, becomes dry also. The
abdominal symptoms, if present — diarrhea, tympanites,
and tenderness — become aggravated. Death may occur
during this week, with pronounced nervous symptoms,
or, toward the end of it, from hemorrhage or perfora-
tion. In mild cases the temperature declines, and by
the fourteenth day may be normal. In the third week,
in cases of moderate severity, the pulse ranges from
110 to 130; the temperature now shows marked morn-
ing remissions, and there is a gradual decline in the
fever. The loss of flesh is now more noticeable, and
the weakness is pronounced. Diarrhea and meteorism
may now occur for the first time. Unfavorable symp-
toms at this stage are the pulmonary complications, in-
creasing feebleness of the heart, and pronounced de-
lirium with muscular tremor. Special dangers are per-
foration and hemorrhage. With the fourth iveeh, in
a majority of instances, convalescence begins. The tem-
perature gradually reaches the normal point, the diar-
rhea stops, the tongue cleans, and the desire for food
returns. In severe cases the fourth and even the fifth
week may present an aggravated picture of the third;
the patient grows weaker, the pulse more rapid and
feeble, the tongue dry, and the abdomen distended. He
lies in a condition of profound stupor, with low mut-
tering delirium and subsultus tendinum, and passes the
feces and urine involuntarily. Heartfailure and second-
ary complications are the chief dangers of this period.
In the fifth and sixth iveeks protracted cases may still
show irregular fever, and convalescence may not set
in until after the fortieth day. In this period we meet
with relapses in the milder forms or slight recrudescence
of the fever. At this time, too, occur many of the
complications and sequelae." — (Osier's Practice of Medi-
cine.)
Treatment. "This is largely supportive and prophy-
lactic. On account of the wide distribution of the bacilli
in the secretions, it is highly important that the ex-
creta and all substances which come in contact with the
patient should be thoroughly disinfected to prevent dis-
semination of the disease. Corrosive sublimate (1:500),
carbolic acid (1:10), and chlorinated lime are used to
disinfect the stools. Weaker solutions may be em-
ployed for sponging the perineum and anal region of
the patient and for washing the hands of the attend-
911
MEDICAL RECORD.
ants. The general treatment consists in absolute rest
in bed with the enforced use of the bed-pan. The diet
should be liquid, largely milk, and should be admin-
istered every three hours. The modern tendency is
toward a more liberal diet, and the high calory diet
(as advocated by Coleman) adds to the comfort of the
patient, shortens the convalescence and lowers the death-
rate. Fever should be controlled by sponging, by the
wet pack, and by the full bath. The Brand method
consists in immersion of the body in a tub of water
(70° F.) for 15 or 20 minutes every third hour when the
temperature rises above 102.5° F. The medicinal treat-
ment includes the use of antipyretics, intestinal anti-
septics, and antityphoid serum. Abdominal pain, tym-
panites, and tenderness are best treated with fomenta-
tions and turpentine stupes, while meteorism may be
relieved by the internal administration of turpentine
and by the use of the rectal tube or injections of the
milk of asafetida (3 5-6). Diarrhea, when it exceeds 4
or 5 stools daily, will require the withholding of all food
except milk and the administration of opium, bismuth,
"codeine, etc. Constipation should be relieved every 2
days by enemas containing soapsuds. When hem-
orrhage occurs, the foot of the bed should be
elevated, an ice-bag or iced cloth should be applied
to the abdomen, morphine should be given hypodermi-
cally, and opium (gr. 1) should be administered by the
mouth every three hours. Peritonitis usually termi-
nates fatally, and requires the same treatment as hemor-
rhage. Abdominal section should be performed as soon
as the diagnosis is positive. Alcohol, ammonia, strych-
nine, digitalis, etc., should be used if heart-failure
supervenes. Nervous symptoms are greatly lessened
by hydrotherapy, but nerve-sedatives may be necessary.
Sore mouth may be prevented by cleanliness and the
use of carbolized glycerin solution (0.5 per cent.) upon
the gums and teeth." — (Pocket Cyclopedia.)
5. Impetigo contagiosa is an acute, contagious, in-
flammatory disease of the skin, characterized by dis-
crete, flat, superficial vesicles or blebs, which rapidly
become pustular and dry upon the skin as thin crusts.
The eruption is most common upon the face and hands.
The lesions begin as flat vesicles or blebs, which, in the
course of twenty-four hours, become vesiculopustular or
pustular. Rupture soon occurs, the exudate drying
upon the skin as thin, wafer-like crusts, which appear
to be "stuck on." The edges of the crusts become de-
tached, curl up, and the crusts drop off, exposing to
view reddish spots which soon fade. The lesions at
912
ONTARIO.
times show a tendency to umbilication. A coalescence
of neighboring pustules may occur, leading to the
formation of patches of considerable size. In severe
cases there may be slight febrile disturbance. Itching
is slight or absent. Occasionally the eruption takes on
a circinate form. The affection is chiefly seen in poor
children. It is likely to accompany pediculosis capitis,
as the result of scratching. Epidemics of contagious
impetigo are not uncommon in institutions for children.
The affection is caused by inoculation with the ordinary
pus microorganisms, particularly the staphylococcus
pyogenes aureus. The chief characteristics are the dis-
creteness, superficiality, and autoinoculability of the
lesions. The affection may be cured in a week or ten
days, or, indeed, may get well spontaneously. The
crusts may be removed with soap and warm water,
after which an ointment of ammoniated mercury (gr.
xxx to 1 ounce of petrolatum) should be applied; mild
antiseptics may be employed, care being taken to avoid
irritation. — (Cyclopedia of Medicine and Surgery.)
Herpes zoster is probably an acute specific disease
of the nervous system, characterized by the formation
of grouped vesicles along the line of a cutaneous nerve,
and accompanied by neuralgic pains. Cold, anemia,
excessive use of arsenic, malaria have been mentioned
as causative factors. There is an irritative or inflam-
matory condition of the central, spinal, or peripheral
nerve apparatus. The process is usually an interstitial
descending neuritis of one of the spinal ganglia. The
parts affected should be protected from injury by a
dusting powder or collodion ; the pain may demand mor-
phine. Internally, zinc phosphide, and tonics have
been recommended.
Alopecia areata is a disease of the hairy system
characterized by the more or less sudden occurrence of
round or oval, circumscribed, bald patches, in rare cases
coalescing and producing total baldness. The cause is
usually neurotic in character, although at times the dis-
ease seems to be caused by a parasite. The character-
istics of the disease are the circumscribed areas of
baldness, the pale, smooth skin, the contracted follicles,
and the rapid onset. Internally, arsenic, in addition to
other tonics and stimulants, is of great service. Locally,
stimulation of the scalp is indicated, for which pur-
pose the essential oils, cantharides, capsicum, turpen-
tine, and sulphur are recommended. The faradic cur-
rent applied with a wire-brush electrode is often useful.
In obstinate cases blistering may be resorted to. —
(Pocket Cyclopedia.)
913
MEDICAL RECORD.
SURGERY.
1. (a) Benign tumors of the breast are generally
found in young women, between the ages of 15 and 80.
They grow very slowly and gradually. As a rule they
are freely movable, are firm, round and oval, and the
nearer they are to the skin the softer they are. They
are not encapsulated, and don't cause retraction of the
nipple or enlargement of the axillary glands. As a
rule they are not painful. Malignant tumors are gen-
erally found in women between 30 and 60 years of age.
Cachexia accompanies them. They grow rapidly. They
are movable in the early stages, later they become
adherent to the skin or pectoralis major muscle, and
are hard and immovable. The nipple is retracted. The
axillary glands are enlarged. Pain is a symptom.
There may be metastatic growths.
(b) In doubtful cases it is well to imagine the growth
to be malignant until it is proved otherwise. If the
breast is removed, and the tumor is proved benign, the
woman has lost a breast; whereas, if it is not re-
moved, and should prove to be malignant, she will lose
her life. The best plan is (with the consent of the
patient) to prepare for a radical operation, excise a
piece of the tumor, have it examined microscopically,
and if it proves to be benign, remove the tumor; if it
is malignant, remove the whole breast and neighboring
lymphatic glands.
(c) "Halsted's operation aims to remove in one piece
the entire breast and overlying skin, the costal portion
of the pectoralis major, the pectoralis minor, and all
the fat and glands of the axilla. The supraclavicular
glands are removed in a second piece. An incision is
carried through the skin and fat, and a triangular flap
turned back. The costal portion of the pectoralis major
is divided close to the ribs and separated from the
clavicular portion, which with the overlying skin is
divided up to the clavicle, exposing the apex of the
axilla; these flaps are drawn upward with a retractor
and separated from the underlying tissues, and the
muscle further split as far as the humerus, where it is
severed close to the bone. The breast, pectoralis major,
and all fat are stripped from the chest wall, including
the pectoralis minor, which is divided at each end, thus
exposing the entire axilla, which is cleansed of fat and
lymphatic glands from above and within, downward
and outward, all small vessels being ligated close to the
axillary vessels, which, with the nerves, should alone
remain. The triangular flap of skin is drawn outward
and the lateral and posterior walls of the axilla like-
914
ONTARIO.
wise cleared, the subscapular vessels being ligated, and
the subscapular nerves preserved if possible. The mass
is then turned inward and removed from the chest. A
vertical incision is now made along the posterior mar-
gin of the sternomastoid, and the supra- and infra-
clavicular fat and glands removed by dissecting from
the junction of the internal jugular and subclavian
veins downward and outward. The cervical wound is
sutured, and the edges of the chest wound approxi-
mated by a buried purse-string suture of silk, which
includes the base of the triangular flap, the apex being
spread over the axilla. The rest of the wound is cov-
ered with Thiersch's skin grafts. The axilla is not
drained. The disability resulting after such an exten-
sive operation is surprisingly slight. The entire wound
may be closed in most cases by fashioning two flaps
from the lower lip of the wound. A small gauze drain
should always be placed in the axilla, preferably
through a small incision at its posterior margin, in
order to drain the large quantity of fluid which escapes
from the severed lymph vessels." — (Stewart's Surgeinj.)
2. Intussusception is the telescoping of one part of
the intestine into the part immediately below. It is said
to be due to irregular peristalsis; trauma, diarrhea,
intestinal worms, polypi and new growths in the in-
testinal wall have all been credited with causing the
condition.
(b) Acute intussusception is most common in chil-
dren. It begins suddenly with severe abdominal pain
and vomiting. Blood-stained mucus is passed, perhaps
with tenesmus. Collapse soon comes on, and may be
fatal in twenty-four hours; otherwise death occurs in a
few days from peritonitis. In most cases a "sausage-
shaped" tumor can be felt, usually along the course of
the colon, but lower down, or just above the pubis
The right iliac fossa feels empty. A natural cure may
follow, but rarely, from sloughing of the intussuscep-
tum, whilst the peritoneal cavity is protected by ad-
hesions uniting the entering and ensheathing layers.
(c) Treatment. "The reduction of the intussuscep-
tion at the earliest possible moment is the only treat-
ment admissible, and this can only be done with cer-
tainty by operation. The abdomen should be opened
over the tumor if it can be felt; if not, in the mid-line
below the umbilicus. The intussusception is then re-
duced by squeezing out the entering portion, beginning
at the lowest part. The intestine should never be pulled
out, for fear of tearing it. If there is any difficulty, the
wound must be enlarged and the lump brought out. If,
915
MEDICAL RECORD.
owing to adhesions, reduction cannot be done, the intus-
suscepted portion must be excised through an incision
in the ensheathing layer, but the outlook is bad in these
cases. If the bowel is gangrenous, the condition is so
bad that nothing more can be done than to bring out
the coil and establish an artificial anus. If, owing to
any reason, an operation is not possible, nonoperative
procedures must be tried. These consist of attempting
to reduce the invagination by inflation with air or, bet-
ter still, by fluid. A catheter is passed into the rectum
and fluid poured in from a funnel raised not more than
2 feet. A hand is placed over the tumor to feel when
the lump disappears. The objections to this are that
after twelve hours reduction cannot be obtained by this
method; that valuable time is wasted if it fails; that
you cannot tell if the last inch has been reduced (and if
it has not, recurrence is certain) • that it is no use in
the enteric or ileocolic forms, and that the bowel may
be ruptured." — (Aids to Surgery.)
5. (a) Amputation in the middle of the forearm.
"An anterior and a posterior U-shaped flap are in-
cised on the respective aspects of the forearm, the base
of each flap at the saw-line being equal to a half-
circumference of the limb at that line and the length of
each equal to three-fourths of the diameter — the hand
being supinated in making the anterior flap and the
forearm vertical in making the posterior flap. Having
cut through skin and fascia in outlining the flaps, these
incisions are now deepened upon the line of the re-
tracted skin, beginning at the ulnar side of the anterior
flap, in case of the right arm (and on the radial side
upon the opposite arm). The vertical ulnar incision
will involve the flexor carpi ulnaris and flexor pro-
fundus — the vertical radial incision will involve the two
radial carpal extensors — both vertical incisions passing
directly to the bones. The muscles on the anterior and
posterior aspects of the forearm, at the lower rounded
extremities of the flaps, are cut from without inward in
such a manner as to bevel them slightly. The entire
flaps are now raised from the bones up to a point suffi-
ciently below the saw-line to furnish a musculoperi-
osteal covering — at which level the periosteum is circu-
larly divided around the bones, the interosseous mem-
brane cut transversely, and the musculoperiosteal cov-
ering freed to the saw-line. The soft parts are then
retracted and the bones sawed. The radial, ulnar, an-
terior and posterior interosseous arteries are tied. The
median, radial, and ulnar nerves should be cut short,
916
ONTARIO.
or even dissected from the flap. The musculoperiosteal
covering is sutured and the muscles quilted — and the
integuments sutured in a lateral line." — (Bickham's
Operative Surgery,)
(6) In amputation of forrarm at middle third there
will be severed: Skin; fascia; muscles: — supinator lon-
gus, extensor carpi radialis longior and brevior, ex-
tensor communis digitorum, extensor carpi ulnaris,
supinator brevis, anconeus, pronator radii teres, flexor
carpi radialis, palmaris longus, flexor sublimis digi-
torum, flexor carpi ulnaris, flexor profundus digitorum;
arteries: — anterior interosseous, posterior interosseous,
radial, ulnar; veins: — radial, interosseous, ulnar, me-
dian; nerves: — posterior interosseous, radial, median,
ulnar; bones: — radius, ulna.
4. Anal fissure is characterized by the very severe
pain on defecation, and for some time afterward; con-
stipation and pruritus are commonly present; local ex-
amination shows a "sentinal pile," on the inner side of
which is a very painful ulcer or fissure.
Hemorrhoids. The patient complains of a feeling of
weight, itching, tenesmus. There is but little pain un-
less a fissure or ulcer is also present. Internal hemor-
rhoids, if protruding, are painful; bleeding may be se-
vere. The hemorrhoids are readily seen if external;
internal hemorrhoids may be seen if the patient strains,
or they protrude during defecation.
Carcinoma of the rectum generally attacks persons
past middle age. At first there may be no symptoms
beyond itching and occasional bleeding; then diarrhea,
straining at stool, the discharge of pus or mucus may be
observed; pain may be present, which radiates to the
back and thighs. Under anesthesia the carcinoma may
be seen by the proctoscope or felt by the examiner's
finger. In the later stages cachexia develops and the
symptoms of stricture are present.
Treatment of anal fisstire. The base of the fissure
(including the external sphincter) must be divided; all
piles (including the "sentinal pile") must be removed;
the ulcer must be excised. The wound then heals by
granulation. The bowels must be kept relaxed.
The treatment of external piles when uninflamed con-
sists in preventing constipation, keeping the parts clean,
and applying hamamelis ointment. They seldom need
removal except when associated with internal piles. In-
flamed piles should be treated by rest, a large warm
enema, and fomentations. If there is much pain the
pile should be incised and the blood-clot turned out.
The treatment of internal piles. Constipation must
917
MEDICAL RECORD.
be avoided, also excesses in eating and drinking. The
parts must be carefully cleansed and hamamelis oint-
ment applied. Operations include clamp and cautery,
ligature, and Whitehead's operation.
Operation for hemorrhoids. Clamp and cautery. Rad-
ical treatment is advisable when there is much pain and
bleeding. It must be ascertained first that the piles are
not due to disease elsewhere, as cirrhosis or stricture,
or to pregnancy. The bowels are emptied and the pa-
tient is placed in the lithotomy position. The sphincter
is then dilated with two thumbs to expose the piles,
which are caught up with ring forceps. A clamp is ap-
plied to the piles in turn, and they are removed by the
cautery. The bowels are kept confined for five or six
days, when castor oil is given. Very little pain and no
bleeding follow this operation. Removal can be done
by snipping the mucous membrane around the pile and
ligaturing its base. Crushing is also done.— (Aids to
Surgery.)
The treatment of cancer of the rectum h excision of
the rectum or colostomy. Kraske's operation (excision
of the rectum by the sacral route) : "With the patient
lying on the right side, a median incision is made from
the anus to the middle of the sacrum. The coccyx is
excised. The ligaments and muscles are detached from
the sides of the sacrum as high as a point just below
the third sacral foramina, at which point the sacrum is
sawn across and the lower piece removed. The rectum
is exposed and cut through above and below the growth.
The peritoneum may have to be opened to get above the
tumor. If the sphincter and anus are unaffected they
are left and the bowel is brought down and an end-to-
end anastomosis is made. If the whole rectum has to
be removed the upper end is either brought down and
stitched to the skin around the original anus, or, if this
is not possible, an anus is made just below the divided
sacrum. During the operation the sacral glands must
be searched for and removed if enlarged. Incontinence
usually remains, and is less easy to manage with a truss
than a colotomy." — (Aids to Surgery.)
5. "If the disease is at the cardiac end of the stomach,
involving the cardiac orifice, the symptoms may resem-
ble those of stricture of the esophagus and be asso-
ciated with dysphagia, ending in an inability to swallow
at first solid and later even fluid nourishment; in such
cases the tumor, being well under cover of the ribs, is
difficult or impossible to palpate, but enlargement of the
supraclavicular glands on the left side is usually pres-
ent.
918
ONTARIO.
"If the pylorus be the part involved, dilatation of the
stomach with retention and decomposition of food and
vomiting are pronounced symptoms, the vomiting being
at first irregular, perhaps every second or third day,
soon becoming daily and later occurring after every
meal. Peristalsis may be accompanied by severe pain
of a crampy character which is relieved by vomiting. ,,
— (Keen's Surgery,) There may be felt a tumor a
little above and to the right of the umbilicus, at first
movable but later fixed by adhesions. The pylorus be-
comes stenosed. In the later stages there are pressure
symptoms, such as ascites, jaundice, edema of the legs,
and varicose veins in the abdominal walls.
Treatment. When the cardiac end is involved only
palliative operations are recommended; gastrostomy
may be tried. When the disease is at the pyloric end,
"complete removal of the affected segment of stomach
and of the associated lymphatics is the only means of
curing the disease. In many cases it is only after the
parts have been exposed by laparotomy that it is pos-
sible to say whether or not the radical operation should
be undertaken. If the associated glands are capable of
being removed, and if there is no evidence of metastasis
having occurred, the radical operation should be carried
out. The term pylorectomy is applied when the opera-
tion is performed for malignant disease of the pylorus,
although a considerable portion of the stomach must
also be removed. Adhesion to and infiltration of the
transverse colon is not usually a contraindication to the
radical operation, as it is quite feasible to resect the
portion of colon involved. The technique of the opera-
tion has been simplified by the preliminary ligation of
the arteries distributed to the stomach and by the use
of clamps. In the majorty of cases it is best to perform
gastroenterostomy in the first place, choosing a healthy
portion of the stomach; the resection is then carried
out and the cut ends of the stomach and duodenum
closed and invaginated. In weakly patients an interval
may be allowed to elapse between the gastroenterostomy
and the resection. The radical operation is contraindi-
cated when the disease is associated with ascites, when
the tumor has infiltrated the omentum, liver, pancreas,
or abdominal wall, or when metastasis has occurred." —
(Thomson and Miles' Manual of Surgery.)
OBSTETRICS AND GYNECOLOGY.
1. The patient should be instructed fully in the
hygiene of pregnancy, by which is meant the care
which should be observed by the pregnant woman for
919
MEDICAL RECORD.
the preservation of health and strength both of her-
self and of the fetus. The pregnant woman should take
moderate exercise in the open air; in the last month
massage may take the place of exercise. Daily bath-
ing in tepid water, care of the teeth, regularity of the
bowels, ample sleep in a well-ventilated room, plenty
(but not too much) of simple, nourishing and easily
digested food at regular hours, clothing not too tight,
especially about the abdomen and breast; attention to
the nipples, regular examination of the urine, and the
restriction of marital relations are the main points to
which advice should be directed. In addition certain
measurements are necessary; a pelvimeter will be re-
quired to make these measurements. The interspinal
and intercristal diameters are measured, also the dis-
tance between the ischial tuberosities and the antero-
posterior diameter, as well as the external conjugate.
It is well to notice if the subpubic arch is narrowed ; the
diagonal conjugate is also estimated; from the latter
the true conjugate can be obtained.
Care of mother during puerperium. "During the
first week the patient keeps the bed, but after the first
few hours she has considerable license. She may as-
sume the sitting or halfsitting posture to take her
meals and to nurse the baby, and, if necessary, for
evacuation of the bladder and rectum. She should
assume the lateroprone posture both right and left sev-
eral times a day, and lie upon her abdomen for at least
an hour daily. Frequent change of position favors
uterine drainage and massages the uterine supports.
During the second week she has greater liberty, while
the greater part of her time is spent on the bed or
lounge. She may sit up for her meals, to urinate, and
for bowel movements, and she should spend at least
half an hour, twice daily, in abdominal and leg exercises
to keep up her muscular tone. The third week she
may be moved to a chair for a part of the day, having
the liberty of the room. After sitting up for any
length of time she should be instructed to take the
genupectoral position before lying down. Prescribed
exercises for the legs and abdominal muscles are to
be taken daily. The fourth week, if all goes well, she
may leave the room and have the benefits of air and
sun. Physical exercises should be continued. The
duration of the lying-in period and the degree of free-
dom to be given the patient after the second week
must, however, depend on the character and amount
of the lochia, the general progress of her convalescence,
and the rate of the uterine involution." — (Polak's
Obstetrics.)
920
ONTARIO.
2. True labor pains are the pains occurring at the
commencement of labor, and which are coincident with
expulsive efforts of the uterus. They begin at the
back, pass to the front, occur at gradually shortening
intervals, are accompanied by uterine contraction and
increased opening of the os externum.
False labor pains occur before labor. They are feeble,
do not last long, occur at long intervals, are not ac-
companied by contraction of the abdominal muscles, are
generally felt in front, and do not cause opening of
the os.
Weak pains are such as do not aid much in the ex-
pulsion of the fetus.
Cutting pains are the early pains experienced by
the woman, and are so called from the "cutting" sensa-
tions experienced by the woman.
Atonic pains are the ineffective pains accompanying
a condition of uterine inertia; the uterus does not
harden to any extent, and contracts feebly and irregu-
larly.
Expulsive pains are such as produce or accompany
the expulsion of the fetus.
After pains are painful contractions of the uterus
which occur after delivery (generally for two or three
days).
3. Indications for the use of forceps are: "1. Forces
at fault: Inertia uteri in the presence of conditions
likely to jeopardize the interests of mother or child,
(a) Impending exhaustion; (b) arrest of head, from
feeble pains. 2. Passages at fault: Moderate narrow-
ing 3 x /4 to 3% inches, true conjugate; moderate obstruc-
tion in the soft parts. 3. Passenger at fault: A
Dystocia due to (a) occipitoposterior, (6) mentoan-
terior face, (c) breech arrested in cavity. B. Evidence
of fetal exhaustion (pulse above 160 or below 100 per-
minute). 3. Accidental complications: Hemorrhage;
prolapsus funis; eclampsia. All acute or chronic
diseases of complications in which immediate delivery
is required in the interest of mother or child or both." —
(From Jewett's Practice of Obstetrics,) Contraindica-
tions: Mechanical obstruction in the parturient canal;
incomplete dilatation of the os; non-rupture of mem-
branes; non-engagement of the presenting part; the
fetal head being too large or too small; distended blad-
der or rectum.
Pituitrin may be used in cases of uterine inertia, pro-
vided the os is dilated and there is no obstruction to
delivery.
4. The condition may be anyone of the following:
921
MEDICAL RECORD.
Pregnancy, uterine fibroid, ascites, ovarian cyst, fat,
pseudocyesis, and subinvolution of the uterus.
Pregnancy: The tumor is hard and does not fluc-
tuate, is situated in the median line, and may give fetal
heart sounds and movements; the cervix is soft, and
the other signs of pregnancy are present. The rate of
growth of the tumor and the general condition of the
patient's health may also help in arriving at a diag-
nosis.
Uterine fibroid: Menstruation is irregular and some-
times very profuse; absence of the signs of pregnancy;
the tumor is nodular, firm, irregular in outline, and
while generally placed somewhat centrally is not in the
median line, and is not symmetrical ; the rate of growth
is irregular, being, as a rule, slow, and sometimes ex-
tending over years.
Ascites : Absence of the signs of pregnancy; the abdo-
men is distended, but the shape varies with the position
of the patient; on lying down there is bulging at the
sides, the tumor fluctuates, and percussion shows dull-
ness in the flanks, with resonance in the median line,
but the dullness varies with the position of the patient.
Ovarian cyst: Absence of the chief signs of preg-
nancy ; there may be the characteristic f acies, the tumor
is soft, fluctuating, is more to one side, and does not
show fetal signs.
Fat: Absence of signs of pregnancy, also of fibroid,
or ascites.
Pseudocyesis: The uterus is not enlarged, and the
administration of a general anesthetic causes the col-
lapse of the "tumor."
Subinvolution of uterus : The uterus does not increase
in size, there is a leucorrhea, there is generally pain
in the back or ovarian region, there is a history of ir-
regular (and profuse) menstruation, and the signs of
pregnancy are absent.
5. Prolapsus uteri. Etiology: Injury at childbirth,
lacerated perineum, relaxation and elongation of the
ligaments of the uterus, loss of rigidity of the abdominal
walls, increase in the weight of the uterus, subinvolu-
tion, increased intraabdominal pressure. Symptoms:
The patient complains of a feeling of "bearing down";
of trouble with micturition and defecation; of pain
and fatigue on walking, and of "falling of the womb."
The cervix is low down in the vagina; the sound shows
that the uterine cavity is lengthened. Procidentia is
evident on inspection. Treatment : "A prolapsed uterus
must first be placed in proper position, or a procidentia
reduced. In many cases the introduction of a rubber
922
ONTARIO.
ring pessary will then suffice to prevent recurrence.
But it will often be found necessary to repair a torn
perineum, removing at the same time redundant por-
tions of the vaginal walls, before the ring will remain
in the vagina. When such an operation is contraindi-
cated, and the vaginal orifice is so wide that a ring
cannot be kept in, some form of pessary with a vaginal
stem and perineal bands will be required. In cases of
procidentia, where the exposed surface is much ulcer-
ated, the patient should be kept in bed, emollient appli-
cations made to the ulcers, and vaginal douches given.
When the ulcers have healed, a pessary may be intro-
duced. Procidentia due to supravaginal elongation of
the cervix must be differently dealt with. Amputation
of a portion of the cervix must therefore form the first
step in the treatment, and it may be required also when
the hyperplasia is secondary to descent. Cases of pro-
lapse and procidentia which resist milder measures re-
quire further operative procedures, such as ventrofixa-
tion of the uterus or the shortening of the round liga-
ments. It is in cases of this kind that hysteropexy has
often given satisfactory results. Total extirpation of
the uterus has been practised for the treatment of
procidentia." — (Sutton and Giles' Diseases of Women.)
MEDICINE.
1. Acute lobar pneumonia "begins with a severe and
usually protracted chill, followed by a rapid rise of tem-
perature, 103° to 104° F., a strong, full, but rapid pulse,
soon showing evidence of embarrassed cardiac action.
There are also present pain near the nipple, aggravated
by pressure, breathing, or coughing; shortness of
breath, the number of respirations increasing to 40, 50,
or more a minute ; disturbance of the ratio between
pulse and respiration ; and cough, at first short, ringing,
and harsh, followed by a scanty, frothy, mucoid expecto-
ration. The sputum soon becomes transparent, viscid,
and tenacious, changing about the second day to the fa-
miliar rusty sputum. The quantity is increased and a
yellow color is assumed as the disease advances. The
prostration is pronounced. The face is flushed, espe-
cially over the malar bones. The lips are more or less
blue and herpes may be observed. Epistaxis, headache,
sleeplessness, and gastric disturbances are common. The
tongue is coated, the appetite is impaired, and there is
constipation. Delirium is sometimes present. The urine
is small in amount, highly colored, deficient in chlorides,
and often slightly albuminous. The blood shows evi-
dences of leucocytosis. The fever usually reaches its
923
MEDICAL RECORD.
maximum within twenty-four hours and continues high,
with diurnal remissions, until the fifth, seventh, ninth,
or eleventh day, when a crisis occurs, and within twen-
ty-four hours all the symptoms are lessened, the fever
absent, and convalescence is established. Occasionally,
the termination is by lysis.
"Physical signs over the affected lung : Palpation dur-
ing the first stage shows the vocal fremitus to be more
distinct than normal. In the second stage, the vocal
fremitus is markedly exaggerated, except in case of oc-
clusion of the bronchi by secretion. In the first stage,
the percussion note is slightly impaired at times, having
a hollow or tympanitic quality. In the second stage
there is dullness over the affected parts, with an in-
creased sense of resistance. In the first stage there is
a feeble vesicular murmur, associated with the true
vesicular (crackling) rale, heard at the end of inspira-
tion only. In the second stage there is harsh, high-
pitched, bronchial respiration, at times resembling a
to-and-fro metallic sound, except when the bronchi are
filled with secretion. Bronchophony is present and at
times pectoriloquy may be heard. In the third stage,
the breathing changes from bronchial to bronchovesicu-
lar and the crepitant rale returns. As resolution pro-
ceeds, the breath sounds are associated with large and
small moist and bubbling rales." — (Hughes' Practice of
Medicine.)
2. Catarrhal Jaundice. "Causes. — Extension of gas-
trointestinal inflammation is the most common cause.
Atmospheric changes, passive congestion of the liver,
and the infectious fevers are less frequent factors.
"Symptoms. — The affection begins with epigastric
distress, coated tongue, impaired appetite, nausea, with
perhaps vomiting, looseness of the bowels, and slight
feverishness. In from three to five days the eyes be-
come yellow, and jaundice gradually appears
over the whole body; the feverishness disap-
pears, the skin becomes harsh, dry, and itchy,
the bowels constipated, the stools whitish or
clay-colored, accompanied with much flatus and col-
icky pains; the urine heavy and dark, loaded with
urates and containing biliary elements. When the
jaundice is complete, the surface is cold, the heart's ac-
tion slow, the mind torpid and greatly depressed, and
there is pain or tenderness on pressure over the hepatic
region. The symptoms subside within a few days after
the jaundice appears, but the depression, discoloration,
and condition of the bowels persist for one or two
weeks."
924
ONTARIO.
"Differential Diagnosis. — When jaundice is induced
by obstruction to the outflow of bile other than that pro-
duced by inflammation, such as arises from stricture of
the common duct, tumors of the abdominal viscera, for-
eign bodies such as gall-stones and parasites, fecal ac-
cumulations, spasms of the bile ducts due to emotion,
etc., the symptoms of these different affections will be
found associated with the icteroid manifestations. Non-
obstructive or hematogenous jaundice is unassociated
with inflammatory changes in the bile ducts, and arises
from disintegration of the blood or hemolysis. It dif-
fers from catarrhal jaundice in its history, the absence
of clay-colored stools, and less staining of the urine.
"Treatment. — The patient should be placed at rest in
bed and the diet restricted to milk and lime-water,
broths, eggs, lean meats, etc., care being taken to elim-
inate all starchy, fatty, or saccharine substances. Cal-
omel, gr. %, with sodium bicarbonate, gr. iij, should be
then given every two hours until twelve doses are taken,
followed by Hunyadi water. Sodium phosphate, 3j,
may also be given, well diluted, every four hours. The
dry, itching skin may be relieved by diaphoresis, a hot
bath containing potassium carbonate night and morn-
ing, or a weak carbolic acid solution. If insomnia is
present potassium bromide, gr. xxx, may be adminis-
tered. Diuretics are indicated if the urine continues
scanty, preference being given to the alkaline waters,
potassium bitartrate lemonade, and spirit of nitrous
ether, trgx to xx. In cases in which the constipation per-
sists, aloes, podophyllum, colocynth, and other chola-
gogues should be employed. Irrigation of the colon
once daily with cold water, gradually increasing the
temperature, is often very effective." — (Hughes' Prac-
tice of Medicine.)
3. Cerebrospinal Meningitis. Causation.— The dis-
ease is caused by the Diplococcus intracellulars menin-
gitidis; other microorganisms are also supposed to be
capable of causing the disease. Predisposing causes
are bad hygiene, overcrowding, foul air, poor food. The
diplococcus is believed to gain entrance to the body
through the nasal mucous membrane, and the infection
leaves the body through the same channel. "Carriers"
may transmit the disease through their nasal discharge.
Symptoms: Sudden onset, with headache, vomiting,
rigors, stiffness of neck and back producing opisthoto-
nos, pulse full and rapid, temperature about 102° P.,
photophobia, delirium ; Kernig's sign is present, and the
diplococci may be found in the cerebrospinal fluid after
lumbar puncture; the tache cerebrale may be observed,
925
MEDICAL RECORD.
and leucocytosis is present. The diagnosis is made
from the symptoms, chiefly the presence of Kernig's
sign and the diplococci in the cerebrospinal fluid. In
typhoid fever the onset is gradual, the temperature is
characteristic, the opisthotonos and Kernig's sign are
absent, there are no diplococci in the cerebrospinal
fluid, and Widal's reaction may be present. Tuber-
culous meningitis is not epidemic, is not of sudden on-
set, and a primary focus of tuberculosis may generally
be detected elsewhere. Treatment: Isolation in an airy
room, rest in bed, nourishing diet, ice bags to the nape
of the neck, morphine for the pain, bromides for the
restlessness, lumbar puncture to relieve the symptoms,
and the injection of Flexner's serum. Stimulation may
be necessary.
4. Tinea tonsurans (ringworm of the scalp) is a con-
tagious affection due to the trichophyton fungus which
invades the hair and hair follicles. It generally occurs
in children, and is characterized by small circumscribed
patches of baldness in which the hair is diseased and
often broken off close to the scalp. Vesicles, pustules,
and scales are observed. The patches spread and may
be as large as a silver dollar. Itching is a constant
symptom. The diagnosis is made certain by the pres-
ence of the fungus; a hair should be extracted, im-
mersed in liquor potassae, and then examined under the
microscope. Vigorous and persistent local treatment is
required. The hair of the affected part should be cut
close, and the head washed daily with soap and hot
water, or an ointment of oleate of mercury, or of sul-
phur should be applied twice a day. Treatment must
be continued as long as the fungus is present.
Scabies. — The diagnostic features are the presence of
the itch mite (acarus scabiei) and its burrows. The
eruption is multiform and generally on the flexor sur-
faces of the body, and the itching is intense and is worse
at night. Treatment consists of a hot bath, followed by
the application of sulphur ointment (one dram to the
ounce of petrolatum) every night for a week; the bed
linen and underclothes should be sterilized. After the
interval of one week treatment must be undertaken
again for a week.
5. The common types of cerebral growths are the tu-
bercle, gumma, sarcoma, carcinoma, and cysts. The
general symptoms are those of apoplexy: There may
be prodromal symptoms such as vertigo, pain in the
head, or impairment of memory; but as a rule the at-
tack is sudden with vertigo and unconsciousness ; there
may be retention or incontinence of urine, the urine has
926
ONTARIO.
a high specific gravity and may contain albumin; hemi-
plegia generally ensues; the tongue protrudes toward
the affected side; aphasia (either motor or sensory)
may be present; the face is flushed, breathing is ster-
torous; the body temperature is first subnormal and
then elevated ; the pulse is slow and full ; in severe cases
the pulse becomes weak, and the respirations become
of the Cheyne-Stokes type ; the reflexes are abolished.
If the tumor is in the prefrontal region, there may be
no symptoms at all, or mental enfeeblement, disturb-
ances of smell and vision, motor agraphia and aphasia.
6. A complete physical examination should be made,
noting especially the condition of the heart, arterial
walls, and abdominal organs; the diastolic blood pres-
sure should also be obtained; the urine should be ex-
amined, noting the specific gravity, 24 hours quantity,
presence of sugar and indican, and the amount of urea
excreted; the patient should be questioned about the
amount of rest, exercise, and recreation (including va-
cation) which he takes; the eyes should be examined
by a competent oculist and any errors of refraction
should be corrected ; a Wassermann test should be made.
The diagnosis lies between nervous fatigue, eye-
strain, simple hypertension, gastrointestinal autointoxi-
cation, arteriosclerosis, chronic interstitial nephritis,
and syphilis. Prognosis. If the condition is dependent
upon causes which may be removed, the prognosis is
fairly good so long as there are not marked changes
in the bloodvessels. With organic arterial changes
there is danger that these symptoms may be precursors
of cerebral hemorrhage or thrombosis, in which case the
outlook for future health and usefulness is bad, and for
life doubtful. Treatment. The indications are: — For
gastrointestinal autointoxication, the diet must be regu-
lated, the total amount limited, and the quantity of pro-
teids restricted; laxatives, especially salines, should be
given. For nervous fatigue, more sleep, or a vacation
may be required. Syphilis requires cautious treatment
with mercury, arsenic and potassium iodide. Arterio-
sclerosis requires a restricted diet (as just given for
autointoxication), also potassium iodide (10 grains,
three times a day) for a long period, nitroglycerin (gr.
1/100 to 1/50) may be tried, and if no bad effects are
noticeable in heart, circulation or urine, it may be used
as required; sodium nitrite may be used instead; the
patient should avoid overeating, constipation, and ex-
posure to chills, and he should limit his business activi-
ties (at least for a time) ; alcohol and tobacco should
be limited to the smallest amount compatible with
927
MEDICAL RECORD.
physical comfort, and beer and heavy wines should be
avoided. Moderate exercise as walking, golf, etc.,
should prove beneficial. Chronic interstial nephritis re-
quires the same treatment as just outlined for arterio-
sclerosis, but in addition it might be advisable to avoid
red meats.
SURGERY.
1. In fracture of the spine in the lower dorsal re-
gion, there will be paralysis of the muscles of the lower
limbs, with total anesthesia of legs and gluteal and
perineal regions ; there may be paralysis of the bladder
or retention of urine with overflow, according as the
vesical center is or is not involved ; there will be incon-
tinence of the feces. The extent of the paralysis and
anesthesia depend on the lesion to the cord; if only
one side of the cord is affected, only one limb will be
paralyzed and anesthetic. The parts immediately above
the lesion are hypersensitive, and there is a zone of pain
around the body ("girdle pain"). Bedsores arise on
very slight irritation, cystitis usually comes on from
septic infection, the temperature and pulse are variable
(according to the amount of toxic absorption). "The
treatment naturally varies with the character of the
case. The patient is carefully placed on a prepared
bed, the greatest gentleness being used in handling and
lifting him, for fear of increasing the damage to the
cord. The bed must be firm though not hard; perhaps
the best type to employ is a horsehair mattress placed
over fracture boards; nothing more soft or yielding is
permissible. Spring beds and wire-wove mattresses are
most undesirable. A water-bed is required in the later
stages, but should not be used at first, as it is scarcely
firm enough. The shock resulting from the accident is
treated in the usual way by warmth and, if need be, by
stimulants; but it must be remembered that anesthetic
regions of the body can be easily blistered or burnt by
hot-water bottles, unless carefully guarded by flannels.
When reaction has occurred, a more thorough examina-
tion of the patient can be made, and the subsequent
course of action decided on. In many cases, as soon as
the patient is laid flat on a bed, the displacement reme-
dies itself, especially if the spine has been comminuted,
and then the treatment must be symptomatic, as also
after reduction or operation, where the paraplegia per-
sists or is only slowly recovered from. He is kept in
bed, absolutely flat, and with the head low; perhaps
some form of mechanical support — e. g., a plaster of
Paris or leather jacket — may be considered advisable;
but its application is always a matter of difficulty, and
928
ONTARIO.
in the early stages it does but little good. Food is reg-
ularly administered, and at first must be light and
readily assimilable. The chief care of the attendants
must be directed to the skin, bladder, and bowels."—
(Rose and Carless' Manual of Surgery.)
Indications for operation (laminectomy). — When the
cord is not completely severed; in fractures of the
arches alone when the cord is pressed upon; when the
paraplegia comes on slowly, after an interval. When
there is complete local destruction of the cord no opera-
tion should be done.
Laminectomy. — "The patient is placed either prone or
lying on his left side with a pillow supporting the chest,
and the spinous processes of the vertebra to be dealt
with are exposed by raising a rectangular flap of skin
and fascia. When there are signs of fracture of the
neural arches, the center of the flap should lie over the
broken vertebra?. When there are no signs of fracture,
the site of the incision is determined by the spinal
symptoms. The muscles, along with the periosteum,
are separated from the spines and laminae, and the
hemorrhage, which is often very free, is arrested by
pressure and forceps. The interspinous ligaments are
then divided with scissors, and the spines snipped off at
their bases with bone pliers. The ligamenta subflava
are next divided close to the bone and the laminae sawn
across and levered out, or cut away with rongeur for-
ceps. The fatty tissue outside the dura is separated,
and any veins that are torn are tied. The extra-dural
space is now examined by pushing aside the dura with
the enclosed cord, and any blood clots or fragments of
bone which may be present are removed. If it is neces-
sary to open the dura, it should be securely sutured
again to prevent leakage of cerebrospinal fluid. The
divided muscles are brought together with catgut
sutures, but, as there is usually a good deal of oozing
for some hours after the operation, a drainage tube
should be inserted down to the gap in the bone, and left
in position for forty-eight hours. Special care must be
taken to avoid soiling of the dressings by discharges
from the paralyzed bowel and bladder." — (Thomson
and Miles' Surgery.)
2. Removal of the kidney may be advisable in exten-
sive tuberculous disease of the kidneys, calculous pyo-
nephrosis, hydionephrosis, malignant disease, and rup-
ture of ureter or kidney if complications are present.
In any case, before deciding to remove one kidney it
must be positively ascertained that the patient has an-
other kidney capable of performing its functions.
929
MEDICAL RECORD.
Tuberculosis of the kidney shows polyuria, acid urine
which may contain pus or blood, the sediment may con-
tain tubercle bacilli. If no tubercle bacilli are found
microscopically, some of the sediment injected into a
guinea pig will cause tuberculosis in that animal. Cys-
toscopic examination with catheterization of ureters
will show w T hich kidney is affected, and tuberculous ul-
cers in the bladder may also be detected close to the
ureteral orifice.
Malignant disease of the kidney gives hematuria,
pain in loin and thigh, and emaciation. A tumor
may be palpable. Cystoscopic examination gives none
of the features noted above, and there are no tubercle
bacilli in the urine.
Nephrectomy. — "The abdominal operation is chiefly
utilized when the organ is much enlarged, on account
of the readier access obtained, especially to the pedicle.
The peritoneum is likely to be opened, and may be ex-
posed to septic contamination, when the pelvis and the
upper part of the ureters are distended with decompos-
ing pus, as is frequently the case; but this is easily pre-
vented. Drainage is obtained for the cavity left after
the removal of the organ by a counter opening made
through the loin. One great advantage is that the
other kidney can be first examined, if required, and its
condition ascertained. As to the technique, there is fre-
quently no necessity to open the peritoneal cavity, since
the kidney is almost always enlarged, but an opening
is often made, intentionally or accidentally. The
colon and peritoneum are peeled off the organ and dis-
placed inwards; it is then freed from its adhesion to
surrounding tissues, the surgeon endeavoring to keep
outside its true capsule, but inside the layer of con-
densed perinephric tissue. Special precautions must be
adopted in dealing with the deep aspect of the tumor,
particularly on the right side, where it is occasionally
adherent to the inferior vena cava. The mass is now
lifted from its bed, and its pedicle, consisting of the
ureter and renal vessels, isolated. These latter are se-
cured separately by ligature and divided, a clamp being
applied to the distal ends. The ureter is dealt with in
the same way, small pieces of gauze being packed around
so as to receive any secretion which may escape; the
exposed mucous membrane in the portion which is left
is carefully touched over with pure carbolic acid. The
kidney thus freed is removed, and the wound in the ab-
dominal parietes closed in the usual way, provision for
drainage having been previously made either through
the loin or from the front. Considerable shock is often
930
ONTARIO.
experienced from this operation and the death rate is
somewhat high. Occasionally the perinephric adhesions
are so firm and extensive that the only practicable
plan of removing the organ is to enucleate it from with-
in the capsule as far as the hilum; the capsule is then
torn or cut through so as to expose the pelvis and renal
vessels, which are secured." — (Rose and Carless' Man-
ual of Surgery.)
3. Ulcer of the stomach. Symptoms. — Pain, which
is intermittent in character, localized in the stomach,
and coming on soon after a meal; vomiting, which also
occurs soon after eating, and often relieves the pain;
hematemesis is common; examination of the gastric
contents shows an excess of free hydrochloric acid.
It is to be differentiated from cancer of the stomach,
duodenal ulcer, gastralgia, gastritis, pylorospasm, hy-
persecretion, cholecystitis, cholelithiasis, and renal cal-
culus.
Operation is indicated when the hemorrhage is copi-
ous and recurrent, when medicinal treatment has been
given a fair trial and no cure has been made, when
after apparent cure a relapse has occurred, when per-
foration occurs, when adhesions about the stomach in-
terfere with the proper performance of its functions.
Posterior gastroenterostomy. — "The abdomen is opened
by a vertical incision to the right of the middle line
above the umbilicus. The stomach, transverse colon,
and omentum are drawn out of the wound and turned
upward, and an opening is made in the mesocolon near
its root, so as to expose the posterior surface of the
stomach; a portion of stomach at the lowest part of
the greater curvature is selected for the anastomosis.
The upper part of the jejunum is then found by passing
the fingers along the under surface of the mesocolon
immediately to the left of the spine, and the highest
available portion of it brought into contact with the
stomach in such a way that the loop of bowel selected
runs from right to left (Mayo). An anastomosis is
then made between the stomach and jejunum, an
ellipse of mucous membrane being excised from each
viscus. The edges of the opening in the mesocolon are
then stitched over the line of junction, so as to bury
it and prevent any hernial protrusion through the gap.
After being cleansed, the viscera are replaced in the
abdomen, and the wound in the parietes closed. When
the patient has recovered from the anesthetic he is
propped up in bed with pillows." — (Thomson and Miles'
Surgery.)
4. Symptoms of strangulated hernia: General* — ■
931
MEDICAL RECORD.
"Severe pain comes on suddenly after some effort, at
first referred to the umbilicus, and subsequently to the
site of the hernia. This is accompanied by some shock.
The pulse is weak, and, though slow at first, becomes
rapid; the skin is cold and clammy; vomiting occurs,
and soon becomes frequent and fecal-smelling. Consti-
pation is complete, though both feces and flatus may
be passed at first from the lower bowel. The patient
generally becomes exhausted from the vomiting and in-
ability to take food. When gangrene occurs the tem-
perature becomes subnormal, the pulse very rapid and
weak, and the patient dies of toxemia from the general
peritonitis which follows gangrene. Local. — A tumor
forms at one of the hernial sites; or more often the
patient has been the subject of a hernia, which he now
finds to be irreducible, tense, tender, and without im-
pulse on coughing. If allowed to persist the sac and
coverings become gangrenous."
Treatment is taxis or operation. "Operative treat-
ment should be undertaken at once when gentle taxis
has failed. An incision is made over the sac, which is
then opened. There is usually fluid in the sac, so there
is no danger of wounding the gut. The fluid is washed
away, then the cause of strangulation is made out,
and a hernia knife guided up to it by a finger or broad
hernia director. The constriction is nicked in one or
two places and the gut is drawn down so that the site
of strangulation may be examined. Omentum is liga-
tured and removed. If the patient is profoundly col-
lapsed and will not bear a prolonged operation, an
artificial anus is established by dividing the constriction
outside the sac, so as not to open the peritoneal cavity.
The loop of bowel is then opened to give free exit to the
feces. Most of the cases which have to be treated in
this way are so bad before treatment is commenced that
a fatal termination must be expected. If the patient
can possibly stand it, immediate resection gives the best
chance, and with Murphy's button or a bobbin much
time can be saved. A radical cure is advisable after the
strangulation has been relieved, unless the patient's
condition contraindicates it. Liquid food is given at the
end of twenty-four hours, and the bowels need not be
disturbed for five or six days, when castor oil may be
given." — (Aids to Surgery.)
5. Symptoms of fracture of the middle of the femur.
— History of injury; disability; pain on movement;
preternatural mobility; crepitus; shortening of the
limb, deformity (simple overriding of fragments, or
angular deformity). The lower fragment is drawn
ONTARIO.
upward and inward, and may be either in front of or
behind the upper fragment; the ends of the fragments
can be felt by the surgeon. The thigh and leg are
slightly flexed and, generally, everted.
Treatment: "The limb is carefully washed and, if
hairy, shaved. Two long strips of strapping, three
inches wide, fixed below to a square piece of board *4
to V2 inch thick (slightly wider than the ankle opposite
the two malleoli), which is known as the stirrup, are
heated and pressed against the lower third of the frac-
tured limb. They are here secured by short, thin pieces
of strapping 1 to l l / 2 inches in width, passed in a
figure of 8 around the limb above the malleoli and end-
ing just below the fracture; the knee may be left un-
covered. It is necessary to see that the pull of the ex-
tension is exerted on the femur and not on the knee.
Large pads of wool should be introduced between the
malleoli and the sides of the strapping, to prevent the
skin over these processes becoming chafed. A cord is
fixed to the stirrup and passes over a pulley at the end
of the bed, and is there secured to a tin can which is
filled with shot up to the required weight. If now the
foot of the bed is raised on blocks, extension and
counterextension are obtained, the patient's body acting
as a counter-extending weight. When the fracture has
been manipulated into a good position under an anes-
thetic (it is always necessary to control the fracture
with some splints before the anesthetic is given), the
extension apparatus is applied, and Liston's splint is
bandaged to the limb. A proper splint of this kind
should extend from the axilla to below the foot, and it
is secured to the patient in three places: (1) round the
thorax, (2) round the limb at seat of fracture, and
(3) to the leg and ankle. In securing the thorax it
is necessary to take the first turn of the bandage round
the splint from within outward, and then round the
back of the patient's thorax, the direction of the band-
age in this way preventing the natural tendency of the
splint to rotate forward. Several turns should be taken
round the thorax in order to retain it in position. The
remaining bandages should be secured from without
inward, in order to check the tendency of the foot and
leg: to roll outward. In order to prevent the rotation
of the limb a method devised by Cheyne and Burghard
may be adopted. This consists in securing the limb at
the level of the popliteal space to a short splint, 8 by
4 inches, bv means of a plaster of Paris bandage. The
presence of this splint effectually prevents any rotation,
either inward or outward. Special care must be taken
933
MEDICAL RECORD.
to see that the malleoli and the skin over the heel are
not subjected to any great pressure. If the fracture is
put up in this way it must be kept up for six to eight
weeks, and the amount of weight applied to the limb
must be varied according to the age of the patient and
the tendency to deformity. Roughly half a pound a
year will be found to answer most purposes, but if
there is much spasm the amount can be increased up to
20 pounds. At the end of six weeks, during which
period the limb should have been regularly massaged —
this can usually be done without disturbing the exten-
sion — the patient should be got up, and some form of
retentive apparatus applied. A Thomas's splint is a
very valuable form of apparatus, since it enables the
patient to get about, and allows of active movements
being undertaken, while he himself can hobble about on
crutches. If such treatment is not considered advis-
able, he should be kept in splints for eight weeks, and
then allowed to lie in bed without any apparatus on at
all, while the limb is regularly massaged, and he should
be encouraged to get up for a short time on crutches,
gradually exercising the limb, until at the end of about
ten weeks he is walking on it as before." — (Pye's
Surgical Handicraft). Some surgeons advise imme-
diate operation, and cut down on to the fractured bone
and, after reduction, fix the fragments by two or three
Lane's plates.
OBSTETRICS AND GYNECOLOGY.
1. Cystitis. — Causes: Retention of urine, tumors,
foreign bodies, calculus, ammoniacal urine, various
pathogenic bacteria producing (for example) gonor-
rhea, tuberculosis of genitourinary tract, pus in the
urine. Symptoms: Frequent urination, with tenesmus
and a burning sensation in the urethra; later on pain
in the bladder, hematuria, and the urine contains pus
and epithelial cells. Chills, fever, rapid pulse, and
headache may also be present. A feeling of weight or
pain in the pelvis is noticed. Treatment : Rest in bed ;
the imbibition of plenty of milk and water, and the
avoidance of all highly seasoned food; laxatives; diu-
retics ; sitz-bath ; irrigation of the bladder with an anti-
septic solution; hot fomentation and vaginal douches
are often helpful; sometimes intravesical medication is
necessary.
2. (a) Operation for recent laceration of the peri-
neum. — "The parts are cleansed and a pledget of sterile
cotton or gauze pushed up the vagina to stop any flow
from the uterus obscuring the wound. The sutures
934
ONTARIO.
(preferably of aseptic silk) are passed with a mod-
erately curved needle about 2 inches long as follows:
Beginning at the posterior end of the laceration (that
nearer the anus), the needle enters the skin near the
edge of the wound and follows a circular course until
its point appears at the very bottom of the laceration
(a finger of the other hand in the rectum guarding
against its penetrating that canal) ; it then enters the
opposite side of the laceration at the bottom of the
wound and comes out of the skin opposite its point of
entrance, having followed a similar circular course to
that pursued on the other side where it first went in.
The ends are loosely tied or secured by catch-forceps,
until the requisite number of sutures are passed in a
similar manner (half an inch apart), when the wound
is again cleansed, the vaginal plug removed, and the
sutures tied tightly enough to coapt the parts without
injurious constriction, the order of succession in tying
being that in which the sutures were passed.
In "complete" lacerations — those of the third degree
— through the sphincter ani to the rectum, the opera-
tion is more difficult. The rectal tear is first stitched
with catgut sutures (a short, curved needle being used)
and going through the rectal wall only. The sutures
are tied on the inside, so that the knots are on the
mucus membrane of the bowel. They begin from above
and come down to the sphincter ani, the cut ends of
which are drawn out with a tenaculum while the su-
tures penetrate them These catgut sutures need not
be removed; they will digest in the tissues and dis-
appear of themselves. The posterior wall of the va-
gina is next sutured with fine silk, from above down-
ward toward the hymen. Finally, skin sutures through
the perineum itself, including muscles of the pelvic floor
(as just described for lacerations of the first and sec-
ond degrees) complete the operation. The silk sutures
may be removed in about a week. Antiseptic dressings
are applied as after an ordinary labor, extra care being
taken to keep the wound aseptically clean by daily irri-
gation with the creolin solution." — (King's Obstetrics.)
(b) Operation for old laceration of the perineum. —
"Lateral tears are best repaired by the Emmett opera-
tion. With the patient in the lithotomy position, guide
sutures or tenacula are passed through the apex of
the rectocele and through each labium ma jus at the
lowest carnuculae myrtiformes. By drawing on the lat-
eral suture and pulling the central suture downward
and to the opposite side, the lateral sulcus appears as
a triangle with the apex up in the vagina. This tri-
935
MEDICAL RECORD.
angle is denuded of mucous membrane by cutting off
long strips by means of forceps and scissors, or by dis-
secting the mucous membrane off in one piece. The
triangle on the opposite side is treated in the same
manner, and the denudation completed by removing
the mucous membrane between the bases of the triangles
and below the central suture. Each lateral triangle is
closed by interrupted sutures of chromicized catgut or
silkworm gut, the latter being shotted. The needle,
which should be curved, is entered near the margin of
the wound on the outer side, passed deeply to catch the
fibers of the levator ani, and brought out at the bottom
of the sulcus, at a point nearer the operator; it is then
reinserted at the bottom of the sulcus, and passed up-
ward and backward in the rectocele, to emerge opposite
the point of the original insertion. The opposite tri-
angle is treated in the same manner, which leaves a
small raw area externally to be closed. The upper or
"crown stitch" passes through the skin of the perineum
below the lateral guide suture, then through the rec-
tocele below the central guide suture, and finally
through the tissues below the opposite guide stitch. As
many sutures as may be necessary are inserted below
this. If silkworm gut is used, the stitches should be
removed on the tenth day. The external genitals are
irrigated with weak bichloride of mercury solution after
each urination; catheterization should, if possible, be
avoided. The bowels are moved on the second day. In-
ternal douches are not needed unless there be infaction.
The patient should be kept in bed two weeks, and heavy
work and sexual intercourse forbidden for three
months. "—(Stewart's Surgery.)
(c) The chief difference between the two operations,
is that in the recent condition denudation is unnecessary
(except for the possible trimming off of any ragged
edges of the wound).
3. The conditions which may be mistaken for preg-
nancy are, uterine fibroid, ascites, ovarian cyst (or
other tumor), fat, pseudocyesis, and subinvolution of
the uterus.
Pregnancy. — Positive signs of pregnancy: Hearing
the fetal heart sound; (2) active movement of the
fetus; (3) ballottementj (4) outlining the fetus in
whole or part by palpation; and (5) the umbilical or
funic souffle. Doubtful signs of pregnancy : (1) Pro-
gressive enlargement of the uterus; (2) Hegar's sign;
(3) Braxton Hick's sign; (4) uterine murmur; (5) ces-
sation of menstruation; (6) changes in the breasts;
(7) discoloration of the vagina and cervix; (8) pig-
mentation and striae; (9) morning sickness.
ONTARIO.
Further, in pregnancy the tumor is hard and does
not fluctuate, it is situated in the median line, the
cervix is soft, the rate of growth of the tumor and the
general condition of the patient's health may help in
arriving at a diagnosis.
Uterine fibroid. — Menstruation is irregular and some-
times very profuse; absence of the signs of pregnancy;
the tumor is nodular, firm, irregular in outline, and
while generally placed somewhat centrally is not in the
median line, and is not symmetrical; the rate of growth
is irregular, being, as a rule, slow, but sometimes ex-
tending over years.
Ascites. — Absence of the signs of pregnancy; the ab-
domen is distended, but the shape varies with the posi-
tion of the patient; on lying down there is bulging at
the sides, the tumor fluctuates, and percussion shows
dullness in the flanks, with resonance in the median
line, but the dullness varies with the position of the
patient.
Ovarian cyst. — Absence of the chief signs of preg-
nancy; there may be the characteristic facies. the tu-
mor is soft, fluctuating, is more to one side, and does
not show fetal signs.
Fat. — Absence of signs of pregnancy, also of fibroid,
or ascites.
Pseudocyesis. — The uterus is not enlarged, and the
administration of a general anesthetic causes the col-
lapse of the "tumor."
Subinvolution of uterus. — The uterus does not in-
crease in size, there is a leucorrhea, there is generally
pain in the back or ovarian region, there is a history of
irregular (and profuse) menstruation, and the signs of
pregnancy are absent.
4. Accidental hemorrhage is the hemorrhage which oc-
curs when a normally situated placenta separates (par-
tially or completely) from its uterine attachment. The
prognosis depends upon the recognition of the condition.
If there is an external flow of blood, and the condition
is recognized and treated promptly, the prognosis is
guardedly favorable; if there is no external flow of
blood, but the hemorrhage is concealed, the prognosis is
very grave, for the diagnosis may not be made suffi-
ciently early to allow of adequate treatment. In this
form, the maternal mortality is at least 50 per cent.,
and the fetal death rate is 90 per cent. Treatment:
"The chief indication is to evacuate the uterus as
speedily as possible, so that the uterine muscle will con-
tract and close the bleeding sinuses. If the bleeding
is slight no immediate intervention may be required ex-
937
MEDICAL RECORD.
cept to rupture the membranes. The patient should be
kept under close observation, and in bed. Chloride of
calcium, gr. xx every three hours, is useful by promot-
ing coagulability of the blood. A very tight abdominal
binder and an icebag upon the lower abdomen may help.
Generally in either variety of hemorrhage the cervix
should be dilated manually. After full dilatation the
delivery is rapidly completed by forceps or version, or
in dead or nonviable fetus by embryotomy. Firm com-
pression of the uterus is maintained manually by a
skilled assistant during delivery. Precautions should
be taken against postpartum hemorrhage. When the
cervix resists manual dilatation and immediate delivery
is urgently demanded, vaginal cesarean section may be
performed. The effects of blood loss are combated as
in other hemorrhages." — (Polak's Manual of Ob-
stetrics.)
5. In the first four or five days the discharge is
bloody in character, and is called the lochia rubra; it
consists of placental tissue, decidua, blood, epithelial
cells, mucus, and microorganisms. For the next two or
three days the discharge is serosanguinolent, and is
called the lochia serosa; then for two or three weeks or
until the endometrium is regenerated, the discharge be-
comes creamy, and contains fat, cholesterin, epithelial
cells and leucocytes ; during this period it is called lochia
alba. The discharge has a peculiar fleshy smell, some-
thing like fresh blood. Ordinarily the lochia continues
for from two and a half to five weeks. Suppression of
lochia may be due to infection or to obstruction of the
outflow. Prolonged continuance of the lochia may be
due to subinvolution of the uterus, posterior displace-
ments of the uterus, and retained secundines ; the condi-
tion is more common in multiparas than in primiparae.
STATE BOARD EXAMINATION QUESTIONS.
Medical Council of Canada.
ANATOMY.
1. Describe the urinary bladder, including its attach-
ments, its blood and nerve supply.
2. Describe the nasal fossae and adjoining air sinuses.
3. Give fully the location and relations of the spleen.
4. Describe accurately the origin, course, relations,
and terminations of a typical intercostal artery.
5. Describe the radiocarpal joint, including bones, lig-
aments, synovial membrane, movements, and relations.
6. Give fully the relations of the trachea.
938
MEDICAL COUNCIL OF CANADA.
PHYSIOLOGY.
1. Describe the mechanism which brings about the re-
flex secretion of submaxillary saliva. What are the histo-
logical differences between an active and a resting sali-
vary gland?
2. Describe the effect of fatigue upon the contraction
of skeletal muscle, drawing muscle curves to elucidate
your answer. Discuss the cause of muscular fatigue.
3. How is blood pressure measured in the human be-
ing? Explain by what means general blood pressure
may be raised and lowered, and also how local blood
pressure may be altered.
4. Describe the structure of the skin. Explain how
the different sensory areas of the skin have been mapped
out. Trace the pathway of the different nerve impulses
from the skin areas to the cerebral and cerebellar cor-
tex.
5. Distinguish the different kinds of white blood cells
and specify their function.
6. What changes does the uterus undergo during men-
struation?
PATHOLOGY AND BACTERIOLOGY.
1. What is meant by agglutinins, precipitins, opson-
ins, and anaphylaxis?
2. What do you understand by edema, anasarca, as-
cites? • What are the causes of these conditions?
3. Describe fully the morbid changes in the lungs in
(a) acute lobar pneumonia, and in (b) acute lobular
pneumonia.
4. Give the pathological-anatomical forms of acute
endocarditis, their situation, and their pathogenesis.
5. Write what you know of the Bacillus diphtheria.
6. What are "carriers"? Mention the diseases that
are admittedly due to the influence of the "carrier"?
HYGIENE AND PUBLIC HEALTH.
1. Define (a) Terminal disinfection; concurrent dis-
infection; (6) Which is the more important, and why?
(c) Describe in outline one good method for each; (d)
In what diseases have (i) terminal disinfection, (ii)
concurrent disinfection, been proved of value in reduc-
ing their spread?
2. (a) Describe clearly the different methods through
which insects transmit disease, with a specific example
of each method; (b) Suggest the best method to get rid
of (i) flies, and (ii) malaria mosquitoes.
3. (a) Define the term "carrier"; (b) Mention those
'939
MEDICAL RECORD.
diseases which are spread by carriers; (c) Describe
proper measures for control of carriers.
4. In case of impure water not corrected by municipal
authorities describe different household measures which
may be taken to successfully purify the water for con-
sumption.
5. State what you know of the cause, mode of trans-
mission, and means of prevention of the following dis-
eases: whooping cough, diphtheria, typhoid, typhus fe-
ver, tetanus, acute anterior poliomyelitis, ophthalmia
neonatorum, smallpox.
6. (a) What ill effects may be produced by (i) cold,
(ii) heat? (b) What preventive measures may be used
against them? (c) What ill effects may be produced by
dampness in a house? (d) What measures may be used
to prevent such dampness?
OBSTETRICS AND GYNECOLOGY.
1. Abortion: (a) Define the terms "threatened," "in-
evitable" "complete" and "incomplete" abortion; (b)
Describe briefly how you would deal with each of these
conditions.
2. What symptoms would lead you to suspect ectopic
gestation? How would you diagnose the condition?
3. Forceps in occipotoposterior position of the head:
Describe application and extraction.
4. What are the indications and the means of induc-
ing labor and immediate delivery?
5. Fibroids of the uterus: Classify as to localization
and give the symptoms of each class.
6. Discuss the causes and treatment of dysmenorrhea
in the virgin.
SURGERY.
1. Fracture of patella: Causes, symptoms, and modes
of treatment.
2. Dislocation of the Hip Joint : Varieties, symptoms
(clinical features) , and modes of reduction.
3. Carbuncle: Definition, pathology, symptoms, diag-
nosis, complications, and treatment.
4. The pathology and symptoms of tuberculosis of the
kidney: Outline your method of examination, with find-
ings, leading to a diagnosis.
5. Cholelithiasis : Diagnosis, complications, and treat-
ment in detail.
6. Give the history, clinical features, and treatment
in detail of a typical case of middle meningeal hemor-
rhage.
940
MEDICAL COUNCIL OF CANADA.
MEDICINE.
1. Discuss the important points in the differential di-
agnosis of cardiac dilatation and pericardial effusion.
2. How would you establish a differential diagnosis
between (a) acute lobar pneumonia, (b) congestion
(active) of the lungs, (c) acute pneumonic phthisis?
3. Write what you know about (a) the etiology and
(6) the diagnosis of epidemic cerebrospinal meningitis.
4. How would you treat a case of typhoid fever com-
plicated by intestinal hemorrhage, giving (a) the hygi-
enic, (b) the dietetic, and (c) the medicinal treatment?
5. Describe the method of giving salvarsan. Discuss
the dosage of the remedy, pointing out the indications
for its use.
6. A woman aged fifty-one years was seen in a rest-
less state, with twitching of muscles. She was slow in
answering questions or obeying orders. Her speech was
rather thick. There was no fever. The pulse was regu-
lar and of high tension (200+) . There was no cough,
cyanosis, nor edema. The pupils were equal with nor-
mal reflexes, while the tendon reflexes were greatly
exaggerated. There was no paralysis. The history
showed that the patient had suffered recently severe
headaches with frequent vomiting. Recently also
her strength had failed and she occasionally com-
plained of severe precordial pain, yet no pericardial
signs were made out. The urine had been free from al-
bumin but now ^contained blood. The Wassermann was
negative. Kermg and Babinsky signs were absent. Dis-
cuss the diagnosis and point out further clinical meth-
ods useful in establishing a diagnosis.
ANSWERS TO STATE BOARD EXAMINATION
QUESTIONS.
Medical Council of Canada.
anatomy.
1. The urinary bladder is a hollow musculo-mem-
branous viscus, situated chiefly in the pelvic cavity,
but when fully distended it extends into the abdominal
cavity. It lies behind the pubes and the rectum in the
male, and between the pubes and cervix uteri and
upper part of the vagina in the female. On the inside,
three openings are observed, the two ureteral openings
behind and that of the urethra in front; the space be-
tween these openings is called the trigone. The peri-
toneum covers the superior surface of the bladder and
941
MEDICAL RECORD.
extends for a variable distance over the anterior sur-
face; that part of the anterior surface which is not
covered by peritoneum is called the prevesical space of
Retzius. Most of the posterior surface is covered by
peritoneum. The attachments are a number of liga-
ments, five true and five false ones; the true ones are
two anterior or puboprostatic, from the back of the
os pubis to the front of the neck of the bladder; two
lateral, which are expansions of the pelvic fascia; and
the urachus, extending between the summit of the blad-
der and the umbilicus. The false ligaments are peri-
toneal folds; two posterior, from the back of the blad-
der to the rectum in the male and the uterus in the
female; two lateral, from the iliac fossae to the sides
of the bladder; and one superior, from the summit of
the bladder to the umbilicus. In addition, the bladder
is attached to the ureters, urethra, and rectum; also
to the prostate in the male, and to uterus and vagina
in the female. The arteries are the superior, middle,
and inferior vesical, and branches from the obturator
and sciatic, all from the internal iliac; in the female,
there are additional branches from the uterine and
vaginal arteries. The veins form plexuses around the
neck, base, and sides of the bladder, and end in the
internal iliac vein. The nerves are derived from the
hypogastric plexus of the sympathetic, and from the
third and fourth sacral nerves.
2. The nasal fossse are two irregular cavities situ-
ated in the middle of the face. They open in front by
the anterior nares, and behind into the nasopharynx by
the posterior nares. They are separated by the sep-
tum, which is generally deviated to one side. The mu-
cous membrane lining the nasal f ossae is called the
Schneiderian membrane. Each fossa has a roof, a
floor, an inner and an outer wall. From the outer wall
there project into each fossa the superior and middle
turbinated processes of the ethmoid bone, and the in-
ferior turbinated bone; these bony processes divide
each fossa into a superior, middle, and inferior meatus.
The nasal fossae communicate with the sphenoidal sinus,
the anterior and posterior ethmoidal cells, the frontal
sinus, and the antrum of Highmore.
The roof is formed by the ethmoid, nasal, frontal,
sphenoid, vomer, and palate bones; the floor is formed
by the maxillary and palate bones; the outer wall, by
the nasal, maxillary, lacrymal, ethmoid, inferior tur-
binated, palate, and sphenoid bones ; the inner wall, or
septum, by the ethmoid, vomer, frontal, nasal, sphenoid,
maxillary and palate bones, and septal cartilage.
942
MEDICAL COUNCIL OF CANADA.
The antrum of Highmore is situated in the body of
the superior maxillary bone, is pyramidal in shape, its
apex being at the malar process and its base forming
the external wall of the nasal cavity. Above it is
covered by the orbital surface of the maxilla, and below
by the alveolar border. Its walls are lined with muco-
periosteum which is continuous with the mucous mem-
brane of the middle meatus of the nose.
The frontal sinus is found between the two layers
of bone in the vertical part of the frontal bone. The
two sinuses are separated by a thin septum. The
cavity is lined with mucoperiosteum which is continu-
ous with the middle meatus of the nose.
The ethmoidal cells are situated in the lateral mass
of the ethmoid bone; the anterior cells open into the
middle meatus of the nose, and the posterior cells into
the superior meatus.
The sphenoidal sinuses are situated in the body of
the sphenoid bone immediately below the fossa which
lodges the pituitary body; they are separated by a
septum, and open into the superior meatus of the nose.
3. The spleen is situated in the upper and left side
of the abdominal cavity; it lies far back in the left
hypochondriac region, behind the stomach. It lies
above the left kidney and the splenic flexure of the
colon. It is surrounded by peritoneum except at the
hilum. Above and externally are the peritoneum, dia-
phragm, left ninth, tenth and eleventh ribs, left lung
and pleura, and posterior thoracic muscles. Below, the
splenic flexure of the colon, costo-colic ligament, and
(sometimes) the tail of the pancreas. Internally, the
stomach (posterior surface of the fundus), left kidney
and suprarenal capsule, and tail of the pancreas.
4. Intercostal arteries, "(a) The vertebral por-
tions of the intercostal arteries, arising in pairs from
the posterior part of the thoracic aorta, pass around
the vertebras — the right being covered by thoracic duct,
vena azygos major, pleura, lung, esophagus — the left,
by vena azygos minor, left superior intercostal vein,
third vena azygos, pleura, lung. The arteries here
divide into posterior or dorsal, and anterior or inter-
costal branches, (b) The intercostal portions run for-
ward and obliquely upward in the intercosal space
to the lower border of the superior rib, and divide near
the angle of the rib into the upper (larger) and lower
(smaller) branches — the former, to run in the groove
along the lower border of the upper rib and anasto-
mose with the superior intercostal branch of the inter-
nal mammary in the upper spaces, and of the musculo-
943
MEDICAL RECORD.
phrenic in the lower — the latter, to run along the up-
per border of the lower rib and anastomose with the
inferior branch of the internal mammary in the upper
spaces, and of the musculophrenic in the lower. At
first these arteries lie between pleurae, lungs, endo-
thoracic fascia, and infracostals internally — and exter-
nal intercostal muscles externally — then (from the
angles of the ribs) between the external and internal
intercostal muscles. The sympathetic nerve crosses
them opposite the head of the ribs. The intercostal
vein lies above and the intercostal nerve below the in-
tercostal arteries — except in the upper spaces." — (Bick-
ham's Operative Surgery.)
5. The radiocarpal joint is formed by the under
surface of the radius and a triangular plate of fibro-
cartilage, which together form a shallow socket for the
scaphoid, semilunar, and cuneiform bones. The ulna
does not take part in this articulation. The ligaments
are the anterior, posterior, internal and external. The
anterior ligament extends from the lower border of the
inferior extremity of the radius, and is inserted below
into the scaphoid, semilunar, and cuneiform bones. The
posterior ligament arises from the posterior aspect of
the lower end of the radius and is inserted into the
scaphoid, semilunar, and cuneiform bones. The exter-
nal lateral ligament extends from the tip of the styloid
process of the radius to the scaphoid bone. The inter-
nal lateral ligament extends from the styloid process
of the ulna to the cuneiform and pisiform bones. These
ligaments are continuous with each other, and so form
a capsule around the joint. The synovial membrane
lines the deep surfaces of the ligaments, it is loose and
lax and presents numerous folds. The movements are
those of flexion, extension, abduction, adduction, and
circumduction. Anterior to the joint are the flexor
carpi radialis, palmaris longus, flexor carpi ulnaris,
flexor sublimis digitorum, flexor profundus digitorum,
and flexor longus pollicis. Posteriorly , extensor carpi
radialis (-longior and brevior) , extensor communis digi-
torum, extensor indicis, extensor minimi digiti, exten-
sor carpi ulnaris. On the radial ^ side, the supinator
longus, extensor ossis metacarpi pollicis , extensor
brevis pollicis, extensor longus pollicis.
6. Relations of the trachea. In the neck. An-
teriorly, the skin, superficial fascia, anterior jugular
veins, inferior thyroid veins, thyroidea ima artery,
sternohyoid and sternothyroid muscles, isthmus of
thyroid gland, thymus or its remains. Posteriorly, the
esophagus. Laterally, the lateral lobes of the thyroid
944
MEDICAL COUNCIL OF CANADA.
gland, inferior thyroid arteries, recurrent laryngeal
nerves, and the sheath containing the common carotid
artery, internal jugular vein and pneumogastric nerve.
In the thorax. Anteriorly, upper part of sternum,
sternohyoid and sternothyroid muscles, thymus or its
remains, left innomimate vein, transverse part of the
arch of the aorta, innominate artery, left common caro-
tid artery, deep cardiac plexus, and left recurrent
laryngeal nerve. Posteriorly, the esophagus. Later-
ally, the pleura?, pneumogastric nerves.
PHYSIOLOGY.
1. The salivary glands have a double nerve supply,
from the sympathetic and from the cranial nerves. The
submaxillary gland receives its sympathetic fibers from
branches of the cervical sympathetic which ramify on
the facial artery, and its cranial fibers from the chorda
tympani nerve. These fibers run for a short time with
the lingual nerve, and then leave it as a slender nerve
which, reaching Wharton's duct, runs along this to the
gland. The fibers are connected in the hilus of the
gland with nerve cells. A small collection of nerve-
cells — the submaxillary ganglion— is found in the tri-
angle between the chorda tympani nerve, lingual nerve,
and duct. Different effects are obtained according as the
chorda tympani or the sympathetic fibers are stimulated.
Stimulation of the chorda tympani in the dog gives rise to
an active dilatation of the vessels of the gland, and a
copious watery secretion containing only a small amount
of mucin and formed elements. Stimulation of the sym-
pathetic causes constriction of the vessels and a
scanty flow of very thick viscid saliva, rich in mucin
and formed elements. The changes that occur in the
cells are much more marked under sympathetic than
under chorda stimulation. In consequence of the dif-
ferences in the action of these two sets of nerve fibers,
they have been supposed to have two distinct func-
tions. The chorda fibers are vasodilator and secreto-
motor of water; the sympathetic fibers are vasocon-
strictor and secretomotor of organic matter. Accord-
ing to Langley the action of the gland fibers of the
sympathetic and the chorda tympani nerve are prob-
ably identical, the differences in the saliva obtained by
the stimulation of the two sets of nerves being con-
ditioned by the concomitant vascular changes. Against
this view may be urged the fact that while atropine
paralyzes the secretory fibers of the chorda tympani,
it has practically no effect on those derived from the
sympathetic. The center for the secretion of saliva
945
MEDICAL RECORD.
is located in the medulla. In the resting condition of
the gland, the acini are seen to be distended with large
cells having clear hyaline contents, so close together
that no lumen can be seen. The nuclei situated at the
outer border of the cells, near the basement membrane,
appear shriveled, with irregular margins. In a gland
that has been actively secreting for some time, the
acini and the cells are smaller, the lumen quite dis-
tinct, and the nuclei round and swollen. The section
appears darker from the fact that the cells have taken
up the staining fluid more readily. — (From Starling's
Elements of Human Physiology.)
2. Effect o.f fatigue upon the contraction of skeletal
muscle: "At first the contractions improve, each being
a little higher than the preceding; this is known as the
beneficial effect of contraction, and the graphic record
is called a staircase. Then the contractions get less
and less. But what is most noticeable is that the curves
are much more prolonged ; the latent period gets longer ;
and the period of relaxation gets very much longer;
this condition is known as contracture, so that the
original base line is not reached by the time the next
stimulus .arrives. In the last stages of fatigue, con-
tracture passes off. Contracture is often absent in
fatigue of mammalian muscle. Cause of muscular
fatigue: This is due to the consumption of the sub-
stances available for the supply of energy in the
muscle, but more particularly to the accumulation of
waste products of contraction; of these sarcolactic acid
is an important one. Fatigue may be artificially in-
duced in a muscle by feeding it with a weak solution
of lactic acid, and then removed by washing out the
muscle with salt solution containing a minute trace of
an alkali. If the muscle is left to itself in the body,
the blood stream washes away the accumulation of acid
products, and fatigue passes off." — (Halliburton's
Physiology.)
3. Blood pressure is estimated by means of a sphyg-
momanometer.
"The individual whose blood pressure is about to be
recorded should be placed in such a position that his
heart, the artery the blood pressure of which is to be
determined, and the manometer are at the same level.
It is usual to record the pressure in the brachial artery.
The india-rubber bag of the instrument should be
wrapped around the bared arm, the metal covering of
the bag should then be adjusted, and firmly strapped
in position. The india-rubber tube leading from the
bag is then adjusted to the proximal limb of the U-
946
MEDICAL COUNCIL OF CANADA.
shaped manometer which contains mercury. The ex-
perimenter places the index finger of his left hand over
the radial pulse of the subject, and with his right hand
he compresses the syringe and so drives air into the
india-rubber tube and the india-rubber bag around the
individual's arm. The pressure of the air in the bag
around the arm is recorded by movement of the mer-
cury from the proximal to the distal limb of the mano-
meter. The operator keeps on pressing the syringe
until oscillatory movements are seen at the surface
of the mercury in the distal limb of the manometer;
the mean point of maximum oscillations registers the
diastolic pressure. If the pressure in the bag is still
further increased, the oscillations diminish in ampli-
tude and finally disappear, and at this point the pulse
can no longer be felt at the wrist. The height of the
mercury supported then registers the amount of sys-
tolic pressure. It will then be noted that the mercury
has descended in the proximal limb of the manometer,
and has ascended in the distal limb of the manometer;
the difference between the two mercurial levels will be
the blood pressure of the brachial artery. The normal
systolic pressure in man is about 120 mm. Hg, and the
diastolic pressure about 100 mm. Hg. In women the
pressures are about 10 per cent. less. In children the
systolic pressure may be as low as 90 mm. Hg, with a
diastolic pressure of about 80 mm. Hg." — (R. Hutchi-
son.)
General blood pressure may be raised by increase in
the rate and power of the heart beat, increase in the
contraction of the arterioles, or increase in the volume
of the blood. It may be lowered by the opposite con-
ditions.
Local blood pressure may be altered by the increase
or decrease in the size of the arterioles in areas other
than the one under investigation.
4. "The skin is composed of a deep portion, the corium,
derma, or true skin; and of a superficial portion, the
epidermis or cuticle.
The corium makes up by far the greater part of the
skin, and within it are the perspiratory glands, the
sebaceous glands, the hairs, together with both blood
and lymphatic vessels. The upper surface, where it
joins the epidermis, is irregular, being composed of ele-
vations — papillae — and intervening depressions. In
some of these papillae are the tactile corpuscles, in
which nerve-fibers end.
The epidermis is made up of a deep and a superficial
layer. The deep layer (rete mucosum or rete Mal-
947
MEDICAL RECORD.
pighii) covers the papilla of the corium and fills the
depressions between them. It is composed of cells,
round or of different shapes due to pressure of con-
tiguous cells, the material of which they are composed
yielding readily. It is in this layer that the pigment
is deposited which characterizes the dark races. The
superficial layer of the epidermis is composed of ceils
which are flat and dry or horny." — (Raymond's Physi-
ology.)
"The surface of the skin appears to be divided into
innumerable small sensory areas, separated by inter-
vals which are not responsive to those stimuli which
are only just above liminal intensity. Each of these
small areas responds to a specific adequate stimulus,
such as pressure, heat, cold, pain. No doubt each area
contains a special sensory end organ. The pressure
spots, heat spots, cold spots, and pain spots are inter-
mingled, but in some regions one variety predominates,
in other regions another variety predominates. The
distribution of these spots is by no means uniform, . . .
The responsiveness of the skin to external stimuli is
investigated by esthesiometers. Pressure sense is es-
timated by little weights placed upon the skin. Heat
and cold sense is investigated by the use of hollow
pencil-shaped rods containing hot and cold water
respectively, or by using minute drops of water at dif-
ferent temperatures as stimuli. Pain sense is investi-
gated by the use of fine needles. . . . The finer un-
crossed tactile sensations pass into the cord at the
posterior root zone, and travel up in the column of
Burdach and column of Goll. For the most part the
impulses from the leg pass up the column of Goll, and
those from the arm up the column of Burdach. . . .
The coarser tactile sensations, along with the sensa-
tions of heat, cold, and pain, travel into the posterior
gray cornua, thence into the central gray matter, cross-
ing the cord at the anterior gray commissure. The
fibers which convey these impulses appear to make cell
stations at the base of the opposite posterior cornua,
and from some of these posterior cornual cells new
fibers arise which conduct these impulses up the spina]
cord through the spinothalamic tract. These impulses
eventually arrive at the optic thalamus, and by the
thalamocortical fibers gain the gray matter of the
cerebral cortex. The nerve fibers from the spinal cord,
which convey the impulses which eventually give rise
to sensations of heat, cold, and pain, travel up through
the medulla, external to the olivary body, and in this
region they mix with the fibers coming up from the
948
MEDICAL COUNCIL OF CANADA.
tract of Gowers. Both these sets of fibers eventually
reach the optic thalamus." — (From Lyle's Manual of
Physiology.)
5. Varieties of white blood cells: (1) Small mono
nuclear leucocytes or lymphocytes , which are a little
larger than red blood cells and consist of a narrow zone
of protoplasm around a relatively large and circulai
nucleus; both nucleus and protoplasm are basophilic;
this variety is about 25 per cent, of the total colorless
corpuscles. (2) Large mononuclear leucocytes, which
consist of a relatively small oval nucleus in the center
of basophilic protoplasm; the diameter is about 12 tc
20 microns, and they constitute about 1 per cent, of
total white corpuscles. (3) Transitional leucocytes
which consist of a smaller cell body than the last, the
protoplasm is basophilic and granular, and the nucleus
is oval or lobed; they make up about 2 to 4 per cent
of the white cells. (4) Polynuclear leucocytes, which
make up the chief mass of white cells, being about 70
per cent, of the whole; they are about 9 to 12 microns
m diameter, and have several nuclei, of differenl
shapes, which are basophilic and granular; the proto-
plasm is finely granular, and stains with neutral staim
and also faintly with acid (eosin) stains. (5) Eosino
phile leucocytes, which are usually about 12 to 15
microns in diameter and contain two or three nuclei oi
one nucleus of irregular shape; the protoplasm is
granular, and readily stains with eosin or other acid
stains; they are about 2 per cent, of the white cor-
puscles.
Their functions are (1) to serve as a protection
to the body from the incursions of pathogenic micro
organisms; (2) they take some part in the process of
the coagulation of the blood; (3) they aid in the ab-
sorption of fats and peptones from the intestine, and
(4) they help to maintain the proper proteid content
of the blood plasma.
6. Changes in the uterus during menstruation. "The
endometrium, in the four or five days preceding the
flow, becomes rapidly thicker and its superficial layers
are congested with blood and, in places, small collec-
tions of blood may be noticed. Opinions differ very
much as to the change undergone by this thickened
membrane during the flow. According to some authors
most of the membrane is thrown off and the blood es-
capes from the denuded surface mixed with pieces of
the membrane. According to others, no material
destruction of the membrane occurs, the blood that
escapes being due to small capillary extravasations or
949
MEDICAL RECORD.
perhaps mainly to a process of diapedesis. It would
seem that the amount of destruction of the endometrium
must be subject to individual variations. After the
cessation of the flow the mucous membrane is rapidly
repaired by regenerative changes in the tissues; the
surface epithelium, if denuded, is replaced by prolifera
tion of the cells lining the uterine glands and the thick-
ened, edematous condition of the membrane rapidly
subsides during a period of six or seven days. The
mucous membrane of the uterus may be said to exhibit
a constantly recurring menstrual cycle which falls into
four periods: (1) Period of growth in the few (five)
days preceding menstruation, characterized by a rapid
increase in the stroma, blood vessels, epithelium, etc.,
of the membrane. (2) The menstruation or period of
degeneration (four days) during which the capillary
hemorrhage takes place and the epithelium suffers de-
generative changes and is cast off more or less. (3)
The period of regeneration (seven days) during which
the mucous membrane returns to normal size. (4) The
period of rest (twelve days) during which the endo-
metrium remains in a quiescent condition." — (Howell's
Text-book of Physiology.)
PATHOLOGY AND BACTERIOLOGY.
1. Agglutinins are antibodies which cause certain
bacteria, when suspended in a fluid, to form clumps.
Precipitins are specific antibodies which develop in
the serum of animals inoculated with bacteria and
which produce a precipitate in a clear solution of the
particular culture filtrate against which the animal
has been immunized.
Opsonins are substances in normal and immune sera
which act upon bacteria and render them more readily
available for being ingested by phagocytes.
Anaphylaxis is a condition of hypersusceptibility in-
duced by the injection of a serum. It is (to some ex-
tent) the opposite of prophylaxis, and in place of
rendering the person injected immune the serum renders
him particularly susceptible.
2. Edema is an excess of transuded fluid in the in-
terstices of the tissues. When such fluid infiltrates
the subcutaneous tissues the condition is called ana-
sarca. A collection of such fluid within the abdominal
cavity is called ascites.
Six factors enter into the production of edema,
usually more than one acting at a time, viz., positive
pressure in the vessels (in proportion as it rises), per-
meability of the vessel wall, osmosis from excess of
950
MEDICAL COUNCIL OF CANADA.
salts outside the vessel as seen in the action of a saline
laxative, selective action of the endothelium, variations
in the blood, plasma, and obstructed onflow in the
lymph channels.
3. Acute lobar pneumonia. "It is convenient to
describe four stages, those, namely, of (1) hyperemia
or engorgement, (2) red hepatization, (3) gray hepati-
zation, and (4) resolution. First stage or splenization. —
The lung is injected, dark red, and heavy, and pits
under the finger; on pressure, there exudes a frothy
serum tinged with blood and slightly aerated. The
lung still floats in water. Second stage or red hepatiza-
tion. — The part involved is solid and friable, presents
a granular or red granite appearance, and sinks in
water. The alveoli are filled with a coagulated exuda-
tion, which shows under the microscope fibrin, leuco-
cytes, red corpuscles, proliferated alveolar epithelium,
and pneumococci. Third stage or gray hepatization. —
The lobe has now the appearance of gray granite, the
lung substance is softer and more friable; on pressure,
a dirty purulent fluid exudes. The gray appearance is
due to four factors: (1) Decolorization of the red blood
corpuscles; (2) obliteration of the alveolar blood ves-
sels from pressure; (3) fatty degeneration of the
coagulated material; (4) great infiltration of leuco-
cytes. A more advanced stage, in which the lung tissue
is bathed in purulent fluid, is known as purulent in-
filtration. It is probably inconsistent with life. Fourth
stage or resolution. — Resolution of the inflammatory
exudation is brought about principally by absorption
(autolysis), but partly by liquefaction and expectora-
tion. Pneumonia may affect a lobe, or the whole of a
lung, or it may attack both lungs. Double pneumonia
occurs in about 10 per cent, of cases. Different parts
of the same lung may at the same time show different
stages. There is always some degree of pleural in-
flammation over the affected area. Modern enlarge-
ment of the spleen is very common." — (Wheeler and
Jack's Practice of Medicine.)
Acute lobular pneumonia. "The disease affects
both lungs, and begins in the terminal bronchioles,
spreading thence to the infundibula and alveoli. The
consolidated patches have therefore a lobular arrange-
ment, but if many adjacent lobules are affected the con-
solidation may be almost lobar. The bronchioles are
inflamed and frequently plugged with mucus, and their
walls and the surrounding interstitial tissue are infil-
trated with small cells. The walls of the air vesicles
in the consolidated area are congested, their epithelium
951
MEDICAL RECORD.
is swollen, and their lumen is filled with proliferated
epithelial cells, leucocytes, and a mucous or mucopuru-
lent (not fibrinous) exudate. Many lobules are col-
lapsed, but not inflamed, from plugging of the
oronchioles. When cut into, the small consolidated
areas are seen to be conical in shape, with their bases
towards the pleura, reddish in color, with indefinite
margins, and separated from each other by crepitant
lung tissue. Adjacent lobules may be emphysematous
(compensatory emphysema). The bluish-gray col-
lapsed areas are most numerous in the lower lobes." —
(Wheeler and Jack's Handbook of Medicine.)
4. Endocarditis.
q» i f Septic
Types: I. Acute {SffifSant or Ulcerative (gggS
II. Chronic.
The difference between simple and malignant endo-
carditis is probably one of degree rather than of kind.
Etiology: Simple endocarditis is associated with
rheumatism or scarlet fever. Malignant endocarditis is
also associated wfth rheumatism, scarlet fever, and also
with pneumonia or septic processes. Micrococci are
often found. Chronic endocarditis may follow an acute
endocarditis, or may be the result of syphilis, old age,
high arterial tension, gout.
Morbid anatomy: In the simple form there will be
found a cloudiness, followed by edematous thickening
of the valvular endocardium; superficial erosions, and
the formation of small granulations; deposits of layers
of fibrin and corpuscles from the blood, the whole proc-
ess resulting in the formation of small warty vegeta-
tions. These vegetations are most marked at a slight
distance from the free borders of the valves — i.e. those
parts which come into opposition during closure. In
course of time they are transformed into fibrous
tissue. According to Poynton and Paine the infective
organisms are conveyed to the base of the valves by the
capillaries, and thence pass to the subendothelial tissues
by the minute nutrient channels in the valvular sub-
stance ; others hold that the organisms are derived from
the blood circulating over the surface of the valves.
In the malignant form the initial changes are similar,
but there are some important differences, inasmuch as
ulcerations may completely replace the vegetations.
The differences are: (1) The vegetations when present
are larger and fungating. (2) The underlying tissues
are necrotic and show loss of substance and round-
celled infiltration. (3) They contain masses of micro-
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cocci, while in simple endocarditis the organisms are
scanty. The two forms cannot be distinguished by the
organisms producing them; either simple or malignant
endocarditis may arise from a pyogenic infection. (4)
When the vegetations become detached they form septic
emboli, giving rise to metastatic abscesses. (5) The
ulcerative process causes great destruction of the
valves, and may even lead to perforation of the curtains.
(6) The subsequent or permanent changes in the valves,
if the patient survive, are much more marked. (7) If
the vegetation touches the mural endocardium as it
flaps to and fro, the part touched becomes affected by
contact.
As regards the side of the heart most affected — Con-
genital endocarditis attacks the right side of the heart
(but note that many congenital cardiac lesions are due
not to endocarditis, but to developmental faults) ; sim-
ple endocarditis attacks the left only; the malignant at-
tacks both sides, though the left is much more impli-
cated than the right side.
The vegetations are upon that side of the valve op-
posed to the blood-stream — viz., at the aortic valve the
vegetations project into the ventricle, at the mitral
valve into the auricle.
As in pericarditis, the myocardium almost always
shares in the inflammatory affection. — (Wheeler and
Jack's Practice of Medicine.)
5. The characteristics of the bacillus of diphtheria:
The bacilli are from 2 to 6 microns in length and from
0.2 to 1.0 micron in breadth, are slightly curved, and
often have clubbed and rounded ends; occur either
singly or in pairs, or in irregular groups, but do not
form chains; they have no flagella, are non-motile, and
aerobic; they are noted for their pleomorphism ; they
do not stain uniformly, but stain well by Gram's meth-
od and very beautifully with Loeffler's alkaline-methy-
lene blue; they grow well on blood serum, slowly on
gelatin, and with difficulty on potato.
6. Carriers are persons who, though apparently well,
harbor within their bodies and distribute to their en-
vironment pathogenic bacteria. Diseases thus "car-
ried" are: Typhoid, diphtheria, meningitis, tetanus,
malignant edema, Asiatic cholera, dysentery, and per-
haps poliomyelitis and other diseases.
HYGIENE AND PUBLIC HEALTH.
1. By terminal disinfection is meant the disinfection
of a sick voom and its contents at the termination of a
disease. By concurrent disinfection is meant the dis-
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infection of discharges, and all infective matter all
through the course of a disease. Concurrent disinfec-
tion is by far the more important of the two, and the
more thoroughly this method is carried out the less
need there is for terminal disinfection. In diseases like
typhoid, scarlet fever, and tuberculosis, concurrent dis-
infection should be insisted upon, and also a terminal
disinfection. The latter may not always be necessary
in a disease like measles. Both methods have reduced
the spread of communicable diseases. Formaldehyde,
in the presence of heat and moisture, is a good general
terminal disinfectant. The formalin-permanganate
method is in common use. 500 c.c. of formalin and
250 grams of potassium permanganate are required
for each 1,000 cubic feet of air space. The perman-
ganate is placed in a pail with a wide top, the formalin
is poured on to the permanganate, and effervescence
results with production of heat. The pail should be
placed on a brick or other object to protect the floor
from the heat evolved. In concurrent disinfection, dif-
ferent materials require different disinfectants; but
in a general way chlorinated lime is a good disinfectant
for stools; carbolic acid for sputum; superheated steam
for linen.
2. Insects may carry disease by contact and by in-
fecting food; typhoid and tuberculosis may thus be
conveyed. Suctorial insects may also transfer in-
fective material from the sick to the well; thus typhus
fever may be spread by lice, and bubonic plague by
fleas from the rat. Certain mosquitos may also act
as intermediary hosts for pathogenic protozoa; malaria
and yellow fever may be conveyed in this way.
To get rid of flies. Accumulations of dirt and filth
must be removed or rendered distasteful to flies or
larvae by the use of lime, kerosene or cresol. Screens
are used to keep flies out of houses; garbage must be
disposed of in a proper manner; fly poisons such as
arsenic or corrosive sublimate may be employed; fly
traps are also useful; so, too, are fly papers.
To get rid of malarial mosquitos. All pools, stag-
nant water, or places where the anopheles may breed
should be removed. Mosquitos and larvae must be
destroyed as far as possible. Fumigation by means of
sulphur or pyrethrum will kill or stupefy the mos-
quitos, and in the latter case they can be swept up
and burnt.
3. A carrier is a person who harbors a pathogenic
microorganism but who shows no sign or symptom of
the disease. The folloiving diseases may be spread by
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carriers: Diphtheria, infantile paralysis, malaria,
meningitis, tetanus, typhoid, cholera, pneumonia, in-
fluenza, cholera.
The control of carriers is extremely difficult. Sani-
tary isolation may be enforced, and the carrier must be
made to exercise scrupulous and intelligent cleanliness,
and must not be allowed to handle food intended for
others. A "carrier" may be safely employed as a car-
penter, seamstress, or in some similar occupation with-
out danger to his fellows. In certain diseases, where it
is possible, autogenous vaccines may be of service,
In cases where treatment is unsuccessful or impossible
the carriers should be under the supervision of the
health authorities.
4. "Domestic water supply may be purified by sedi-
mentation, boiling, distillation, chemicals, or by filtra-
tion. By sedimentation it is possible to free the
water from its mechanical impurities, sand, dirt, etc.,
without, however, ' much affecting matters held in
solution. By boiling, all organic matter and germs are
destroyed; the taste of the water is, however, changed,
owing to expulsion of gases. By distillation, a chem-
ically pure water is gained, which may be made palat-
able by the addition of carbonic acid. By the addition
of chemicals to suspicious water — small doses of borax,
boracic acid, potassium permanganate, copper sulphate,
etc. — the organic matter may be rendered harmless;
but as those chemicals are not a desirable addition
to water, this method of purification is objectionable.
In ordinary households the boiling of waters is a good
precaution whenever the water supply is suspicious.
Distillation, provided the proper apparatus is at hand,
is the ideal method. Water may be purified of all, or
nearly all, of its impurities by filtration, the value of
the process depending upon the medium of filtering,
the efficiency of the filter, and the thoroughness of the
process. The materials used for filters are wool,
asbestos, sand, stone, porcelain, infusorial earth, carbide
of iron, charcoal, etc. Infusorial earth pressed in the
form of hollow tubes is used in the Berkefeld filters,
which are efficient, although needing frequent cleans-
ing. ,, — (Price's Epitome of Hygiene!)
5. Whooping cough is caused by the bacillus of
Bordet and Gengou. It is transmitted by the secretions
of the nose and mouth, droplet infection, by the use
of handkerchiefs, cups, toys, etc., also by domestic
animals. Prevention is effected by fourteen days isola-
tion of those who have been exposed to infection; the
patient must avoid contact with others; isolation and
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MEDICAL RECORD.
avoidance of infection are necessary. Vaccines have
been used.
Diphtheria is caused by the Bacillus diptherix. It
enters the body by the mouth or nose (occasionally
elsewhere), and is conveyed by contact, coughing, speak-
ing, fingers, toys, food, droplet infection, and by car-
riers. It may be prevented by isolation of cases and
carriers, by the injection of diphtheria antitoxin, dis-
infection of mouth and nose discharges and of toys,
cups, spoons, etc., used by the patient.
Typhoid is caused by the Bacillus typhosus. It enters
the body by the mouth, and is conveyed by food, fingers,
flies, carriers, and fomites. It may be prevented by
inoculations'; early diagnosis and isolation, with proper
disinfection of secretions arg necessary; proper water
supply, and suppression of flies are important factors
in the prevention of this disease.
Typhus is caused by an anerobic bacillus, described
by Plotz. It is transmitted by the body louse. It may
be prevented by cleanliness of person and clothing,
destruction of lice and nits; the patient's hair must be
clipped, and his clothing baked or steamed.
Tetanus is caused by the tetanus bacillus. It is
spread by soil, dust, flies, and is a wound complication.
Prevention consists of cleanliness, avoidance of wounds,
free opening of punctured and lacerated wounds with
removal of foreign matter. Excision of the wound may
be advisable; tetanus antitoxin is a specific.
Acute anterior poliomyelitis is caused by a filterable,
"ultramicroscopic" virus. It is transmitted by contact,
the virus leaving by the discharges of the nose and
mouth of one person and entering by the same route
in another; insects are also believed to transmit the
disease. Prevention is uncertain; isolation, cleanliness,
and destruction of insects may all be tried.
Ophthalmia neonatorum. It is caused by the gono-
coccus or some other pyogenic microorganism ; the secre-
tions of the mother contain the infecting agent, and
transmission may occur directly during parturition, or
indirectly by the fingers of physician or nurse, cloths,
instruments, etc. Prevention: Whenever there is the
possibility of infection, or in every case, wash the eye-
lids of the newborn child with clean warm water, and
drop on the cornea of each eye one drop of a 1 per
cent, solution of nitrate of silver, immediately after
birth.
Smallpox. The cause is unknown ; so, too, is the mode
of transmission. Prevention consists in vaccination,
and prompt isolation of patient.
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6. Cold may produce the following ill effects: Sense
of chilliness, paleness of the skin, shivering, numbness,
livid spots on skin, syncope, lassitude, languor, confu-
sion of senses, dulness of mind, slow or interrupted
respiration, small pulse, feeble and quick or irregular
heart-beat, coma, and death. Tissue metamorphosis is
rapid; more food (especially carbonaceous food) is
required; oxygenation of blood and elimination of
carbon dioxide are increased ; skin functions are reduced
to a minimum, and excretion of urine is increased.
Heat may produce the following ill effects: Kespira-
tions are lessened, elimination of water and C0 2 is
diminished, the heart's action is slowed, the appetite
and digestion are impaired, the nervous system is de-
pressed, the action of the kidneys is increased and that
of the lungs is diminished, less food is required, meta-
bolism is decreased, less urea is eliminated. Preventive
measures include the avoidance of too sudden change
from heat to cold, the protection of the body from cold
and draughts, the wearing of proper clothing, and the
protection of the extremities from cold. Attention
must be paid to the skin and the urine, a proper amount
of water must be drunk, alcohol should be avoided,
and food must be suitable in quality and quantity.
Probable effects of dampness: "Damp houses are
cold houses, damp walls are cold walls,' because damp
walls and moist air are good conductors of heat. In-
dividuals lose more body heat in damp houses; more
fuel is needed to warm such houses. Damp houses
favor chilling of the body surfaces, have a depressing
effect on the human organism, and decrease its resist-
ing powers. Damp houses favor development of moulds,
fungi, dry rot in wood, efflorescence and saltpetering
in masonry, and also favor insects and germ life within
the house. Damp houses cause the mildewing of
clothes, injure furniture, produce spots on walls, make
house cleaning difficult, heating expensive, interfere
with ventilation, and decrease the suitability of the
house as to comfort and shelter. Damp houses may
safely be regarded as predisposing causes of tuber-
culosis, bronchitis, pneumonia, nephritis, rheumatism,
and other diseases." — (Price's Epitome of Hygiene.)
To prevent dampness: "Perfect dryness of founda-
tion, walls, and roof, and exclusion of ground air, are
necessary conditions of house construction. The subsoil
around the site, and, if there is much damp, also below
it, should be drained, and, except where there is a rock
foundation, the walls should be embedded in concrete,
and under the whole house should be a layer of concrete
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MEDICAL RECORD.
6 inches thick, having on the top a layer 1 inch thick
of some impervious material, such as asphalt or cement.
In order to prevent damp rising from the ground a
damp-proof course should be inserted in the wall just
above the ground level. Perforated slabs of glazed
stoneware may be made to serve not only as a damp-
proof course, but to ventilate the space under the floor.
It is advisable to have a damp-proof course also where
the rain-gutter joins the parapet, and in chimney-stacks
just above the roof. Basement walls are liable to be-
come wet when in contact with a damp soil even when
there are drains and damp-proof courses. In this case
'a dry area' must be formed by digging out or by build-
ing a second thin wall outside and a few inches away
from the main wall, or by inserting slabs in a slanting
position between the soil and the house wall, or the
walls may be built hollow (with two damp courses)
and joined together with iron ties or bonding bricks,
or the hollow may be filled with asphalt. Walls ex-
posed to driving rain or sea spray may be coated with
slates, vitrified slabs, alkaline silicates, or cement; but
such coating should continue down to the 'footings/ and
should not be applied while the bricks are wet. The
walls of a newly built house are damp from the water
used in mixing the mortar, and also that absorbed by
the bricks. If salt water, sea sand, or refuse lime from
soap works, containing glycerin, has been used in the
mortar, it will never dry. Mortar should be composed
of good lime combined with clean sharp sand, free from
earthy matter (road scrapings or mold have sometimes
been used by unscrupulous builders), or with crushed
stone, slag, or well-burnt clay. Walls are sometimes
built of concrete made with cement. For internal
walls, where space is limited, coke-breeze with cement
has been used. The settling of the walls sometimes
breaks the drain passing underneath, if not properly
protected by concrete or by the formation of an arched
opening in the wall. It is usual to defer putting in
drains until after the building has been carried up,
with the view of allowing it to settle upon its founda-
tions. If there be no cellars the flooring ought to be
raised two feet above the ground, which should be
covered with cement and the space ventilated to pre-
vent growth of the fungus of 'dry rot/ Walls and ceil-
ings are usually covered with plaster, which should be
of good materials ('jerry* builders have been known
to use a mixture of lime and sifted mold or street refuse
for this purpose) . It should be finished with a smooth,
non-porous surface. If a room is not to be papered the
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walls should be coated with some form of cement 01
distemper, which sets hard and prevents percolation.
In cheaply built modern houses the inner walls are
often not carried up in brick beyond the first floor, and
above this height are continued by a frame of wood
filled in with lath and plaster." — (Aids to Sanitary
Science.)
OBSTETRICS AND GYNECOLOGY.
1. In threatened abortion there are slight pains or
hemorrhage which indicate that the uterus may empty
itself, but there is a fair prospect that this may be
prevented.
An abortion is inevitable when the signs and symp-
toms indicate that there is no method of preventing the
uterus from emptying itself.
A complete abortion is one in which both the ovum
and its membranes are cast off intact.
An incomplete abortion is one in which part of the
ovum or membranes is retained in the uterus.
In threatened abortion the woman should be put to
bed and her rectum should be emptied by an enema, a
suppository containing morphine may be administered;,
if the hemorrhage is more than moderate in amount a
vaginal tampon of sterile or iodoform gauze may be
indicated.
Inevitable abortion demands rest in bed, and tam-
ponade of the cervix and vagina; after the cervix is
dilated the ovum must be removed and the uterus thor-
oughly cleaned out. Aseptic technique is necessary, and
trauma and lacerations must be avoided.
In incomplete abortion the cervix must be dilated (if
necessary), the uterus thoroughly cleaned out, and an
intrauterine douche of sterile water given, a light
tampon of iodoform gauze is placed in the vagina; a
strip of gauze may be placed in the uterus in case of
sharp retroflexion to secure free drainage, and some-
times an intrauterine tampon will be necessary when
the hemorrhage persists or the uterus refuses to con-
• tract.
2. Ectopic gestation. Diagnosis: "When extra-
uterine pregnancy exists there are: (1) The general
and reflex symptoms of pregnancy; they have often
come on after an uncertain period of sterility; nausea
and vomiting appear aggravated. (2) Then comes a
disordered menstruation, especially metrorrhagia, ac-
companied with gushes of blood, and with pelvic pain
coincident with the above symptoms of pregnancy;
pains are often very severe, with marked tenderness
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MEDICAL RECORD.
within the pelvis ; such symptoms are highly suggestive.
(3) There is the presence of a pelvic tumor character-
ized as a tense cyst, sensitive to the touch, actively pul-
sating; this tumor has a steady and progressive
growth. In the first two months it has .the size of a
pigeon's egg; in the third month it has the size of a hen's
egg; in the fourth month it has the size of two
fists. (4) The os uteri is patulous; the uterus is dis-
placed, but is slightly enlarged and empty. (5) Symp-
toms No. 2 may be absent until the end of the third
month, when suddenly they become severe, with spas-
modic pains, followed by the general symptoms of col-
lapse. (6) Expulsion of the decidua, in part or whole.
Nos. 1 and 2 are presumptive signs; Nos. 3 and 4 are
probable signs; Nos. 5 and 6 are positive signs"—
(American Text Book of Obstetrics.)
3. Forceps in occipito-posterior positions: "The
blades are put in exactly as for cases where the occiput
has rotated anteriorly. But since the occiput is now
toward the sacrum, the extension will, of course, be
downward and backward over the perineum, instead of
upward toward the pubes; hence the handles of the in-
strument, at first lifted somewhat upward toward the
pubes to draw the occiput up to the edge of the per-
ineum, must, when the head emerges, be directed doivn-
ivard and backward, instead of toward the mons
veneris. A moment's reflection will show that the short
straight forceps (without any sacral curve) should be
used in these cases; for the said curve is only adapted
to follow the axis of the pelvic canal, but during back-
ward extension of the occiput over the perineum the
head departs from the axial line and goes in an almost
opposite direction. If the curved forceps were used,
the ends of the blades would impinge against the pubic
arch while the handles were being depressed in follow-
ing the movement of backward extension. Again, ow-
ing to the depth of the posterior pelvic wall being three
times as great as that of the anterior one, there is so
much the more difficulty in getting the occipital end of
the occipitomental diameter to escape over the edge of .
the perineum, hence greater danger of laceration, and
necessity for extra care that the occipital pole really
shall have cleared the perineum before extension is
attempted." — (King's Obstetrics.)
4. Conditions that justify the induction of premature
labor: (1) Certain pelvic deformities; (2) placenta
prasvia; (3) pernicious anemia; (4) toxemia of preg-
nancy; (5) habitual death of a fetus toward the end
of pregnancy; (6) hydatidiform mole; (7) habitually
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MEDICAL COUNCIL OF CANADA.
large fetal head. The methods that may be employed
are: Partial dilatation of the cervix and the introduc-
tion within the cervix (and vagina) of a tamponade of
sterile gauze; (2) dilatation of the cervix; (3) punc-
turing the membranes; (4) introduction of a soft rub-
ber bougie into the uterus; (5) intrauterine injection
of glycerin, water, or some other fluid.
5. Fibroids are classified as: (1) Interstitial or intra-
mural, when they are entirely in the muscular wall of
the uterus; (2) Subperitoneal or subserous, when they
bulge ontward beneath the peritoneum; (3) Submu-
cous, when they bulge into the uterine cavity.
The symptoms are: (1) Hemorrhage, the degree of
which depends upon the nearness of the tumor to the
endometrium or to the peritoneum; the nearer to the
uterine mucosa, the greater the hemorrhage, and the
nearer the tumor is to the peritoneum, the less the
hemorrhage. There is no relation between the degree
of hemorrhage and the size of the tumor. (2) Pressure
and traction may cause disturbances of rectum, bladder,
ureters, urethra, and uterus ; hence there may be tenes-
mus, diarrhea, frequency of urination, dysuria, reten-
tion of urine, uterine displacements, hydronephrosis,
and cystitis. Other symptoms are pain, leucorrhea,
anemia, and generally impaired health.
6. Causes of dysmenorrhea : Pelvic congestion, pelvic
inflammation, malnutrition, overwork, lack of develop-
ment, neuralgia, stenosis or obstruction of the cervix,
prolapse or displacement of the uterus.
Treatment should first of all be directed toward dis-
covering the cause and (if possible) removing it. Gen-
eral methods of treatment and hygiene are indicated;
advice should be given on such matters as rest, exercise,
proper diet, care of bowels and bladder, bathing, cloth-
ing, change of residence; massage, douches, tampons,
and electricity may prove of service. Innumerable
drugs have been recommended, such as apiol, bromides,
phenacetin, antipyrin, cannabis indica, viburnum pruni-
folium, amyl nitrite, and salicylates. Alcohol should
be avoided, if possible; so, too, should unnecessary local
examinations and applications.
SURGERY.
1. Fracture of the patella is caused by muscular
violence and by direct violence. "Fracture by direct
violence is often star-shaped, and the aponeurosis is
not torn, so that the fragments are not separated.
Signs of local injury, pain, and bruising are apparent.
Treatment consists in keeping the limb at rest on a
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MEDICAL RECORD.
back-splint and applying an ice-bag. Early passive
movement and massage are advisable.
"Fractures due to muscular violence are more com-
mon. They are always transverse ; the aponeurosis and
capsule on either side of the patella are torn, and the
fragments are separated. The patella is broken when
poised on the condyles in the semiflexed position. It is
then held down by the ligamentum patella?, and when
the quadriceps is suddenly contracted, as in a person
trying to regain the upright position, the patella snaps.
Signs: There is loss of the power of extension, sepa-
ration of the fragments, and pain, followed by distension
of the joint with blood, and synovitis. The aponeurosis
is torn at a different level to the fracture, and hangs
over between the fragments. The lower fragment is
tilted forwards. Treatment: The best method is open
operation, and wiring four or five days after the acci-
dent; for only by this means can bony union be ob-
tained. The obstacles to bony union, without open
operation, are that the tilting of the lower fragment
cannot be overcome in any other way; the aponeurosis
cannot be removed from between the fragments, nor
the blood-clot from the joint, except by slow absorption.
If no operation is done the union is fibrous, and the
fibrous bond will stretch unless the patient be con-
demned to a stiff knee for six to twelve months. A
working man is badly off with either a stiff knee for
that time or a stretched bond forever. The open opera-
tion must necessarily be aseptic. The knee may be
washed out with 1 in 40 carbolic or 1 in 2,000 bichloride
without injury, or sterilized saline solution may be
used. The joint is opened by a horseshoe incision, the
blood-clot is removed, the aponeurosis clipped away, the
bones drilled and fixed in accurate apposition with silver
wire, and the wound is closed without drainage. As
atrophy of the quadriceps occurs early, massage and
passive movements must be begun in ten days. The pa-
tient may go about on crutches in three weeks. Bony
union is firm in six weeks. Retentive apparatus is used
where operation is inadvisable or refused. This may
be plaster of Paris, but does not admit of massage,
Another plan is to use mole-skin plaster covering the
thigh, and kept fastened to the lower part of a back-
splint by elastic extension. Or poroplastic may be
moulded, one piece over the thigh, the other over the
leg, the upper piece being cut out to fit around the
upper part of the patella, and the lower to fit around
the lower part. These are bandaged firmly to the limb,
and fastened together on either side of the patella by
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Malgaigne's hooks, which are screwed up daily as they
become loose. At the end of six weeks the patient is
allowed up, but must wear a knee-splint to keep the
joint stiff for six to twelve months." — (Aids to Sur-
gery.)
2. Hip Joint Dislocations. — Varieties — Backward:
(1) On to the dorsum ilii; (2) on to the sciatic notch.
Forward: (3) On to the obturator foramen; (4) Onto
the pubis.
Dorsal dislocation: Head of femur lies on the dorsum
ilii, and can be felt in the buttock. The obturator in-
ternus is ruptured in most cases. The short rotator
muscles are lacerated. The trochanter lies well above
Nelaton's line and approximated to the anterior su-
perior iliac spine. The leg is shortened two to three
inches. The iliotibial band is relaxed. The leg is flexed,
adducted, and inverted. The femur crosses the lower
third of the opposite thigh. The toe rests on the op-
posite instep. A hollow exists in Scarpa's triangle.
Sciatic dislocation: Similar to the above, except in
the following: — The obturator internus tendon is intact
and lies over the neck of the femur, holding it down
in the sciatic notch. Shortening amounts only to one
inch or less. The axis of the femur crosses the opposite
knee. The great toe rests on the dorsum of the op^
posite great toe.
Treatment of the backward dislocations: Flex the
knee and thigh in position of adduction. Abduct the
thigh and evert simultaneously. Bring the leg down
straight. "Lift up, bend out, roll out."
Obturator dislocation: The head of the bone lies on
the obturator externus in the obturator foramen. The
abductor muscles are lacerated. The trochanter is ob-
scured, the iliotibial band is tense. The leg is length-
ened, the toes point forward and outward. Flexion,
abduction, and rotation outward are well marked. The
head of the femur is felt in the perineum. The capsule
is torn in its lower part. Pain referred to the distribu-
tion of the obturator nerve.
Public dislocation: Similar to the above except: The
femoral head is felt under Poupart's ligament. The leg
is shortened about one inch. Abduction and eversion
are more marked, the toes pointing outward.
Treatment of forward dislocations: Thigh is flexed
in a position of abduction. Adduct the thigh and then
invert it. Bring the thigh down straight. "Lift up,
bend in, roll in." — (From Groves' Synopsis of Surgery.)
3. Carbuncle is a localized inflammation of the sub-
cutaneous tissue, which has gone on to sloughing.
963
MEDICAL RECORD.
Staphylococci are the exciting cause ; diabetes, albumin-
uria, infective fevers, and lowered vitality are the pre-
disposing causes.
The disease begins as an infiltration of a patch of
subcutaneous tissue, which is hard, painful and tender,
and the skin over it red and hot. The infiltration may
extend till it is the size of a dinner-plate, and the in-
flammation ends in sloughing and suppuration, not only
of the subcutaneous tissues, but of small areas of the
skin over it, so that openings develop in the skin, and
allow of the exit of pus and sloughs. The openings
extend, the sloughs separate, and the wound heals by
granulation. The back is a common situation. Some-
times the face is affected, and there is then a danger
of thrombosis extending to the cavernous sinus and
producing pyemia.
Treatment: Anesthetize, scrape away the slough,
treat the surface with pure phenol, dress with antiseptic
gauze, and give the patient good food and tonics.
4. "Tuberculous disease of the kidney occurs in three
forms: 1. As part of general tuberculosis, and giving
rise to no special symptoms. 2. It may extend up-
wards from tuberculous disease of the bladder and affect
both kidneys. The mucous membrane of the ureters,
pelvis, and calyces, and finally the kidney itself, become
converted into tuberculous granulation tissue. The
kidneys become enlarged owing to hydronephrosis or
pyonephrosis, and a perinephric abscess may follow.
Death occurs from chronic toxemia or uremia. Treat-
ment is of little use. 3. Primary tuberculosis of the
kidney is unilateral. A focus of tubercle begins in the
cortex, caseates, and spreads to the pelvis, infecting it.
Pyonephrosis follows, and infection of the bladder may
succeed it. Perinephric suppuration may also occur.
The symptoms at first consist of aching pain in the
loin and frequent micturition, not improved by rest.
Hematuria comes on early and without apparent cause,
is not increased by movement or improved by rest. Pus
is usually present in acid urine, and the Bacillus tuber-
culosis may in some cases be detected. In the late stages
the kidneys may be felt much enlarged. The diagnosis
is doubtful in the early stages, unless bacilli can be
demonstrated by the microscope or inoculation of a
guinea-pig. The hematuria is much slighter than in
cases of renal calculus, and is not influenced by rest.
The hemorrhage is not so profuse as in cases of new
growth. Slight attacks of renal colic may occur from
the passage of caseous matter, but not severe attacks
like those due to calculus. An exploratory kicision
964
MEDICAL COUNCIL OF CANADA.
settles the diagnosis in doubtful cases/ 7 — (Aids to
Surgery.)
5. Gallstones. "While the calculus remains free in
the gall-bladder, usually there are no symptoms. Im-
paction of the stone in the common duct gives rise to
intermittent jaundice, following sharp pain in the right
hypochondriac or epigastric region, frequently radiating
toward the right scapula, nausea, vomiting, sweating,
depression, and often intermittent fever (Charcot's in-
termittent fever). When the stone is impacted in the
cystic duct, jaundice is less common, but the hepatic
colic is severe, and dropsy of the gall-bladder may occur.
The diagnostic points are the age, sex, history of pre-
vious attack, with jaundice and intermittent fever, loca-
tion of the pain, dark, amber-colored urine, containing
bile, and sometimes the finding of the stone in the feces.
Complications and sequels. (1) Suppurative chole-
cystitis (empyema of the gall-bladder) ; (2) secondary
abscesses; (3) permanent jaundice, with production of
Charcot's intermittent fever; (4) ulceration and pas-
sage of stone into the intestine; (5) obstruction of
the bowels from gallstone; (6) stricture of the ducts
and atrophy of the gall-bladder." — (Pocket Cyclopedia.)
Surgical treatment. Cholecystotomy is done through
an incision parallel to and IY2 inches below the costal
margin over the gall-bladder. The liver is drawn up
and the intestines packed away with gauze. If the
gall-bladder is distended the fluid is removed by tapping
it with a trocar and cannula. The opening is then
enlarged, and the stones are removed with a scoop.
The bile-ducts are examined along their whole course
by a finger externally, and by a long probe internally.
If the interior is fairly healthy, the opening is sutured
with two layers of continuous sutures and the abdomen
is closed. Usually it is necessary to drain the gall-
bladder for a time, in which case the margins of the
opening are stitched to the peritoneum and transversalis
fascia of the abdominal wound, The fistula thus estab-
lished soon closes if there is no obstruction to the
passage of the bile into the intestine. If not, it must
be closed by a plastic operation or cholecystenteros-
tomy." — (Aids to Surgery.)
6. Middle meningeal hemorrhage. "Symptoms:
When not obscured by some other cerebral lesion,
the typical symptoms are — (1) temporary concus-
sion; (2) a lucid interval of a few minutes to a
few hours; (3) gradually increasing drowsiness ending
in coma. If the hemorrhage is rapid or there is cerebral
laceration as well, there may be no interval of con-
965
MEDICAL RECORD.
sciousness. In addition there may be, from pressure
on the motor area, twitching of the corresponding parts
followed by paralysis. The pupil on the injured side
becomes first fixed and dilated, the other following.
When the coma is well marked the pulse is slow and
full, and the breathing is stertorous. When the brain
is lacerated there are alternating tonic contraction and
relaxation of the muscles supplied from the injured
area. The Prognosis is very grave. The Diagnosis is
difficult, unless the symptoms are typical, and they
seldom are. Treatment consists in trephining, remov-
ing the blood-clot, and stopping the bleeding. A flap
is turned down, and a trephine hole made over a spot
1% inches above and behind the external angular pro-
cess exposes the anterior branch. After the blood-clot
is removed the bleeding-point is searched for and tied;
if it is not seen, more bone must be clipped away. If
the bleeding comes from a canal in the bone, it may be
stopped with gauze, sponge, or aseptic wax. If the
brain then expands, the bone may be replaced and
the wound stitched ur? without drainage; if not, the
bone must not be replaced, and the wound should be
drained for twenty-four hours. The posterior branch
can be reached by a hole made just below the parietal
eminence." — (Aids to Surgery.)
1.
MEDICINE,
Pericarditis with Effu-
sion
Recent history of gout,
acute rheumatism, acute
infectious or septic dis-
ease, scurvy, nephritis,
or tuberculosis, chronic
gonorrhea.
Fever and slight pain
often associated.
Nervous symptoms are
often present.
Inspection often reveals
bulging. Apex-beat is
elevated, feeble, and
later absent.
Heart's impulse usually
absent, or occupies cen-
ter or upper border of
dull area. Friction fre-
mitus may be present.
Cardiac Dilatation
Usual history of chronic
valvular disease of the
heart.
No fever or pain, as a rule.
Absent or but slight.
Apex-beat usually visible,
wavy, and diffuse.
Though feeble, the impulse
is palpable.
MEDICAL COUNCIL OF CANADA.
Percarditis with Effu-
sion
Percussion shows a trian-
gular flat area, and the
boundary line alone
changes on altering the
position of the patient.
There is dull tympany
in the axillary region.
Dullness over left lung
below angle of scapula
common.
Auscultation shows the
first sound* distant and
muffled ; a friction rub is
often present.
Cardiac Dilatation
Dull area varies with the
chambers dilated; it is
co-existent with a wavy
impulse, does not extend
so high (except in mi-
tral stenosis), and does
not vary with change of
position. There is no dull
tympany.
First sound clear, short,
and sharp resembling
the second sound. Fric-
tion murmur rare, but
an endocardial murmui
may appear later.
— (From Anders and Boston's Diagnosis.)
2. Lobar Pneumonia. Diagnosis: (1) From acute
phthisis: The symptoms and physical signs of lobar
pneumonia and acute pneumonic phthisis may be the
same for the first eight or ten days; at this period
the fever in pneumonia drops by crisis; whereas in
phthisis the fever continues for some time longer and
the patient ge,ts worse; the sputum contains tubercle
bacilli and elastic fibers, and instead of retaining the
rusty color it becomes purulent and greenish.
In pneumonia, the breathing is very rapid, the pulse-
respiration rate is disturbed, the fever is usually high,
and runs a regular course, crepitant rales are heard
at first, then signs of consolidation follow, and crepi-
tant rales again succeed.
In phthisis, the breathing is hurried and there is
dyspnea; the fever is- often high, but does not run a
regular course. At first the signs are those of bron-
chitis, followed by consolidation, a softening, or exca-
vation in different parts of the lungs; sometimes there
is nothing to be heard but scattered rales.
Acute pulmonary congestion is "undistinguishable
from the first stage of pneumonia." — (Butler.)
3. Epidemic cerebrospinal < meningitis. Etiology :
The Diplococcus intracellularis meningitis. Sporadic
cases may be due to the pneumococcus, streptococcus,
colon bacillus, typhoid bacillus, bacillus of influenza, or
gonococcus; but the epidemic form is always caused bj
the Diplococcus intracellularis. It enters the system
through the mucous membrane of nose, mouth, or
967
MEDICAL RECORD.
pharynx, and reaches the meninges by way of the
lymphatics or the circulation. The disease may be con-
veyed by "carriers." Diagnosis is made from (1) the
symptoms, (2) Kernig's sign, and (3) lumbar punc-
ture. Symptoms: The onset is generally sudden, with
headache, rigors, stiff neck, opisthotonos, vomiting,
moderately high (102° F.) and irregular fever, full
and rapid pulse, herpes, photophobia; convulsions, de-
lirium, monoplegia or hemiplegia, enlarged spleen, re-
tracted abdomen, and disturbed reflexes may be present
Kernig's sign is obtained (if the thigh is flexed at right
angles to the abdomen, the leg cannot be fully extended
on the thigh, as it can in health, owing to the contrac-
tion of the flexor muscles). By lumbar puncture, some
of the cerebrospinal fluid may be withdrawn and ex-
amined for the presence of the diplococcus.
4. General treatment of typhoid fever. "As soon as
the nature of the disease is recognized the patient
should be confined to bed. The room should be large
and airy, and provided with efficient means of securing
thorough ventilation. The temperature of the room
should be maintained between 65° and 70° F. The bed-
pan must be used from the beginning until convales-
cence is well advanced. The stools and urine should
be rendered innocuous before being thrown out. This
may be done by treating the evacuation with twice its
volume of a 1 per cent, solution of chlorinated lime or
a 5 per cent, solution of carbolic acid, and allowing it to
stand in a covered vessel for two hours before emptying
it into the closet. Soiled clothing should be thoroughly
boiled. The diet should be liquid or semisolid, unirri-
tating, and easily digestible. Milk alone (6 ounces
every four hours) does not supply the required number
of calories (2,500-3,000), but, as a rule, it should form
a large part of the diet. It may be given diluted with
lime water, or as buttermilk, malted milk, koumiss,
junket, or ice cream. Among other suitable foods may
be mentioned raw or soft boiled eggs, chicken jelly, milk
toast, strained oatmeal gruel, potato puree, tea, coffee,
cocoa, fruit juices, wine jelly, and custard. Beef tea
and broths may be harmful. In the event of digestive
disturbances the diet should be restricted for a time to
whey or albumin water. Water, plain or flavored
(lemonade, soda water, etc.), should be given in large
amounts between the feedings. When the first sound
of the heart becomes weak and the pulse dicrotic, al-
cohol is usually indicated. From 4 to 8 ounces of
whisky or brandy may be given in the twenty-four
hours, the amount being determined by the general
968
MEDICAL COUNCIL OF CANADA.
effect. The cold bath or the cold pack affords the best
means of controlling fever and preventing the develop-
ment of severe nervous symptoms. It may be employed
every three or four hours when the temperature is
102.5° F. or over. Hemorrhage, signs of perforation,
menstruation, and great prostration are contraindica-
tions.
"For the hemorrhage: Absolute rest is imperative.
Cold bathing should be suspended. It is advisable to
elevate the foot of the bed. An ice-bag may be applied
with advantage to the right iliac region, and ice may
be given to suck. The best drug is morphine (% to X A
grain) hypodermically. Ergot is useless. In cases of
recurrent hemorrhage calcium lactate (10 grains thrice
daily) and gelatin may be given by the mouth." —
(Stevens' Manual of Practice.)
5. Salvarsan is indicated in: "(a) Early cases of
syphilis in which contagious manifestations are appear-
ing in rapid succession, in spite of efficient mercurial
medication, (b) Cases in which, for family or social
reasons, it is of special importance to limit the produc-
tion of infective material or cause the disappearance of
symptoms in the shortest possible time, (e) Cases in
which the symptoms are recalcitrant to the action of
mercury, or in which, from idiosyncrasy, that drug can-
not be exhibited in sufficient dose, (d) Cases of syphilo-
phobia and syphilomania, whether showing symptoms
or not; its psychic action in these instances being of
greater importance than its therapeutic effect, (e)
Very early cases of the sequelae of the luetic infection,
before organic changes have occurred."
Salvarsan is contraindicated in: "(a) Cases that are
doing well, i.e. in which the disease is pursuing its
normal mild course under ordinary medication. (b)
Cases with serious organic lesions of the eyes, kidneys,
heart, or other internal organs, (c) Cases with post-
syphilitic or parasyphilitic disease of the internal or-
gans, more especially of the nervous system." —
(Progressive Medicine.)
It may be administered intramuscularly or intra-
venously. The intravenous injection is described by
Hirsch as follows: Two graduated glass containers of
250 c.c. capacity are used. Into one is poured 150 to
200 c.c. of sterile salvarsan solution. The other is filled
with a like volume of sterile saline solution (made with
sterile distilled water and chemically pure sodium
chloride). The saline solution is allowed to flow out
of the needle so as to expel all air from the tube. The
stopcock is now reversed, allowing the salvarsan solu-
969
MEDICAL RECORD.
tion to flow out of the needle, thereby expelling all air
from its tubing. The stopcock is now reversed to its
former position, until the saline solution is running in
a slow, even stream from the needle. The desired site
of puncture is selected on the arm or at the elbow, and
the needle is gently pushed or thrust through the skin
into the vein. Meanwhile the saline solution is con-
tinuously running from it. The needle is held at about
an angle of 10 to 15 degrees to the skin surface, depend-
ing on the prominence and caliber of the vein. Care
must be exercised not to push the needle through both
walls of the vein. This accident can best be avoided by
not introducing too long a surface of the needle into the
tissues.
Dosage depends on the type and stage of the disease.
Generally from 0.1 to 0.6 gm. is used at intervals of
from 5 to 10 days.
6. The diagnostic possibilities are: Uremia, with im-
pending convulsions and coma, with chronic nephritis;
cerebral thrombosis (in spite of the high blood pres-
sure) ; small hemorrhage or tumor in the neighborhood
of the island of Reil; arteriosclerosis, with vascular
spasm; diabetes. Further clinical methods would in-
clude examination of the fundus oculi; complete ex-
amination of urine, including a measure of the total
quantity passed by day and by night separately, an
estimation of the total urea eliminated, the phenolsul-
phonephthalein test, and tests for sugar.
970
MEDICAL RECORD
.4 Weekly Journal of Medicine and Surgery
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971
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