Complimentary Copy. Pulte Medical College CINCINNATI, ■',•, GLASS, liliS. *«'•&* (.„»*. i' ■•« oic:»• i NLf1 001022B2 3 | l«*b- 1 '-/^ 45 73 ;.i> Oxarrjirjalior) • apers OF « < olfe, ©ULTB (QBDIGAL ©OLiLEGE, Glass • IS _^@ 0MNNATI, OHIO, 1S56. w 1> \M 0 5 k ti& ^0PPe.spor)d crjce-. 146 SMITH STREET, CINCINNATI, 0., March 10, 1882. Professor J. M. CRAWFORD, Dear Sir : The complimentary terms in which you spoke of Mary Wolfe's written examination in Physiology and Histology in your public speech, at the Commencement Exer- cises of Pulte Medical College, at College Hall in the Mercan- tile Literary Building in this city, March 1st, 1882, and to memorialize which was awarded an elegant gold medal, have caused many personal friends to express a desire to read it. Will you be kind enough to allow me a verbatim copy of her paper ? Yours truly, N. B. WOLFE. -r----*----*- COR. SEVENTH AND MOUND, CINCINNATI, 0.. March 11, 1882. Dr. N. B. WOLFE, Dear Sir: Your note of yesterday is before me, asking for a verbatim copy of your daughter's examination paper, and I cheerfully comply with your request. The committee that awarded the medal to Miss Mary Wolfe did so with entire unanimity. Her paper was best in that comprehensive sense which includes general scholarship, as well as physiological knowledge. The reading of it, I trust, will show to yourself and friends, as it did to the members of the committee, that the medal was worthily bestowed. I am sincerely yours, J. M. CRAWFORD. INTRODUCTION. It will be a matter of interest to our friends to learn the circumstances under which the following paper on Physiology and Histology was written, and how the award of the gold medal was made. Professor J. M. Crawford announced to the members of the class that he desired them to assemble in the amphi- theater of the college, on Wednesday, at ten o'clock A. M. of examination week. When they came together, he handed each student a paper containing the following ex- amination decalogue: I. Name the Contents of the Respective Regions of the Anterior Portions of the Chest, and give the Signs of Normal Func- tions of the Organs in each Region. II. Give the Divisions of Proximate Principles of the Blood, and the important Peculiarities of each. III. Describe fully the Process of Mastication, and give the Mech- anism of Deglutition. IV. Describe Saliva, Gastric Juice, Pancreatic Juice, and give the Mechanism of their Secretion and the Function of each. V. In the Digestive Process, give the Successive Steps by which the Food finally enters the Blood, VI. Give the Relations of the Nervous System to the Glycogenic Function of the Liver. VII. Give the Physiological Anatomy of the Kidney, and Mechan- ism of the Secretion and excretion of Urine. 6 INTRODUCTION. VIII. Give the Mechanism of Respiration, and the Means by ivhich Oxygen is conveyed to the Tissues. IX. Give the Mechanism of the Continuous Flow of Blood in the Veins, and the Cause of a Systemic Venous Pulse. X. Describe fully a Nerve, and give its Physiological Properties. The Professor supplemented these problems by stating that during the examination the students were expected not to converse with each other, nor to ask questions or refer to memoranda. In short, the class was given to understand that every student was expected to do square tvork. As each paper was finished it was delivered to Pro- fessor Crawford, who was present during the entire exam- ination. At the commencement exercises of Pulte Medical Col- lege, in College Hall of the Mercantile Library Building, March 1, 1882, after the addresses and valedictory had been delivered, the Dean of the College, Professor J. D. Buck, announced that "the next thing on the printed programme is the delivery of the diplomas to the graduating class; but, before doing this, one of the exercises of the evening, not set down, as it should have been, will now take place." Hereupon Professor J. M. Crawford came to the front of the rostrum, and said substantially: "A friend to education and/to Pulte Medical College, who does not wish his name made public, but who enter- tains a high appreciation of the study of Physiology and Histology, as constituting the foundation of a reliable med- ical education, in order to encourage application and reward success, placed in my hands, early in the term, funds to provide an annual prize, to be presented to the student who gives the bed examination paper in this department of med- ical study. This award will be called ' The Unknown Prize,' and, like the Protean body, will take any shape INTRODUCTION. 7 that may seem at the time best calculated to reward the victorious competitor. This year it takes the form of a gold medal. Whence it comes you will never know ; but whither it goes, each succeeding commencement, during my connection with the college, will reveal. '' The duty of selecting the one entitled to receive this award has been scrupulously performed by the Professor of Physiology, assisted by the Dean and other members of the Faculty. Among the papers of merit which they have examined and indorsed as worthy of honorable mention, there was one that attracted special attention, and com- manded the admiration of the examining committee. This paper was found not only to be unusually comprehensive and exact in its grasp and arrangement of physiological and histological facts, but its statements were clear, concise, and in classic English. "The prize I hold in my hand. You perceive it has the shape of a Greek cross, the base modified to resemble the human heart. On the face of the top section of the cross is engraved the symbol of the astral lights, a dual tri- angle forming a star, in the center of which is the radiant face of the sun. On the right section appears Mercury, with winged feet, walking upon a troubled sea, himself re- splendent in the ambient air, bringing his appropriate mes- sage. On the left is ornately engraved a representation of Hygeia, the daughter of Esculapius, in the attitude of receiving light for her lamp from the emblem of wis- dom, the serpent. The lower part of the cross is heart- shaped, on which is engraved the mundane egg, the mother source of natural life. Thus are symbolized in this beau- tiful jewel, the four elements, Fire, Water, Air, and Earth, associated with Wisdom, all contributing to Health. The circle in the center of the cross contains a beautiful enameled monogram, surrounded, in engraved Greek char- 8 INTRODUCTION. acters, with the well-known motto, Fvutfri Zsaorov, ' Know Thyself.' On the reverse of this medal is inscribed this personal legend: AWARDED TO pttss ptag WLaliz, FOB THE Be8t Written Examination IN PHYSIOLOGY AND HISTOLOGY, fultt J&t&ital CoIUflt, Cincinnati, March ist, 1882. "My duty is now done. Miss Wolfe, receive your medal. I trust the success which this symbolizes will stim- ulate you to still greater efforts in the pursuit of knowl- edge." ^M^M^C^^M^^I^M^^^M^MSi^M^^My^ *;•*& 0^ .xwsioloqy errjel Jiisfoloqy. Written Wednesday, February 15, 1832, from V/2 to 5^ P. M. I Name the Contents of the Respective Regions in the Anterior Portion of the Chest, and give the Signs of Normal Function in each Region. A. Supra-clavicular Region. Content*. On both sides it contains the apices of the lungs, the common carotid arteries and jugular veins, and the subclavian arteries and veins. S!ffti.i of Xormal Function. On palpation is found the pulsation of the carotid arteries; on percussion, pulmonary resonance; on auscultation, pure vesicular murmur, and scarcely audible voice. B. Clavicular Region. Content*. On both sides is found vesicular lung struc- ture. On the right side are the innominate and subclavian arteries and their accompanying veins. On the left side are the common, carotid and subclavian arteries, with their veins. Sifjns of Xormal Function. On palpation, the clavicle is felt; on percussion, dullness, and high-pitched resonance result; on auscultation, pure vesicular murmur, and scarcely audible voice are heard, except at the sternal end, where are found bronchial breathing and bronchophony. 10 PULTE COLLEGE PRIZE PAPER. C. Infra-clavicular Region. Contents. On both sides are found the vesicular struc- ture of the lungs, and the main branches of the bronchial tubes. On the right side, the vena cava and aorta are found, the right bronchus, the bronchial artery and vein. On the left side is a portion of the pulmonary artery, the bronchial artery, the left bronchus, and the vein. Signs of Xormal Function. On palpation, vocal fremitus is felt, more on the right side; on percussion, pulmonary resonance results; on auscultation, scarcely audible voice, and pure vesicular murmur, mixed with bronchial breathing, blended throughout the whole region, are heard, the vesicu- lar murmur being more distinct toward the axillary region, the bronchial breathing toward the sternal; the heart sounds are found on the left side, at the lower border of this region. D. Mammary Rixuox. Content*. On both sides are lung structure and bron- chial bifurcations. On the right side the heart's border is found behind the lung; also, on deep inspiration, the liver, when it rises to a level with the fifth rib. On the left side the lung is moved aside for the heart; beginning at the fourth sterno-costal articulation, extending down to the fifth intercostal space, and returning again at the sixth. Signs of Xormal Function. On palpation, there is slight vocal fremitus; on percussion, there is resonance on both sides, except on the left, over the region of the heart, where there is dullness and higher pitch; on auscultation, there is feeble vesicular murmur on the right side below, on both sides above; on the left side, at the junction of the third rib with the sternum, is heard the second sound of the heart; at the junction of the fourth rib with the sternum is heard the first sound of the heart. These are the points PHYSIOLOGY AND HISTOLOGY. 11 of greatest intensity; the sounds are propagated into the surrounding area, and diffused throughout the chest. The voice is hardly audible. E. Infra-mammary Region. Contents. On the right side is found the liver; in the superior portion of the region the lung is in front of it. On the left side are the anterior portion of the base of the lung, a small part of the left lobe of the liver, the anterior border of the spleen and the cardiac end of the stomach. Signs of Xormal Function. On palpation, resistance from the presence of the liver, and the apex beat of the heart are found; on percussion, dullness and high pitch over the region of the liver and spleen, and tympanitic resonance over the stomach, result; on auscultation, vesicu- lar murmur is heard on both sides. F. Supra-sternal Region. Contents. The trachea, and sometimes the tip of the transverse portion of the arch of the aorta, are found; also the arteria innominata at its lower border. Signs of Xormal Function. Palpation and percussion are of little value here; on auscultation, tracheal breathing is heard. G. Superior or Upper Sternal Region. Contents. The division of the trachea, the aorta, and great vessels are found here. The heart lies partly in this region. The pulmonary valves are on a level with the third rib, the aortic valves below. Signs of Xormal Function. Palpation reveals the pres- ence of the sternum; on percussion there is clear resonance of high pitch; on auscultation, bronchial breathing, bron- chophony, and reflected heart-sounds are heard. 12 PULTE COLLEGE PRIZE PAPER. H. Inferior or Lower Sternal Region. Contents. The anterior mediastinum above, the stomach below, a part of the heart and a small portion of the lung on its right border are found; also the attachment of the pericardium to the diaphragm. The mitral valves are sit- uated near the left side at the sterno-costal articulation of the fourth rib; the tricuspid valves are nearer the median line, below the aortic valves. Signs of Xormal Function. On percussion, resonance is clear in the upper part of the region, and tympanitic in the lower part; on auscultation, the heart-sounds are heard. The first sound is synchronous with the closing of the auri- culo-ventricular openings; the second, with that of the pul- monary and aortic. The normal heart-beat may be divided into four periods: the first sound occupying four-tenths of the time; the first rest, one-tenth; the second sound, three- tenths; the second rest, two-tenths. Pure vesicular murmur is heard above, and but feebly below. The voice is hardly audible in this region. PHYSIOLOGY AND HISTOLOGY. 13 II. Give the Divisions of the Proximate Principles of the Blood, and the Important Peculiarities of Each. The proximate principles of the blood are found in the plasma. They may be divided into five classes, as below: A. Organic Nitrogenized. These are intimately connected with the vital principles, and enter directly into the nourishment of the tissues. They are all in a state of continual change in the body, constantly wearing out and becoming effete, when they take the form of excrementitious substances. This class of proximate principles is of organic origin exclusively; they are not crystallizable, and are of indefinite chemical composition. Plasma is largely made up of them; fibrin, plasmin, paraglobulin, and metalbumin are examples. B. Organic Non-nitrogenized. These principles are essential to development and nour- ishment. They are deposited in the tissues, and are seem- ingly stored there for emergencies. They usually exist in the blood in but small quantities, and are derived from the food; the glycogenic matter comes partly from the food and partly from the liver. They are of definite chemical composition. The fats, sugars, and starches are examples. 14 PULTE COLLEGE PRIZE PAPER. C. Organic Saline. These principles are formed in the body by true chem- ical union. Pneumates and lactates are examples. D. Inorganic. These are principles not formed in the organism, and that remain unchanged while in the body. They are of definite chemical composition, and are crystallizable. The substances forming these are introduced from without the body, and are discharged from it in the same chemical form in which they entered the organism. In the body, how- ever, they behave as organic principles, and are necessary for nutrition, The carbonates, phosphates, sulphates, water, and sodium-chloride are examples. E. Excrementitious. These are the waste principles and poisonous matter from the system, and result frem the breaking down of tissues. Urea, carbonic acid, and cholesterin are examples. Cholesterin is a principle separated from the blood, in all probability, as shown by Flint and Miiller, through the excrementitious function of the liver, and is discharged in the form of stercorin with the fseces. Urea is mainly dis- charged in the urine and sweat, the excrementitious fluids of the organism. PHYSIOLOGY AND HISTOLOGY. 15 III. Describe fully the Process of Mastication, and give the Mechanism of Deglutition. A. Mastication. Mastication is the process of dividing the food by the teeth, assisted by the tongue, cheeks, and lips, to prepare it for deglutition. Mechanism. The movements in mastication are those of the lower jaw, the tougue, cheeks, and lips. The lower jaw has three movements, a vertical, a lat- eral, and an antero-posterior. The vertical movement is an upward and downward motion. The upward motion, or closing the jaws, is caused by the contraction of the tem- poral, masseter, and internal pterygoid muscles. The down- ward motion, or opening the jaws, is caused by the action of the digastric, the mylo-hyoid, the genio-hyoid, and the platysma myoides muscles. The lateral and the antero- posterior movements are caused, the former by the con- traction of the muscles that elevate the lower jaw, acting uni-laterally ; the latter by the anterior and posterior por- tions of the pterygoid muscles contracting separately. The tongue is in active and eccentric motion, the in- trinsic fibers and extrinsic muscles both being engaged. The muscles of the cheeks and lips act, also, in helping to keep the food between the teeth. After the bolus is thoroughly masticated and insalivated it is ready for deglutition. 16 PULTE COLLEGE PRIZE PAPER. B. Deglutition. Deglutition may be divided into three stages. The first stage is voluntary, and extends from the time the food is pushed back, after being masticated,' collected into a bolus, and insalivated, until it enters the isthmus faucium. The second stage extends from the time the food enters the isthmus faucium until the constrictors of the pharynx grasp it. The third stage extends from the time it enters the grasp of the constrictors until it reaches the oesophagus. Tlie First Stage. After the thoroughly masticated and insalivated bolus of food is forced back by the tongue, it rests on the posterior portion of that organ, which presses against it, and which is also applied to the roof of the mouth to prevent the return of the bolus. By this press- ure of the tongue it enters the isthmus faucium. The Second Stage. After the bolus has been pressed into the isthmus of the fauces, the tensor palati renders the soft palate tense; the levator palati draws it upward; at the same time the posterior pillars of the isthmus faucium con- tract, the chink between them being filled by the azygos uvulae; the stylo-pharyngeus acts in concert now, and pulls the pharynx back, like the finger of a glove. This brings the roof in apposition to the superior constrictors, and ex- cites just enough action in them to grasp it, thus closing the opening into the posterior nares. At this time the larynx is being raised by its five levators, the digastric, the stylo-hyoid, the mylo-hyoid, the genio-hyoid, and a few fibers of the hyo-glossus. The epiglottis is now covering the glottis, the floor of the pharynx is now an inclined plane, and the anterior pillars, the palato-glossus muscles, now contracting, force the bolus along this plane into the grasp of the superior constrictors. PHYSIOL OGY AND HISTOL OGY. 17 The TJiird Stage. The constrictors, the superior, mid- dle, and inferior, contract upon the bolus from above downward, and thus it is forced into the upper opening of the oesophagus, to be conveyed thence to the stomach by the peristaltic action of the oesophageal muscles. 2 18 PULTE COLLEGE PRIZE PAPER. IV. Describe Saliva, Gastric Juice, Pancreatic Juice0 and give the Mechanism of their Secretion and the Function of each. A. Saliva. Description. Saliva is a fluid which is secreted by glands situated around the cavity of the mouth. It is rather tur- bid, somewhat viscid, almost tasteless, and its reaction is alkaline. The turbidity is caused by the presence of epi- thelial cells, which are mixed with the salivary secretion. These cells come from the mucous glands of the mouth, and from the ducts of the salivary glands. Meclianism of Secretion. The salivary glands are race- mose glands, situated in the buccal cavities, in the fossse of the lower jaw, and under the posterior portion of the tongue. They are lined with mucous membrane, and the investing epithelium differs in the ducts and in the glands. The glands proper, or terminations of the ducts, are lined with spheroidal or true glandular epithelium. The ducts are lined with columnar epithelium. In the body of the gland the proper secretion is separated from the blood. This is the function of the true gland cell wherever found. The epithelium lining the ducts secretes mucus. The glands and their ducts are : The parotid, with Steno's duct. The submaxillary, with Wharton's duct. The sublingual, with the small ducts of Riviere. PHYSIOLOGY AND HISTOLOGY. 19 The secretion from the parotid is least viscid; that from the submaxillary next; and that from the sublingual most of all. Function. The principal office of the saliva is, mechan- ically, to moisten the food and thereby assist deglutition; and, chemically, to thoroughly change the starches into dextrin, and then into sugar, either in the mouth or after- wards in the stomach. The active principle is ptyalin. B. Gastric Juice. Description. Gastric juice is a fluid clear and amber- colored, with an acid reaction. It contains hydrochloric acid and mucus. It is secreted by the peptic glands, situ- ated in the mucous coat of the stomach, by the glands that secrete hydrochloric acid, and by mucous follicles. The different glands secrete the different constituents, all being mixed together to form gastric juice. Mechanism of Secretion. The peptic and the hydro- chloric acid glands are very similar in their microscopic anatomy. They are racemose glands, and in the cellular or lobular portion are lined with spheroidal epithelium. The ducts are lined with columnar epithelium. The mu- cous follicles are lined throughout with columnar epithe- lium, and are mostly situated about the pyloric end of the stomach. Function. The action of the gastric juice is upon the proteids. The product of its digestion is peptone. There is a small by-product which is called parapeptone. The gastric juice dissolves the envelope in which is held the fats, and it acts upon the fibrins, albumins, and gelatins by a disintegrating process. The substances swell up and are reduced to a thin, pultaceous mass. Hydrochloric acid is necessary to its proper function, and to the presence of this 20 PULTE COLLEGE PRIZE PAPER. principle is due the fact that gastric juice is normally acid in its reaction. The active principle is pepsin. C. Pancreatic Juice. Description. Pancreatic juice is the digestive factor. It is similar to the salivary secretion in that its reaction is alkaline. It is viscid and translucent. Mechanism of Secretion. The pancreatic juice is secreted by the pancreas. This is a long, narrow organ, situated below and behind the stomach. It extends from the right to the left hypochondriac region, completely across the epi- gastric. It is composed of lobes. The secreting sacs, or terminations of the divisions of the ducts, are lined at the base with demilune cells; on these are the true gland cells. The ducts are lined with columnar epithelium. The small ducts join together and form two: one that is large and opens into the duodenum, in company with the bile duct; and one that is smaller, and opens a little above this, which Bernard alone has found. Function The pancreatic fluid acts on all the food that has not been digested by either the saliva or gastric juice. It emulsifies the fats. The active principle is trypsin. PHYSIOL OGY AND HISTOL OGY. 21 V. In the Digestive Process, describe the Successive Stages by which the Food final'y enters the Blood. The food, after being properly digested, enters the blood by some process of absorption. In the stomach the water and more fluid portions of the food are taken up by the capillaries, and enter directly into the venous circulation. In the intestines are found the villi. These contain lac- teals and capillary blood-vessels. The chief office of the lacteals is to absorb the fats; but during active digestion they are found to contain other substances. The lacteals convey their contents to the receptaculum chyli, and thence the thoracic duct carries it to the venous blood. The capil- lary blood-vessels in the villi take up the fluid, which, after absorption, is known as chyle. These capillaries pour this into the portal vein. Absorption takes place from the mouth to the anus, the degree being different in different parts of the alimentary canal, the process always the same. 22 PULTE COLLEGE PRIZE PAPER. VI. Give the Relation of the Nervous System to the Glycogenic Function of the Liver. The relation of the nervous system to the glycogenic function of the liver is not clearly known. It is intimate, however. The controlling influence seems to be centered in the floor of the fourth ventricle; for if this is punctured, artificial diabetes will result. The impulse is sent to the liver by other nerves than the pneumogastric; for even if these are severed the glycogenic function, though suspended for a time, again becomes normal. The connection of the sympathetic system is not known. PHYSIOLOGY AND HISTOLOGY. 23 VII. Give the Physiological Anatomy of the Kidney, and the Mechanism of the Secretion and Ex- cretion of Urine. A. Physiological Anatomy. The kidneys are situated in the lumbar region, and are oblong, symmetrical bodies. They are inclosed in a coat of adipose tissue, inside of which is their proper covering, the fibrous capsule. The fibrous capsule surrounds the kidney, and is contin- uous with the fibrous covering of the pelvis and ureters. It sends trabecular into the cortical substance of the kidney. The kidney is composed of a cortical and a medullary substance. The cortical substance is granular. It occupies the exte- rior portion of the organ to the general depth of one-sixth of an inch, and sends down prolongations into the medul- larv substance. The cortical substance contains granular matter, Malpighian bodies, capillary plexuses of blood- vessels, convoluted uriniferous tubules, and the columns of Bertin. The medullary substance is found interior to this cortical layer, and is sometimes called the pyramidal substance, being composed of the pyramids of Malpighi. Blood Supply. The renal artery enters at the hilum, and, after dividing, passes forward toward the cortical sub- stance. The divided arteries continue to follow the same 24 PULTE COLLEGE PRIZE PAPER. direction until they reach the bases of the pyramids, on which they form an anastamosing plexus. From this plexus branches are given off; those on the convex side extend out into the cortical substance, and each ramification becomes the afferent vessel of a Malpighian body, and after entering the body breaks up into minute branches, which form a dense convolution known as the glomerulus. The branches toward the concavity of the base of the pyramid pass back- ward toward the hilum, and terminate in the capillaries of the pyramidal substance. These are called the arteriolar recta?. The veins originate in three ways,—from stellated rad- icles near the external surface of the cortical substance; from the capillary plexus about the convoluted tubes; and from the capillary plexus, in which the arteriolar rectse terminate. Malpighian Body. This is composed of an afferent and an efferent vessel, forming a capillary plexus, without anas- tomosis, within the terminal expansion of a uriniferous tubule, the capsule of Muller. Tubidi Uriniferi. These are tubes beginning in the capsule of Muller, and extending to the calices. They are convoluted in the cortical substance; on reaching the bor- der of the medullary substance they become less so, and much narrower, and dip down into the pyramids, returning again to the cortical substance. Throughout this part of their course they are called the looped tubes of Henle. They again enter the pyramids of Malpighi, and their course is now more directly toward the pelvis. Several of them join together, forming larger tubes. In this part of their course they are called tubuli recti uriniferi, or the strait tubes of Bellini. Pyramids of Malpighi. These are the large pyramids of the medullary substance, and are composed of lesser pyra- mids, called pyramids of Ferrein. PHYSIOLOGY AND HISTOLOGY. 25 Pyramids of Ferrein. These are collections of urinifer- ous strait tubes, about a hundred in each. Calices. These are little openings into which the apices of the pyramids are received. Infundibida. These are the short, funnel-shaped tubes into Avhich the calices open. Pelvis. This is the expansion of the ureter, and into it the infundibula open. Hilus. This is the gateway of the kidney. Epithelium. The cells lining the strait tubes are polyg- onal in shape. It is supposed that those in the convoluted portion of the tubules are true gland cells, and that the capsule of Muller is lined with pavement epithelium. B. Mechanism of Secretion. The secretion of urine takes place in the Malpighian body and convoluted uriniferous tubes. The watery ele- ments are principally separated in the glomerulus; the other constituents in the tubes, from the blood in the capillaries that surround them. The separation in the Malpighian body is effected mainly by pressure; that in the tubes, by the action of the true gland cell. The efferent vessel, after leaving the Malpighian body, is about one-half the size of the afferent. It still contains matter that is excrementi- tious ; so its course is directed toward the convoluted tubes, and it forms a plexus about them to allow this waste matter to be extracted from the blood. When the renal vein is finally formed, it contains the purest blood in the body. 26 PULTE COLLEGE PRIZE PAPER. VIII. Give the Mechanism of Respiration, and the Means by which Oxygen is conveyed to the Tissues. Respiration is of three kinds—pulmonary, cutaneous, and muscular. A. Mechanism of Pulmonary Respiration. Inspiration. The act of inspiration is performed by the muscles of inspiration, working in concert with those muscles that open the rima glottidis. In inspiration the rima glot- tidis is opened, and the Avails of the thorax are extended. This extension of the walls causes a tendency to a vacuum, and the air rushes in to fill it. The muscles of inspiration are the diaphragm, the scaleni, the external intercostals, and the levators of the ribs, Avith accessory muscles, Avhich are the serratus posticus superior, the sterno-cleido-mastoi- deus, the pectoralis major and minor, the serratus magnus, and the le\rator anguli scapula?. Expiration. The act of expiration is performed bv the muscles of expiration and by the contraction of the tra- cheales muscles and of the elastic fibers found in the wralls of the air-cells. The expiratory act is more passive than the inspiratory, and occupies about one-fourth the time of respiration. The muscles of expiration are the triangularis sterni, the sacro-lumbalis, the external and internal abdom- inal oblique, the transversalis, the infra-costales, and the internal intercostals. PHYSIOL OGY AND HISTOL OGY. 27 B. Means by which Oxygen is conveyed to the Tissues. Oxygen rushes in Avith the air Avhen the lungs are filled. By the law of diffusion of gases, it rapidly passes through the air already in the lungs, and is brought in apposition Avith the membrane which lies between it, and the blood charged Avith carbonic acid gas. The interposition of the membrane favors diffusion. The oxygen passes in, and the carbon di-oxide out, still by the law of diffusion. The oxygen now enters into chemical union Avith the hemaglobin of the red corpuscle, forming oxy-hemaglobin, and then this servant of the cells, the red corpuscle, carries the oxygen to the capillaries; here, the tissues having a greater affinity for the oxygen than has the hemaglobin, it enters their structure, and leaves the corpuscle, the carbon di-oxide being taken back to the lungs in exchange for the oxygen left with the tissues. 28 PULTE COLLEGE PRIZE PAPER. IX. Give the Mechanism of a Continuous Flow of Blood in the Veins, and the Causes of a Sys- temic Venous Pulse. The three factors of a continuous flow of blood in the veins are the vis a tergo, or action of the heart, the over- distension of the arteries, and the peripheral resistance of the capillaries. When these three factors bear a normal relation to each other, the stream of blood flows continu- ously in the veins. When any one of them is disturbed without a proper compensation in another, a venous pulse is the result. The First Factor. If the defect is either in the valves of the heart or in the stroke, there will not be sufficient force to over-distend the arteries. The impulse Avill be trans- mitted on through the capillaries into the veins, for the arteries are then, practically, inelastic tubes, and exert no modifying influence. Ihe Second Factor. If the weakness is in the coats of the artery, even though there be a sufficient heart-impulse, the elasticity of the arteries not being great enough to mod- ulate it, it Avill still propagate itself through the capillaries into the \reins. PHYSIOLOGY AND HISTOLOGY. 29 The Third Factor. If the peripheral resistance of the capillaries is lessened sufficiently, as when their walls are dilated from any nervous cause, the arteries will not be over-distended, and the impulse will continue on through the Avhole circulation. 30 PULTE COLLEGE PRIZE PAPER. X Describe fully a Nerve, and give its Physiolog ical Properties. A. Description. A nerve is a conductor of impulses and impressions. It is composed of one or more bundles of nerve fibers, held together by an investing sheath. Nerve fibers are of three kinds,—the medullated, the non-medullated, and the gelatinous. The Medullated Fibers are those which contain, in addi- tion to the axis-cylinder, a surrounding envelope of med- ullary substance, called the white substance of Schwann. This is in turn surrounded by the sheath of Schwann, a homogeneous membrane containing oval nuclei longi- tudinally arranged. In this sheath are contractions, the stria? of Frommann, but they do not extend to the axis- cylinder. The Non-medullated Fibers are those which are of the same structure as the foregoing, except they do not contain medullated substance. They are found at the origin and at the peripheral extremities of the nerves generally. The Gelatinous Fibers, or fibers of Remak, are. gray in color, of a flattened shape, and contain oval nuclei. They are not abundantly found. More are present in the sympathetic than in the cerebro-spinal system. They are most numerous in foetal life, and are present in regenerating PHYSIOLOGY AND HISTOLOGY. 31 nerve tissue. They have been denied a classification as nerve fiber by some authors, and have been called simply connective tissue. Others have not regarded them as dis- tinctive nerve fibers, but have considered them to be un- developed or rudimentary fibers of the medullated or non- medullated variety. The axis-cylinder seems to be the part of the nerve essen- tial to its proper function, as it is constant from the origin to the termination. It is marked by longitudinal striations, which are thought, by some writers, to indicate a fibrillated structure. The nerve fibers are bound together by the perinevre into primitive bundles or funiculi. These bundles are again gathered together, and held by the perineurium. This constitutes a nerve, although the smaller nerves con- tain sometimes but one funiculus. Besides the nerve fibers and sheaths, each nerve contains accessory anatomical ele- ments; as, blood-vessels, probably lymphatics, connective tissue, and nervi nervorum. Xerve fibers neither branch nor divide, but continue uninterruptedly from center to periphery. A fiber from one nerve will cross to another, thus assisting in co-ordination. The nerves of the cerebro-spinal system originate in the brain from different parts of its structure; in the spinal column by the anterior and posterior roots, the motor, and co-ordinating and sensory, from the spinal cord. The sympathetic system is a chain of nerves and ganglia con- nected Avith the cerebro-spinal system, and dependent upon it. Xerves terminate, generally, by gradually becoming less in diameter, until they are lost to the microscopic eye. They terminate specially in the terminal plates of the mus- cles,- the taste bulbs, the tactile corpuscles, and the corpus- cles of Krause. 32 PULTE COLLEGE PRIZE PAPER. B. Physiological Properties. The axis-cylinder conducts, the other parts are accessory. The nerves are carriers, both from the center to the periph- ery and in the opposite direction. The efferent fibers bear motor impulses from the brain. The afferent fibers convey sensory impressions to the brain. There is no known dif- ference betAveen the afferent and efferent nerves in anatom- ical structure. Nerves possess the property of irritability to a marked degree. They can be stimulated by electricity, Avhich re- sembles nerve force. They are capable of being regen- erated. They are conductors of nerve force or vitality. That they are the connecting link betAveen the brain and the outside world is knoAvn; but how the brain and the governing mind are united, neither the physiologist nor the microscopist has revealed. NERVOUS DISEASES. Professor A. C. Rickey requested the members of the Senior Class to meet in the hall of the college Febru- ary 28, 1882, to be examined in Nervous Diseases. He gave permission to any member of the Junior Class who desired the examination to meet with the Seniors. Mary Wolfe, of the Juniors, accepted the privilege. When the students Avere assembled, Professor Rickey wrote on the blackboard the following problems, and re- quested they should be answered in writing then and there in his presence, viz: NERVOUS DISEASES. I. Give the Pathology, General Symptoms, and Treatment of Neurasthenia. II. What Tissue Changes usually result in Inflammation of the Nervous Tissue and its Coverings f III. Define Paralysis, Hemiplegia, Paraplegia, Hyjjerasthesia, Anasthesia, Paresis. IV. Give the Pathology of the Epileptic Seizure. V. Give the Pathology and Nature of Locomotor Ataxia. VI. Give the Pathology and Symptoms of Cerebral Hemorrhage. VII. Name and Describe Three Leading Pathological Conditions in Insanity. VIII. State the Symptoms and Prognosis in the Different Forms of Tubercular Meningitis. IX. State in General Terms the Use of Electricity in Nervous Diseases. To the above problems Mary Wolfe wrote the follow- ing answers: „ 'eWoiis \@)ise,ps. CLASS 1883. Examination Week in a medical college is always an event of deep interest to the average medical student. The time has come for him to give an account of himself— as to whether he has employed his opportunities profitably or been a spendthrift of his golden chances in the gay dis- sipations of city life. He must now stand face to face with his teachers, and in no doubtful sense answer the questions staring at him from the blackboard or handed him in writing by the exacting professor himself. He must answer at once, with no time for stuffing preparation, in the presence of the professor, and under the searching scru- tiny of his eye. No "boy" ever passed through such an ordeal Avithout feeling his heart beat quicker and stronger than is common to it in health. He has noAv to "toe the mark," and win his grade for graduation. If he fails, he is disgraced, in his own estimation at least. If he succeeds, it is of the greatest interest, not only to himself but friends, to know by what per cent he has passed his examinations, and whether he has fairly Avon a rosette, a medal, or an honor- able mention. To him a ribbon is not a gewgaw, but a badge of honor, when it signalizes a triumph for his indus- try or genius. It ennobles the wearer when he has Avon ;Y2 EX AM IN A Tl OX PA PERS. it for saying the right thing, in the right way, at the right time, and in the right place. When Professor William Owens, Sen., M. D., announced to the class, on Monday, February 26, 1883, that he would on the following day examine the students of Pulte Med- ical College in Materia Medica, more than one heart flut- tered in anticipating the trying ordeal through which '' Old Pap" would put them. True to his announcement, on Tuesday morning he gave to every student in the amphi- theater a list of Ten Drugs for general analysis, one of which only he indicated to each student, to be specially analyzed and classified with reference to its botanical and therapeutic character and qualities. To five members of the graduating class for 1883 he gave for special analysis printed slips containing the following: NUX VOMICA. I. Give Scientific and Common Names, the Natural Order to which it belongs, the Active Principles it contains, and the Part of the Plant used in Medicine. IT. Describe the Paroxysms that Nux Vomica induces. III. Upon what Organ does it produce its Principal Action f State the Manner in which it is affected, and the Condi- tions which result. IV. Give its Sphere of Action. V. Describe its Effect upon the Heart. VI. Describe its Influence on the Brain and Cord. VII. Describe the Mental and Moral Disturbance it induces. VIII. Describe its Effects on the Alimentary Canal. IX. Describe the Effects of Nux Vomica upon the Mucous Mem- brane. X. Give Leading Indications and Therapeutic Use. EXAMINATION PAPERS. 53 On this Drug (Nux Vomica) and its special analysis, Mary Wolfe, of the graduating class of 1883, wrote a paper, of which the following is a transcription, and sub- mitted it for inspection to the professor, who, on Com- mencement night, in College Hall, in Cincinnati, on the 6th of March, 1883, in a speech (says a city journalist) replete Avith personal compliment to the ability of the young Avoman, presented her with a gold medal, of which the following is a facsimile: iTjetiePiet /Jieelicer. Written Tuesday, February 27,1833, from 10 A. M. to 12y2 P. M. NUX VOMICA, I. Give Scientific and Common Names, the Natural Order to which it belongs, the Active Principle if contains, and the Part of the Plant used in Medicine. Technical Name, .... Strychnos Nrx Vomica. Common Names, .... Strychnine—Vomic Nut. Natural Order,.....Apocynaceje. Active Principle. The active principle resides in the alkaloids, Avhich do not differ in the mode of their action, only in the degree of its intensity. They are, Strychnia. Brusia. Igasuria. Of these, strychnia is the most powerful, being twelve times stronger than the weakest. Qualities of the Active Principle. Character. It exists in long crystals, four to eight sided. Color. Grayish white. 56 PULTE COLLEGE PRIZE PAPER. Taste. Intensely bitter. Reaction. Alkaline. Solubility. It is slightly soluble in water, more soluble in alcohol or ether. Portion of the Plant used in Medicine. The germ is the part used. The fruit is about the size and shape of an orange. It has a smooth surface. The pulp of the fruit is innoxious; the seed is very poisonous. The seed is flat aud round, about the size and shape of a silver quarter of a dollar. It is this seed that is improp- erly called the Aromic nut. In the contents of this seed is found the active principle. It is extracted by macera- tion, warm water being generally used to render the process more easy, and a gray powder is the result. From this is obtained the active principle in crystals, as before stated. MATERIA MEDIC A. 57 II. Describe the Paroxysms that Nux Vomica induces. Large Dose. The injection of a large dose of nux vomica causes par- oxysms. There is an afflux of blood to the spinal cord and medulla, affecting the anterior columns of the cord. The whole system of voluntary muscles is affected first, and the involuntary afterwards. The spasm begins by twitching of the extremities and limbs; then the muscles of the trunk, the face, and eyes; then the whole body becomes rigid, and so great is the contraction that opis- thotonus results. The spasm is folloAved by relaxation gradually coming on; but on the application of the slight- est irritation the convulsions Avill recur. The compulsions will continue, unless relieved, until death supervenes from one of two causes : 1st. Asphyxiation. 2d. Exhaustion. Besides the muscles mentioned, those of the throat are violently contracted. The mucous membranes are also congested, and the injection may become so intense that bloody or pinkish frothy secretions follow. Appearances in tlie Paroxysm. The whole body is in a state of tetanus. The eyes protrude, and are staring; the 58 PULTE COLLEGE PRIZE PAPER. pupil is dilated, or just before death is contracted. The face is livid, or pale. The lips are blue; and saliva, ropy and viscid, oozes from the mouth. The teeth are firmly clenched; and often the tongue is wounded and bleeding, which causes the blood in the secretion. The muscles of the throat are firmly contracted. The internal viscera are congested. The mental faculties are generally not disturbed. The hands are clenched; and the whole bcdy is bent up- ward like a bow, resting on the hands and feet. MATERIA MEDIC A. 59 III. Upon what Organ does it produce its Principal Action ? State the Manner in which it is affected, and the Conditions which result. Spinal Cord and Medulla. It produces its principal action on the spinal cord and medulla, causing disturbance of the motor functions of the cord, and also of the functions of those organs whose cen- ters are in the medulla. The disturbance is caused by altered blood supply. The congestion in the medulla is principally along the pons. The respiratory function is disturbed. The special senses are exalted. The mucous surfaces have increased secretions. The muscles, the flex- ors principally, are contracted firmly. The extensors are affected, but the greater poAver of the flexors counteracts their contraction, and the influence of the drug upon the former is only *een in the rigid, stone-like condition of the body apparent to the sense of touch. 60 PULTE COLLEGE PRIZE PAPER. IV. Give its Sphere of Action. Sphere of Action. The chief sphere of action is the solar plexus, and through this it produces its effects upon the various structures of the body. The vaso-motors are also affected. It is by the influ- ence of the drug upon them that the congestion that exists in the cord and medulla and various organs is caused. Nux may be said to act in two Avays: 1st. Traumatically. 2d. Dynamically. 1st. Traumatically by irritating the peripheral filaments of the pneumogastric nerves in the stomach, and by these nerves the influence is transmitted to their centers. Still there could be no disturbance of function without change in the blood supply, so the nerves of organic life which control the blood-supply must be affected even here. The action of the pneumogastric seems to be simply to convey the im- pression or stimulus, and then the other system receiAres it and acts. Until the organic system is impressed there can be no change in the function or state of an organ or tissue. 2d. Dynamically by its direct influence upon the organic nerves. The influence here is neither traumatic or chem- ical, but that of force to force, and is the true homoe- opathic relation of the drug to the system. Nux acts as an irritant to these nerves, causing increased function, then decreased and exhaustion. Upon the struc- ture of the tissue they supply it acts in the same way. MATERIA MEDICA. 61 V. Describe its Effects upon the Heart. Effects upon the Heart. Upon the heart its influence is first to depress and then to increase its action, causing also violent spasmodic palpi- tation. The increased action of the heart accelerates the circulation, and it is through this quickening of the circu- lation that the effects on many organs of the body are produced. This action is through the cardiac ganglia of the organic system. The reaction of the system against the drug results in the stage of relaxation and depression. 62 PULTE COLLEGE PRIZE PAPER. VI. Describe its Influence on the Brain and Cord. Influence on the Brain and Cord. The effects which it produces on the brain and spinal cord are the result of altered blood supply. A. Brain. 1. Upon the cerebrum. There may be a momentary depression of the faculties. This is almost immediately folloAved by exaltation, even intoxication, and extreme clearness of ideas, and subsequently by stupor or dullness. 2. Upon tlie sensorium. The special senses are disturbed. The senses of smell and taste are perverted, and also that of hearing. The general effects on the brain are to be attributed to the congestion and conditions following this. There is headache in the region of the temples OATer the eyes, and a sensation of fullness, as if the pains Avere pressing outward. 3. Medidla. The respiratory centers are disturbed, and the function of respiration is thus perverted. In the large dose asphyxiation may result even. B. Spinal Cord. Here the congestion of the capillaries causes by lateral fluxion a disturbance of the functions of the motor columns of the cord. The muscles receiving nervous stimulus here are first throAvn into a violent state of contraction, and then exhaustion results. The muscles of the throat, of the whole voluntary structure, are affected. MATERIA MEDICA. 63 VII. Mental and Moral Disturbances. The condition of the mind during the paroxysms in- duced by Nux is either undisturbed or exalted. The symp- toms Avhich may occur at the different stages of the action of the drug can all be traced to the altered blood supply. There may be confusion of ideas, affections of the sight, delirium, raving, and hallucinations. The congestion in the cerebro-spinal system induced by this drug is generally at the parts to Avhich the irritation is first transmitted by the pneumogastric nerve from irritation of its peripheral filaments. 64 PULTE COLLEGE PRIZE PAPER. VIII. ' Describe its Effects on the Alimentary Canal. Digestive Tract. Tongue. The tongue is heavily coated, at the back part especially. The coating may be Avhite, yellowish, or brown. Taste. The taste is abnormal. There is a rancid taste as of old butter, or the taste may be acrid or sour, or even bitter from the condition of the organs of digestion. Stomach. As the drug begins to act, the secretions are slightly increased; this improves the appetite. As the action of the drug becomes more intense, the greater in- crease of the secretions and their perversions destroy it. The food is undigested, and remains as a foreign body in the stomach, causing a sensation as if a stone were there. There are eructations of rancid, sour, and CATen bilious character. Catarrhal conditions in the stomach, Avith nau- sea and vomiting. Food passes into the intestine undi- gested. Sensation as of overloaded stomach, as if the result of too hurried eating, irritable condition of membrane lin- ing the stomach, as in drunkards. Desire for stimulants early in the morning. Burning and discomfort in the epigastrium. Intestinal Tract. Food passes undigested. May be pain in the abdomen and tympanitis. Diarrhea painless. Pain may occur before the stool. May be lienteric or catarrhal. Constipation follows from exhaustion, and is prolonged. MATERIA MEDICA. 65 IX. Describe the Effects of Nux Vomica upon the Mucous Membrane. Mucous Membrane. Eyes. The conjunctiva is injected, and there is conges- tion in streaks, particularly at the inner canthus. The lachrymal secretion is increased. The vision is blurred. Sensation of heat and burning in the eyes. Xose. Slight increase of secretion, Avith perverted sense of smell. Patient smells candle-Avick and sulphur. Mouth and Pharynx. The secretion is first increased in quantity, then its quality becomes changed. It is viscid and slimy, and the contraction in the throat causes it to be ejected in jerks. Stomach. There is increased secretion. By this the di- gestive process is first favored, and then by the continued increase it is disturbed. The function of the gastric juice is rendered abnormal, and the process of absorption is disturbed. Intestinal Tract. Here the secretion is increased, and a catarrhal condition results. Absorption is interfered with, and a diarrhea of a lienteric or papescent character results. All these conditions in the digestive tract are followed by exhaustion, which is the reaction after the influence of the drug has passed away. Respiratory Tract. The effect here is not marked, being but slight increase of function and consequent depression. 5 66 PULTE COLLEGE PRIZE PAPER. X. Give Leading Indications, and its use thera- peutically. therapeutic relations. Head. Headaches, lateral headaches, pressing out over the eyes. Congestive headaches; headaches connected with gastric derangement when bilious. Sedentary '' nux " habits ; head- aches in drinkers. Conjunctivitis. When in conjunction with gastric trou- ble, and when the congestion is most at the inner canthus, with the conjunctivitis symptoms. Throat. Tetanus. When the teeth are firmly locked, and when the spasm extends all over the body. Even if of traumatic origin. Type of effect of drug on motor nerves. Spasm of Throat. Preventing swallowing. Increased secretions in the throat, ejected in jerks. Hydrophobia. Spasmodic conditions about the throat. Dread of swallowing fluids. Slightest irritation, even a draft of air, will cause a spasm. Alimentary Tract. Gastric Catarrh. When increased secretion and digestion disturbed. When the result of intemperance or hurried MATERIA MEDICA. 67 eating, accompanied by nausea. May or may not have thirst. Craves stimulants. Loss of appetite. Burning sensation in parts affected. Gastralgia—Dyspepsia. When the foregoing symptoms, sensation as of a load in the stomach. Vomiting, eructa- tions. Digestive function impaired. Headache accompa- nying, etc. Diarrhea. Painless. May be pain before the stool, but not at the time of stool. May be flatus also. Worse in the early morning. Constipation, obstinate, persistent, has been relieved by nux high. Tongue coated. Catarrh of the Ducts of Liver. Epilepsy and Chorea. The tetanic spasms and tAvitchings of the muscles, the oozing saliva and rigid contractions, with other symptoms characteristic. Leading Uses. In all gastric affections, when the results of catarrhal conditions, intemperance, hurried eating, and sedentary habits. In fevers, Avhen gastric derangements complicate. In disturbances of the brain which result from impaired digestion, as headaches, convulsions, vertigo. When thirst is present before and after, but not during fever. In spasmodic affections, when the convulsions are tetanic and characteristic. SURGERY. Written Wednesday, February 28,1883, from 10 A. M. to 1 P. M. On Wednesday morning, February 28th, the day suc- ceeding Dr. Owen's examination on materia medica, Dr. Hartshorn had the class assembled in the amphitheater to be examined in surgery. Lady members of this class had good reason to be a little nervous before this man. He had made them painfully conscious of the fact in his lec- tures during the Winter that he was not friendly to their co-education \vith men in the profession of medicine, and by his individual mannerisms had made their situation so unpleasant that, in the maintenance of self-respect, the continuity of their studies had been seriously interrupted. This petty persecution Avas reported to the other members of the faculty of the college, and Avas made a subject of discussion in their regular meeting, Avith Hartshorn pres- ent. At this meeting, a clause in the prospectus of the college was pointed out to Hartshorn, Avhich, as an induce- ment to ladies to enter the alumnaB, required certain lec- tures to be given them in a class apart from the men. When he submitted the following list of surgical problems to the class the ladies knew they must do square Avork and ask no favors: SURGERY I. Give the Symptoms of Shock. II. Give the Treatment of Shock. III. Give the Different Forms of Hemorrhage. IV Give the Kinds a,nd Forms of Wounds. V. Give the Signs of Fracture. 70 PULTE COLLEGE EXAMINATION PAPERS. VI. Give the Kinds of Fracture. VII. Give the Signs of Dislocation. VIII. Give the Differential Signs that Determine a Fracture of the neck of the Scapula jrom Subglenoid Dislocation of the Humerus. IX. What Muscles are on the Stretch in Subglenoid Dislocation of the Humerus. X. What a,re the Signs of Inguinal Hernia f XI. What are the Signs of Strangulated Hernia f XII. In what Position would you place the Patient to best enable you to Reduce Inguinal Hernia ? XIII. In what Direction would you make Taxis f XIV. Give the Differential Diagnosis between Hydrocele, Hemato- cele, and Scrotal Hernia f XV. Name the Different Forms of Aneurism. XVI. Wliat are the Signs of Aneurism f XVII. What is the Pathological Difference between True and False Aneurism. XVIII. In Dislocation of the Head of the Femur on the Dorsum Ilii, what Muscles are relaxed and what in a State of Tension 1 XIX. What are the Signs of Concussion of the Brain f XX. What Conditions call for and justify the Operation of Colotomy ? AnsAvers to all of the above questions and propositions were written by Mary Wolfe in the presence of Professor Hartshorn in a closely compiled paper of about seventeen large pages, and submitted to him for inspection. The reason Avhy it does not appear here, and the treatment Hartshorn gave this paper, and the final disposition he made of it is shown in the appendix. See Appendix. PHYSICAL DIAGNOSIS. Written Wednesday, February 28,1883, from 1% to 5K P- M. Following the examination in surgery, in the after- noon, of the same day, February 28th, Professor Crawford examined the class in physical diagnosis. The questions and propositions submitted Avere as follows: PHYSICAL DIAGNOSIS. I. Differentiate between Functional Disturbance and Organic Heart Disease. II. Differentiate Mitral Insufficiency from Mitral Constriction, Aortic Insufficiency and Aortic Constriction. III. Give the Signs in Incipient Phthisis. Also those in the more advanced, stage. IV. Give the Differential Diagnosis between Lobar and Lobular Pneumonia. V. Give Method of making Examination of the Liver, and Differ- entiate between Cirrhosis and Cancer of the Liver. To the foregoing Mary Wolfe Avrote the following paper. 'Iwsicei ID; ia ^r)©s is. I. Differentiate between Functional Disturbance and Organic Heart Disease. Functional Disturbance. 1. Rhythm. The rhythm of the heart is not disturbed. 2. The Pulse. The pulse may intermit, but it will beat in time Avhen the pulsation is resumed, as beat, rest, rest, beat, beat, rest, the time for each beat and rest being the same. The character of the pulsa- tion as regards force and qual- ity is generally normal. 3. Palpitation. Palpitation occurs from external causes, as excitement, indigestion, and pressure, and passes away when the cause is removed. Organic Disease. 1. Rhythm. The rhythm is disturbed. 2. The Pulse. The distur- bance is not a true intermis- sion, but rather an irregular, unrhythmical beating; as there may be a feAV fast beats, then a few sIoav ones, and then several fast, then one sIoav, and all out of time. The character of the pul- sation as regards force and quality is generally less than normal, being Aveak and com- pressible, shoAving the lack of proper "A'is a tergo" in the circulation. 3. Palpitation. Palpitation occurs from internal causes— the condition of the heart— and can only be overcome by the disappearance of the heart disease itself. It is the effort of the suffering organ to find rest, a struggle against the progress of the lesion. PHYSICAL DIA GNOSIS. 73 ■4. Character of Murmur. The murmurs are more blow- ing in sound. The murmur is affected by exercise being diminished or obliterated. 5. Mode of Appearance. The patient is made suddenly aAvare of the fact that the organ functions abnormally. The causes might with pro- priety be called acute in functional disease. 6. Syynptomatic. 7. Pain. Generally pre- cardial distress, dyspnoea, and fluttering. 8. General Appearance. Does not indicate heart dis- ease. 4. Character of Murmur. The murmurs have a more substantial sound, a rushing or surging noise. The murmur is affected by exercise, being increased in intensity. 5. Mode of Appearance. The approach is more insid- ious. It may be a year before the patient has sufficiently severe symptoms to diagnose it subjectively. The causes are generally chronic or long operating. Almost all organic disease is originally functional. 6. Idiopathic. 7. Pain. Pain is not marked; may extend doAvn the left arm; is frequently absent. 8. General Appearance. May be cyanotic look or an- emic expression. II. Differentiate— Mitral Insufficiency from Mitral Constriction, I. Mitral Insufficiency. 1. Synonym. Mitral regurgi- tation. 2. Time of Murmur. The murmur is synchronous with the first sound of the heart. 3- Cause of Murmur. The regurgitation of blood through the left auriculo - ventricular opening, permitted by the in- sufficiency of the valves. 4. Frequency of Occurrence. First in frequency. 5. Area of Greatest Intensity. The area of greatest intensity is a circle about two inches in diameter, which has for its center a point a little to the left of the apex beat of the heart. The murmur can also be heard in the dorsal region, from the fifth to the eighth vertebra?. Mitral murmurs are heard in the elbow (?) II. Mitral Constriction. 1. Synonym. Mitral obstruc- tion. Mitral stenosis. 2. Time of Murmur. The murmur is Avith the second sound of the heart. 3. Cause of Murmur. The ob- struction to the onward course of the blood through the left auriculo - ventricular opening, caused by a constriction or ste- nosis of the valves. 4. Frequency of Occurrence. Rarer than the two forms spe- cially mentioned. 5. Area of Greatest Intensity. The area is similar to the fore- going, only the center of the circle of greatest intensity is at the apex beat or a little to the right of it. The other conditions are the same. It can not be heard posteriorly. Xote. These differential points may be affected by abnor- mal surrounding conditions, and changes in the position and size of the heart itself. It would be impossible to e\-en attempt to mention all these; but they are all to be deduced logically from the normal differential signs. II. Aortic Insufficiency and Aortic Constriction. III. Aortic Insufficiency. 1. Synonym. Aortic regurgi- tation. 2. Time of Murmur. The murmur is with the second sound of the heart. 3. Cause of Murmur. The regurgitation of blood through the left semi-lunar valves, caused by their incompetency. 4. Frequency of Occurrence. Rarer than the two forms spe- cially mentioned. 5. Area of Greatest Intensity. The area of greatest intensity is a surface that corresponds to the sternum, in the projection to the right, just beloAV the clavicle, over the junction of the third and fourth costal cartilages, extending out about an inch. The point or center of greatest intensity in this area is behind the sternum, a half-inch to the right of the junction of the fourth costal cartilage to the sternum. Aor- tic murmurs are also heard in the dorsal region the whole length of the thoracic cavity, especially at the lower angle of the scapula. They are also heard in the general circulation, prominent- ly in the carotids. IV. Aortic Constriction. 1. Synonym. Aortic obstruc- tion. Aortic Stenosis. 2. Time of Murmur. The murmur is with the first sound of the heart. 3. Cause of t Murmur. The obstruction to the onward course of the blood through the left semi-lunar valves, caused by constriction or ste- nosis. 4. Frequency of Occurrence. Second in frequency. 5 Area of Greatest Intensity. The area is similar to the fore- going. The murmur is heard with greater facility when the rhythm of the heart is not dis- turbed, as it accompanies the first sound, and the time is longer. The murmur is also heard dorsally, and is propa- gated throughout the circula- tion, being heard in the caro- tids, above the clavicle. N. B. Be careful to catch the murmur in the artery, because it may sometimes be confused with a mitral murmur, propa- gated through the tissues when in an abnormal state; as when a hepatized lung coexists, the law of sonorous vibration in solid bodies might propagate a mitral murmur widelv. 76 PULTE COLLEGE EXAMINA TION PAPERS. III. Give the Signs of Incipient Phthisis ; also those of the More Advanced Stage. A. Incipient Phthisis. 1. Family History. A permissible means of physical diagnosis. 2. General Appearance. If well nourished, or the re- verse. If good circulation. If Avell-formed chest. Tem- perament. 3. Contour of Bones. They shoAv a tendency to tuber- cular habit, if the shafts are slender and the extremities large. 4. Emaciation. Just beginning, noticeable about the neck, the larynx, and clavicle. 5. Change of natural complexion. 6. Preternatural brightness of the eyes. 7. Twitching of the muscles of the face and chest. 8. D Hit at ion of the ala nasi on the affected side. 9. Hectic Hush on the cheek. 10. Cyanosis seen in sclerotic. 11. Clubbing and curving of the finger nails, from malnu- trition caused by obstruction of the circulation through the subclavian veins by tubercular deposits. 12. (Edema of the glottis. 13. Thickening, by infiltration, of the vocal cords. 14. Tubercles in larynx. 15. Voice of lary)igeal Plithisix. 16. " Thenuometric Wuce." Pathognomic c. The tern- PHYSICAL DIAGNOSIS. i l perature is normal in the morning. It begins to rise about ten o'clock, and continues to ascend until two o'clock in the afternoon, Avhen it reaches its greatest elevation. It re- mains high until ten o'clock in the evening, when it begins to decline, and is again (about) normal in the morning. B. More Advanced Stage. 1. The sigm in the incipient stage are all present. The change in the general appearance, the progressive emacia- tion, the hectic flush and laryngial complications, becoming more marked. 2. The apices of the lungs are the seat of the first deposits of tubercles. These gradually extend downward until depo- sition takes place in the loAver lobes. Auscultation and percussion reveal this, the region Avhere they exist being marked by an absence of vesicular murmur and dullness on percussion—higher pitch. There is shortness of breath; at first only on exertion, aftenvards at all times. There is increased frequency of respiration. As new and more ex- tensive portions of the lung become involved in the deposit, constitutional disturbance increases. There is expectora- tion ; this is the result of the inflammatory action set up by the true tubercles, acting by their presence as foreign bodies. The presence of the true tubercle in the sputum can be determined by the microscope. There may be ab- scess Avhich can be diagnosed objectively. There may be hemorrhage, or expectoration streaked with blood. When the specific gravity of the expectoration is greater than AArater it is generally broken-down lung-tissue and pus, not the muco-purulent secretions of chronic bronchitis. As the disease advances, still more serious complications occur to disharmonize the system, such as disturbed gastric and in- testinal function and oedema of the extremities. The Avhole appearance of the patient says phthisis, wasting away. 78 PULTE COLLEGE EXAMINATION PAPERS. Give the Differential Di and Lobular Lobar Pneumonia. 1. Synonyms. Croupotts Pneumonia, Diffused Pneu- monia (diffused in the sense of being evenly or contin- uously extended over the lobe). 2. Physical Signs. 1st Stage or Engorgement. Vesicular murmur grows fee- ble until the beginning of the second stage, when it is lost in hepatization. As the Ares- icles fill with the exudation from the blood vessels, rales can be heard on inspiration. These are crepitant sounds and are pathognomonic. 2d Stage. Red Hepatization. When the lungs hepatize the vesicular murmur all sounds are absent excepting those abnormal in the bronchial tubes. Percussion reveals dullness over the whole lobe in this stage. agnosis between Lobar Pneumonia. Lobular Pneumonia. 1. Synonyms. Catarrhal Pneumonia, Interstitial Pneu- monia, Parenchymatous Pneu- monia, Disseminated Pneumo- nia (disseminated in the sense of scattered through). 2. Physical Signs. The stages are the same, but the manner in which the disease is located is different. There are patches of reso- nance and patches of dull- ness and other parts void of all sound. During the sec- ond stage crepitant rales are heard desseminated through- out the lungs, not continu- ously over them. PHYSICAL DIA GNOSIS. 79 3d Stage. Resolution. The rales gradually return, until they become entirely restored in distinctness and volume. 3. Limitation. The disease is generally limited in area by the inter- lobar fissures. One lobe or more of the lung being in- volved. 4. Extent. Generally but one lung or part of one lung affected uni- lateral. 3. Limitation. The disease is limited by the inter-lobular fissures. One lobule or very many being involved. The lobules being isolated each one, or each col- lection of a few. 4. Extent. May extend throughout both lungs, being then bi- lateral. 80 PULTE COLLEGE EXAMINATION PAPERS. V. Give Methods of Making Examination of the Liver, and Differentiate between Cirrhosis and Cancer of the Liver. A. In Marino an Examination of the Liver, the patient should be lying on his back with the abdominal mus- cles relaxed. The bowels should be evacuated prior to the examination. The physical means of diagnosis of most service are: 1. Inspection. 2. Palpation. 3. Percussion. 4. Mensuration. 5. Aspiration 1. Inspection. Notice if there is any circumscribed tumor. If there is general enlargement of the abdomen. If the superficial veins are prominent. Also, if there is a lessening of the proper size. Also, look for ascites. 2. Palpation. The general contour of the liver can be determined. If enlarged or atrophied or smooth or nod- ular. Tenderness can be discovered also by pressure. The general consistency of the organ may be determined. 3 and 4. Percussion and Mensuration. The area of the liver can be defined by these means, and they are of great value in determining the relation of the size to the normal standard. PHYSICAL DIAGNOSIS. 81 5. Aspiration. This means is of service when there is reason to suspect an abscess has formed. When the con- stitutional and local symptoms point this way do not hesi- tate to use the aspirator, as it can do no possible harm and will determine the case at once. B. Differential Diagnosis between Cirrhosis and Cancer, objectively. Cirrhosis. 1. Class of Patients. Gen- erally in drinkers and in those Avhose livers have been overworked. 2. An Atrophy. The liver is small and nodulated. "Hob- nail Liver." 3. Superficial prominent. 4. Pains dull. Veins are Cancer. 1. Class of Patients. In people of the cancerous cachexia. 2. A Hyperplasia, not hy- pertrophy. The liver is larger than normal and nod- ulated. 3. The Superficial Veins are prominent in all cancers, and are so here. 4. Pains sharp and acute. 6 OPHTHALMOLOGY AND OTOLOGY. Written Thursday. March 1. 1883, from 9% A. M. to 12y2 P. M. Writing two papers on Wednesday, " Surgery" in the morning and " Physical Diagnosis" in the afternoon, had a perceptible effect on the spirits of the students. When they met in the amphitheater on Thursday morning they alf looked serious, and some bore the evidence of having passed a sleepless night. Prepared or not, they Avere now expected to tell Professor McDermott, in the forenoon, what they knew about the "Eye and Ear;" and in the afternoon enlighten Professor Buck with their knowledge of "Theory and Practice." On coming before the class, Professor McDermott, in his characteristically rapid way, said substantially that he was in quest of information on several subjects, but, to be definite in his desires, he wanted information on OPHTHALMOLOGY. I. Iritis, its Varieties, Symptoms and Pathology, Progress and Limitation, Local Treatment and Cure. II. Ophthalmia Neonatorum, Cause, Symptoms, Complications, and Local Treatment. III. Errors of Refractions, and Mode of correcting them. OTOLOGY. I. Describe Sub-acute Catarrh of Middle Ear, and give Local Treatment. II. Describe Chronic Suppuration of the Middle Ear. Give Cause, Course, Termination, and Local Treatment. The following paper Avas written then and there by Mary Wolfe, and, Avithout change or modification, handed to Professor McDermott. l^pJ^ffjeiliTjolocrj •