Report

on

The First Examination

of

The National Board of Medical Examiners

Report of the First Examination OF THE

National Board of Medical Examiners.

The report of the first examination of the National Board of Medical Examiners was published in the December 9, 1916, issue of the J01wnal of the A . M. A . and in the Decemher B11lletin of the Federation of State Medical Boards of the United States.

It would appear unnecessary at this time to repeat the in­formation contained in that repor t, which was very carefully compiled in the office of the Secretary of t he Board before it was delivered for printing.

To bring the present report up to the moment, however, it may serve to summarize the statements of the Secretary :

1. There were 32 applicants f or t he examination.

2. Sixteen had acceptable qualifications.

3. Ten of the sixt een registered f or the examination.

4. F ive of the t en were successf ul.

5. The general averages of these fiye were 81, 80, l:jO, 78 and 78 on the basis of 100, 75 being the passing mark.

6. The required subjects were Anatomy, Chemist ry, P hysics, Physiology, Pathology, Bacteriology, P harmacology with Materia Medica and Therapeut ics, Me(licine, Surgery, Obstetrics and Gynecology, Hygiene, Medical Jurisprud­ence and a practical examination only in t he Eye, Ear, Nose and Throat.

7. The examination consisted of writt n, oral, laboratory and clinical t ests.

8. The scope of each subject is covered in t he f ollowing ex­hibit :

EXAMINATIONS ANO TIME ALLOWED.

Subject Anatomy .................. .................... .

Cheollst ry nnd phyalcs .......... _ P hyslology .................................. _ P 'lthology .................................... .

Dncter!ololty ........................ _ ...... . Pharmacology. mlltcrla med-

I ~.~ and therllpeutlcs ........... . lledlclne ...................... _._ .......... .

Surgery ........................ _ ............. _

Obstet r ics and gynecology ... . Hygiene ...................... ................. . Medlcnl jurlsprudent·e ............ . Eye, ear, nose nnd throat. ..... . Dermntology ................................ .

WrlUon 3 hours

3 hours 2 hours 4 hours

2 hours

2 hours :1 hours

3 hours

3 hours 3 hours 2 hours

Kind of Examinati on other and Remarks

Oral with prepared specimens; 20 minutes for each candidate

2 hours laboratory In physiologic chemistry I,aborator)". 2 hours I,aboratory examination. 20 minutes, e ch

candidate Lahoratory, 2 hou rs

Laboratory. 2 hours Clinical laboratory, 'AI hour each candidate ;

chemical examination, 2 hours I,nb., Oil. Burg. and Appl. Ana t., 2 hours ;

clinical examination, 2 hours Oral, 20 minutes each candidate

Clin ical examination, 2 bours. ClInlcnl, 20 minutes each candidate

9. The examinat ions began on the morni ng of Monday, October 16, 1916, and were concluded Saturday af t ernoon a t about 5 P. M., October 21. Two night examinations were held (Medical Jurispr udence, writ~en, and Eye, E ar, Nose and Throat, clinical) .

10. The part icular quest ions askell, and t he character of labo· r atory and clinical t ests are detailed in extenso in t he Secretary's r eport.

11. The colleges r epresent ell by the eanclhlates were Rush Medi· cal College (Unh·ersity of Chicago); Johns H opkins; Uni· versity of Michigan; Harvard University; University and Belleyue H ospital Medical College.

12. The successf ul candidates were : Dr. Thomas Arthur Johnson, Rush; Dr. H jorleifur T. Krisjunson, Rush; Dr. Harry Sidney Newcomer, Johns Hopkins ; Dr. William White Southarll, Johns Hopkins; Dr. Orlow Chapin Snyder, University of Michigan.

When the idea of the National Medical Examining Board was submitted at the 1915 meeting of the A. IVI:. A., by the late Wm. L. Rodman, there was large room for belief that a plan for such a Board would meet with obstacles which would be lik ely to prevent its maturity.

The cour age of his own convictions, however, so st imu­lated the author of the idea and the founder of the Board that he carried with him the support of a large proport ion of those

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first opposed and with an energy which seemed inspired by the cause in which he worked, Dr. Rodman sp cad the gospel from one end of the United States to the other, counting no sacrifice too great in the interest of the National Board, which, it is hoped, may remain as a living memorial of his public service.

No detail was spared in maturing the plan conceived by the late Dr. Rodman and he lived to see the Board ready for its first examination, planned upon standards not as yet reached by any examining body in this country and surpassed by none elsewhere.

With two years of college work after a four-year high school course, from institutions of acceptable grade and standing, followed by four years of college work at a Class A medical school, and further supported by one year of internship in an acceptable hospital, the standard for qualification was set by the Board.

EXHIBIT A.

Form of Analytic Record of each approved appUcant for the En.mi­nation of the National Board of Medical Examiners.

NAME .............................................................. ADDRESS .............. _ ............................................. .

High School College M.D. Hospital Charaoter Name of Name of Name of Name of Tbree letters Hlgb Scbool College Scbool of grnd- Hospital of In- of satisfactory wltb year of wltb dates of uatlon wltb tern service content required. graduation. courses or of date and with wltb .In.dlca -

graduation wltb title of ofllclal tlon of cbar-detailed state- furnlshlni cer- acter of service ment of science tillcate. and cbarncter of courses and certl1kate lur-name of ofllclal nlsbed. furnlsblng cer-tlllcate .

Remarks:

The requirement of science credits in the college pre-medi­cal courses was strictly adhered to and more than one applicant with college credit, even with baccalaureate degrees, was thrown out for deficiency in this particular.

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The analysis of the fi 'st examination of the National Board supports the conclusion that it has becn quit e satisfactory from the several object ives for which the Board has been created.

1. It has demonstrated that there a re men who a re willing to undertake a se\' ere test of their proficiency with a view to its certification by a body qualified by experience and training to conduct an examination, based on high st and-­ards.

2. It has demonstrated the yalue of practical examinations in t esting the knowledge of g raduates in medicine.

3. It has shown t he possibility of coordinating material f or clinical examinations and of providing laboratory f acili· t ics f or testing the more academic training of the medical graduate.

4. It has established the usefulness of a thorough t est in de· veloping the best of material f or the personnel of the Corps of the F ederal Services as the , only applicant fo r the Army Medical Corps among the 1h 'e successful candi­dates was admitted to the Reserve Corps of the Army without further mental examinat ion.

In itself this has been an acknowledgment of the thoroughness of the Board 's examination, as the severity of the Army examination for its Medical Corps is prover­bial.

Those who are engaged in medical education may have already studied the report of the Secretary as bearing upon the work of medical schools, for just as the results of State Board examinations have heretofore in large measure served as a test of the pr eparation of the medical graduat e for pr actice, so thc survey of the examination of the National Board must in so e degr ee serve as a basis for comparison of the preparation of thc candidates which' come before it.

The purpose of this Board should not be discouraged by any sent iment about deferring criticism in this regard, where it may be appar ent to others that it has any office to perform. It would seem helpful, therefore, to go further in the analysis of the first examination of the Board with reference to its service as a criticism of the methods of medical college instruc­tion.

The Secretary's report presents in tableau the detail of the grades obtained by the ten candidates, showing the marks in each subject, with final averages of each candidate and with

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final averages of all candidates in each subject. It is the latter column of averages which occasions commentary. Here is the list of subjccts with their avcrages, recast in their percentages, beginning with the highest:

86. 2 ........................ Phnrmncology. Mnterla Medlcll Ilnd Ther peutlcs 80. . ....................... Physlololly 78.1 ........ ................ CheDllstry Ilnd Phys ics 7i. ........................ Obstetrics a nd Gynecology 73.5 ........................ AnntoDly 73.4 ...... _ ................ ~redl clne

71.1 ........................ Medical Jurisprudence 71. . .................. _ ... Pll thololly,. 69.6 . __ ................... HyICiene 69. .. ...................... Bacterlology 68.9 ........................ Surgery

In this table the practical branchcs seem to suffer by com­parison, excepting with the two subjects of Hygiene and Bac­teriology, both of which show poor averages.

On the other hand, with so considerable a number of examiners, the method of arriving at grades may make the dif­ference in per centages, for some men are proverbially severe in grading.

The Board, howeve , in passing finally upon each candidate, subjected him to the commentary of each examiner and it is among the purposes of this report to set forth the character of this analysis of the candidate.

Except to the Secretary, all candidates were known to the examiners by their numbers only. As it happens, only one examiner of the present Board is a member of the Faculty of the school from which one of the candidates came, so com­mentary on the candidates was wholly frank and free of any reservation.

The general conclusions were that the candidates as a whole were average medical graduates; that in the clinical subjects they were fairly grounded; exception is made in the subject of Obstetrics and Gynecology, in which there seemed to be a general lack of practical knowledge.

In the laboratory branches, there was a rather notable weakness in Pathology and in Bacteriology, in the practical laboratory examinations especially. In Pathology, there was general lack of familiarity with gross specimens.

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In Bacteriology, the crit icism developed that while the writ­ten examinations showed fair theoretical knowledge, there was much evidence that medical schools appear to neglect medical zoology, and that much of the practical identification of bac­teriological and parasitological specimens seemed to offer con­siderable difficulty.

In Hygiene, there appear ed a rather wholesale deficiency, and this was especially noteworthy as no attempt was made with a practical laboratory test. None of the candidates re­ceived a passing-grade, the highest mark being 73.3. The ex­aminer specifically remarks that, judging from the marks re­ceived by the candidates in other branches, it would seem as though Hygiene was the most poorly taught subject in our med­ical schools.

As the candidates who were successful were derived from among the best medical schools in the country, such commen­tary may be taken to heart by all of us who may be engaged in medical education.

It is to be remembered that all such statements in this re­port are made without animadversion and solely because the Na­tional Board is on trial and its success must depend upon the confidence it may inspire among those who are earnest in the effort for better prepared medical graduates, for whom no group of individuals is more responsible than those who con­duct and administer medical schools.

The National Board itself has learned much from its first examination. There stands out the fact that such an exami­nation, concluded in six days, is a large tax upon the candidates and on the examiners, as well. Further experience may modify the scope and character of the tests, but for th~ present no change is likely in the plan followed in the first examination.

The coordination of the Army and Navy Medical Schools and the Public Health Service, in their laboratories and with their teaching personnel, materially lessened the labors of the members of the Board. The large service rendered by the staffs of the several Government and other hospitals in Washington, affording clinical material, in bringing patients to one central place for examination, made it possible to pick the best of a

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multitude of cases. As the examinations recur, these facilities will make for more and more systematic arrangement of ma­terial.

Altogether Washington proved ideal for the purposes of the examination and the hearty cooperation of · the Federal Ser vices indicates a continuation of a most successful arrange­ment.

Since the introduction of the National Board of Medical Ex­aminers to the Conference on Medical Education in 1916, con­siderable progress has been made in the general recognition of the Board, and while any notation of this may, in a way, be foreign to a report on the first examination, at the same time, there is a direct bearing upon the examination in that any real support or acknowledgment of the work of the Board has made the members of the Board more confident in their endeavor. While a general assurance had been given to the Board that the Army and Navy Departments would cooperate, it was only within the month preceding the examination that a specific understanding was established with the offices of the Surgeon General of the Army and of the Surgeon General of the Navy, with regard to the status of licentiates of the National Board and these Federal services.

The matter now stands that any successful candidate before the National Board may be accepted without further mental test in either of the Reserve Corps of the Army or Navy upon the following conditions:

1. That the regular formal application for such Federal service must be made through t he regular channels, bef ore the National Board examination is held.

2. That all written papers of such applicants, successful before the National Board, shall be delivered intact and without markings to the Army or Navy Board designated by the

• office of the Surgeon General of the respective services. These papers are to be e"aluated by such Army or Navy Boards, without knowledge or ref erence to the gra des or marks obtained before the Nat ional Board.

The effective relation to such Boards has already been noted in the statement above that the only applicant among the snc-

S

cessful candidates before this Board was admitted to the Re­serve Corps of the Army upon his papers presented in the Board examination.

The large increase projected in the personnel of t1).e Medical Corps of the Army and Navy makes the office of the National Board one of immediate service and of large 'responsibility.

There has been a very general support of the work of the Board among medical journals which have editorially encour­aged its efforts. Perhaps the most direct expression of ap­proval of the Board has come from the Mayo Foundation of the University of Minnesota, which has offered fellowships to the five successful candidates.

The applicants for the first examination, thirty-two in all, show a wide geographic distribution-Illinois (5), New York (4), District of Columbia (3), Georgia (3), Pennsylvania (2), New Jersey (2), Wisconsin (2), Virginia (2), Massachusetts (1), South Dakota (1), Maryland (1), Nebraska (1), North Carolina (1), South Carolina (1), Florida (1), Texas (1), and California (1).

Recognition by Sta.te Boards: The National Board has en­deavored to demonstrate its position as related to the State Examining Boards and is in no way interfering with their office. The National Board for some years to come will be likely to examine but a small percentage of medical graduates. Those who may be successful will surely be qualified to prac­tice in most States and should be acceptable to all of the United States.

This point of view has been taken by many of the States. The Board has solicited from every State and other United States' possessions an opinion, and a summary of all of those is here submitted:

Alabamllr-Recognit ion to come before State Association in June 1917.

Alaskllr-To come up for favorable legislative action in March, 1917.

Arizonllr-Willing to have legislative approval. . Arkansas-To be acted upon by Legislature. California-Law to be offered f or amendment J anuary, 1917. Colorado-P robably willing. No official action. Connecticut-Not willlng.

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Delaware-To ask f avora.ble legisla tive action in J anuary, 1917. District of Oolumbla--Willing to come bef ore official body next

meeting. Floridar-Fa vorable. To ask legislation. Georg1&-Willing to ask legislatiye action. DlinoiB--' 'Cannot recognize Board." Idaho-Will accept Board. Iowar-Endorsed by State Board. Kansae-Unw1ll1ng to recognize. Kentucky-Favorable. No legal action. Louisianar-Favorable. No legal action. Maine-Favorable. No legal act ion. Maryland-Legal recognition. Maasa.chusette-No officia l action. Michigan-Unw1ll1ng. Mississlppl-N oll-committal. Minnesota.-No action. Think Board should be legal. Nebraska.-Opposed to present organization of Board. Virginlar-E ndorsed. Official action in 1918. West Virginlar-No action.

It is the purpose of the Board to increase the representation of the Federation of State Examining Boards, as the terms of the present members expire. Upon the vacancy occasioned by the loss of Dr. Rodman, Dr. Walter L. Bierring was elected for the unexpired term.

It is the opinion of the Board that no group of men is better qualified for service on the Board than those who have worked for better State standards.

Finally, in presenting this report the National Board de­sires to express the highest appreciation of the privilege, ac­corded last year and again at this Conference, of presenting the objects, aims, and operation of the Board. It wishes to give the assurance of the endeavor to maintain a high standard for its examinations-free of all influences and governed by the sole object of serving the medical profession.

ISADORE DYER, Delegate f rom the National Board of Medical

Examiners to the AnnUAl Congress on Medi­cal Educat ion, Public Health and Medical Licensure, Chicago, February 5 and 6, 1917.

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EXHIBIT B.

Detall of Oral and Practical Examinations of the National Board of Medical EXaminers.

ANATOMY ..

Oral Examination.-Canelidates examineu individually f or twenty minutes each during course of written exami nations. Questions ask ed: 1. Osteology: Scapula, axis, atlas anu middle cervical, uorsal and lum­bar vertebrae; temporal bone, f emur, humerus. 2. Neurology: Brain models, casts, spinal cord. 3. Dissections: Showing knee and f ace and neck. 4. Microscopic slides for identification ; zone, cartilage, blood, epithelium, and spinal corel.

In the oral examination in Osteology one or more of the bones men­tioned were used, most f requently the temporal bone and one of the cervical vertebrae.

In Neurology, with a brain cast or mouel, the candidates were asked to point out and name chief divisions, lobes, fissures, convolutions and cranial nerves, anll something of brain localizations.

Unller Dissections there were two wet speci mens f rom the Army Museum, showing the muscles, neryes and blood vessels in f ace and lleck, allll in and about the popliteal space.

There were five microscopes with a. slide for identification under each. The selections were bone, cartilage, skin a.nd a cross section of the spinal cord, and human blood.

The applicants had f rom 15 to 20 minutes each devoted to th oral examination on Osteology, Neurology and Dissection.

PHYSIOLOGY

Laboratory Examination (two hours allowed).-Each applicant re­quired to solve at least one and at most three ' of the f ollowing problems: 1. Put up the appnratus and prepare the gastrocnemius muscle of n f rog, with i ts attacheu nerve, and do men strate on it the cUl'ce of single mus­cular contraction and the synthesis of tetanus. Show that nerve con­duction is a vital prenomenon. 2. Demonstrate the" independent irrita­bility" of muscle in a f rog. Set up the apparatus and demonstrate P lI.iiger's law of cont raction on the nerve-muscle preparation of a f rog. Construct a table representing the f acts. 3. Demonstrate reflex action on a cerebrum-f ree f rog, and the influence of inhibitory mechanisms and processes. 4. P repare apparatus, and the body of the rabbit provided, f or the demonstration of arterial blood pressure and the effects on it of stimulation of the eardiac nel'ves. Isolate the pneumogastric, the sympa­thetic and the depressor nerve in the neck. Draw tracings illustrat ing arterial blood pressure in the rabbit and the influence on it of excitation of the cardiac nerves. 5. Prepare f rom the material provideu a schema f or the conversion of an intermittent into a continuous flow of , fluiu, and apply it to the explanation of the prenomena of the animal circula­tion. 6. (a ) Set up an experiment for recording blood pressure in caro-

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tid artery of rabbit. Isolate vagus nerve and depressor ner ve of heart. (b) :Make synchronous t racings of venous and carotid pulse and analyze findings. 7. Record human arter ial blood pressures by the auscultatory met hod; det er mine ' the length of each auscultatory" phase" and discuss its suspectell r elation to cardiac ef ficiency. 8. Draw tracings illustra ting the f ollowing physiologic prenomena: 1. Arteria l blood pressure in the dog; ihe effect on it of v agus inhibition; of stimulation of the accelera­tor nerves; of asphyxia. 2. Blood pressure in the rabbit; effects of vagus stimulation; effect of depressor st imulation ; 3. Draw anll analyze three sphygmomanographis tracings of the radial a rtery indicating the out­flow pm'iod of the he[nt ana yariable states of 11eripheral resistance. 9. Demonstrate cardiac action in a pithed f rog. Isolate the vagus nerve and demonst rate its inhibitory action. Show the relation of a tropin to vagus inhibition. Perf orm and discuss the experiment of Stamius. 10. From the specimen of aefibrinated blood proYide(l, prepare a dilute solut ion of hemoglobin. Determine its absorption spectrum and depict on the blank scale provided, on which are mad{cd the Frauenhof er lines B to F , first having located the spectrum of sodium vapor. Not e the chance in the spectrum from increasing the concentration of the hemoglobin solution. Prepare reduced hemoglobin with Stokes flui d and obtain its spectrum; reoxidize this and describe the color changes. Pre­pare ca rbon monoxid hemoglobin and determine its spectrum; try to reduce i t; try to convert it to oxyhemoglobin. P repare crystals of hemin f rom a blood stain. 11. Demonstrate on the spirometer the various possi­ble yolume changes in the lungs. Determine as f ar as possible, and illus­trate by a diagram the quantitative relations of the complemental, sup­plemental, t idal and r esidual air; the" dead space" and the" vital capa­city." 12. Demonstrate the action of the intercostal muscles. 13. P re­pare a 1 per cent sta rch mucilage; a 5 per cent aqueous dextrin and a 0.1 per cent. solution of dextrose and some of your own saliya. With the r eagents procided test the solution!!. Demonstrate the reaction of the saliva and the result of incubat ing it 'wi th the starch. From time to time test the resulting chemical changes. Place crystal of sugar on the back and on t ip of tongue in succession and describe the sensory result s ; re­peat with a crystal of quinin on the tip of the tongue. 14. Closing one eye and looking at an upright needle through a card pricked with t wo holes closer t ogether than t he diameter of t he pupil; deter mine the near and far points of vision; nothe that the image of the n eedle becomes double when the eye is focused on points nearer or f arther. Close one of the holes under each condition and note which image disappears. Draw and explain a diagram illustrating the course of light rays in the eye under the yarious circumstances. Obtain and describe a series of negative af ter-images by means of the various disks of cardboard pro­vided. Draw t he out line of the" blind spot" in the eye. 15. With a pair of compasses determine the relative fineness of localizat ion on the t ip of the tongue, t ips of fingers, palm of hand, cheek, back of hand, forehead, back of neck. With a warm metallic knob determine sensitiveness to

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temperature in these parts. With a pointed metallic rod determine the distribution of temperature points on the Hexor surface of your wr ist. Compare your appreciation of small differences in weight through pressure sense alone and combined pressure and muscular sense. Show how to demonstrate Weber's law. I

CHEMISTRY.

Laboratory Examination in Physiologic Ohemistry.-Candidates di­vided in two groups of five each. Each group allowed two hours. Ques­t ions asked: 1 and 2. Analyze urine for sugar. (a) Positive. (b) Nega­tive specimens. 3. Do a complete analysis of urine including urea esti­mation. 4_ Gastric contents, t itration for acidity. 5. Quantit ative sugar. Estima t ion in given specimen.

PATHOLOGY.

Laboratory Examination.-During course of written examination each candidate was given gross specimens and microscopic sections chosen f rom the f ollowing :

Gross Specimens. 1. Cancer of lip. 2. Hyperplastic thyroid. 3. Cancer of breast. 4. Mastitis. 5. Miliary tb. of lung. 6. Cavity formation in tb. of

lung. 7. Pneumonia, red hepatization. 8. Cirrhotic liver. 9. Chronic athrophic nephritis.

10. Nephroma (hypernephroma).

Microscopic Specimens. 1. Ulcer of lip. 2. Epithetioma of lip. 3. Mammary cancer, advanced. 4. Mammary cancer, early. 5. Mammary adenoma. 6. Miliary tuberculosis of lung. 7. Pneumonia, lobar. R. Hepatic eirr.hosis. 9. Chronic diffuse nephritis.

10. Acute nephritis, early.

BACTERIOLOGY.

Laboratory Examination (time allowed, two hours).-1. Stain cul­ture by Gram's method and report as to presence or absence of organism having morphologic and Gram staining characteristics of the meningo­coccus. 2. Examine throat culture for the diphtheria bacillus. 3. Make microscopic agglutination of unknown organism with typhoid serum. 4. Given an animal parasite for identification. 5. Given a stained blood smear for examination as to prcsence of the malarial parasi te. 6. Given specimen of feces containing ova of intestinal parasites-identify one ovum.

PHARMACOLOGY.

Laboratory Examination.-The first of the practical examination eon­sl!lter of a demonstration on a dog that was prepared as f ollows: Anes­thetized with ether, trachea exposed and severed, after which tracheal cannula was inserted and connected with ether bottle, artificial respira-

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tion being continued. Carotid artery was exposed and arterial cannula i nserted, connected with manometer. Vagus nerve exposed but intact. Right f emoral vein exposed and cannula inserted.

Various drugs were introduced into the animal, and the candidate was required to note his observation as to the effect on the blood pressure 0.11<1 the respiration, and to interpret the same. The f ollowing was the order. 1. Effect of ether. 2. Electric st imulation of vagus. 3. Effect of amyl nitrite inhaled into tracheal cannula. 4. Effect of epinephrin (intravenous). 5. E lectric vagus stimulation (second time). 6. Effect of chlorof orm (tracheal cannula). 7. E ffeet of digitalis (intravenous) liu·ge dose t incture (alcohol f ree).

Individual Laboratory Tests in Pharmacology.-In this test each candidate was r equired t o carry out one of the f ollowing : Six f rog ex­lleriments: I njection of unknown solutions: strychnin ; caffein, chloral. F our eat's eye experiments: Introduction of unkno\'I'll solutions : atropin; physostigmin. The candidate was r equestecl to carry out the experiment on t he animal, reeorcl the results with his interpretation, ancl write as complete a protocol as possible.

MEDICINE.

Clinical Laboratory (one hour).-1. Speeimen of urine, chemical analysis 0.11<1 microscopic examination of sediment. 2. Reeognition of hook wor m ova, t amia scoliees, Trichina spiralis, and clifferent types of plasmo(lium. 3. Clinical examination at Garfi ehl Memorial Hospital cov­ering a period of two hours. To each ca11<lidate were assigllecl three patients, referrecl to as one long 0.11<1 two short cases.

The candidate was giv en one hour and twenty minutes f or t he ex­amination of the long case, and required to present a written clinical lIistory, including the physical examination. H e was expect ed f urther to ask f or t he laboratory t ests required by the nature of the cliseased condit ion, and to stand an oral examination on the clini eal history and diagnostic conclusions.

The two short cases were accorded twenty minutes each, and the examinat ion was confined to the physical examination of a well-defined condi tion, as a typieal heart lesion, aortic ancurysm, exophthalmic goiter or enlarged liver.

The pat ients assignecl f or examination represented the f ollowing dis­eases: Typhoid (1) ; tuberculosis of lung (3); aeute endocarclitis (1); aortitis with aortic insufficiency (2); aortic insufficiency (1); aortic aneurysm (2); chronic nephritis (1) ; bronchial asthma (2); chronic myoearditis (1); exophthalmic goiter (1); pernicious anemia (1); clia­betes mellitus (2); hypertrophic cirrhosis of liver (1); tabes dorsalis (1); motor hemiplegia (1).

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OBSTETRIOS AND GYNEOOLOGY.

Oral Examination.-During the course of the written examinat ion each candidate was eXjlmined f or t wenty minutes orally. Quest ions asked: 1. Forceps : Classification of operat ions; indications and limit a­tions of the high operation; indications f or the low operation. 2. Mechanism of labor in a simple fla ttened pclvis: Enlargemcnt and movement s of mechanism, including internal rotat ion. 3. Repair of lacerations af ter labor: I ndica t ions and advantages of the immediat e operation ; technic. 4. Cesarean section: Indications f or the mOllern operat ion. Limits of contract ion in t he absolute indication. 5. I ndica­t ions f or the induction of premature labor: Indications, advantages over cesarean section in contracted pelvis. Relative indicat ions in t reatment of toxemia of pregnancy and of placenta prrovia. 6. Salpingit is : Varie­ties, causes (including bacteriology), clinical history, diagnosis. 7. Cysto­cele : Definition, ordinary complications, symptoms and treatment. S. Ectopic gest a t ion : Definit ion, clinical history, diagnosis, treatment.

I n addit ion to these, each candidate was asked one or two r andom questions, such as t he use of anesthet ics in obstetrics, the usc of pit uitary exaract s, displacements of the uterus, hemorrhage f rom the uterus, and disorders of menstruat ion.

SURGERY.

L aboratory Examination in Operative Surgery and Applied Anat­omy.-Candidates examined in two groups of iive; two hours allowed each group.

First t est (dogs were supplied which had been killed on preceding evening a t the " pound' ' ) : Remoye a portion of the small int estine about 10 inches in length, making two " blind ends" and a lateral anast o­mosis. F or this one hour ~as allowed and the suture lines tested under wat er pressure. Candidates were t hen given living models on whom t hey were to point out: 1. The different incisions used in exposing the gall­bladder, and discuss the advantages and (lisadvantages of each. 2. De­termine by measurements point at which t rephining would be done f or hemorrhage f rom t he · anterior branch of the middle meningeal ar t ery. 3. Outline the surf ace measurements f or locating the fissure of Rolando. 4. Outline the incisions used for amputation at the shoulder joint and discuss methods of control of hemor rhage.

Ollnical Examination.-Candida tes were examined in two groups of five each, two hours f or each group_ Each candida te was given one long case which he could examine for one-half hour, then being examined on it fo r t en minutes, and two short cases which candidates could ex­amine f or fifteen minutes each, t hen being examined f or five minutes on each case.

Long cases: Tumor of liver (probably sarcoma) ; tumor of g roin (carcinoma of inguinal glands); ost eoma of f emur; gast ric ulcer ; tumor of neck (carcinoma of the cervical glands f ollowing carcinoma of the tongue).

IS

Short cases: Intracapsular fracture of hip; tuberculosis epididymi­tis; hydrocele; united fracture of clavicle; myostitis ossificans of vastus internus; hernia (complete indirect inguinal); bone graf t (Albc ) for Pott's discase cancer of mouth; varicosc veins; subsiding appenuicitis.

In addition to thc surgical casc!, there were two patients with skin disease present. Each canuiuate was takcn over then by the examiner on skin diseases. These patients were: 1. Negress, aged abont 23, with seborrheic eczema ; 2. Negress, aged about 29, purpura (or peliosis) rheumati ca.

,EYE, EAR, NOSE AND THROAT. Clinical Examination.-This consisted in demonstration of the can­

didILte's ability to use speciILl instruments required in eye, ear, nose and throat examining.

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