no marked contracture of the hip joint is demonstrable, except that flexion cannot be carried out ad maximum, and that abduction and adduction are limited. The trochanteric region is flattened; right trochanter 11⁄2 cm. nearer to median nearer to median plane of body than left trochanter. A bony tumor in the pelvis, on the right side, is now more readily demonstrable per rectum, but this is less prominent than in case I, and more pointed and irregular at the pole. X-Ray findings same as at time of admission.

Re-examination on May 21, 1907.-Patient walks well with two canes, and can stand alone on the injured leg. No contracture of right hip, flexion possible beyond a right angle, abduction and adduction limited; rotation very limited and painful. Very slight shortening of leg. A bony bulging of the region of the right acetabulum is palpable per rectum and by way of the abdomen. Patient chiefly complains of rectal disturbances, pressure sensation and pain during evacuation of bowels. Claims to be still unable to work.

Case 3-Laborer, 56 years of age. Fall from a ladder; patient intoxicated at the time; ladder falling with him toward left side, so that he struck with full force on the hip-bone against the hard floor of the barn. Was found next morning in a stall at about 20 steps' distance.

Examination in hospital.-Left leg barely shortened; could not be abducted; other movements in hip likewise limited. Inguinal region very tender on pressure. Flattening of trochanteric region when seen from behind, patient standing with closed legs. Distinct bulging felt per rectum at left innominate line. Ecchymoses in hip and inguinal region appeared a few days after the accident. The X-Ray picture showed on the left side, instead of the normal contours of the acetabulum, a

distinct prominence corresponding to the femoral head, which projected about onehalf into the pelvis. The patient was in the hospital for one month, and was able to walk fairly well, although with a slight limp. On the day of his discharge he over-indulged in whiskey to such an extent that he was brought back to the hospital in a dying condition.

Description of prepared specimen: Femur very solid and heavy, shaft as firm. as ivory, wall in places 12 mm. thick, medullary cavity narrow, femoral head short and bulky. Pelvis on the other hand unusually light and delicate, giving rise to a noteworthy disproportion. Articular head of thigh unchanged, well provided with cartilage. Floor of acetabulum is burst apart, articular head has left its position, and has slipped so far into the pelvis that slight abduction causes the trochanter to touch the anterior iliac spine. A new acetabulum has been formed from the fragments, with a smooth. inner surface, but no cartilage. The floor of the acetabulum is open, the fragments gape wide apart, forming an oval gap of 221⁄2 cm. in width and 6 cm. in length. The new acetabulum at the outer side of the pelvis presents a circular configuration, and a diameter of 5 cm.; the head has sufficient room, its mobility is in no way limited, except abduction, the roof of the old acetabulum interfering. Only a scanty amount of new bone has been formed as much as necessary to solder the fragments together. The pelvis in a general way has not changed its shape as a result of the injury.

Case 4-Man, age 71 years; mason. Fall upon right side, from a tree; height of 15 m. Unconscious for some time, afterward. The diagnosis at the timesix years ago

was fracture of the right

acetabulum. Treatment consisted in rest in bed. Findings six years later:

Frail old man; walks with a limp; right hip-joint permits movements to a very limited extent only, so that there is almost complete ankylosis. Right trochanteric region visibly sunken, especially when seen from in front. Trochanter major projects 2-3 cm. beyond RoserNélaton's line, and leg is shortened by that amount. Thigh very atrophic. A painful globular tumor is palpable above Poupart's ligament, as hard as a bone, and apparently not following the movements in the hip-joint. An irregular bony tumor is palpable per rectum on the right side. X-ray picture taken in the dorsal position showed a typical luxatio centralis femoris, femoral head standing as far as at all possible in the pelvis; small trochanter at ischium. A thick, solid, apparently exclusively bony acetabular acetabular floor had formed around the head, assuming a good hemispherical shape. The femoral head and neck appeared entirely unchanged.

The author interprets these cases as demonstrating the occurrence of fractures of the floor of the acetabulum, produced by the forcible entrance of the femoral head into the acetabulum, the head emerging into the pelvis. These cases should be regarded as a sole and characteristic injury also when the fracture lines of the acetabulum are continued into neighboring portions of the pelvis. This injury may be produced by a single act of violence, usually a fall upon the region of the hip, for in the author's cases, as well as in a number of other cases from the literature, only this single traumatic action was demonstrable.

Another case of acetabular fracture observed by the author is reported as illustrating the failure of central luxation to

occur because the femur was obliquely broken off below the great trochanter, thus lessening the blow against the acetabulum produced by the head. If the femur had offered a greater resistance, central luxation would necessarily have occurred, since the acetabular fracture, according to the X-ray picture, entirely corresponds to the other cases, only with this noteworthy distinction that even the slightest associated lesion of the pelvis is lacking, which may be taken to show that these pelvic injuries are produced by the emergence of the head through the acetabular fragments. Illustrative case:

Man, age 57 years; laborer. Fall from a great height (railroad carriage), November 26, 1906. Became unconscious and was removed to hospital. Findings: Right leg about 3 cm. shortened, rotated outward; thigh much swollen in upper half; great trochanter follows rotatory movements; distinct crepitation, apparently in femoral neck. Pain on pressure through abdomen upon acetabular region; no swelling and no bloody extravasate. X-ray picture: Head a little deeper in acetabulum than on opposite side; bony fragment broken off from acetabular floor, and displayed outward. No other injury demonstrable at pelvis. Great trochanter broken away from femur, with a long and very pointed fragment, apparently spiral fracture.

Treatment: Extension with weights in longitudinal direction in strongly abducted position of leg, with elastic traction and countertraction at pelvis and upper end of femur. Attempts with walking early in February, 1907. Discharged March 7 with good repair and function.

Those cases from the literature-16 in number which correspond to the author's assumption of luxatio centralis in regard to the clinical or anatomical find

ings or the kind of traumatism were tabulated by him in chronological order as pure cases of luxatio centralis. These are followed by another table of doubtful and

not pure cases of luxatio centralis-25 in number-which, in his opinion, ought to be omitted in future from the list of cases of luxatio centralis femoris. F. R.

State Medical Examination Questions. Prof. Willis G. Tucker's article upon this subject appears in the last number of the Bulletin of the American Academy of Medicine, from which we quote as follows:

1. That all examinations should be so planned as to be fair both to old practitioners and recent graduates. To this end some latitude in the choice of topics ought to be allowed, and the method in use in New York, New Jersey and possibly a few other States, of giving 15 topics from which the candidate may select 10, is highly to be commended. And for a similar reason the topics ought to cover a wide range and not be confined to some part of the subject, as, for example, to theoretical or to descriptive chemistry, but they should deal chiefly with matters which have some practical bearing or interest. A person may be a very competent practitioner of medicine and yet unable to say very much about "valence,"

or the "four functions of a symbol" (So. Dak. exam., Jan., 1908), though a pupil fresh from a high-school course might find no difficulty in answering such questions.

2. Technical analytical processes in special departments, such as food or water analysis, should not be called for. In the January, 1908, examination in the State of Washington we find this question: "How would you detect the pres

ence of one of the following in food products: Boric acid; formalin; salicylic acid?" The official answer as published in the New York Medical Record of September 12, 1908, selects boric acid and. gives II lines of fine print extracted from a treatise on hygiene describing a particular process as given in a particular book. This is quite indefensible. The practical analyst makes no attempt to carry the details of such processes in his head, but is accustomed to work by his books, and examiners have no right to demand the possession of such detailed knowledge from applicants for license, and the setting of such questions illustrates a remarkable misconception entertained by many examiners, which is a very unfortunate fact from the point of view of the applicant for license.

3. The completion of partially stated chemical equations should seldom be called for. In this respect examiners not

infrequently exhibit a remarkable misapprehension. They appear to imagine that a chemical equation, like certain equations in pure mathematics, may always be solved and can only be completed. in a single manner. Such is by no means the fact. Chemical equations exhibit to us in a quantitative manner what may take place when certain substances act upon others under certain conditions, and physical state, temperature, pressure and

other factors have much to do in determining what the action will be. In many cases there may be no action at all unless certain conditions exist, and in all cases the results are such only as can experimentally be proved, and in many instances these results cannot be foretold.

Chemical equations, then, are radically different from pure mathematical statements, and the habit of selecting equations at random from standard textbooks

and requiring their completion, a part only being given, is an abominable practice which cannot be too strongly condemned. It frequently betokens an imperfect understanding, and may even be indicative of great ignorance on the part of the examiner. I do not wish to be misunderstood here, and desire to add that certain equations representing typical reactions and familiar chemical changes may be properly selected as examination topics, but must be chosen with intelligent consideration or they will be entirely unfair as tests of knowledge, and may, indeed, be such as no ordinary chemist could answer, because the data supplied may be insufficient or the facts called for such as lie outside his experience.

4. As a rule, isolated facts having no practical application nor particular interest should be avoided. For example, such questions as, What is the rarest element, the heaviest metal, etc., should not be given. Probably no one knows, and if anyone does it is of little interest or importance.

5. Questions should be clearly stated, free from all ambiguity, and technical terms should be used correctly. An "equation" should not be referred to as a "formula" (Illinois, October, 1907), nor should ether be called "sulfuric ether" (New York, May, 1908). Such ques

tions as "What is a chemical mixture?" (Idaho, April, 1908) are quite unmeaning, and it is certainly hard to understand what the examiner had in mind by asking, "Under what circumstances is ozone found?" (New Jersey, June, 1908). In recent papers "phosphids" in the urine, probably meaning “phosphates,” are referred to, and we find, "Describe the preparation and state the uses of cyanogen," in which demand the examiners' meaning is exceedingly doubtful, to say

the least of it. Candidates who fail to answer such questions to the satisfaction of the examiner ought not to be blamed. The blame should rest elsewhere.

6. Questions involving methods of manufacture of chemical and medicinal compounds are seldom justifiable. For example, "How is tartar emetic made?" (Michigan, June, 1908). It never is made either by the physician or pharmacist, and no process of manufacture is given in the U. S. Pharmacopoeia. Some manufacturing operations may properly be described in a course of lectures, and, of course, such processes are properly given in books which are intended to be used as works of reference, but students should not be required to burden their minds with such details, and it is very seldom that questions of this class can be selected with fairness as examination topics.

7. Examination questions should be confined to well-established facts and principles, and should not deal with transient fads or individual theories in medicine. In the Michigan examination in May, 1908, one of the questions dealt with the influence of atmospheric ozone upon epidemic diseases and its effect on the respiratory organs. Now, as a matter of fact, we know very little about

atmospheric ozone, its quantity, variations in quantity and influence upon animal life and health, and such subjects ought not to be selected as examination questions.

8. Such questions as "Give Marsh's test" (New Jersey, June, 1908) are not well chosen. There are hundreds of tests known by individual names, and the student may easily confound them. It would be much fairer to call for Marsh's test for arsenic, Griess' test for nitrites, etc.

In conclusion, if no injustice is to be done to the candidate, the marking of the papers must be patiently, intelligently and carefully done. I know of no more tiring task than the reading of examination papers, but he who assumes the responsibility should perform the task faithfully and fairly or resign it to another. We may repeat at the close what was said at the outset, that the written examination is at best an incomplete and unsatisfactory test of knowledge and capacity, and if it is to be employed at all it must be used with discrimination and consideration. When I observe that candidates fail before some of our State boards who had recently passed the repeated examinations, and complied with the other requirements of the faculties of some of our best schools from which they have been graduated, I am greatly in doubt. which judgment as to fitness is correctthat of the faculty which has trained and has personal knowledge of the character and capacity of these graduates, or of the examining board which has judged them by a single series of exclusively written examinations, perhaps poorly adapted to the end in view and possibly with an improper valuation of the papers submitted by the candidates. On the whole, I am

inclined to think that the mere fact of graduation from any one of a large number of our medical schools is prima facie evidence of competency requiring good and well-established evidence to refute, and that, in the interests of justice, some method of appeal to a competent and impartial tribunal from the decisions of our examining boards ought to be provided. I believe that it would be proper to examine the examiners on appointment, and from time to time thereafter, just as army surgeons are required to come up at occasional intervals for re-examination. Were such a test of competency required it would be interesting to observe how many of them would be willing to undergo such a test and how large a proportion would resign their office rather than submit to it. Certainly those who serve the State in positions of such responsibility should be willing to have their ability to discharge their duties properly and justly determined by such tests as are applied in our civil-service examinations. There would be no impropriety nor any indignity in this. If the State is to determine a man's competency to practice. medicine and I think it may properly do this then it behooves the State to provide, under all circumstances and at any cost, examiners of proved capacity and competency, that the rights of applicants be not infringed and all their interests be abundantly protected. There is much here that needs discussion and careful consideration to the end that some betterment may be effected where faulty conditions exist, and if, by bringing some of these matters to the attention of the profession, I may aid in any degree in the inauguration of a new era, my efforts will not have been entirely in vain.