Past exam of the medicine course of the University of Oxford / 1865 / Second examination / Diseases of women and children, and surgery (No. III.)

Original volume: Examination papers for the Degree of Bachelor of Medicine by the University of Oxford (1864–1867). PDF volume p. 43; Oxford, December 1865, No. III. Open the original paper in the scanned volume.

Original questions are transcribed from the public-domain edition. Credit: Wellcome Collection; original supplied by Royal College of Physicians, London. Source and public-domain rights statement.

Enumerate the sources of haemorrhage from the organs of generation in the female, and state the mode of treatment in each case.

Classify the bleeding by anatomical source and by its relation to pregnancy, childbirth and menstruation; treatment must address that source. The amount of visible genital haemorrhage does not measure all the loss: a ruptured ectopic pregnancy or concealed placental abruption can cause major internal blood loss. Initial assessment of severe bleeding concerns the circulation, anaemia and the need for resuscitation while the cause is established. Bleeding from the urethra or rectum must first be distinguished from genital bleeding.

Local sources outside the uterine cavity. The vulva and vagina may bleed from lacerations after childbirth or other trauma, an inflamed lesion, a foreign body, a vascular lesion or cancer. Examination localizes the loss; treatment is local compression and repair of a significant laceration, removal of the foreign body, cause-directed treatment of infection, or specialist management of the lesion. A cervical polyp, cervical ectropion, cervicitis or cervical cancer can cause bleeding from the cervix, often noticed between periods or after intercourse. A suitable polyp can be removed and examined; inflammation requires its cause to be established, while a suspicious lesion requires diagnostic assessment rather than indiscriminate cauterization. After menopause, thin, fragile vulvovaginal tissues can also bleed; this does not remove the need to investigate a suspicious lesion. These are different conditions, not one disease called “uterine haemorrhage”. ^[ref]

Bleeding from the endometrium. Heavy or irregular menstruation may accompany ovulatory dysfunction, uterine fibroids, endometrial polyps, adenomyosis, a coagulopathy, medication effects or endometrial cancer. Modern assessment includes the menstrual and drug history, a full blood count, and selected ultrasound, hysteroscopy or tissue sampling according to the suspected cause. Where appropriate, menstrual bleeding can be reduced with tranexamic acid or hormonal treatment; an intracavitary polyp or uterine fibroid may instead need targeted removal. Persistent postmenopausal bleeding must not simply be treated as an ordinary period. ^[ref]

Early pregnancy. A miscarriage may bleed while pregnancy tissue separates or remains in the uterus. In a stable, confirmed case, expectant, medical or surgical management may be appropriate; heavy continuing loss or infection changes the urgency. Ectopic pregnancy requires a separate plan: selected stable cases may be monitored or treated medically, but rupture with haemorrhagic collapse requires urgent operative control, not treatment of the vagina as though it were the principal source. A hydatidiform mole is another pregnancy-related source of abnormal bleeding; current management includes removal by suction evacuation and subsequent human chorionic gonadotropin surveillance for persistent disease. ^{[ref] [ref] [ref]}

Later pregnancy and labour. Placenta praevia commonly produces relatively painless bleeding, whereas placental abruption more often causes pain and uterine tenderness; these are useful patterns, not infallible rules. Management depends on the mother's circulation, the fetus, the placental lesion and the stage of pregnancy, with urgent delivery when required. A blind digital cervical examination is inappropriate before a possible placenta praevia has been excluded. Ruptured vasa praevia causes fetal rather than maternal bleeding and demands a different interpretation. A small blood-stained mucous “show” during cervical change is not equivalent to these pathological losses. ^{[ref] [ref]}

After delivery. The principal categories are failure of uterine contraction, retained placental tissue, trauma and disordered coagulation. For uterine atony, the aim is to restore contraction with uterine massage and an appropriate uterotonic. Retained tissue, a genital laceration or uterine inversion requires correction of that particular cause; a coagulopathy requires haemostatic support. With placenta accreta spectrum, attempted forcible separation can provoke severe haemorrhage. Current care combines resuscitation with cause-directed measures, and can require tranexamic acid, balloon tamponade, embolisation or surgery when initial measures fail. Later postpartum bleeding also raises retained tissue and endometritis. ^[ref]

The 1865 distinction. An answer of the period could distinguish menstrual loss, local lesions, pregnancy-related haemorrhage and post-delivery failure of contraction through the history and physical examination. Compression, local plugging, removal of an accessible lesion and obstetric intervention were among the available approaches; their use was debated. The 1864 discussion of placenta praevia documents such disagreement. Modern imaging, blood banking, the present drug regimens and current operative pathways must not be attributed to that practice. Nor should historical astringents or depletion be substituted for identifying the source. ^[ref]

State the signs of Pregnancy.

Separate evidence produced by the mother from evidence identifying the fetus. The classical presumptive, probable and positive grouping expresses increasing diagnostic confidence; it is not a numerical probability scale.

Presumptive signs include missed menstruation, nausea or pregnancy-associated vomiting, breast enlargement and tenderness, changes in the areola, urinary frequency and the mother's sensation of fetal movement, traditionally called quickening. Each can have another explanation. Amenorrhoea may result from illness or endocrine disturbance; abdominal enlargement can arise from a pelvic mass, ascites or other causes. A report of movement is not equivalent to movement detected independently by the examiner.

Probable physical signs include a progressively enlarged uterus with the appropriate change in contour, softening of the cervix and uterine tissues, increased vascularity and colour change of the genital mucosa, and intermittent uterine contractions. Ballottement is the rebound of a movable object within fluid when it is displaced: in the right clinical setting it supports a gravid uterus, but the physical phenomenon alone does not identify a living fetus. A vascular sound heard over the uterus follows the maternal circulation and is not the fetal heartbeat.

Positive evidence available to the 1865 examiner was a fetal heartbeat heard with a stethoscope, unmistakable fetal movements appreciated during examination, and identification of fetal parts. Repeated examination as pregnancy advances strengthens their interpretation. The examiner should compare the perceived heartbeat with the maternal pulse rather than accept any abdominal sound as fetal. These findings generally become useful later than the earliest symptoms, so their absence early on does not exclude pregnancy. The mother’s quickening remains a symptom; independently established fetal movement is a different kind of evidence.

Modern additions. Human chorionic gonadotropin testing can detect pregnancy-related tissue before the classical physical signs become conclusive. A positive test does not establish location or continuing viability: it can occur in ectopic pregnancy and must be interpreted in context. Ultrasound can establish location and show an embryo or fetus with cardiac activity. Very early uncertain findings may require repeat assessment rather than a premature conclusion. These technologies are later developments, not signs that an 1865 candidate could have obtained. ^{[ref] [ref]}

With what diseases may Scarlet Fever and Croup be confounded, and how would you distinguish them from those diseases ?

Compare the pattern and sequence of findings; neither a red rash nor stridor is a diagnosis. Historical disease names also need care: nineteenth-century “true” or membranous croup can overlap with laryngeal diphtheria, whereas common modern croup usually means viral laryngotracheitis.

Scarlet fever. An acute throat illness with fever, a fine rough or sandpaper-like rash, a characteristic red tongue and subsequent peeling suggests scarlet fever. Modern scarlet fever is associated with toxin-producing group A Streptococcus; symptoms alone do not uniquely establish the organism. The main comparisons are:

A modern throat test can confirm group A streptococcal infection; it was unavailable in 1865. The useful historical answer therefore rests on careful examination and the clinical sequence, while admitting uncertain or overlapping cases.

Croup and its mimics. A harsh barking cough, hoarseness and stridor suggest narrowing of the upper airway. In common viral croup, the child may have an antecedent respiratory illness without the marked toxicity of a severe bacterial process. In the historical question, however, distinguishing “croup” from diphtheria cannot mean assuming they were mutually exclusive labels. A membrane extending from the throat into the larynx could form part of what was called membranous croup.

The practical priority is the severity of obstruction, not winning a verbal distinction at the bedside. Current guidance minimizes distress and unnecessary throat examination, obtains skilled airway support for deterioration, and does not require routine radiography or swabs in typical croup. These modern precautions also explain why a child should not be forcibly examined merely to demonstrate a membrane. ^[ref]

Describe Muguet—its causes, nature, and treatment.

Muguet denotes the adherent white fungal coating of oral thrush, now oral candidiasis; it is not simply any white tongue or any mouth ulcer. Patches occur on the tongue and oral mucosa and may merge into broader plaques. The underlying surface can be red, sore and liable to bleed when a plaque is disturbed. An infant may feed poorly because the mouth hurts. Milk residue lacks the same persistent inflamed adherent lesion, while an aphthous ulcer is a focal ulcer rather than a confluent fungal plaque. ^[ref]

Cause and nature. The modern explanation is opportunistic overgrowth of Candida, commonly Candida albicans, on a susceptible mucosal surface. An immature or impaired immune system, illness and altered local conditions favour it. Antibiotics, corticosteroids, diabetes and other causes of reduced host defence are relevant modern risk factors. These were not all understood in 1865, and exposure to the organism alone does not explain every case. Local oral candidiasis also does not, by itself, establish invasive fungal disease. ^[ref]

Evidence available in the nineteenth century. Fungal forms could already be observed with a microscope. A contemporary 1849 review reports Charles West's suggestion that the organisms could be transferred by shared cups and spoons, while the reviewer preferred an explanation involving decomposition and acidity. The review is evidence of the disagreement, not authority for spontaneous generation of a fungus. It also illustrates why historical “aphthae”, ulceration and Muguet should not all be treated as identical modern diagnoses. ^[ref]

Diagnosis and treatment. Clinical inspection is often sufficient; when uncertain or atypical, material from the lesion can be examined microscopically for fungal forms, with further laboratory testing when needed. Repeated or unusually severe disease calls for attention to underlying illness and host defence, rather than simply repeating local cleansing. ^[ref]

The historically defensible measures include maintaining adequate feeding, gentle mouth care and clean feeding utensils. Harsh scraping and treating every white patch as the same disease are inappropriate. Present-day treatment adds an age-appropriate antifungal drug, such as a suitable topical nystatin preparation; more extensive or resistant disease may require systemic treatment such as fluconazole. Drug choice and formulation depend on the patient's age and clinical state. Those agents are later additions and must not be placed in an 1865 prescription. Hygiene and correction of predisposing factors accompany, rather than replace, effective antifungal treatment. ^[ref]

How would you perform the operation of tapping the abdomen and the thorax, and in what pathological states may it be expedient to resort to it?

Tapping must follow identification of the fluid-containing cavity: abdominal paracentesis for ascites, thoracentesis for a pleural effusion. An enlarged abdomen or a dull area of chest is not, by itself, a sufficient indication for blind puncture. The object may be relief of pressure or obtaining fluid for diagnosis; neither necessarily removes the underlying cause.

Abdomen: states in which tapping is useful. Tense or troublesome ascites can interfere with breathing, eating and comfort, particularly when it persists despite treatment of its cause. Causes include cirrhosis with portal hypertension, heart failure, malignant peritoneal disease and some inflammatory or infective conditions. New or unexplained ascites can also require diagnostic sampling. General swelling without a drainable peritoneal collection is a different problem. An ovarian cyst, a gravid uterus, a distended urinary bladder and gaseous distension must not be mistaken for free ascites. ^{[ref] [ref]}

Abdomen: operative account. The characteristic historical apparatus is a sharp trocar within a hollow cannula. The patient is supported, the presence and distribution of fluid established, and the urinary bladder emptied to keep it away from the lower abdominal puncture route. Traditional descriptions use an appropriate abdominal site, often in the midline below the umbilicus; a landmark is not sufficient if an enlarged organ, a vessel or adherent intestine is in the way. Once the instrument has entered fluid, withdrawal of the trocar leaves the cannula as the drainage channel. The patient and the flow are observed, and the opening is dressed after removal. This describes the operation's principle, not a universally safe blind puncture point.

Modern performance uses sterile preparation, appropriate local anaesthesia, a selected fluid pocket and a catheter system rather than assuming that every distended abdomen can be tapped in the same place. Ultrasound helps identify a safe pocket and avoid organs and vessels. Samples may be sent for cell counts, protein and albumin measurements, culture or cytology according to the clinical question. Therapeutic drainage requires reassessment because haemorrhage, intestinal injury, leakage, infection and circulatory or renal disturbance can occur. In cirrhotic large-volume drainage, albumin replacement has a specific modern role; it is not an 1865 routine to be projected backwards. ^[ref]

Thorax: states in which tapping is useful. A large pleural effusion producing respiratory difficulty can be relieved, and an unexplained effusion can be sampled to identify its cause. Serous fluid, blood and pus have different implications: pleural effusion associated with heart failure, malignant disease or inflammation is not identical to empyema. A purulent collection may require continuing drainage and treatment of the infection, not merely one palliative aspiration. Contemporary experience already included tapping in hydrothorax; an 1864 report with subsequent anatomical examination illustrates how removal of fluid could coexist with serious underlying disease. ^[ref]

Thorax: operative account. The supported position exposes a suitable part of the chest; the operator first distinguishes fluid from consolidated lung and identifies its upper extent and the diaphragm. An appropriate intercostal route enters the fluid above a rib, avoiding the principal vessels and nerve running along its lower border. The drainage apparatus should permit controlled outflow without freely introducing air. The position of the lung, diaphragm, liver and spleen makes an arbitrarily low puncture unsafe. Historic trocar-and-cannula entry and modern small catheter aspiration share the need to enter the collection without injuring these structures.

Current guidance requires thoracic ultrasound for aspiration of a pleural effusion, a suitable needle or catheter, and slow controlled drainage. Chest tightness, pain, persistent cough or increasing breathlessness are reasons to stop and reassess, not simply to continue until no more fluid runs. Complications include pneumothorax, haemorrhage, injury to an abdominal organ, infection and re-expansion pulmonary oedema. These precautions belong to current practice; they must not be represented as technology available in 1865. ^[ref]

What are the circumstances which determine the selection of Lithotomy or Lithotrity in the treatment of Stone.

Choose the method that can remove the whole bladder stone with the least overall danger in that patient. Here lithotomy means cutting into the urinary bladder to extract the stone; lithotrity means instrumental crushing through the urethra. The latter is not the later technique of external shock-wave treatment, and “no incision” does not mean “no tissue injury”.

The stone. A small, accessible, freely movable stone that can be grasped and broken without excessive force favours lithotrity. Great bulk, great hardness, an awkward shape, several substantial stones or a stone fixed in a recess increases the difficulty of fragmentation and complete clearance. The amount of debris matters: pieces left in the urinary bladder can irritate it, obstruct the passage or provide material for further growth. A historical comparison must count the burden of manipulation and clearance, not imagine that pulverization makes the stone disappear. No single size threshold can be specified independently of the instrument, the stone and the patient.

The access passage and the urinary bladder. Urethral stricture, inadequate urethral calibre, an existing false passage or difficult prostatic obstruction can make introduction of a useful crushing instrument unsafe. A urinary bladder that tolerates exploration, holds a reasonable volume and empties effectively is more favourable than one with marked cystitis, bleeding, extreme irritability or retention of urine. The operator must also consider kidney function, active infection and general reserve. A severely ill patient should not be exposed to a prolonged elective sequence of instrumentation merely because the stone itself seems crushable.

Age and anatomy. In a small child, the urethra may not admit an adequately strong instrument, which helps explain the historical preference for lithotomy in many children. Age is a proxy for anatomy and tolerance, not an absolute law: small instruments and different modern access routes change the comparison. In an older man, the prostate, urinary bladder emptying and general illness can be more important than age alone. In a woman, easier access through a shorter urethra may favour an endoscopic route, but forceful dilation or extraction can still damage the continence mechanism.

The operation and its operator. Cutting risks haemorrhage, urinary leakage, injury and postoperative infection; crushing risks injury from the instrument and retained or impacted fragments. Each method requires skill, appropriate apparatus and aftercare. A contemporary 1859 lecture explicitly contrasts older complicated drilling apparatus with the curved crushing instrument then in use. That is evidence that the available instrument was part of the decision, rather than a timeless property of “lithotrity”. ^[ref]

Practical selection. With a modest stone, passable urethra, tolerably healthy urinary bladder, effective emptying and suitable expertise, lithotrity has a strong rationale. When the stone is too large or resistant for safe fragmentation, access is unsafe or fragments cannot reasonably be cleared, extraction through another route becomes preferable. At the same time, poor general health may make either operation hazardous, so the preliminary task can be stabilization and management of associated disease rather than immediate choice of an instrument.

Modern guidance usually favours transurethral endoscopic fragmentation where feasible, offers a percutaneous route when transurethral treatment is unsuitable, and retains open surgery as an option for very large stones. In children, urethral injury risk can determine the route. These current options illustrate the same anatomical trade-offs but must not be imported wholesale into an 1865 recommendation. Nor should a historical preference for cutting in children be treated as a modern rule. ^[ref]

What are the chances of the return of Cancer after its removal from the Breast.

The historical prognosis was guarded: malignant disease could return after apparently complete removal, and operative recovery was not equivalent to cure. There is no defensible single percentage for the unspecified case in this question. An answer should explain the seriousness of recurrence, its forms and the evidence needed to estimate it, rather than invent an exact probability.

What counts as return? A new nodule in the scar or nearby skin is a local recurrence; involvement of regional lymph nodes is regional recurrence; disease in distant organs is metastasis. These may represent residual local disease, disease already present but undetected, or later growth of disseminated cells. A grossly clear wound therefore does not prove absence of malignant cells elsewhere. A benign mammary tumour erroneously included with cancers would distort any estimate in the opposite direction.

What an 1865 observer could reasonably say. Visible removal could relieve an ulcerating, painful or bleeding breast lesion, but the subsequent course still had to be observed. The extent of the original growth, fixation to surrounding parts, involvement of axillary nodes, the ability to remove it completely and the interval free from disease all mattered to prognosis. Neither early apparent healing nor a short symptom-free interval established that return could no longer occur.

A contemporary 1863 review makes an especially relevant methodological point: recurrence after operation could not be accurately determined among hospital patients who disappeared from observation unless a rapid return brought them back. Thus a statement about the proportion who returned to the surgeon is not the same as a complete recurrence risk among everyone operated on. This contemporary evidence supports a cautious answer without borrowing a later operation or a modern survival statistic. ^[ref]

Present-day explanation. Breast cancer recurrence risk depends on stage, tumour size and grade, lymph node involvement, completeness of excision and tumour biology. Modern assessment also distinguishes hormone-receptor and other molecular subtypes and takes account of additional treatment. Positive margins, more advanced disease and certain aggressive subtypes increase risk. Consequently a modern estimate requires the actual tumour and treatment information; it cannot be inferred from the bare fact that a breast cancer was removed. ^[ref]

Any numerical claim must specify the population, what event is counted, the treatment, the follow-up period and how patients lost to observation are handled. Death before observed recurrence and the difference between local recurrence and distant disease also affect interpretation. A recurrence percentage is not automatically an operative death rate or a survival rate. The appropriate concise conclusion for this historical question is therefore a substantial concern for return, with prognosis conditioned by extent and completeness of removal, and no guaranteed disease-free interval or universal percentage.