Monday, 3 October 2011

Self Defence


VITAL TARGETS
The body is divided into three sections: high, middle, and low. Each
section contains vital targets. The effects of
striking these targets follow:

a. High Section. The high section includes the head and neck; it is the most dangerous target area.

(1) Top of the head. The skull is weak where the frontal cranial bones join. A forceful strike causes trauma to the cranial cavity, resulting in unconsciousness and hemorrhage. A severe strike can result in death.

(2) Forehead. A forceful blow can cause whiplash; a severe blow can cause cerebral hemorrhage and death.

(3) Temple. The bones of the skull are weak at the temple, and an artery and large nerve lie close to the skin. A powerful strike can cause unconsciousness and brain concussion. If the artery is severed, the resulting massive hemorrhage compresses the brain, causing coma and or death.

(4) Eyes. A slight jab in the eyes causes uncontrol lable watering and blurred vision. A forceful jab or poke can cause temporary blindness, or the eyes can be gouged out. Death can result if the fingers penetrate through the thin bone behind the eyes and into the brain.

(5) Ears. A strike to the ear with cupped hands can rupture the eardrum and may cause a brain concussion.


(6) Nose. Any blow can easily break the thin bones of the nose, causing extreme pain and eye watering.

(7) Under the nose. A blow to the nerve center, which is close to the surface under the nose, can cause great pain and watery eyes.

(8) Jaw. A blow to the jaw can break or dislocate it. If the facial nerve is pinched against the lower jaw, one side of the face will be paralyzed.

(9) Chin. A blow to the chin can cause paralysis, mild concussion, and unconsciousness. The jawbone acts as a lever that can transmit the force of a blow to the back of the brain where the cardiac and respiratory mechan isms are controlled.

(10) Back of ears and base of skull. A moderate blow to the back of the ears or the base of the skull can cause unconsciousness by the jarring effect on the back of the brain. However, a powerful blow can cause a concussion or brain hemorrhage and death.

(11) Throat. A powerful blow to the front of the throat can cause death by crushing the windpipe. A forceful blow causes extreme pain and gagging or vomiting.

(12) Side of neck. A sharp blow to the side of the neck causes unconsciousness by shock to the carotid artery, jugular vein, and vagus nerve. For maximum effect, the blow should be focused below and slightly in front of the ear. A less powerful blow causes involuntary muscle spasms and intense pain. The side of the neck is one of the best targets to use to drop an opponent immediately or to disable him temporarily to finish him later.

(13) Back of neck. A powerful blow to the back of one's neck can cause whiplash, concussion, or even a broken neck and death.
b. Middle Section.

The middle section extends from the shoulders to the area just above the hips. Most blows to vital points in this region are not fatal but can have serious, long-term complications that range from trauma to internal organs to spinal cord injuries.

(1) Front of shoulder muscle. A large bundle of nerves passes in front of the shoulder joint. A forceful blow causes extreme pain and can make the whole arm ineffective if the nerves are struck just right.

(2) Collarbone. A blow to the collarbone can fracture it, causing intense pain and rendering the arm on the side of the fracture ineffective. The fracture can also sever the brachial nerve or subclavian artery.

(3) Armpit. A large nerve lies close to the skin in each armpit. A blow to this nerve causes severe pain and partial paralysis. A knife inserted into the armpit is fatal as it severs a major artery leading from the heart.

(4) S pine. A blow to the spinal column can sever the spinal cord, resulting in paralysis or in death.


(5) Nipples. A large network of nerves passes near the skin at the nipples. A blow here can cause extreme pain and hemorrhage to the many blood vessels beneath.

(6) Heart. A jolting blow to the heart can stun the opponent and allow time for follow-up or finishing techniques.

(7) Solar plexus. The solar plexus is a center for nerves that control the cardiorespiratory system. A blow to this location is painful and can take the
breath from the opponent. A powerful blow causes unconsciousness by shock to the nerve center. A penetrating blow can also damage internal organs.

(8) Diaphragm. A blow to the lower front of the ribs can cause the diaphragm and the other muscles that control breathing to relax. This causes loss of breath and can result in unconsciousness due to respiratory failure.

(9) Floating ribs. A blow to the floating ribs can easily fracture them because they are not attached to the rib cage. Fractured ribs on the right side can cause internal injury to the liver; fractured ribs on either side can possibly puncture or collapse a lung.

(10) Kidneys. A powerful blow to the kidneys can induce shock and can possibly cause internal injury to these organs. A stab to the kidneys induces instant shock and can cause death from severe internal bleeding.

(11) Abdomen below navel. A powerful blow to the area below the navel and above the groin can cause shock, unconsciousness, and internal bleeding.

(12) Biceps. A strike to the biceps is most painful and renders the arm ineffective. The biceps is an especially good target when an opponent holds a weapon.

(13) Forearm muscle. The radial nerve, which controls much of the movement in the hand, passes over the forearm bone just below the elbow. A strike to the radial nerve renders the hand and arm ineffective. An opponent can be disarmed by a strike to the forearm; if the strike is powerful enough, he can be knocked unconscious.

(14) Back of hand. The backs of the hands are sensitive. Since the nerves pass over the bones in the hand, a strike to this area is intensely painful. The small bones on the back of the hand are easily broken and such a strike can also render the hand ineffective.

c. Low Section

The low section of the body includes everything from the groin area to the feet. Strikes to these areas are seldom fatal, but they can be incapacitating.


(1) Groin. A moderate blow to the groin can incapacitate an opponent and cause intense pain. A powerful blow can result in unconsciousness and shock.

(2) Outside of thigh. A large nerve passes near the surface on the outside of the thigh about four finger-widths above the knee. A powerful strike to this region can render the entire leg inef fective, causing an opponent to drop. This target is especially suitable for knee strikes and shin kicks.

(3) Inside of thigh. A large nerve passes over the bone about in the middle of the inner thigh. A blow to this area also incapacitates the leg and can cause the opponent to drop. Knee strikes and heel kicks are the weapons of choice for this target.

(4) Hamstring. A severe strike to the hamstring can cause muscle spasms and inhibit mobility. If the hamstring is cut, the leg is useless.

(5) Knee. Because the knee is a major supporting structure of the body, damage to this joint is especially detrimental to an opponent. The knee is easily dislocated when struck at an opposing angle to the joint's normal range of motion, especially when it is bearing the opponent's weight. The knee can be dislocated or hyperextended by kicks and strikes with the entire body.

(6) Calf. A powerful blow to the top of the calf causes painful muscle sp asms and also inhibits mobility.

(7) Shin. A moderate blow to the shin produces great pain, especially a blow with a hard object. A powerful blow can possibly fracture the bone that supports most of the body weight.

(8) Achilles tendon. A powerful strike to the Achilles tendon on the back of the heel can cause ankle sprain and dislocation of the foot. If the tendon is torn, the opponent is incapacitated. The Achilles tendon is a good target to cut with a knife.

(9) Ankle. A blow to the ankle causes pain; if a forceful blow is delivered, the ankle can be sprained or broken.

(10) Instep. The small bones on the top of the foot are easily broken. A
strike here will hinder the opponent's mobility.


Sunday, 2 October 2011

Types of Arterial system


Here are different types of arterial system of human body.

Pulmonary arteries Systemic arteries The Aorta Arterioles Arterioles and blood pressure 6. Capillaries Functions Now we will see the functions of these parts of arterial system in detail.

Pulmonary arteries

It is a large artery which comes from the superior surface of right ventricle and it carries the deoxygenated blood from the heart to the lungs. It has a unique property that it has exception from the rule that the arteries contain oxygenated blood from the heart to the all remaining parts of body. It exchanges the carbon dioxide with oxygen in lungs.

Systemic arteries

Systemic arteries are an important part of arterial system which can be subdivided into 2 types. Muscular Arteries Elastic Arteries In their tunica media, according to their relative compositions of elastic and muscular arteries, as well as their size and the makeup of internal and external elastic lamina, the large arteries are elastic while small arteries are muscular. These systematic arteries provide blood to the arterioles and after that provides blood to capillaries where nutrients and gases are exchanged.

The Aorta

It is the largest artery of the body. It arises from the left ventricle of the heart and goes up a little. After arising it bends over then it descends through 2 parts of the body, Chest and Abdomen and where it ends it divides into 2 arteries which are called Common Iliac Arteries These iliac arteries then go towards the legs. Traditionally the aorta is divided into the ascending aorta and descending aorta. The descending aorta then divides into thoracic aorta and the abdominal aorta. The very first branches of aorta are coronary arteries which supply blood to the heart muscles. After that come the brachiocephalic artery, the left common carotid and the left subclavian arteries.

Arterioles

These are the smallest part of arteries which by the contraction of smooth muscles of their walls, help to regulate the blood pressure. The arterioles also provide blood to the capillaries.

Arterioles and blood pressure

When arteries go towards the other parts of body from the heart they get smaller. When they reach at one point by decreasing in size they are called arterioles. Theses are strong and have relatively thick walls in size. These contain a high percentage of smooth muscles. These are very important because as a group they are the most regulated blood vessels in the body. They mostly overall contribute in blood pressure. When blood flow speed up and speed down these constantly changes their size. Capillaries It is located within the tissues of the body which transport blood from arteries to the veins and extremely small body vessel. Capillaries play very significant role in microcirculation. Microcirculation is a process in which blood is transferred from heart to arteries, smaller arteries, capillaries, venules, veins and then back to heart. Works of capillaries 1. In the kidneys, wastes are released to be eliminated from the body. 2. In the tissues, oxygen and carbon dioxide and nutrients and wastes are exchanged. 3. In the lungs, carbon dioxide is exchanged for oxygen. 4. In the intestine, nutrients are picked up, and wastes released.

www.arterialsystem.com


Settle On Which Primary Code This Case Suggests: +33225


Start by analyzing the report excerpt

An incision was made along the left deltopectoral groove, and an ICD pocket was dissected out, was geared up with extensive dissection.

Three different guidewires were advanced into the left subclavian vein using the Seldinger technique across the open pocket. The middle of these wires were then used to further a coronary sinus sheath for placement of the left ventricular lead. With some complexity, we were in the end able to advance the coronary sinus sheath in the mid coronary sinus and an angiogram was obtained. After this a left ventricular lead was advanced in the lateral cardiac vein and the tip was advanced to the near LV apex. Electrical testing was done at three separate locations and the rest of these noted a lead impedance of 840 ohms and an R wave value of 17.1 mV.

After this, the bipolar right ventricular defibrillator active fixation lead was advanced to the right ve ntricle, various areas were checked and the lead was lastly fixated along the RV.

Next the bipolar right ventricular defibrillator active fixation lead was advanced to the right atrium. Various areas checked and the lead was in the end fixated along the RV septum and tested.

Post this, a bipolar screw in type right atrial lead was advanced to the right atrium and the lead was fixated to the right atrial wall. Then the coronary sinus sheath was removed with the cutting device maintaining a good lead position of the LV lead.

All three leads were then sutured to the pectoral fascia over the Silastic sleeves; the pocket was then irrigated. Pretty soon the leads were attached to the ICD/BiV device. Then the ICD was placed in the pacer pocket after a standard dose of thrombin material in the pocket. Pocket was then sutured closed.
The patient was given propofol and the following establishment of adequate general anesthesia. Ventricular fibrillation was induced; the advice analyzed and delivered three different DC counter shocks, at last at 36V and the patient converted back to normal sinus rhythm. Patient was awakened from sedation minus obvious side effects.

Find your first stop at an add-on code

The case study appears to be a new implant of a Biventricular Defibrillator with follow-up testing at implant.

While making your way through the first two paragraphs, you should train eyes on the terms describing placement of the left ventricular lead through the coronary sinus. The proper code for this portion is +33225.

Documentation tip: You may see this lead referred to as either a left ventricular (LV) lead or coronary sinus lead.

Add the primary code for that add-on code

The next few par agraphs of the documentation describe lead fixation for the right ventricle (RV) and the right atrium (RA). Also the cardiologist attaches the leads to the device, places the device in the pacer pocket, and sutures the pocket closed. All of this is covered by one code: 33249.

Add-on note: CPT code lists 33249 as a proper primary code for add-on code +33225. Remember that add-on' codes are always carried out in addition to the primary service or procedure and must never be reported as a stand-alone code.

Defib testing earns the final code

The last paragraph of the case study excerpt describes 93641. With defib testing, you want to see impedance in the documentation. Generally physicians will state something like Ventricular fibrillation was induced. The device analyzed and delivered 3 separate DC countershocks, at last at 36V and the patient converted back to normal sinus rhythm. The high-voltage impedanc e was 45 ohms.

Term tip: The defibrillation threshold (DFT) is the minimum energy amount required during ventricular arrhythmia to defibrillate the heart reliably. Knowing the patient's DFT aids the cardiologist confirm that the cardioverter-defibrillator (ICD) programming will provide enough of a surprise to defibrillate the patient's heart.

Ensure your practice hits these points

In a situation like this, the doctor would typically use fluoroscopy, as well; however, it is not documented in this case.

No documentation of fluoroscopy means you should not bill fluoroscopy. When fluoroscopy is documented, you should go for 71090-26.

ICD-9: What's more, the case study does not mention indications for you to select ICD-9 diagnosis codes. Minus a VT [ventricular tachycardia] diagnosis or information relating to primary prevention criteria, this cannot be coded. Either you have to ha ve a payable diagnosis for the ICD or data to support adding a Q0 modifier to 33249.

What's more, check your local requirements for diagnosis codes that support medical necessity for 33225.


Bilateral Neck Dissection with Thyroidectomy Claims


Otolaryngology coding can spring a lot of surprises for you. To cite an instance, let's say your surgeon plans to carry out a bilateral neck dissection with thyroidectomyand trachea resection however ends up having to also perform plate stabilization for access to the lymph nodes in the superior mediastinum. You can overcome this challenge with a thorough review of the documentation and careful use of modifiers.

If you need further proof, take into consideration the following op report. After you review the op note, code the procedure prior to checking out our expert advice below.

Preoperative diagnosis: Medullary carcinoma of the right lobe of the thyroid, stage T4-A, N1-B, M0.

Procedure overview: One more ENT previously started a total thyroidectomy on this patient; however that the cancer was eroding into the trachea; as such he referred the patient to this surgeon. The new surgeon carried out a right modified radical neck dissection with preservation of the spinal accessory nerve and sternocleidomastoid muscle, as well as a left selective neck dissection, removing the lymph node levels II through IV. He also carried out a right thyroidectomy, a resection of the right lateral trachea, and osteotomy of the right clavicle with plate stabilization for access to lymph nodes in the superior mediastinum.
Op Note: Trace the surgeon's work

The relevant details of the op report: We carried out a modified radical neck dissection on the right neck, with preservation of the spinal accessory nerve and sternocleidomastoid muscle. We figured out that the internal jugular vein was involved by disease at level IV, and as such sacrificed the internal jugular vein along with the rest of the neck contents. As we tracked the disease near the phrenic nerve, we saw that the disease was tracking down into the superior mediastinum and possibly involved the right subclavian vein.

In order to offer better exposure to the vasculature in the superior mediastinum, we fractured the clavicle using a Gigli saw. We removed the lymph nodes that were tracking down along the carotid artery and jugular vein. Then we carried out a left neck dissection, removing lymph node levels II, III and IV.

We separated the fascia from the deep surfaces of the sternocleidomas toid muscle, which allowed us to remove the lymph node tissue from levels II, III and IV, thus bringing it anteriorly across the great vessels. As soon as we had it into the anterior aspect of temperature neck, we terminated the specimen and sent it to pathology.

For the entire article and further details on bilateral neck dissection with thyroidectomyand trachea resection, sign up for a one-stop medical coding guide like Supercoder.


Saturday, 1 October 2011

Ensuring Proper Infection Prevention Techniques With A Needleless IV Port


Ensuring Proper Infection Prevention Techniques With A Needleless IV Port

Preventing infection of needleless IV ports could save 30,000 lives a year. According to the Center for Disease Control, that is the number of annual patient deaths from catheter related bloodstream infections. Employing infection prevention techniques becomes paramount to prevent unnecessary patient mortality. So what how are patients protected?

Needleless IV ports are most commonly inserted when patients will be undergoing a continuous infusion regimen such as chemotherapy. Thus, a potential infection may occur each time the port is accessed to administer treatment. Infection prevention requires careful disinfection of the port following each use. Rigorous Best Practices protocols have been implemented nationwide to support a zero tolerance policy on catheter related bloodstream infections.
When inserting the needleless IV port, the infusion nurse is required to maximize a sterile barrier by using a surgical mask and gloves, and sterile drapes. To reduce infection risk the catheter should be placed in a subclavian vein instead of a femoral vein. And the needleless IV ports and dressings should only be changed out if absolutely necessary.

When utilizing a needleless IV port for patient treatment, the infusion nurse must disinfect the port prior to accessing it. The port connector must also be allowed to dry completely.

All of these measures rely on individual compliance and proper technique infection protection.

Now there are several devices clinicians can use to disinfect and protect needleless IV ports that reduce patient infection risk. These port protection devices contain a spongy center or foam pad that is saturated with a disinfectant solution. When secured onto the port, the device is compressed so that the treated sponge disperses the disinfectant, thoroughly cleansing the needleless IV port. The device remains attached to the port until the next treatment administration. Between treatments, patients benefit from added infection protection against airborne pathogens. In a white paper published by St. Francis Hospital of Columbus, Georgia, using a disinfecting device over manual disinfection procedures reduced bloodstream infection occurrences by 56 percent.

Needleless IV port protection devices offer consistent patient infection protection and provide hospitals with better compliance control for reducing catheter related bloodstream infection.


Portacath Placement


Portacath catheter, also known as a port is an appliance that is installed under the skin. It comprises of a septum where different drugs are injected and a catheter that enters the vein. This allows doctors to draw blood samples as often as it is necessary and makes it easier for different medical substances to be injected into the patient's body. With the portacath catheter the discomfort for the patient is reduced because of the fact that their skin is not punctured tens of times a day. The portacath chamber has a silicon cap on top of it. This cap allows hundreds of punctures and after each puncture it seals itself. By doing this it both prevents bacteria from coming in and allows many injections to be done without removing the first catheter.

For every specialist it would be a child's game to place the portacath properly. The doctor has to find the subclavian vein which is just below the clavicle bone. It is easily found by a trained specialist. The needle should slide on the lower part of the bone and that would ensure that the doctor would not miss the vein. What's more, the procedure is done under the supervision of a monitor that guides the doctor. The syringe has to fill with a little blood. This is a result of the blood pressure and indicates that the doctor hasn't missed the vein and has placed the catheter in the right place. Later, a small incision is made a little lower on the chest. The portacath chamber is installed under the skin. Then it is important to clear the whole system with heparin. This is a chemical substance that prevents clots from forming. Both incisions are put stitches in then and the whole procedure of the portacath placement is over.

When you want to have the catheter removed the surgery is even easier. All the surgeon has to do is reopen the two wounds, remove the catheter and the portacath chamber and put stitches in the wounds again. What's important is that you should not forget about the port and neglect it. If you do so it may get blocked by clots and it may cause major problems for you. So, visiting your doctor once a week would prevent you from having any problems.

The whole manipulation can be described as routine and there are very little risks concerning it.

Infections are really rare because the main purpose of this method is to avoid different infections by avoiding a lot of punctures to the skin. This appliance can stay under the patient's skin for quite a lot of time and it doesn't need changing but only cleaning with heparin.

Complications are not totally excluded but they appear extremely rarely. What's more, even when they appear they are not at all serious and are very easily treatable. The main purpose of this device is to keep the patient safer and away from infections and to reduce the discomfort for them.


The Physician Job Interview - Essential Tips for Success


Interviewing for physician jobs can be stressful, as your entire candidacy for what may in fact be the ideal job is on the line. Knowing that a good or bad interview can directly affect the job outcome, physicians often worry, and stress out about the interview - and understandably so! In my years as a practicing physician, as well as an administrator, I have learned a few tips I have found successful for me and those who either I have interviewed or know of as successful physicians in ideal jobs. Here are a few of my Tips for success:

1. I don't know! - yes, for those perfectionists I am going to say it again - I don't know! Seriously, physicians have much trouble with these words. However, the successful physician job seeker knows the value in being prepared to say them. It's okay, though - really! In fact, comfortableness with these words will foster more strength and self-confidence. Additionally, self-confidence will not only allow you to rest easily before the interview, it will radiate from you during the interview, and significantly enhance your visit. As an example, for those medicine and surgery folks that have ever put in a subclavian central line, the saying is "the only doctor who has not dropped a lung (caused a pneumothorax) is the one who has not done enough subclavians!" In placing a subclavian central line, there is the chance of creating a pneumo. Knowing and understanding this, and going over what you know about the procedure all help mitigate your anxiety preemptively. This is im portant when coping in the unfortunate event of actually creating an iatrogenic pneumothorax. Moreover, know that a pneumothorax can and will happen at some point even for the best, will instill confidence before, during, and after the procedure. This will allow you to better prepare and focus on cannulating that vein successfully, rather than anxiously, and cautiously worrying about a complication that is statistically inevitable.

The interview is the same. Know that you are going to get a question that may stump you, or cause you to stumble. Interviewers often have their one favorite tough question meant to stump you to see your response. Most physician interviewers though, greatly appreciate a physician candidate's honesty in an answer . . . the doctor that says "wow, that's a good question . . . I don't know" and then who later follows with "I would probably, etc..." This is a very good response to a tough question. The honest disclaimer is thrown out there and somewhat protects you from whatever answer you then provide. Much like the defensive flag thrown in football after the snap - it is basically a free pass and free down for the offense. This type of upfront openness and honesty will serve you well during the interview. Alternatively, if you force, fake, lie, or develop erratic behavior upon receipt of a tough question, it is likely that your actions will compromise your perceived integrity, an d damage your chance of getting the job. Again, be comfortable and confident in what you know; likewise, it is okay to admit that you do not know - it is actually preferred. Let this sink in, believe and understand it. This will drastically reduce your anxiety, enable you to perform better during the interview, and allow you to present yourself as an intelligent, knowing, and honest physician candidate!

2. Presentation - judgment is quickly passed, and the dinner just about ruined when the thanksgiving turkey that is un shaven, smells, has the garnishments mismatched and thrown everywhere, that is rushed to the table late, and sizzling as if it just came out of the oven, while the cook is tucking in the foil! Well, neither do physician interviewers. Unlike responding to ER call let's say at 3:30 am, it is not okay to show up at an interview disheveled. It is imperative that the interviewee is clean, punctual, and sharp. If you have to drive hours to arrive at your interview, bring a change of clothes just to be fresh. Try to avoid the jacket with countless wrinkles, etc., unless you are prepared to wear a sign on your back asking everyone to excuse you, because you had to drive 2 hours! Now there is no need to by the Armani suit with gold cufflinks. Any suit is fine it's just that it has to be conservative, professional, clean, and pressed. Avoid having interviews on vacation with family where you are just passing through, and decided to check out an opportunity. Unless you have your interview suit, I would wait until you can return. First impressions matter, much like the thanksgiving turkey! And oh by the way, just as there is now room for excessive garlic, clove, or cumin on the turkey, it goes without saying, excessive perfumes and colognes are unacceptable, unless you know exactly what cologne or perfume your interviewer likes. In that case, spray away! If not, do not risk completely distracting or turning an interviewer off because of your strong, offensive, perfume! On the other hand, breath mints can save embarrassing post-prandial halitosis. They can even give you a lift during a long boring interview. Carry a few in your pocket.
3. Enthusiastic Engagement - you will never know the number of non-doctor personnel that hold great influence on your successful candidacy for a position. For example, the secretary and administrative assistant to the Program Chairman of 30 years; or the Directors housekeeper nicknamed "Ma"; or the security officer at the parking lot who son had the . . . etc., etc. Bottom line here is treat everyone with enthusiasm, excitement, and engagement. Look everyone in the eye, warmly shake their hand, and don't rush to look away or else risk appearing superficial or dismissive. Talk with them, ask questions to get them to talk about their hospital, or practice which they love.

As for the interviewer, show interest. Be observant to the pictures in the office, awards, objects, and ask questions. Likewise, while walking through the practice setting, do the same. You should have also done the necessary online research to learn about the interviewer and group. You must ask the appropriate questions for these will cause the interviewer to proudly talk about their accomplishments, achievements, or special interests - and everyone loves to themselves in a show and tell manner . . . even interviewers!. In doing so, you will be liked because you will appear to have similar interests, or at least an appreciation and awareness of the interviewers most proud and enjoyable memories - and you will be remembered.

Posture and positioning are both essential, and worth mention here. It is a delicate balance between respect and rigidness. Finesse must be both practiced and exercised here in order to do this properly. As an example, imagine the military officer on base. There is a time to be rigid, formal, and upright, and yet there is time and place to be at ease. On the interview, walk briskly, assertively, firm handshakes, sit upright (and not laid back legs spread) until you know it is time to do otherwise. If you are being 'cross examined' and the interviewer is walking or pacing around the room so to speak, remain upright. If the interview is in the medical staff lounge, and the interviewer takes off his lab coat, leans back on a sofa, it's time for you to do the same. All the while, maintain your enthusiastic engagement, and you will succeed.

4. Mind Your Manners - this tends to tie in with the aforementioned sections, but it deserves separate mention because so many of us doctors feel that we are above reproach. Yes we are good, yes we are the best in what we do, yes we save lives, but also, yes we all have mothers who will slap our hands and wash our mouths our with soap for misbehaving! So mind your manners on the interview - even if you don't in your daily life! Ladies first, opening doors and waiting for the trailing person to pass, not interrupting someone else talking are key. This may seem basic, but trust me, over the years, you would not believe the number of physician candidates I have encountered who didn't understand this. One does not have to be ridiculously excessive, but appropriate is ideal. Although I was never in the military, I must mention it here again. Think of the soldier in uniform . . . everyone just loves their demeanor, manners, courtesy and appropriateness. On your interview, be have like that soldier. Everyone will like you just the same as the solider. Moreover, this too will aid in attaining the best physician job.

5. Stories and Anecdotes - are often entertaining, and allow you to leave lasting impressions. When answering a question about you, your reasons for moving to this city, or joining the practice - tell a story. Importantly of course, is that you must directly answer the question. However, adding a descriptive, brief story allows for your creative, engaging, jovial, side to appear. Note that you should only do this only a few times during the interview. An excessive amount of storytelling or anecdotes will distract from the interview. You don't want to have more stories to tell than the interviewer! The other benefit to stories and anecdotes for the savvy and wise physician interviewee, it allows you to smoothly transition onto an attribute that you are waiting and hoping to discuss. For example, if you have applying for an infectious disease position, and as a child spent years in South America with your family in the military - when asked "what are your strong attribut es?" consider this reply: My strong attributes in my work ethic arise from my father's military background. For many years we lived in various countries during my childhood, in South America, Latin America, etc." This should then trigger the next question from the infectious disease chairman to be one that excitedly and curiously delves into the infectious disease experiences in South America. Smoothness, and timing are key, so be on the lookout for the right time.

6. The Minor Details - cumulatively are worthy of their own section. These are important aspects of preparation and execution that help make your interview complete:

a. Bring extra, clean and unblemished copies of your CV or resume

b. NEVER bring up salary or remuneration unless directly asked of you.

c. Do not arrive on time to the interview -ARRIVE EARLY!

d. Obtain business cards at the end - useful for thank you cards later

e. Eat light when dining with interviewer, and avoid alcohol

f. Express gratitude and thanks for the interview


Cardiovascular System: Blood Vessels


The three layers of the artery include the intima, media, and adeventia. Intima is the inner most layer that comprise the artery wall. It is a thin wall lines that lines the artery wall with endothelial cells successfully separating blood flow from other layers of the wall of artery

The media is the middle and the thickest of the three walls (Wright, 1993). Media contain strength mechanism like smooth muscles, elastin, and collagen.

The last layer, Adventia is the outermost layer of the artery wall that mostly contains collagen. Adventia provides form and strength of the artery wall.

How do arterial walls differ from venous walls?

There is great difference between arterial wall and the venous wall. Artery usually takes oxygenated blood to various parts of the body while venous take blood back to the heart. Therefore, arteries have to carry blood with high resistance due to heart pumping system. To stand this resistance, arterial walls are thicker while the venous wall is thinner. Venous wall contain valves that prevent push blood back to the heart.

What is the function of valves in the peripheral veins?

Peripheral veins usually take blood from the peripheral parts the body back to the heart. The blood going back to the heart is not pumped and therefore flows back to the heart freely (Wright, 1993). Peripheral veins usually contain vales that prevent the blood from flowing back. Valves are designed to help blood go in one direction against gravity up towards the heart.

Why are arteries deeper than veins in the body?

Arteries appear deeper in the body while veins appear superficially. Arteries work under intense pressure taking blood to organs from the heart. This means that they have to be deeper to withstand the high pressure and be able to reach the vital organs while veins operate under low pressure with no rush return path that can be put superficially (Wright, 1993). Therefore it appears arteries lies deeper in the body to protect them and help them contain high pressure.

Activity 2: Identifying the Major Arteries and Veins on a Fetal Pig


Name the major artery and vein that deliver and drain blood to and from the head.

Carotid arteries supply blood to the head and neck. Blood from the head is taken back to the heart by internal and external jugular vein, subclavian vein, brachiocephalic vein and finally into the superior vena cava vein that enters into the heart (Wright, 1993).

Name the blood vessels that deliver and drain blood to and from the heart.

Major arteries leaving the heart including aorta, pulmonary trunk, arterial duct, and pulmonary arteries

Major veins entering the heart including anterior vena cava and posterior venacava

Describe the branching of the aorta as it leaves the heart. Where does it go?

As the aorta takes blood away from the heart, it braches into the following arteries taking blood to different parts of the body (Wright, 1993):

Carotid arteries taking blood to neck and head Coronary arteries supplying heart with the blood Hepatic artery taking blood to the liver Mesenteric artery taking blood to the intestines Renal arteries taking blood to the kidneys Femoral arteries taking blood to the legs Name the major arteries and veins that deliver and drain blood to and from the upper appendages.

Left subclavian artery supplies blood to the shoulder area. Axillary artery supplies blood to the upper arm while brachial artery supply upper arm region below the elbow. Radial artery supply lateral side of forearm, ulnar artery supply medial side of the forearm, and palmar arches supplies hand and fingers (Wright, 1993) Palmar venous arches drain hands and fingers while cephalic veins empty into axillary vein. Medin cubital vein connects cephalic and basic vein at the elbow. Radial veins drain lateral side of forearm and ulnar vein drains medial side of the forearm. Axillary vein drains the axillary areas and empties into axillary vein. On the toher hand, subclavian vein drains blood from the shoulder.

Name the major arteries and veins that deliver and drain blood to and from the lower appendages.

Femoral arteries take blood to the legs. This branches to right and left iliac arteries which supplies pelvic organs. Femoral artery supplies thighs, popliteal artery supplies knee and tibial arteries supplies area below knees (Wright, 1993). Plantar arches supplies foot and toes. Plantar venous arches veins drain feet and toes while anterior and posterior tibial veins returns to the heart blood from below the knee. Femoral veins drain the thigh. External ilica vein drain the groin, internal iliac vein drain pelvic organs. External and Internal iliac vein forms the inferior vena cava that enters the heart

What is the large vein that enters the liver? Where do its branches originate from?

The large vein that enters into the liver is hepatic portal vein. Hepatic portal vein carries blood that has been drained from spleen, gastrointestinal tract, and other associated organs. This vein carries blood contain absorbed nutrients from food (Wright, 1993).

Name the major artery and vein that deliver and drain blood to and from the kidneys.

Renal arties are chief artery that supplies blood to the kidney (Wright, 1993). Right and left renal arteries supplies blood to each kidney. Renal veins drains blood from the kidneys.

What are the differences (if any) you noticed between the major arteries and veins in the human versus those in the pig?

Comparing blood supply in pigs and humans, it is evident that pigs have a larger internal thoracid and subscpular arteries compared to humans. This provides for extensive flow of blood (Wright, 1993).

Conclusion:

Deep vein thrombosis or DVT is a condition that leads to formation of blood clots (thrombus) in deep veins. It is a form of inflammation of the vein that leads to clot formation. The conditions mostly affect the leg veins like femoral vein and popliteal vein or the pelvis veins. It is caused by mechanism including decrease in blood flow the damaged blood vessel wall or due to increase tendency of formation of blood clots (Wells, Owen, Doucette, Fergusson, Tran, 2006). Sometimes the veins of the arms are also affected. Although it may sometimes occur without symptoms the affected part will be painful, swollen, red, warm and engorged. Sometimes, the clot may dislodge and travel to lungs leading to pulmonary embolism.

Lab Report: Exercise 5: Cardiovascular Physiology

Purpose: To understand the working of the cardiovascular system

Activity 1: Heart Sounds What is the cardiac cycle?

Cardiac cycle refers to any event that is related to the flow of blood that takes place from the beginning of the heartbeat up to the beginning of the next.

Explain the steps of a cardiac cycle.

There are five stages of a cardiac cycle. First late diastole occurs when semilunar valves close and AV vales open relaxing the heart. Second is arterial systole where artia contract, AV vales open and blood flow to atrium. Third is Isovolumic ventricular contraction where ventricles contract, AV vales close, and no change in volume (Black and Hokanson, 2004). Fourth is ventricular ejection when ventricles empty and semilunar vales open. The last stage is Isovolumic ventricular relaxation where pressure decrease and no blood enters into ventricles, ventricular stops contracting and relax, and semilunars shuts as the blood from aorta push them out.

What do the "lubb" and "dupp" heard through a stethoscope represent?

"lubb" is the first sound that is produced in the heart by the closure of the of two atrio-ventricular vales occurring when the ventricles starts to contract. On the other hand, "dubb" is the second heart sound (Black and Hokanson, 2004). This sound is produced by the closure of the aortic and pulmonary valves. It is the louder aortic valve closure that precedes a quieter triscuspid vale closure.

What is a heart murmur?

Heart murmur is extra heart should, which is produced due to turbulent blood flows sufficient enough to produce audible noise (Black and Hokanson, 2004). Murmurs are usually listened through the stethoscope whiel some may be heard without a stethoscope.

What information can a physician obtain from auscultating your heart with a stethoscope?

Stethoscope is a medical device mainly used for auscultation. It is used to listen to internal sounds of the body. It listens to lung and heart sounds (Wright, 1993). It also listens to intestine and blood flows in arteries and veins. It generates information that can diagnose defect heart, lung, stomach, human fetuses, and others. It can also generate information on abnormal respiratory, cardiac, pleural, arterial, and intestinal sounds.


Friday, 30 September 2011

Affordable cost Coarctation of the Aorta surgery in India


Affordable cost Coarctation of the Aorta surgery in India.

Coarctation of the Aorta surgery in India – an Overview

Coarctation of the Aorta surgery in India:

Coarctation of Aorta surgery in India is being provided to international as well as Indian patients with best healthcare facilities. The patients are being hospitalized in corporate hospitals which are available in all major metropolitan cities of India having well trained and fully equipped staff present 24*7 at the service of the patients. These hospitals have JCI certified senior and immensely experienced surgeons having abroad expertise in their own specialty.

What is Coarctation of the Aorta?

Coarctation of the aorta (CoA) is a relatively common defect that accounts for 5-8% of all congenital heart defects. Coarctation of the aorta may occur as an isolated defect or in association with various other lesions, most commonly bicuspid aortic valve and ventricular septal defect (VSD). The diagnosis of coarctation of the aorta may be missed unless an index of suspicion is maintained, and diagnosis is often delayed until the patient develops congestive heart failure (CHF), which is common in infants, or hypertension, which is common in older children. This article discusses the pathology, pathophysiology, clinical features, noninvasive and invasive evaluation, and therapy in patients with coarctation of the aorta.

Causes:

Numerous theories have been proposed for the etiology of coarctation of the aorta, including postnatal ductal constriction, translocation of ductal tissue onto the aorta, and a theory that alterations in intrauterine blood flow cause altered flow through the aortic arch and result in the substrate for coarctation. Coarctation of the aorta manifests when the ductus closes starting at the pulmonary end, with gradual involution of ductal tissue toward the aorta. Similar to most forms of congenital heart disease (CHD), the etiology of coarctation of the aorta may be explained by multifactorial inheritance hypothesis. The prevalence of coarctation of the aorta in genetic abnormalities such as Turner syndrome (45,X), is as high as 15-20%. Familial patterns of inheritance of coarctation have been reported, as well as for other left heart obstructive lesions. An increase in seasonal occurrence of coarctation of the aorta is reported in September and November.

History

The presentation of patients with coarctation of the aorta (CoA) varies but may be discussed relative to the patients who present early, often with congestive heart failure (CHF), and the patients who present later, most often with hypertension.

Early presentation: The presence of associated defects and aortic arch anomalies, the extent of patency of the ductus arteriosus, the rapidity of the process of closure of the ductus arteriosus, and the level of pulmonary vascular resistance determine the timing of clinical presentation and the severity of symptoms. Young patients may present in the first few weeks of life with poor feeding, tachypnea, and lethargy and progress to overt CHF and shock.20,15 These patients may have appeared well prior to hospital discharge, and deterioration coincides with closure of the patent ductus arteriosus. Presentation may be abrupt and acute with ductal closure. Development of symptoms is often accelerated by the presence of associated major cardiac anomalies, such as ventricular septal defect (VSD). Symptoms may be subtle at first, and patients may make repeated trips to the physician before finally presenting in extremis. Late presentation: Patients often present after the neonatal period with hypertension or a murmur. These patients often have not developed overt CHF because of the presence of arterial collateral vessels. Diagnosis is often made after hypertension is noted as an incidental finding during evaluation of other problems, such as trauma or more routine illness. Other presenting symptoms may include headaches, chest pain, fatigue, or even life-threatening intracranial hemorrhage. True claudication is rare, although an occasional child may experience pain or weakness in the legs. Many patients are asymptomatic except for the incidentally noted hypertension. Frequently, coarctation of the aorta is not recognized by the primary care physician. Palpation of femoral pulses and measurement of blood pressure during routine examination is necessary to avoid a delay in the diagnosis.

Surgical Care

Significant hypertension or congestive heart failure (CHF) is an indication for intervention. Surgical relief of the aortic obstruction and catheter interventional techniques (balloon angioplasty and stents) are available alternatives. Symptomatic neonates and infants should undergo urgent intervention soon after the infant is stabilized. Asymptomatic infants, children, adolescents, and adults should undergo the procedure electively. If neither hypertension nor heart failure is present, elective surgical or balloon therapy in children aged 2-5 years is suggested. Waiting beyond age 5 years for surgery or balloon therapy to relieve aortic obstruction is not advisable because of the evidence of residual hypertension if intervention is performed after age 5 years.

Since the introduction of surgical correction by Crafoord and Nylin (1945) and by Gross and Hufnagel (1945) in the early 1940s, surgical therapy has been the preferred treatment for aortic coarctation. Various surgical techniques have been used to treat patients with coarctation of the aorta, namely, resection and end-to-end anastomosis, patch aortoplasty, left subclavian flap aortoplasty, and tubular bypass grafts. The techniques are occasionally combined or modified to fit the individual patient's anatomy.

For instance, a reverse left subclavian flap aortoplasty may be used, turning the left subclavian artery as a patch back toward the left carotid artery to enlarge an area of transverse arch hypoplasia. In addition, an extended end-to-end repair may be used, in which the segment of descending aorta is beveled and brought up to the underside of the transverse arch to enlarge areas of transverse arch hypoplasia. The exact technique used varies depending on the patient's age at presentation, size, associated abnormalities, and arch anatomy. A surgical approach from a median sternotomy, rather than the classic left lateral thoracotomy, is used commonly in complex arch repairs.

In a review of 1337 patients undergoing repair of coarctation in infancy, the following findings were reported: Subclavian flap aortoplasty was performed in 763 patients (57%). Resection in end-to-end anastomosis was used in 406 patients (30%), and patch aortoplasty was used in 133 patients (9.9%). In addition, 20 patients underwent placement of an interposition graft or bypass graft. In the series, the mortality risk was highest in neonates in whom surgery was performed during the first week of life, whereas only 8 of 279 infants aged 3 months to 1 year who underwent surgery died. Mortality associated with surgery was also higher in smaller infants, particularly in infants who weighed less than 3 kg and infants with associated cardiac anomalies. The presence of a ventricular septal defect (VSD) with or without minor associated anomalies increased the risk of death from 0.9% (no anomalies) to 6.8% (with VSD). Complex associated anomalies, such as a single ventricle or transposition of the great arteries, greatly increased the mortality rate to 16.6%. Similarly, the surgical mortality rate in neonates who required surgery prior to coarctation repair was 45%. Urgent surgery may be required if the patent ductus arteriosus cannot be opened and the patient continues to have poor urine output and acidosis.

Why India:

We always put our “Patients First”. We strive to provide comprehensive, quality and cost-effective healthcare services. A specialist hospital that provides advanced, leading-edge medical care…India’s hospital enables us to be at the forefront of clinical research, and to translate new knowledge into safe, advanced treatment options for our patients. With state-of-the-art facilities and dedicated, well-trained staff. Our medical expertise is internationally recognized for its high standards and medical breakthroughs. Doctors and surgeons undergo rigorous training at established medical institutions, and continually upgrade their knowledge and skills. They are supported by qualified nurses, clinicians and other healthcare professionals. Experience our world class healthcare system in cosmopolitan and culturally vibrant cities of grace.


Sherlock Holmes by Conan Doyle


MR. SHERLOCK HOLMES.part1:
IN the year 1878 I took my degree of Doctor of Medicine of the University of London, and proceeded to Netley to go through the course prescribed for surgeons in the army. Having completed my studies there, I was duly attached to the Fifth Northumberland Fusiliers as Assistant Surgeon. The regiment was stationed in India at the time, and before I could join it, the second Afghan war had broken out. On landing at Bombay, I learned that my corps had advanced through the passes, and was already deep in the enemy's country. I followed, however, with many other officers who were in the same situation as myself, and succeeded in reaching Candahar in safety, where I found my regiment, and at once entered upon my new duties.
The campaign brought honours and promotion to many, but for me it had nothing but misfortune and disaster. I was removed from my brigade and attached to the Berkshires, with whom I served at the fatal battle of Maiwand. Ther e I was struck on the shoulder by a Jezail bullet, which shattered the bone and grazed the subclavian artery. I should have fallen into the hands of the murderous Ghazis had it not been for the devotion and courage shown by Murray, my orderly, who threw me across a pack-horse, and succeeded in bringing me safely to the British lines.
Worn with pain, and weak from the prolonged hardships which I had undergone, I was removed, with a great train of wounded sufferers, to the base hospital at Peshawar. Here I rallied, and had already improved so far as to be able to walk about the wards, and even to bask a little upon the verandah, when I was struck down by enteric fever, that curse of our Indian possessions. For months my life was despaired of, and when at last I came to myself and became convalescent, I was so weak and emaciated that a medical board determined that not a day should be lost in sending me back to England. I was dispatched, accordingly, in the troopship "Oron tes," and landed a month later on Portsmouth jetty, with my health irretrievably ruined, but with permission from a paternal government to spend the next nine months in attempting to improve it.
I had neither kith nor kin in England, and was therefore as free as air -- or as free as an income of eleven shillings and sixpence a day will permit a man to be. Under such circumstances, I naturally gravitated to London, that great cesspool into which all the loungers and idlers of the Empire are irresistibly drained. There I stayed for some time at a private hotel in the Strand, leading a comfortless, meaningless existence, and spending such money as I had, considerably more freely than I ought. So alarming did the state of my finances become, that I soon realized that I must either leave the metropolis and rusticate somewhere in the country, or that I must make a complete alteration in my style of living. Choosing the latter alternative, I began by making up my mind to leave the hotel, and to take up my quarters in some less pretentious and less expensive domicile.
On the very day that I had come to this conclusion, I was standing at the Criterion Bar, when some one tapped me on the shoulder, and turning round I recognized young Stamford, who had been a dresser under me at Barts. The sight of a friendly face in the great wilderness of London is a pleasant thing indeed to a lonely man. In old days Stamford had never been a particular crony of mine, but now I hailed him with enthusiasm, and he, in his turn, appeared to be delighted to see me. In the exuberance of my joy, I asked him to lunch with me at the Holborn, and we started off together in a hansom.
"Whatever have you been doing with yourself, Watson?" he asked in undisguised wonder, as we rattled through the crowded London streets. "You are as thin as a lath and as brown as a nut."
I gave him a short sketch of my adventures, and had hardly concluded it by the time that we re ached our destination.
part2:
"Poor devil!" he said, commiseratingly, after he had listened to my misfortunes. "What are you up to now?"
"Looking for lodgings." {3} I answered. "Trying to solve the problem as to whether it is possible to get comfortable rooms at a reasonable price."
"That's a strange thing," remarked my companion; "you are the second man to-day that has used that expression to me."
"And who was the first?" I asked.
"A fellow who is working at the chemical laboratory up at the hospital. He was bemoaning himself this morning because he could not get someone to go halves with him in some nice rooms which he had found, and which were too much for his purse."
"By Jove!" I cried, "if he really wants someone to share the rooms and the expense, I am the very man for him. I should prefer having a partner to being alone."
Young Stamford looked rather strangely at me over his wine-glass. "You don't know Sherlock Holmes yet," he s aid; "perhaps you would not care for him as a constant companion."
"Why, what is there against him?"
"Oh, I didn't say there was anything against him. He is a little queer in his ideas -- an enthusiast in some branches of science. As far as I know he is a decent fellow enough."
"A medical student, I suppose?" said I.
"No -- I have no idea what he intends to go in for. I believe he is well up in anatomy, and he is a first-class chemist; but, as far as I know, he has never taken out any systematic medical classes. His studies are very desultory and eccentric, but he has amassed a lot of out-of-the way knowledge which would astonish his professors."
"Did you never ask him what he was going in for?" I asked.
"No; he is not a man that it is easy to draw out, though he can be communicative enough when the fancy seizes him."
"I should like to meet him," I said. "If I am to lodge with anyone, I should prefer a man of studious and quiet habits. I am not strong enough yet to stand much noise or excitement. I had enough of both in Afghanistan to last me for the remainder of my natural existence. How could I meet this friend of yours?"
"He is sure to be at the laboratory," returned my companion. "He either avoids the place for weeks, or else he works there from morning to night. If you like, we shall drive round together after luncheon."
"Certainly," I answered, and the conversation drifted away into other channels.
As we made our way to the hospital after leaving the Holborn, Stamford gave me a few more particulars about the gentleman whom I proposed to take as a fellow-lodger.
"You mustn't blame me if you don't get on with him," he said; "I know nothing more of him than I have learned from meeting him occasionally in the laboratory. You proposed this arrangement, so you must not hold me responsible."
"If we don't get on it will be easy to part company," I answered. "It seems to me, Stamford," I added, looking hard at my companion, "that you have some reason for washing your hands of the matter. Is this fellow's temper so formidable, or what is it? Don't be mealy-mouthed about it."
"It is not easy to express the inexpressible," he answered with a laugh. "Holmes is a little too scientific for my tastes -- it approaches to cold-bloodedness. I could imagine his giving a friend a little pinch of the latest vegetable alkaloid, not out of malevolence, you understand, but simply out of a spirit of inquiry in order to have an accurate idea of the effects. To do him justice, I think that he would take it himself with the same readiness. He appears to have a passion for definite and exact knowledge."
"Very right too."
"Yes, but it may be pushed to excess. When it comes to beating the subjects in the dissecting-rooms with a stick, it is certainly taking rather a bizarre shape."
"Beating the subjects!"
"Yes, to verify how far bruises may be produced aft er death. I saw him at it with my own eyes."
"And yet you say he is not a medical student?"
"No. Heaven knows what the objects of his studies are. But here we are, and you must form your own impressions about him." As he spoke, we turned down a narrow lane and passed through a small side-door, which opened into a wing of the great hospital.
part3:
It was familiar ground to me, and I needed no guiding as we ascended the bleak stone staircase and made our way down the long corridor with its vista of whitewashed wall and dun-coloured doors. Near the further end a low arched passage branched away from it and led to the chemical laboratory.
This was a lofty chamber, lined and littered with countless bottles. Broad, low tables were scattered about, which bristled with retorts, test-tubes, and little Bunsen lamps, with their blue flickering flames. There was only one student in the room, who was bending over a distant table absorbed in his work. At the soun d of our steps he glanced round and sprang to his feet with a cry of pleasure. "I've found it! I've found it," he shouted to my companion, running towards us with a test-tube in his hand. "I have found a re-agent which is precipitated by hoemoglobin, {4} and by nothing else." Had he discovered a gold mine, greater delight could not have shone upon his features.
"Dr. Watson, Mr. Sherlock Holmes," said Stamford, introducing us.
"How are you?" he said cordially, gripping my hand with a strength for which I should hardly have given him credit. "You have been in Afghanistan, I perceive."
"How on earth did you know that?" I asked in astonishment.
"Never mind," said he, chuckling to himself. "The question now is about hoemoglobin. No doubt you see the significance of this discovery of mine?"
"It is interesting, chemically, no doubt," I answered, "but practically ----"
"Why, man, it is the most practical medico-legal discovery for years. Don't you see t hat it gives us an infallible test for blood stains. Come over here now!" He seized me by the coat-sleeve in his eagerness, and drew me over to the table at which he had been working. "Let us have some fresh blood," he said, digging a long bodkin into his finger, and drawing off the resulting drop of blood in a chemical pipette. "Now, I add this small quantity of blood to a litre of water. You perceive that the resulting mixture has the appearance of pure water. The proportion of blood cannot be more than one in a million. I have no doubt, however, that we shall be able to obtain the characteristic reaction." As he spoke, he threw into the vessel a few white crystals, and then added some drops of a transparent fluid. In an instant the contents assumed a dull mahogany colour, and a brownish dust was precipitated to the bottom of the glass jar.
"Ha! ha!" he cried, clapping his hands, and looking as delighted as a child with a new toy. "What do you think of that?"
"It seems to be a very delicate test," I remarked.
"Beautiful! beautiful! The old Guiacum test was very clumsy and uncertain. So is the microscopic examination for blood corpuscles. The latter is valueless if the stains are a few hours old. Now, this appears to act as well whether the blood is old or new. Had this test been invented, there are hundreds of men now walking the earth who would long ago have paid the penalty of their crimes."
"Indeed!" I murmured.
"Criminal cases are continually hinging upon that one point. A man is suspected of a crime months perhaps after it has been committed. His linen or clothes are examined, and brownish stains discovered upon them. Are they blood stains, or mud stains, or rust stains, or fruit stains, or what are they? That is a question which has puzzled many an expert, and why? Because there was no reliable test. Now we have the Sherlock Holmes' test, and there will no longer be any difficulty."
His eyes fairly glittere d as he spoke, and he put his hand over his heart and bowed as if to some applauding crowd conjured up by his imagination.
"You are to be congratulated," I remarked, considerably surprised at his enthusiasm.
"There was the case of Von Bischoff at Frankfort last year. He would certainly have been hung had this test been in existence. Then there was Mason of Bradford, and the notorious Muller, and Lefevre of Montpellier, and Samson of new Orleans.
part4:
That done, we gradually began to settle down and to accommodate ourselves to our new surroundings.
Holmes was certainly not a difficult man to live with. He was quiet in his ways, and his habits were regular. It was rare for him to be up after ten at night, and he had invariably breakfasted and gone out before I rose in the morning. Sometimes he spent his day at the chemical laboratory, sometimes in the dissecting-rooms, and occasionally in long walks, which appeared to take him into the lowest portion s of the City. Nothing could exceed his energy when the working fit was upon him; but now and again a reaction would seize him, and for days on end he would lie upon the sofa in the sitting-room, hardly uttering a word or moving a muscle from morning to night. On these occasions I have noticed such a dreamy, vacant expression in his eyes, that I might have suspected him of being addicted to the use of some narcotic, had not the temperance and cleanliness of his whole life forbidden such a notion.
As the weeks went by, my interest in him and my curiosity as to his aims in life, gradually deepened and increased. His very person and appearance were such as to strike the attention of the most casual observer. In height he was rather over six feet, and so excessively lean that he seemed to be considerably taller. His eyes were sharp and piercing, save during those intervals of torpor to which I have alluded; and his thin, hawk-like nose gave his whole expression an air of al ertness and decision. His chin, too, had the prominence and squareness which mark the man of determination. His hands were invariably blotted with ink and stained with chemicals, yet he was possessed of extraordinary delicacy of touch, as I frequently had occasion to observe when I watched him manipulating his fragile philosophical instruments.
The reader may set me down as a hopeless busybody, when I confess how much this man stimulated my curiosity, and how often I endeavoured to break through the reticence which he showed on all that concerned himself. Before pronouncing judgment, however, be it remembered, how objectless was my life, and how little there was to engage my attention. My health forbade me from venturing out unless the weather was exceptionally genial, and I had no friends who would call upon me and break the monotony of my daily existence. Under these circumstances, I eagerly hailed the little mystery which hung around my companion, and spent much of m y time in endeavouring to unravel it.
He was not studying medicine. He had himself, in reply to a question, confirmed Stamford's opinion upon that point. Neither did he appear to have pursued any course of reading which might fit him for a degree in science or any other recognized portal which would give him an entrance into the learned world. Yet his zeal for certain studies was remarkable, and within eccentric limits his knowledge was so extraordinarily ample and minute that his observations have fairly astounded me. Surely no man would work so hard or attain such precise information unless he had some definite end in view. Desultory readers are seldom remarkable for the exactness of their learning. No man burdens his mind with small matters unless he has some very good reason for doing so.
His ignorance was as remarkable as his knowledge. Of contemporary literature, philosophy and politics he appeared to know next to nothing. Upon my quoting Thomas Carlyle, he i nquired in the naivest way who he might be and what he had done. My surprise reached a climax, however, when I found incidentally that he was ignorant of the Copernican Theory and of the composition of the Solar System. That any civilized human being in this nineteenth century should not be aware that the earth travelled round the sun appeared to be to me such an extraordinary fact that I could hardly realize it.
"You appear to be astonished," he said, smiling at my expression of surprise. "Now that I do know it I shall do my best to forget it."
"To forget it!"
"You see," he explained, "I consider that a man's brain originally is like a little empty attic, and you have to stock it with such furniture as you choose.
part5:
That done, we gradually began to settle down and to accommodate ourselves to our new surroundings.
Holmes was certainly not a difficult man to live with. He was quiet in his ways, and his habits were regular. It was rare for hi m to be up after ten at night, and he had invariably breakfasted and gone out before I rose in the morning. Sometimes he spent his day at the chemical laboratory, sometimes in the dissecting-rooms, and occasionally in long walks, which appeared to take him into the lowest portions of the City. Nothing could exceed his energy when the working fit was upon him; but now and again a reaction would seize him, and for days on end he would lie upon the sofa in the sitting-room, hardly uttering a word or moving a muscle from morning to night. On these occasions I have noticed such a dreamy, vacant expression in his eyes, that I might have suspected him of being addicted to the use of some narcotic, had not the temperance and cleanliness of his whole life forbidden such a notion.
As the weeks went by, my interest in him and my curiosity as to his aims in life, gradually deepened and increased. His very person and appearance were such as to strike the attention of the most casual observer. In height he was rather over six feet, and so excessively lean that he seemed to be considerably taller. His eyes were sharp and piercing, save during those intervals of torpor to which I have alluded; and his thin, hawk-like nose gave his whole expression an air of alertness and decision. His chin, too, had the prominence and squareness which mark the man of determination. His hands were invariably blotted with ink and stained with chemicals, yet he was possessed of extraordinary delicacy of touch, as I frequently had occasion to observe when I watched him manipulating his fragile philosophical instruments.
The reader may set me down as a hopeless busybody, when I confess how much this man stimulated my curiosity, and how often I endeavoured to break through the reticence which he showed on all that concerned himself. Before pronouncing judgment, however, be it remembered, how objectless was my life, and how little there was to engage my attention. My health forbade me from venturing out unless the weather was exceptionally genial, and I had no friends who would call upon me and break the monotony of my daily existence. Under these circumstances, I eagerly hailed the little mystery which hung around my companion, and spent much of my time in endeavouring to unravel it.
He was not studying medicine. He had himself, in reply to a question, confirmed Stamford's opinion upon that point. Neither did he appear to have pursued any course of reading which might fit him for a degree in science or any other recognized portal which would give him an entrance into the learned world. Yet his zeal for certain studies was remarkable, and within eccentric limits his knowledge was so extraordinarily ample and minute that his observations have fairly astounded me. Surely no man would work so hard or attain such precise information unless he had some definite end in view. Desultory readers are seldom remarkable for the exactness of their lea rning. No man burdens his mind with small matters unless he has some very good reason for doing so.
His ignorance was as remarkable as his knowledge. Of contemporary literature, philosophy and politics he appeared to know next to nothing. Upon my quoting Thomas Carlyle, he inquired in the naivest way who he might be and what he had done. My surprise reached a climax, however, when I found incidentally that he was ignorant of the Copernican Theory and of the composition of the Solar System. That any civilized human being in this nineteenth century should not be aware that the earth travelled round the sun appeared to be to me such an extraordinary fact that I could hardly realize it.
"You appear to be astonished," he said, smiling at my expression of surprise. "Now that I do know it I shall do my best to forget it."
"To forget it!"
"You see," he explained, "I consider that a man's brain originally is like a little empty attic, and you have to stock it with such furniture as you choose.
part6:
A fool takes in all the lumber of every sort that he comes across, so that the knowledge which might be useful to him gets crowded out, or at best is jumbled up with a lot of other things so that he has a difficulty in laying his hands upon it. Now the skilful workman is very careful indeed as to what he takes into his brain-attic. He will have nothing but the tools which may help him in doing his work, but of these he has a large assortment, and all in the most perfect order. It is a mistake to think that that little room has elastic walls and can distend to any extent. Depend upon it there comes a time when for every addition of knowledge you forget something that you knew before. It is of the highest importance, therefore, not to have useless facts elbowing out the useful ones."
"But the Solar System!" I protested.
"What the deuce is it to me?" he interrupted impatiently; "you say that we go round the sun. If we we nt round the moon it would not make a pennyworth of difference to me or to my work."
I was on the point of asking him what that work might be, but something in his manner showed me that the question would be an unwelcome one. I pondered over our short conversation, however, and endeavoured to draw my deductions from it. He said that he would acquire no knowledge which did not bear upon his object. Therefore all the knowledge which he possessed was such as would be useful to him. I enumerated in my own mind all the various points upon which he had shown me that he was exceptionally well-informed. I even took a pencil and jotted them down. I could not help smiling at the document when I had completed it. It ran in this way --
SHERLOCK HOLMES -- his limits.
1. Knowledge of Literature. -- Nil. 2. Philosophy. -- Nil. 3. Astronomy. -- Nil. 4. Politics. -- Feeble. 5. Botany. -- Variable. Well up in belladonna, opium, and poisons generally. Knows nothing of practical gardening. 6. Geology. -- Practical, but limited. Tells at a glance different soils from each other. After walks has shown me splashes upon his trousers, and told me by their colour and consistence in what part of London he had received them. 7. Chemistry. -- Profound. 8. Anatomy. -- Accurate, but unsystematic. 9. Sensational Literature. -- Immense. He appears to know every detail of every horror perpetrated in the century. 10. Plays the violin well. 11. Is an expert singlestick player, boxer, and swordsman. 12. Has a good practical knowledge of British law.
When I had got so far in my list I threw it into the fire in despair. "If I can only find what the fellow is driving at by reconciling all these accomplishments, and discovering a calling which needs them all," I said to myself, "I may as well give up the attempt at once."
I see that I have alluded above to his powers upon the violin. These were very remarkable, but as eccentric as all his other accomplishments . That he could play pieces, and difficult pieces, I knew well, because at my request he has played me some of Mendelssohn's Lieder, and other favourites. When left to himself, however, he would seldom produce any music or attempt any recognized air. Leaning back in his arm-chair of an evening, he would close his eyes and scrape carelessly at the fiddle which was thrown across his knee. Sometimes the chords were sonorous and melancholy. Occasionally they were fantastic and cheerful. Clearly they reflected the thoughts which possessed him, but whether the music aided those thoughts, or whether the playing was simply the result of a whim or fancy was more than I could determine. I might have rebelled against these exasperating solos had it not been that he usually terminated them by playing in quick succession a whole series of my favourite airs as a slight compensation for the trial upon my patience.
part7:
During the first week or so we had no callers, and I had be gun to think that my companion was as friendless a man as I was myself. Presently, however, I found that he had many acquaintances, and those in the most different classes of society. There was one little sallow rat-faced, dark-eyed fellow who was introduced to me as Mr. Lestrade, and who came three or four times in a single week. One morning a young girl called, fashionably dressed, and stayed for half an hour or more. The same afternoon brought a grey-headed, seedy visitor, looking like a Jew pedlar, who appeared to me to be much excited, and who was closely followed by a slip-shod elderly woman. On another occasion an old white-haired gentleman had an interview with my companion; and on another a railway porter in his velveteen uniform. When any of these nondescript individuals put in an appearance, Sherlock Holmes used to beg for the use of the sitting-room, and I would retire to my bed-room. He always apologized to me for putting me to this inconvenience. "I have to use this room as a place of business," he said, "and these people are my clients." Again I had an opportunity of asking him a point blank question, and again my delicacy prevented me from forcing another man to confide in me. I imagined at the time that he had some strong reason for not alluding to it, but he soon dispelled the idea by coming round to the subject of his own accord.
It was upon the 4th of March, as I have good reason to remember, that I rose somewhat earlier than usual, and found that Sherlock Holmes had not yet finished his breakfast. The landlady had become so accustomed to my late habits that my place had not been laid nor my coffee prepared. With the unreasonable petulance of mankind I rang the bell and gave a curt intimation that I was ready. Then I picked up a magazine from the table and attempted to while away the time with it, while my companion munched silently at his toast. One of the articles had a pencil mark at the heading, and I naturally bega n to run my eye through it.
Its somewhat ambitious title was "The Book of Life," and it attempted to show how much an observant man might learn by an accurate and systematic examination of all that came in his way. It struck me as being a remarkable mixture of shrewdness and of absurdity. The reasoning was close and intense, but the deductions appeared to me to be far-fetched and exaggerated. The writer claimed by a momentary expression, a twitch of a muscle or a glance of an eye, to fathom a man's inmost thoughts. Deceit, according to him, was an impossibility in the case of one trained to observation and analysis. His conclusions were as infallible as so many propositions of Euclid. So startling would his results appear to the uninitiated that until they learned the processes by which he had arrived at them they might well consider him as a necromancer.
"From a drop of water," said the writer, "a logician could infer the possibility of an Atlantic or a Niagara wi thout having seen or heard of one or the other. So all life is a great chain, the nature of which is known whenever we are shown a single link of it. Like all other arts, the Science of Deduction and Analysis is one which can only be acquired by long and patient study nor is life long enough to allow any mortal to attain the highest possible perfection in it. Before turning to those moral and mental aspects of the matter which present the greatest difficulties, let the enquirer begin by mastering more elementary problems. Let him, on meeting a fellow-mortal, learn at a glance to distinguish the history of the man, and the trade or profession to which he belongs. Puerile as such an exercise may seem, it sharpens the faculties of observation, and teaches one where to look and what to look for. By a man's finger nails, by his coat-sleeve, by his boot, by his trouser knees, by the callosities of his forefinger and thumb, by his expression, by his shirt cuffs -- by each of these things a man's calling is plainly revealed.
part8:
That all united should fail to enlighten the competent enquirer in any case is almost inconceivable."
"What ineffable twaddle!" I cried, slapping the magazine down on the table, "I never read such rubbish in my life."
"What is it?" asked Sherlock Holmes.
"Why, this article," I said, pointing at it with my egg spoon as I sat down to my breakfast. "I see that you have read it since you have marked it. I don't deny that it is smartly written. It irritates me though. It is evidently the theory of some arm-chair lounger who evolves all these neat little paradoxes in the seclusion of his own study. It is not practical. I should like to see him clapped down in a third class carriage on the Underground, and asked to give the trades of all his fellow-travellers. I would lay a thousand to one against him."
"You would lose your money," Sherlock Holmes remarked calmly. "As for the article I wrote it myself. "
"You!"
"Yes, I have a turn both for observation and for deduction. The theories which I have expressed there, and which appear to you to be so chimerical are really extremely practical -- so practical that I depend upon them for my bread and cheese."
"And how?" I asked involuntarily.
"Well, I have a trade of my own. I suppose I am the only one in the world. I'm a consulting detective, if you can understand what that is. Here in London we have lots of Government detectives and lots of private ones. When these fellows are at fault they come to me, and I manage to put them on the right scent. They lay all the evidence before me, and I am generally able, by the help of my knowledge of the history of crime, to set them straight. There is a strong family resemblance about misdeeds, and if you have all the details of a thousand at your finger ends, it is odd if you can't unravel the thousand and first. Lestrade is a well-known detective. He got himself into a fog recently over a forgery case, and that was what brought him here."
"And these other people?"
"They are mostly sent on by private inquiry agencies. They are all people who are in trouble about something, and want a little enlightening. I listen to their story, they listen to my comments, and then I pocket my fee."
"But do you mean to say," I said, "that without leaving your room you can unravel some knot which other men can make nothing of, although they have seen every detail for themselves?"
"Quite so. I have a kind of intuition that way. Now and again a case turns up which is a little more complex. Then I have to bustle about and see things with my own eyes. You see I have a lot of special knowledge which I apply to the problem, and which facilitates matters wonderfully. Those rules of deduction laid down in that article which aroused your scorn, are invaluable to me in practical work. Observation with me is second nature. You appeared to be surpris ed when I told you, on our first meeting, that you had come from Afghanistan."
"You were told, no doubt."
"Nothing of the sort. I _knew_ you came from Afghanistan. From long habit the train of thoughts ran so swiftly through my mind, that I arrived at the conclusion without being conscious of intermediate steps. There were such steps, however. The train of reasoning ran, `Here is a gentleman of a medical type, but with the air of a military man. Clearly an army doctor, then. He has just come from the tropics, for his face is dark, and that is not the natural tint of his skin, for his wrists are fair. He has undergone hardship and sickness, as his haggard face says clearly. His left arm has been injured. He holds it in a stiff and unnatural manner. Where in the tropics could an English army doctor have seen much hardship and got his arm wounded? Clearly in Afghanistan.' The whole train of thought did not occupy a second. I then remarked that you came from Afghanista n, and you were astonished."
"It is simple enough as you explain it," I said, smiling. "You remind me of Edgar Allen Poe's Dupin. I had no idea that such individuals did exist outside of stories."
Sherlock Holmes rose and lit his pipe.
part9:"No doubt you think that you are complimenting me in comparing me to Dupin," he observed. "Now, in my opinion, Dupin was a very inferior fellow. That trick of his of breaking in on his friends' thoughts with an apropos remark after a quarter of an hour's silence is really very showy and superficial. He had some analytical genius, no doubt; but he was by no means such a phenomenon as Poe appeared to imagine."
"Have you read Gaboriau's works?" I asked. "Does Lecoq come up to your idea of a detective?"
Sherlock Holmes sniffed sardonically. "Lecoq was a miserable bungler," he said, in an angry voice; "he had only one thing to recommend him, and that was his energy. That book made me positively ill. The question was h ow to identify an unknown prisoner. I could have done it in twenty-four hours. Lecoq took six months or so. It might be made a text-book for detectives to teach them what to avoid."
I felt rather indignant at having two characters whom I had admired treated in this cavalier style. I walked over to the window, and stood looking out into the busy street. "This fellow may be very clever," I said to myself, "but he is certainly very conceited."
"There are no crimes and no criminals in these days," he said, querulously. "What is the use of having brains in our profession. I know well that I have it in me to make my name famous. No man lives or has ever lived who has brought the same amount of study and of natural talent to the detection of crime which I have done. And what is the result? There is no crime to detect, or, at most, some bungling villany with a motive so transparent that even a Scotland Yard official can see through it."
I was still annoyed at his bump tious style of conversation. I thought it best to change the topic.
"I wonder what that fellow is looking for?" I asked, pointing to a stalwart, plainly-dressed individual who was walking slowly down the other side of the street, looking anxiously at the numbers. He had a large blue envelope in his hand, and was evidently the bearer of a message.
"You mean the retired sergeant of Marines," said Sherlock Holmes.
"Brag and bounce!" thought I to myself. "He knows that I cannot verify his guess."
The thought had hardly passed through my mind when the man whom we were watching caught sight of the number on our door, and ran rapidly across the roadway. We heard a loud knock, a deep voice below, and heavy steps ascending the stair.
"For Mr. Sherlock Holmes," he said, stepping into the room and handing my friend the letter.
Here was an opportunity of taking the conceit out of him. He little thought of this when he made that random shot. "May I ask, my l ad," I said, in the blandest voice, "what your trade may be?"
"Commissionaire, sir," he said, gruffly. "Uniform away for repairs."
"And you were?" I asked, with a slightly malicious glance at my companion.
"A sergeant, sir, Royal Marine Light Infantry, sir. No answer? Right, sir."
He clicked his heels together, raised his hand in a salute, and was gone.
CHAPTER III.
THE LAURISTON GARDEN MYSTERY {6}
I CONFESS that I was considerably startled by this fresh proof of the practical nature of my companion's theories. My respect for his powers of analysis increased wondrously. There still remained some lurking suspicion in my mind, however, that the whole thing was a pre-arranged episode, intended to dazzle me, though what earthly object he could have in taking me in was past my comprehension. When I looked at him he had finished reading the note, and his eyes had assumed the vacant, lack-lustre expression which showed mental abstraction.
"Ho w in the world did you deduce that?" I asked.
"Deduce what?" said he, petulantly.
"Why, that he was a retired sergeant of Marines."
"I have no time for trifles," he answered, brusquely; then with a smile, "Excuse my rudeness. You broke the thread of my thoughts; but perhaps it is as well. So you actually were not able to see that that man was a sergeant of Marines?"
"No, indeed."
"It was easier to know it than to explain why I knew it. If you were asked to prove that two and two made four, you might find some difficulty, and yet you are quite sure of the fact. Even across the street I could see a great blue anchor tattooed on the back of the fellow's hand.
part 10:That smacked of the sea. He had a military carriage, however, and regulation side whiskers. There we have the marine. He was a man with some amount of self-importance and a certain air of command. You must have observed the way in which he held his head and swung his cane. A steady, re spectable, middle-aged man, too, on the face of him -- all facts which led me to believe that he had been a sergeant."
"Wonderful!" I ejaculated.
"Commonplace," said Holmes, though I thought from his expression that he was pleased at my evident surprise and admiration. "I said just now that there were no criminals. It appears that I am wrong -- look at this!" He threw me over the note which the commissionaire had brought." {7}
"Why," I cried, as I cast my eye over it, "this is terrible!"
"It does seem to be a little out of the common," he remarked, calmly. "Would you mind reading it to me aloud?"
This is the letter which I read to him ----
"MY DEAR MR. SHERLOCK HOLMES, -- "There has been a bad business during the night at 3, Lauriston Gardens, off the Brixton Road. Our man on the beat saw a light there about two in the morning, and as the house was an empty one, suspected that something was amiss. He found the door open, and in the front room, w hich is bare of furniture, discovered the body of a gentleman, well dressed, and having cards in his pocket bearing the name of `Enoch J. Drebber, Cleveland, Ohio, U.S.A.' There had been no robbery, nor is there any evidence as to how the man met his death. There are marks of blood in the room, but there is no wound upon his person. We are at a loss as to how he came into the empty house; indeed, the whole affair is a puzzler. If you can come round to the house any time before twelve, you will find me there. I have left everything _in statu quo_ until I hear from you. If you are unable to come I shall give you fuller details, and would esteem it a great kindness if you would favour me with your opinion. Yours faithfully, "TOBIAS GREGSON."
"Gregson is the smartest of the Scotland Yarders," my friend remarked; "he and Lestrade are the pick of a bad lot. They are both quick and energetic, but conventional -- shockingly so. They have their knives into one another, too. They are as jealous as a pair of professional beauties. There will be some fun over this case if they are both put upon the scent."
I was amazed at the calm way in which he rippled on. "Surely there is not a moment to be lost," I cried, "shall I go and order you a cab?"
"I'm not sure about whether I shall go. I am the most incurably lazy devil that ever stood in shoe leather -- that is, when the fit is on me, for I can be spry enough at times."
"Why, it is just such a chance as you have been longing for."
"My dear fellow, what does it matter to me. Supposing I unravel the whole matter, you may be sure that Gregson, Lestrade, and Co. will pocket all the credit. That comes of being an unofficial personage."
"But he begs you to help him."
"Yes. He knows that I am his superior, and acknowledges it to me; but he would cut his tongue out before he would own it to any third person. However, we may as well go and have a look. I shall work it out on my own h ook. I may have a laugh at them if I have nothing else. Come on!"
He hustled on his overcoat, and bustled about in a way that showed that an energetic fit had superseded the apathetic one.
"Get your hat," he said.
"You wish me to come?"
"Yes, if you have nothing better to do." A minute later we were both in a hansom, driving furiously for the Brixton Road.
It was a foggy, cloudy morning, and a dun-coloured veil hung over the house-tops, looking like the reflection of the mud-coloured streets beneath. My companion was in the best of spirits, and prattled away about Cremona fiddles, and the difference between a Stradivarius and an Amati. As for myself, I was silent, for the dull weather and the melancholy business upon which we were engaged, depressed my spirits.
part 11:"You don't seem to give much thought to the matter in hand," I said at last, interrupting Holmes' musical disquisition.
"No data yet," he answered. "It is a capital mistake t o theorize before you have all the evidence. It biases the judgment."
"You will have your data soon," I remarked, pointing with my finger; "this is the Brixton Road, and that is the house, if I am not very much mistaken."
"So it is. Stop, driver, stop!" We were still a hundred yards or so from it, but he insisted upon our alighting, and we finished our journey upon foot.
Number 3, Lauriston Gardens wore an ill-omened and minatory look. It was one of four which stood back some little way from the street, two being occupied and two empty. The latter looked out with three tiers of vacant melancholy windows, which were blank and dreary, save that here and there a "To Let" card had developed like a cataract upon the bleared panes. A small garden sprinkled over with a scattered eruption of sickly plants separated each of these houses from the street, and was traversed by a narrow pathway, yellowish in colour, and consisting apparently of a mixture of clay and of gra vel. The whole place was very sloppy from the rain which had fallen through the night. The garden was bounded by a three-foot brick wall with a fringe of wood rails upon the top, and against this wall was leaning a stalwart police constable, surrounded by a small knot of loafers, who craned their necks and strained their eyes in the vain hope of catching some glimpse of the proceedings within.
I had imagined that Sherlock Holmes would at once have hurried into the house and plunged into a study of the mystery. Nothing appeared to be further from his intention. With an air of nonchalance which, under the circumstances, seemed to me to border upon affectation, he lounged up and down the pavement, and gazed vacantly at the ground, the sky, the opposite houses and the line of railings. Having finished his scrutiny, he proceeded slowly down the path, or rather down the fringe of grass which flanked the path, keeping his eyes riveted upon the ground. Twice he stopped, and onc e I saw him smile, and heard him utter an exclamation of satisfaction. There were many marks of footsteps upon the wet clayey soil, but since the police had been coming and going over it, I was unable to see how my companion could hope to learn anything from it. Still I had had such extraordinary evidence of the quickness of his perceptive faculties, that I had no doubt that he could see a great deal which was hidden from me.
At the door of the house we were met by a tall, white-faced, flaxen-haired man, with a notebook in his hand, who rushed forward and wrung my companion's hand with effusion. "It is indeed kind of you to come," he said, "I have had everything left untouched."
"Except that!" my friend answered, pointing at the pathway. "If a herd of buffaloes had passed along there could not be a greater mess. No doubt, however, you had drawn your own conclusions, Gregson, before you permitted this."
"I have had so much to do inside the house," the detective said evasively. "My colleague, Mr. Lestrade, is here. I had relied upon him to look after this."
Holmes glanced at me and raised his eyebrows sardonically. "With two such men as yourself and Lestrade upon the ground, there will not be much for a third party to find out," he said.
Gregson rubbed his hands in a self-satisfied way. "I think we have done all that can be done," he answered; "it's a queer case though, and I knew your taste for such things."
"You did not come here in a cab?" asked Sherlock Holmes.
"No, sir."
"Nor Lestrade?"
"No, sir."
"Then let us go and look at the room." With which inconsequent remark he strode on into the house, followed by Gregson, whose features expressed his astonishment.
A short passage, bare planked and dusty, led to the kitchen and offices. Two doors opened out of it to the left and to the right. One of these had obviously been closed for many weeks.
part 12:The other belonged to the dining-roo m, which was the apartment in which the mysterious affair had occurred. Holmes walked in, and I followed him with that subdued feeling at my heart which the presence of death inspires.
It was a large square room, looking all the larger from the absence of all furniture. A vulgar flaring paper adorned the walls, but it was blotched in places with mildew, and here and there great strips had become detached and hung down, exposing the yellow plaster beneath. Opposite the door was a showy fireplace, surmounted by a mantelpiece of imitation white marble. On one corner of this was stuck the stump of a red wax candle. The solitary window was so dirty that the light was hazy and uncertain, giving a dull grey tinge to everything, which was intensified by the thick layer of dust which coated the whole apartment.
All these details I observed afterwards. At present my attention was centred upon the single grim motionless figure which lay stretched upon the boards, with vacant sightless eyes staring up at the discoloured ceiling. It was that of a man about forty-three or forty-four years of age, middle-sized, broad shouldered, with crisp curling black hair, and a short stubbly beard. He was dressed in a heavy broadcloth frock coat and waistcoat, with light-coloured trousers, and immaculate collar and cuffs. A top hat, well brushed and trim, was placed upon the floor beside him. His hands were clenched and his arms thrown abroad, while his lower limbs were interlocked as though his death struggle had been a grievous one. On his rigid face there stood an expression of horror, and as it seemed to me, of hatred, such as I have never seen upon human features. This malignant and terrible contortion, combined with the low forehead, blunt nose, and prognathous jaw gave the dead man a singularly simious and ape-like appearance, which was increased by his writhing, unnatural posture. I have seen death in many forms, but never has it appeared to me in a more fearsome aspect than in that dark grimy apartment, which looked out upon one of the main arteries of suburban London.
Lestrade, lean and ferret-like as ever, was standing by the doorway, and greeted my companion and myself.
"This case will make a stir, sir," he remarked. "It beats anything I have seen, and I am no chicken."
"There is no clue?" said Gregson.
"None at all," chimed in Lestrade.
Sherlock Holmes approached the body, and, kneeling down, examined it intently. "You are sure that there is no wound?" he asked, pointing to numerous gouts and splashes of blood which lay all round.
"Positive!" cried both detectives.
"Then, of course, this blood belongs to a second individual -- {8} presumably the murderer, if murder has been committed. It reminds me of the circumstances attendant on the death of Van Jansen, in Utrecht, in the year '34. Do you remember the case, Gregson?"
"No, sir."
"Read it up -- you really should. There is n othing new under the sun. It has all been done before."
As he spoke, his nimble fingers were flying here, there, and everywhere, feeling, pressing, unbuttoning, examining, while his eyes wore the same far-away expression which I have already remarked upon. So swiftly was the examination made, that one would hardly have guessed the minuteness with which it was conducted. Finally, he sniffed the dead man's lips, and then glanced at the soles of his patent leather boots.
"He has not been moved at all?" he asked.
"No more than was necessary for the purposes of our examination."
"You can take him to the mortuary now," he said. "There is nothing more to be learned."
Gregson had a stretcher and four men at hand. At his call they entered the room, and the stranger was lifted and carried out. As they raised him, a ring tinkled down and rolled across the floor. Lestrade grabbed it up and stared at it with mystified eyes.
"There's been a woman here," he cr ied. "It's a woman's wedding-ring."
He held it out, as he spoke, upon the palm of his hand. We all gathered round him and gazed at it.
part 13:There could be no doubt that that circlet of plain gold had once adorned the finger of a bride.
"This complicates matters," said Gregson. "Heaven knows, they were complicated enough before."
"You're sure it doesn't simplify them?" observed Holmes. "There's nothing to be learned by staring at it. What did you find in his pockets?"
"We have it all here," said Gregson, pointing to a litter of objects upon one of the bottom steps of the stairs. "A gold watch, No. 97163, by Barraud, of London. Gold Albert chain, very heavy and solid. Gold ring, with masonic device. Gold pin -- bull-dog's head, with rubies as eyes. Russian leather card-case, with cards of Enoch J. Drebber of Cleveland, corresponding with the E. J. D. upon the linen. No purse, but loose money to the extent of seven pounds thirteen. Pocket edition of Boccaccio's `Decameron,' with name of Joseph Stangerson upon the fly-leaf. Two letters -- one addressed to E. J. Drebber and one to Joseph Stangerson."
"At what address?"
"American Exchange, Strand -- to be left till called for. They are both from the Guion Steamship Company, and refer to the sailing of their boats from Liverpool. It is clear that this unfortunate man was about to return to New York."
"Have you made any inquiries as to this man, Stangerson?"
"I did it at once, sir," said Gregson. "I have had advertisements sent to all the newspapers, and one of my men has gone to the American Exchange, but he has not returned yet."
"Have you sent to Cleveland?"
"We telegraphed this morning."
"How did you word your inquiries?"
"We simply detailed the circumstances, and said that we should be glad of any information which could help us."
"You did not ask for particulars on any point which appeared to you to be crucial?"
"I aske d about Stangerson."
"Nothing else? Is there no circumstance on which this whole case appears to hinge? Will you not telegraph again?"
"I have said all I have to say," said Gregson, in an offended voice.
Sherlock Holmes chuckled to himself, and appeared to be about to make some remark, when Lestrade, who had been in the front room while we were holding this conversation in the hall, reappeared upon the scene, rubbing his hands in a pompous and self-satisfied manner.
part 14:"Mr. Gregson," he said, "I have just made a discovery of the highest importance, and one which would have been overlooked had I not made a careful examination of the walls."
The little man's eyes sparkled as he spoke, and he was evidently in a state of suppressed exultation at having scored a point against his colleague.
"Come here," he said, bustling back into the room, the atmosphere of which felt clearer since the removal of its ghastly inmate. "Now, stand there!"
He struck a match on his boot and held it up against the wall.
"Look at that!" he said, triumphantly.
I have remarked that the paper had fallen away in parts. In this particular corner of the room a large piece had peeled off, leaving a yellow square of coarse plastering. Across this bare space there was scrawled in blood-red letters a single word --
RACHE.
"What do you think of that?" cried the detective, with the air of a showman exhibiting his show. "This was overlooked because it was in the darkest corner of the room, and no one thought of looking there. The murderer has written it with his or her own blood. See this smear where it has trickled down the wall! That disposes of the idea of suicide anyhow. Why was that corner chosen to write it on? I will tell you. See that candle on the mantelpiece. It was lit at the time, and if it was lit this corner would be the brightest instead of the darkest portion of the wall."
"And what does it mean now that you _have_ found it?" asked Gregson in a depreciatory voice.
"Mean? Why, it means that the writer was going to put the female name Rachel, but was disturbed before he or she had time to finish. You mark my words, when this case comes to be cleared up you will find that a woman named Rachel has something to do with it.

Part 15:

CHAPTER IV.

WHAT JOHN RANCE HAD TO TELL.

IT was one o'clock when we left No. 3, Lauriston Gardens. Sherlock Holmes led me to the nearest telegraph office, whence he dispatched a long telegram. He then hailed a cab, and ordered the driver to take us to the address given us by Lestrade.

"There is nothing like first hand evidence," he remarked; "as a matter of fact, my mind is entirely made up upon the case, but still we may as well learn all that is to be learned."

"You amaze me, Holmes," said I. "Surely you are not as sure as you pretend to be of all those particulars which you gave."

"There's no room for a mistake," he answered. "The very first thing which I observed on arriving there was that a cab had made two ruts with its wheels close to the curb. Now, up to last night, we have had no rain for a week, so that those wheels which left such a deep impression must have been there during the night. There were the marks of the horse's hoofs, too, the outline of one of which was far more clearly cut than that of the other three, showing that that was a new shoe. Since the cab was there after the rain began, and was not there at any time during the morning -- I have Gregson's word for that -- it follows that it must have been there during the night, and, therefore, that it brought those two individuals to the house."

"That seems simple enough," said I; "but how about the other man's height?"

"Why, the height of a man, in nine cases out of ten, can be told from the length of his stride. It is a simple calculation enough, though there is no use my boring you with figures. I had this fellow's stride both on the clay outside and on the dust within. Then I had a way of checking my calculation. When a man writes on a wall, his instinct leads him to write about the level of his own eyes. Now that writing was just over six feet from the ground. It was child's play."

"And his age?" I asked.

"Well, if a man can stride four and a-half feet without the smallest effort, he can't be quite in the sere and yellow. That was the breadth of a puddle on the garden walk which he had evidently walked across. Patent-leather boots had gone round, and Square-toes had hopped over. There is no mystery about it at all. I am simply applying to ordinary life a few of those precepts of observation and deduction which I advocated in that article. Is there anything else that puzzles you?"

"The finger nails and the Trichinopoly," I suggested.

"The writing on the wall was done with a man's forefinger dipped in blood. My glass allowed me to observe that the plaster was slightly scratched in doing it, which would not have been the case if the man's nail had been trimmed. I gathered up some scattered ash from the floor. It was dark in colour and flakey -- such an ash as is only made by a Trichinopoly. I have made a special study of cigar ashes -- in fact, I have written a monograph upon the subject. I flatter myself that I can distinguish at a glance the ash of any known brand, either of cigar or of tobacco. It is just in such details that the skilled detective differs from the Gregson and Lestrade type."

"And the florid face?" I asked.

"Ah, that was a more daring shot, though I have no doubt that I was right. You must not ask me that at the present state of the affair."

I passed my hand over my brow. "My head is in a whirl," I remarked; "the more one thinks of it the more mysterious it grows. How came these two men -- if there were two men -- into an empty house? What has become of the cabman who drove them? How could one man compel another to take poison? Where did the blood come from? What was the object of the murderer, since robbery had no part in it? How came the woman's ring there? Above all, why should the second man write up the German word RACHE before decamping? I confess that I cannot see any possible way of reconciling all these facts."

My companion smiled approvingly.

"You sum up the difficulties of the situation succinctly and well," he said.

Part 16:

"There is much that is still obscure, though I have quite made up my mind on the main facts. As to poor Lestrade's discovery it was simply a blind intended to put the police upon a wrong track, by suggesting Socialism and secret societies. It was not done by a German. The A, if you noticed, was printed somewhat after the German fashion. Now, a real German invariably prints in the Latin character, so that we may safely say that this was not written by one, but by a clumsy imitator who overdid his part. It was simply a ruse to divert inquiry into a wrong channel. I'm not going to tell you much more of the case, Doctor. You know a conjuror gets no credit when once he has explained his trick, and if I show you too much of my method of working, you will come to the conclusion that I am a very ordinary individual after all."

"I shall never do that," I answered; "you have brought detection as near an exact science as it ever will be brought in this world."

My companion flushed up with pleasure at my words, and the earnest way in which I uttered them. I had already observed that he was as sensitive to flattery on the score of his art as any girl could be of her beauty.

"I'll tell you one other thing," he said. "Patent leathers {10} and Square-toes came in the same cab, and they walked down the pathway together as friendly as possible -- arm-in-arm, in all probability. When they got inside they walked up and down the room -- or rather, Patent-leathers stood still while Square-toes walked up and down. I could read all that in the dust; and I could read that as he walked he grew more and more excited. That is shown by the increased length of his strides. He was talking all the while, and working himself up, no doubt, into a fury. Then the tragedy occurred. I've told you all I know myself now, for the rest is mere surmise and conjecture. We have a good working basis, however, on which to start. We must hurry up, for I want to go to Halle's concert to hear Norman Neruda this afternoon."

This conversation had occurred while our cab had been threading its way through a long succession of dingy streets and dreary by-ways. In the dingiest and dreariest of them our driver suddenly came to a stand. "That's Audley Court in there," he said, pointing to a narrow slit in the line of dead-coloured brick. "You'll find me here when you come back."

Audley Court was not an attractive locality. The narrow passage led us into a quadrangle paved with flags and lined by sordid dwellings. We picked our way among groups of dirty children, and through lines of discoloured linen, until we came to Number 46, the door of which was decorated with a small slip of brass on which the name Rance was engraved. On enquiry we found that the constable was in bed, and we were shown into a little front parlour to await his coming.

He appeared presently, looking a little irritable at being disturbed in his slumbers. "I made my report at the office," he said.

Holmes took a half-sovereign from his pocket and played with it pensively. "We thought that we should like to hear it all from your own lips," he said.

"I shall be most happy to tell you anything I can," the constable answered with his eyes upon the little golden disk.

"Just let us hear it all in your own way as it occurred."

Rance sat down on the horsehair sofa, and knitted his brows as though determined not to omit anything in his narrative.

"I'll tell it ye from the beginning," he said. "My time is from ten at night to six in the morning. At eleven there was a fight at the `White Hart'; but bar that all was quiet enough on the beat. At one o'clock it began to rain, and I met Harry Murcher -- him who has the Holland Grove beat -- and we stood together at the corner of Henrietta Street a-talkin'. Presently -- maybe about two or a little after -- I thought I would take a look round and see that all was right down the Brixton Road. It was precious dirty and lonely. Not a soul did I meet all the way down, though a cab or two went past me.

Part 17:

I was a strollin' down, thinkin' between ourselves how uncommon handy a four of gin hot would be, when suddenly the glint of a light caught my eye in the window of that same house. Now, I knew that them two houses in Lauriston Gardens was empty on account of him that owns them who won't have the drains seed to, though the very last tenant what lived in one of them died o' typhoid fever. I was knocked all in a heap therefore at seeing a light in the window, and I suspected as something was wrong. When I got to the door ----"

"You stopped, and then walked back to the garden gate," my companion interrupted. "What did you do that for?"

Rance gave a violent jump, and stared at Sherlock Holmes with the utmost amazement upon his features.

"Why, that's true, sir," he said; "though how you come to know it, Heaven only knows. Ye see, when I got up to the door it was so still and so lonesome, that I thought I'd be none the worse for some one with me. I ain't afeared of anything on this side o' the grave; but I thought that maybe it was him that died o' the typhoid inspecting the drains what killed him. The thought gave me a kind o' turn, and I walked back to the gate to see if I could see Murcher's lantern, but there wasn't no sign of him nor of anyone else."

"There was no one in the street?"

"Not a livin' soul, sir, nor as much as a dog. Then I pulled myself together and went back and pushed the door open. All was quiet inside, so I went into the room where the light was a-burnin'. There was a candle flickerin' on the mantelpiece -- a red wax one -- and by its light I saw ----"

"Yes, I know all that you saw. You walked round the room several times, and you knelt down by the body, and then you walked through and tried the kitchen door, and then ----"

John Rance sprang to his feet with a frightened face and suspicion in his eyes. "Where was you hid to see all that?" he cried. "It seems to me that you knows a deal more than you should."

Holmes laughed and threw his card across the table to the constable. "Don't get arresting me for the murder," he said. "I am one of the hounds and not the wolf; Mr. Gregson or Mr. Lestrade will answer for that. Go on, though. What did you do next?"

Rance resumed his seat, without however losing his mystified expression. "I went back to the gate and sounded my whistle. That brought Murcher and two more to the spot."

"Was the street empty then?"

"Well, it was, as far as anybody that could be of any good goes."

"What do you mean?"

The constable's features broadened into a grin. "I've seen many a drunk chap in my time," he said, "but never anyone so cryin' drunk as that cove. He was at the gate when I came out, a-leanin' up agin the railings, and a-singin' at the pitch o' his lungs about Columbine's New-fangled Banner, or some such stuff. He couldn't stand, far less help."

"What sort of a man was he?" asked Sherlock Holmes.

John Rance appeared to be somewhat irritated at this digression. "He was an uncommon drunk sort o' man," he said. "He'd ha' found hisself in the station if we hadn't been so took up."

"His face -- his dress -- didn't you notice them?" Holmes broke in impatiently.

"I should think I did notice them, seeing that I had to prop him up -- me and Murcher between us. He was a long chap, with a red face, the lower part muffled round ----"

"That will do," cried Holmes. "What became of him?"

"We'd enough