BIRMINGHAM MEETING. -"What, then, is the penal check which your experience suggests? We reply, let the law distintly affirm, that no one shall practice the healing art, with a view to gain, who has not given evidence of his competency. Punish those who offend against the law in this respect; let the process be simple and inexpensive, the punishment certain, and following closely upon the commission of the offence; give a power to two magistrates to convict, and punish by fine and imprisonment, with appeal to the quarter sessions." In all other cases, there was first the law to forbid the act; but by this singular part of the present bill, persons were allowed to practice, and yet the power to sue for charges was to be taken away from them. Little effect would, however, ensue from this, as all honest people would pay those whom they voluntarily employed. This did not remove the anomaly of the act, arising from the absence of a general penal clause. They had heard much of putting the cart before the horse-but here was a cart and no horse at all-a passive machine without a locomotive attached accomplishing what Hudibras contemplated, "To keep us equally in awe, Of breaking and maintaining law." It was a great point to have a general penal clause, and to render it as effective as possible. 421 ment of a high and uniform standard of qualification for all members of the medical profession, and it is earnestly hoped, in the progress of the Bill through the Houses of Parliament, its provisions may be rendered as complete as possible. Moved by Mr. Price, and seconded by Mr. Pullan :"That, whilst it is admitted that it may be exceedingly difficult entirely to suppress quackery, this Meeting is decidedly of opinion that some more stringent measures than are contained in the proposed Bill ought to be adopted for the protection of the public and the profession against ignorant and unqualified persons. Proposed by Mr. Braithwaite and seconded by Mr. Evans:-" That a permanent Committee, consisting of the following gentlemen-Messrs. Braithwaite, Brown, Bulmer, Cass, Chorley, Garlick, Hall, Hey, Land, Macfarlan, Nunneley, Price, Ratcliffe, Smith, and Teale, with power to add to their number, be now appointed for the purpose of communicating with the Borough Members, of watching the progress of the Bill, and taking such other steps as they may think necessary for carrying out the views of this Meeting." BIRMINGHAM MEETING. On Tuesday, Sept. 10th, a very numerous and highly The Chairman then put the resolution, which, as well respectable meeting of the medical profession of Birmingham and the neighbourhood, was held at the as the preceding resolutions, was carried unanimously. Moved by Mr. R. J. Tunaley, of Wymondham, and Public Office, for the purpose of taking into consiseconded by Mr. Drake, of Norwich: "That the fore-deration the bill lately introduced by Sir Jas. Graham for Medical Reform. and going resolutions be published in the local papers, a copy of them sent to each Member of Parliament for this city, the county of Norfolk, and its boroughs; and that a petition based upon these resolutions be prepared by the following committee, and after receiving the signatures of those members of the profession who are willing to support its prayer, be presented to each House of Parliament, and that the committee be requested to continue their services for the purpose of watching the interests of the profession. Committee: Dr. Evans, Dr. Lynn, Dr. Wayte, J. G. Crosse, B. H. Norgate, J. G. Johnson, C. Costerton, W. P. Nichols, A. Dalrymple, W. S. Ferrier, R. D. Hale, D. Dalrymple, and P. Eade, Esqrs., with power to add to their number." At a meeting of the Medical Profession of the Borough of Leeds, held at the Philosophical Hall, on Thursday, the 12th instant, Samuel Smith, Esq., in the chair, the following resolutions were adopted : Moved by Mr. Hey, and seconded by Mr. Cass :"That this meeting observes with pleasure that by the introduction into Parliament of a Bill intitled 'A Bill for the better Regulation of Medical Practice throughout the United Kingdom,' Her Majesty' Ministers bave at length admitted the necessity which has been so long felt by the Profession of making some alteration in its government." Moved by Mr. Nunneley, and seconded by Mr. Hall:-"That this Meeting views with satisfaction the approximation made by this bill towards the attain Among those present were the following gentlemen: -Dr. Fletcher, Dr. Birt Davies, Dr. Skerratt, Dr. Mackay, Messrs. Thomas Chavasse, Pye Chavasse, Swinson, George Elkington, Crompton, Holbech, Wickenden, Russell, Knowles, Crompton, F. Elkington, Ryland, Partridge, Bindley, Taylor, Cartwright, Allarton, A. Baker, Saunders, Bracey, Simons, Archer, Wilders, Harmer, Hadley, Chesshire, Sproston, Parsons, Watson, Hind, Green, Parker, Lawrence, and Mash, of North ampton. Dr. Bell Fletcher was called to the chair, and among the resolutions passed were the following : "That this meeting, having had its attention called to the provisions of a Bill which has been submitted to the House of Commons by Sir James Graham, on the subject of Medical Reform, is of opinion that there are some very important objects not provided for in that measure, to which the attention of the Legislature should be earnestly and respectfully called. "That in the opinion of this meeting the system at present pursued in this country by druggists, and other unqualified persons, of prescribing for and attending patients, is fraught with serious danger to the public at large, and more particularly to the poor;' and that the absence of all restrictions in the Bill now before Parliament, beyond the mere disqualification for holding public appointments, is deeply to be lamented, as it is evident the mass of the population cannot discriminate between the ignorant pretender and the regularly educated practitioner-the fact of registration being utterly insufficient for that purpose. "It appearing to this meeting that the direct sanction given by Government to quackery, by legalising the sale of stamped medicines, has a tendency greatly to deceive and to prejudice the minds of the public, and is fraught with danger to the lives of her Majesty's subjects: Resolved, That in the opinion of this meeting it is expedient that Government should provide some measure for the suppression of the sale of stamped medicines. "That petitions, embodying the foregoing resolutions, be addressed to both Houses of Parliament; and that a deputation do wait upon the Earl of Dartmouth and the Borough Members, to request them to present the same, and to use their best exertions to promote the success of its prayer. That this meeting acknowledges with pleasure the communication received from the Chairman of the Birmingham and Midland Districts Medical and Surgical Association, and is anxious to express its approbation of the principles on which that Society is formed." HASTINGS MEETING. At a meeting of the medical practitioners resident in Hastings and St. Leonards, held on Monday the 16th of September, and convened for the purpose of discussing the medical bill of Sir James Graham; W. Duke, Esq., in the chair :— Resolved:-That this meeting views with disapprobation the proposed constitution of the Council of Health and Medical Education, inasmuch as no general practitioner is by this bill proposed to be appointed on the council, thereby withholding from that numerous body a voice in the formation of all the laws and regulations which will have so important an effect on the future condition of the great body of medical practitioners throughout the United Kingdom. Resolved:-That in the opinion of this meeting the Bill for the better Regulation of Medical Practice throughout the United Kingdom, repealing as it does the Apothecaries' Act of 1815, and substituting no adequate protection to the great body of medical practitioners, would, if carried in its present form, be highly prejudicial to the interests of the profession and to the public welfare. Resolved:-That the Society of Apothecaries are entitled to the best thanks of the profession, for having enforced a gradual and extended course of study and examination, which has elevated the position of the general practitioner, and that the removal of all restrictions and penalties from unlicensed practitioners of medicine, which the repeal of the Act of 1815 would effect, would be greatly injurious to the profession, and to the public at large, Resolved :-That a deputation be formed, consisting of the Chairman, Dr. Mackness, R. Ranking, Esq., F. Ticehurst, Esq., J. Savory, Esq., W. H. Gardner, Esq., J. Ranger, Esq., and the Secretary, to wait upon the Members for the borough, and to afford them any necessary explanation, requesting them to support the views of this meeting, urging upon them the injustice to the profession, and the injury to the public, certain to result from the carrying out of the proposed Bill of Sir James Graham. Resolved :-That a petition to the House of Commons be prepared, founded on the above resolutions, and that it be presented to the House by R. Holland, ROCHDALE MEETING. A meeting of the Medical Practitioners of Rochdale and the neighbourhood was held on Thursday, the 26th instant, to take into consideration the provisions of Sir J. Graham's Medical Reform Bill, There were present-Mr. Dunlop, chairman; Dr. Edwards; Messrs. Wood, F.R.C.S.; Bower, Dicken, Barker, Sellers, Lamb, Lawton, R. Barker, Schofield, N. Buckley, Collingwood, Coventry, Taylor, and Thomasson. A petition to the House of Commons, strongly condemnatory of that portion of Sir J. Graham's measure which proposes to repeal the Act of 1815, without the substitution of any other equally stringent enactment for the protection of the legally qualified practitioner, was unanimously agreed to. A deputation was also appointed to wait upon the Honourable Member for the borough, to request him to present the petition, and to support its prayer, at the meeting of Parliament. SALISBURY MEETING. At meeting of the medical practitioners in Salisbury, held at the Salisbury Infirmary, September 21, 1844, present, Dr. Grove, in the chair, Dr. W. C. Finch, H. Coates, Esq., W. Andrews, Esq., G. Tatum, Esq., John Toone, Esq., John Winzar, Esq., W. M. Coates, Esq., T. R. Moore, Esq., J. A. Lush, Esq., A. Middleton, Esq., G. Senior, Esq.:-It was resolved that a General Meeting of the Medical Practitioners of the county should be convened to discuss the provisions of Sir James Graham's Bill for the better Regulation of Medical Practice throughout the United Kingdom. The meeting was appointed to be held at the Council Chamber, Salisbury, on Tuesday, the 8th of October, at two o'clock in the afternoon. BOOKS RECEIVED. Twenty-fourth Annual Report of the Directors of the Dundee Royal Asylum for Lunatics, &c. Dundee: 1844, 8vo. pp. 48. State of an Institution near York, called the Retreat for Persons afflicted with Disorders of the Mind. Fortyeighth Report. York: 1844, 12mo., pp. 26. ERRATUM. Page 388, col. 2, line 32. The measurement of the diameter of the pelvis in the case narrated in the Journal of September 18th, was from one inch and a half to one inch and five eighths, instead of from one inch and three eighths to one inch and a half, as there stated. TO CORRESPONDENTS. Communications have been received from Dr. Cullen; Dr. Hindle; Mr. G. King; and Dr. Paxton. PROVINCIAL MEDICAL & SURGICAL JOURNAL. CLINICAL LECTURES ON DISLOCATIONS, | arm is carried across the chest, this depression is "DELIVERED AT THE CHARING CROSS not so evident, as the head of the humerus is then HOSPITAL. SUMMER SESSION, 1844. By HENRY HANCOCK, Esq., Surgeon to the Hospital. LECTURE IV. I shall commence the present lecture by describing to you the appearances which the shoulder presents in its natural state, and also the points or processes necessary to be observed in relation to dislocations of the joint. The shoulder is some what conical in shape, the base being at the axillary border, whilst the apex is directed upwards and forwards. It presents four aspects-an anterior, postérior, superior, and external. On the anterior aspect, commencing at the border of the axilla, is a deep groove leading up to the anterior margin of the clavicle, at about an inch and a half from its acromial extremity, at the angle between its concave and convex portions. Place your finger upon this spot, and carry it outwards and then backwards around the shoulder, and you will be able to trace the end of the clavicle, the acromion process, and, lastly, the spine of the scapula, very well marked, and easily discerned, especially in thin muscular individuals. Next retrace your finger and place it in the groove immediately below the clavicle. This spot corresponds to the division between the anterior edge of the deltoid and upper edge of the pectoralis major muscles. Carry your finger outwards and you will then feel the dense ligament or rather fascia extending from the coracoid process to the clavicle and ribs, the coracoid process, the anterior edge of the deltoid muscle, and the prominence of the head of the humerus. On the posterior aspect you may observe the supra-spinal fossa, beneath which is the spine of the scapula; pass your finger along this process from within, outwards, or from the vertebrae towards the humerus, and you will be able to feel the well defined posterior margin of the acromial process, beneath which, if you exercise a little pressure upon the posterior portion of the deltoid muscle, you will Sobserve, when the arm is at rest by the side, a "depression, the acromion overlapping the head of the humerus in this direction; when, however, the No. 28, October 9, 1844. thrown more backward. Extending down from the head to the shoulder, on the posterior part of the neck, is a prominent but obtuse border. This is the external edge of the trapezius muscle. Carry your finger from above, downwards, and from within, outwards, along the cap of the shoulder, and you will distinguish the following objects. At the termination of this border or margin you will feel a ledge or ridge much more distinct in some individuals than in others, this is the acromial extremity of the clavicle articulating with the acromial process upon which your finger next rests; pass your finger for rather more than an inch outwards, and it will slip over the edge of this process directly upon the projecting bead of the humerus, covered by the deltoid muscle. You must bear in mind the different degrees of projection presented by the clavicle. In some individuals it is so much elevated and enlarged that a considerable projection results, liable to be mistaken for luxation or disease of the bone. M. Huguier has observed that this projection is very common among convicts sentenced to penal labour, and he attributes it to the incessant pressure exercised by the clavicle and acromion, one against the other. You will frequently meet with this excess of formation among the hard-working poor, and you must be careful not to mistake it either for accident or disease. In most instances, however, you will be guided by examining both shoulders of the patient, when you will usually find a similar projection on both. Indeed, I should strongly recommend you in every case of injury to joints, for which you are consulted, to examine the corresponding joint, for if you omit to do this, you will constantly be liable to fall into some error or other. On the external aspect the points to be remarked are the outer edge of the acromion process, below which is the rounded eminence of the head of the humerus and deltoid muscles projecting considerably in this direction. We will now proceed to the consideration of the motions of the shoulder joint, and the mechanism by which those FF 424 LECTURE ON DISLOCATIONS. motions are executed. The shoulder joint enjoys | which they are inserted around the humerus. Thus greater extent and latitude of motion than any joint in the human frame. Its motions are those of flexion, extension, abduction, adduction, rotation, and circumduction, or a combination of these motions. When the humerus is carried backwards, the shoulder joint is in a state of extension. The muscles by which this motion is effected are the deltoid, by its scapular portion, the teres minor, teres major, long head of the triceps, and the latissimus dorsi. When, on the contrary, the humerus is carried forwards, the shoulder joint is in the position of flexion produced by the action of the acromial and clavicular portions of the deltoid, the supraspinatus, biceps, coraco-brachialis, and clavicular portion of the pectoralis major muscles; and when the humerus is elevated in a plane parallel to that of the scapula, these muscles are to a small degree assisted by the infra-spinatus and subscapularis. Abduction is where the humerus is carried from within outwards, away from the side, being directed neither forwards nor backwards. This motion is effected by the combined action of the deltoid, the supra-spinatus and infra-spinatus muscles, assisted by the biceps and coraco-brachialis. In adduction the arm is returned to the side by the pectoralis and latissimus dorsi muscles. it is commenced by the pectoralis major which raises the arm forwards, inwards, and upwards, until it comes within the sphere of action of the flexors and abductors, which continue the movement upwards, outwards, and backwards, until the arm is placed under the influence of the extensor muscles, which carry it backwards, inwards, and downwards, thus completing the motion of circumduction. But you must bear in mind that the movements of the shoulder joint are not confined to the mere revolution or gliding of the humerus upon the scapula, but that a great latitude is added to these movements by the scapula not being a fixed bone, but, on the contrary, retained in its situation and influenced by the action of muscles which enable it to yield to and follow the several motions of the humerus, thus bestowing greater freedom and sphere of action upon the upper extremity. Indeed, were we to confine our examination to the muscles usually described as effecting the movements of the shoulder joint, we should omit several very important agents. It is true that they do not act directly upon the humerus, but by adapting the scapula to the necessities of that bone, they enable the joint to perform the functions for which it was designed in a perfect and eficient manner. How comparatively limited would be the sphere of action, were it not for this beautiful arrangement I am now endeavouring to explain to you, and how constantly would jars and concussions be referred to the shoulder joint. The value of these muscles is particularly illustrated by those artisans who have to wield heavy sledge hammers; take the black The motion of rotation is of two kinds, for instance, where the thumb is turned outwards and sideways, where the palm of the hand is directed forwards, the limb is said to be in a state of supination, or rotated outwards, or radiad; where on the contrary the back of the hand is directed for-smith for instance, and observe with what power wards with the thumb turned inwards towards the he is enabled to strike the heated metal. He does mesial line, it is pronated or rotated inwards or not derive this power from what have usually been ulnad. These rotations may be performed when the described as the muscles of the shoulder joint arm is in a state of extension, flexion, abduction, or alone, but is mainly indebted for the great strength adduction, as indeed may be abduction or adduc- and ease with which he performs these evolutions tion when the limb is flexed or extended, and vice to the accessory power the joint thus derives from versa. The muscles which rotate the humerus the arrangement of the scapula, and the influence outwards are the supra-spinatus, infra-spinatus, exerted upon that bone by the trapezius, levator teres minor, scapular portion of the deltoid, and anguli scapulæ and rhomboid muscles, and by which when the humerus has been rolled inwards, the arrangement he escapes those shocks and concuscoraco-brachialis to a small extent. The rotators sions which his shoulder joint would otherwise inwards are the subscapularis, the clavicular portion inevitably encounter. of the deltoid, and when the humerus has already been rotated outwards, the latissimus dorsi, teres major, and, at the commencement of rotation, the pectoralis major. Circumduction is a compound movement comprising the whole of the preceding motions; in this the humerus is made to describe the circumference of a cone, the base of which is towards the elbow, the apex being at the shoulder joint. This movement is produced by the flexors, abductors, extensors, and adductors, acting to the same degree, and also in the same order of succession as that in Dislocations of the shoulder are either complete, incomplete, congenital, simple compound, or complicated. But as the object of these lectures is rather to point out to you the phenomena of dislocation resulting from violence or accident, we will commence, if you please, with the consideration of simple complete dislocations of this joint. From the review of the anatomy of the part through which we have passed in this and the preceding lectures, you will doubtless have observed that there are situations in which dislocation cannot occur unless complicated with other mischief. LECTURE ON DISLOCATIONS. The motion of abduction being limited by the elbow striking against the thorax, the head of the humerus can scarcely be dislocated directly outwards through the deltoid muscle, or from beneath the acromion process of the scapula; neither can it be displaced directly upwards, as it there meets with the insurmountable obstacle presented by the coraco-acromial arch. Luxation backwards, or into the infra-spinatus fossa, though very rare, is by no means impossible. Sir A. Cooper mentions having seen two instances in a practice of thirtyeight years, but there are several cases recorded of this accident. The supra-spinatus and deltoid tend to prevent the head of the bone slipping directly forwards. Nothing, on the contary, prevents dislocation downwards, and when the arm is raised from the side the deltoid may assist it in a very decided manner. The capsule, internally much thinner than in other situations, is only sustained by the tendon of the sub-scapularis muscle, which tends to push the head of the bone with great force towards the glenoid cavity when dislocation is likely to occur. When the arm is elevated to a right angle with the trunk, the axis of the humerus is very near the inferior border of the glenoid cavity. The deltoid, pectoralis major, latisimus dorsi, and teres major muscles, then become auxiliaries to the power of displacement, which, in point of fact, meets with no other opposition than that experienced from the capsule. Luxation downwards and inwards, therefore, may easily occur, and is consequently a very common accident. Luxation in front occurs under two forms. First, the head of the humerus, arrested by the tip of the coracoid process and the capsular ligament, may remain with the groove or anatomical neck placed on the edge of the glenoid cavity. This accident has been described as an incomplete or sub-luxation of the humerus, by Sir A. Cooper, Messrs. Physic, Velpeau, Malle, Howship, Fisher, and other writers on this subject. In the other form, the head of the bone may be forced upwards and inwards, either above the tendon of the subscapularis muscle, or by that muscle being ruptured, and be fixed beneath the clavicle, although Petit has observed that the head of the bone can never be dislocated upwards aud inwards, because the head of the bone is arrested by the coraco-brachialis, two heads of of the biceps, and the coracoid process. Nevertheless, these accidents do occur, and occur frequently, although less so than in the direction of the axilla. M. Petit indeed placed too much reliance upon the power of muscles in preventing dislocations, whilst he appears to have overlooked how much the strength of a joint and its immunity from these accidents depends upon shape and the arrangement of the bony articulatory surfaces; for he observes, with reference to this subject, that those articulations which are surrounded by the 425 largest number of muscles are those which are luxated with the greatest difficulty; a theory completely overset by the greater frequency of this accident to the shoulder than to any other joint of the body. Most of the older authors have fallen into the same error; from not having had opportunities of examining the parts and judging from actual dissection, they were obliged to guess, indeed, as recently as the year 1810. Mr. Hey, of Leeds, than whom a better surgeon never existed, in his observations on surgery, lamented that the opportunities of dissecting the shoulder joint in a state of dislocation were so exceedingly rare. So rare were these opportunities, that Mr. Crampton, who has assisted materially in removing our ignorance upon this subject, states, in the third volume of the Medico-Chirurgical Transactions, that at the time Mr. Hey wrote his work on surgery, there was, he believes, but one case on record in which the actual state of the joint, in a recent dislocation of the shoulder, was described and delineated, and you will find that case recorded in the medical observations and enquiries for the year 1761, entitled observations on a dislocated shoulder, by Henry Thompson. We know from experience, that the muscles afford but little protection when taken by surprise. Mr. John Hunter justly observed, that when muscles were so taken by surprise, their force or power was then eluded, and he asserts, that before a muscle can put forth its full force, it must be in a state of preparation for action, and that this state of preparation must be produced either by the stimulus of the will conveyed by the nerves, or by mechanical or chemical stimulus applied or acting directly on the muscle itself. Hence we can easily understand how these joints, which, under certain circumstances are so easily dislocated, are capable of performing and sustaining the powerful actions which they constantly exert. But dissection has proved that so far from preventing displacement, the muscles themselves are lacerated, thus rendering the accident more severe than was formerly supposed, but at the same time accounting for the unfortunate symptoms which sometimes result, and for which, were it not for these pathological researches, we should be at a loss to account. A great deal still remains to be done in this particular. Our knowledge upon this point still falls very far short of perfection, and I would seriously impress upon you the great benefit which you would confer upon the profession, and upon mankind in general, by availing yourselves of every opportunity which presents itself, of carefully examining the injured parts, and by imparting the results of these examinations to your professional brethren. It is not by isolated cases that we can any of us judge of disease or accident, let it be what it may; but it is only by collecting cases, and carefully studying numerous |