LECTURE ON DISLOCATIONS. George Ballingall considered the tendon to have been torn from its insertion into the radius, and that flexion was performed by the brachialis anticus, and flexors of the carpus and fingers. Some defects existed eight months after the accident. This case is decidedly interesting, but would have been much more so, had not the patient so obstinately opposed the endeavours of his surgeon, by persisting in using his arm; and we are deprived of the advantage of knowing what the result might have been, had he submitted to proper treatment. It does not appear that the methods employed were quite adapted to the urgency of the case; no restraint was placed upon the hand, and when we recollect how the biceps is inserted normally into the radius, how almost entirely the hand is connected with the latter bone, and moreover, that the radius is the movable bone of the forearm, it must be evident, that when the patient used his hand he moved the radius, and at the same time prevented the tendon -uniting as favourably as it might otherwise have done. The same line of treatment ought to be adopted in this case as in that of rupture of the long tendon of the biceps; only here you should commence your bandage at the shoulder and carry it down to the elbow, instead of beginning below and proceeding upwards, as I have there recommended. Be careful to place your patients hand upon his opposite shoulder, before applying the bandage; in other respects proceed in a similar manner. In my last lecture I described Mr. Earle's apparatus for injuries about the shoulder, and also that modified by Mr. Chapman, and I then mentioned, that although well adapted for the purposes intended, they were liable to the objection of being very complicated and consequently very expensive, and moreover, that unless a surgeon living in the country had already provided himself with one upon the expectation of meeting with a case, much time would be lost before he could obtain it. To obviate these objections I have invented an apparatus, a modification—but a very simple modification of the late Mr. Earle's, and which has the advantage over that invented by the latter gentleman in being both simple and cheap, and one which can be made by any one who can stitch, in less than half an hour. It consists of a long sleeve,made either of old sheeting or bed-ticking, which should be long enough to extend from the middle of the humerus to about three inches beyond the patient's fingers, and having, consequently, what (for the purposes of description) I shall call a humeral and a digital extremity, and also a hole corresponding to the olecranon to allow that process to project through. The digital extremity terminates in a cul de sac, or, in other words, is sewn up, and to it is attached a bandage three inches wide, made either of the same material as the sleeve, or of strong webbing, which is firmer and consequently better. This bandage should be at least three yards long, but you must be guided as to its length by the corpulence and size of your patient. To the posterior and external margin of the humeral extremity of the sleeve is attached another strap, from three quarters to a yard long, of the same width, and made of the same material. A pad for the axilla, made with bran, with a tape to pass round the patient's neck, completes the apparatus. I will now show you the manner in which it is to be | 541 applied: we will suppose that you have a fracture of the acromion process or of the neck of the scapula; în the former, as I have already told you, you should not place a pad in the axilla. In the latter, you must not only use the pad for the axilla, but also one between the elbow and the side, or one which, extending from the axilla to the elbow, will answer the purpose of both. I first put the sleeve on the injured arm, with the elbow projecting through the opening made for that purpose, and then, bending the patient's forearm, pláce it horizontally across his chest. I carry the bandage from the digital end of the sleeve under the opposite arm, obliquely across the back, from below upwards over the front of the injured shoulder, without pressing upon the acromion process, under the opposite arm round the back under the elbow of the injured side, and pin the end to the band crossing the breast. now carry the strap from the humeral end of the sleeve upwards across the back towards the opposite shoulder, and pin it up to the oblique band, by which the head of the bone is drawn upwards and backwards and completely supported against the acromion process. Should the case be one of rupture of the bicipital tendon or fracture of the coracoid process, you employ the axillary pad, and apply the apparatus as follows :--Having put the patient's arm in the sleeve, you rest his hand on the shoulder of the opposite side, and carry the long bandage obliquely across the back, over the elbow of the injured side, and round the waist as often as it will go; pin it there, and support the elbow by carrying the short strap over to the sound shoulder and fasten it to the bandage encircling the waist. You will observe that this apparatus is free from the objection urged by Mr. Chapman against that invented by Mr. Earle, as it leaves the motions of the sound shoulder entirely free and unimpeded, and the seat of injury uncovered, enabling you to watch the state of parts, without the necessity of disturbing the apparatus. Since my last lecture, Mr. Houlton, our House Surgeon, called my attention to an out-patient, who had fallen down upon her left shoulder. She experienced great pain at the time, but could move the limb and raise the arm to her head when she applied to him immediately after the accident, two days previously. As, however, the arm had become motionless, and she complained of so much pain, he requested me to examine her. She told me that when she attempted to move or bend her arm she suffered greatly, espécially in the course of the belly and long tendon of the biceps muscle. I desired her to raise her arm to her head, but although she endeavoured to do so she could not, and complained greatly of the pain which the attempt caused her, but at the same time the pain was confined entirely to the situation of the biceps. I examined the arm very carefully, and could detect neither fracture nor dislocation, but upon tracing up the tendon of the biceps in the axilla, I found it more prominent than natural, and evidently thrown inwards upon the inner tubercle, whilst pressure upon it gave her pain as she experienced when the arm was moved, I therefore decided that the case was one of displacement of the tendon of the long head of the biceps, and I accordingly rotated the arm strongly inwards, at the same time giving the elbow a sweep from below upwards, 542 ANALYSIS OF THE FACTS OF DISEASE. across the chest, by which means the tendon was returned to its natural position, and upon my now requesting the patient to raise her arm to her head, she did so with perfect facility and without complaining of any pain. 1 A CRITICAL ANALYSIS OF THE PRINCIPAL FACTS OF disease. In this paper I propose to make a critical analysis of the principal facts of irritation and congestion, as antecedent phenomena of inflammation. Subsequently, in other papers, I design to treat in the same manner the facts of inflammation, fever, &c. The principles of treatment will likewise be examined, and their value tested physiologically. Time is not mis-spent in trying to improve the basis of medical practice by the study of, and search after, principles, and by the endeavour to make them fruitful in the exercise of the healing art. IRRITATION AND CONGESTION. H. J. The word irritation is made use of to express states of the nervous system, or its parts, known only by their effects. This is a self-evident proposition, and is founded merely on the conventional use of the word irritation, in the language of medical science. II. The antecedents of these states (1.) may be mental excitement; the application of a stimulant ; an injury; or the equivalents of these. Mental excitement, as an irritant of nerves, excites pallor, or the blush, or both, in capillaries acting in concert with them. This is the simplest instance of sensation acting upon the velocity of the circulation in a part. Its effects are transitory; but an injury continues, therefore its effects are persistent. III. Irritation varies in its effects according to the character of its antecedents (11.), its situations, and relations. Dubois has remarked ("Préleçons de Pathologie Experimentale") that cessation of circulation precedes increase in its velocity, after a puncture in the web of the frog's foot. Thompson made the same remark. ("Traité de l'Inflammation." French edition.) Paflor and the blush, cessation and increased velocity of the circulation; these opposite effects are produced by different degrees of the same state of the nervous system. The same injury (Dubois) gives rise, locally, to arrest of the circulation, and to subsequent increase in its velocity; the same idea to the blanched and crimsoned cheek. Ammonia causes the circulation to be less rapid, (Thompson,) but its action is probably chemical, (Müller,) and therefore its effects, which differ remarkably, are not to be relied on. The same observation may apply to other stimulants, in the present imperfect state of knowledge in the matter. IV. Irritation may be both normal and abnormal. › This and the preceding proposition embrace all the varieties of irritation, in whatever structure they may arise, under whatever circumstances they may subsist, and by whatever agency they may have been excited. Their development is reserved for the opportunity when the facts on which they are based call for full' elucidation. V. Irritation is normal when its effects are brought, about by a natural cause, or its equivalent, and which disappear soon after the cause is removed (111, IV.); abnormal when its effects are persistent, owing to the permanence of its cause (11, 111). VI. When irritation is normal (v.) and is excited in a vascular structure (111.), it is followed by increase in the velocity, sometimes preceded by arrest of the circulation of the part (11.). VII. When irritation is abnormal (v.) and occurs in a vascular part, there is a temporary cessation succeeded by preternatural velocity of the circulation (vs.); the diameter of the capillaries is lessened; the usual change in the blood, from arterial to venous, does not take place within them; the blood globules coalesce, and secretion is suspended. Normal and abnormal irritation produce the same functional disturbance in the capillaries; but, if the irritant action continue beyond a certain period, the characteristic phenomena of congestion become developed. Under whatever circumstances an arrest of the circulation precedes an increase in its velocity, the diameter of the capillaries must be lessened, for these vessels collapse when empty, and the force of the heart has to overcome gradually the resistance, made to it by firmly closed tubes. It is probable, that a local increase in the velocity of capillary circulation, is always preceded by a partial emptying, and, consequently by a reduction in the diameter of the vessels. The force of the heart being in an inverse ratio to the diameter of the vessels, it follows, that a decrease in the diameter of the capillary tubes must be succeeded by an increase in the velocity of the circulation. The presence of irritation implies the presence of nervous matter (1.) "The retina affords the most striking demonstration of the general termination of a nerve, and does it in a manner so satisfactory, that little further can be desired ; and it gives ample reason for concluding that the rest have a similar but modified termination. Although many of the nerves may be traced to form a membranous expansion, yet these are so small in proportion to, and so much interwoven with, their respective organs, as to leave the anatomist incapable of demonstrating to the same degree their the Nerves of the Human body.") ultimate termination." (Swan, "A Demonstration of The connection which exists between the nervous and capillary systems cannot be established by minute when the intercapillary spaces are punctured, and the anatomy. But the sensibility manifested by animals disturbance which ensues in the circulation of the part, demonstrate with the utmost certainty that such sation at their roots, destroys all sensibility in the a union subsists. The severing of the nerves of senthem then no longer affects the circulation, intercapillary spaces, and a puncture made within The left limb of a frog having been deprived of sensation and motion, by an injury of the spinal cord at the loins, the circulation was examined immediately in the webs of both feet, and the following results were noted: Most of the capillaries in the paralysed limb were empty and invisible. Here and there one or two CRANIOTOMY. small veins were observed to contain globules, which moved as tardily as possible, and sometimes stopped entirely. A circulation equally slow was maintained in the larger vessels of the part. The web was then punctured through, and the circulation was unaffected by the injury. The right web was then examined, and the circulation was there found to be equally slow. The diameter of the vessels was natural where circulation was observable; but where it had ceased and the vessels were empty, no capillaries were to be seen. The visible vessels were equally few in both feet. The web was then punctured through. The animal made a vast effort at escape. For a minute the circulation ceased altogether. It was soon re-established with increasing velocity, and was shortly as rapid as in health, both around the puncture, and in each of the divisions of the web. After an interval the circulation was retarded around the puncture, but continued to be rapid elsewhere. In an hour the circulation was proceeding as before in the sound limb, but had made no advance in the other. Five hours later the circulation was still brisk, and generally diffused in the healthy web; brisk in several parts, tardy in others in the paralysed. Fifteen hours later the circulation was nearly equalized, and nothing new was observable. A little reflection will show that these results are of some importance. They involve the discovery that the sensitive nerves at their termination, though not essential to the maintenance of the capillary circulation, may, nevertheless, exert an important influence over it when they are excited. Their influence is local, for had it been reflected in a manner to increase the force of the heart, it would have been felt in the web of both feet equally. It would thus almost seem that an afflux of nervous power to a part, as in vital turgescence or blushing (11.), exerted an affinity for the blood. That the blood should traverse the capillary vessels unchanged, as authenticated by several observers, if such a fact be capable of ocular demonstration, must not be passed over unnoticed. The change of blood from arterial to venous is a chemical phenomenon, and is caused, on the authority of Liebig, ("Theory of Respiration,") by a conversion of peroxide of iron into carbonate of protoxide in the capillary vessels, these changes are suspended animal temperature ceases to be generated in the part. If The blood globules coalesce during congestion, not owing to reduction of animal heat; for they do not immediately coalesce even on removal from the vessels themselves; not indeed until they have been isolated for a sufficient length of time to become obnoxious to chemical changes; an agency which probably gives rise to their coalescence in congestion? The arrest of secretion is best explained by a consideration of the fact, that remora and stasis are conditions of the circulation best calculated to favour secretion, and that in active congestion the torrent of the The influence which the circulation is increased. condition of the nerves exerts will be examined under the head of inflammation. (To be continued.) ON CRANIOTOMY: MR. COX'S CASE OF TO THE EDITOR OF THE PROVINCIAL MEDICAL AND SIR, I am tempted once more to trouble you, requesting you to allow the insertion of the following explanatory remarks relative to my recent case of Cæsarian operation, called forth by the letters of Mr. Knowles and Dr. McEgan. I must premise that I by no means regret the appearance of these observations; on the other hand, I am pleased to see them, my object in publishing the case being to elicit, if it should comand sufficient interest and attention, the opinion of my professional brethren. It is by controversies upon difficult and doubtful points of practice, that science is advanced, and the truth established; and as long as the dispute is carried on in a fair and gentlemanly spirit, it matters not who goes to the wall, the great human family being the gainers. I am much pleased with the generous tone of Mr. Knowles's remarks; it is pleasant to have such a man for an opponent, and it must be very delightful to find him our ally. A fair estimate of the success or failure of an operation or plan of treatment, can of course never be obtained unless all the cases are honestly laid before the profession. It unfortunately happens that too many are apt to withhold the unsuccessful and make known only those of fortunate termination, letting the world into the secret only of what "Strangely visited people, The mere despair of surgery, they cure." To my thinking, the man who would shrink from the fulfilment of an unpleasant obligation his duty imposes on him, solely from the consequences to himself, is unfit to practice that profession, the great aim of which is the prolonging of human life, and the relief of human suffering; and the sooner he employs his talents in another sphere, the more conducive will it be to the dignity of his profession and the best interests of humanity. I must say it too often happens that censures and critiques follow the publication of unsuccessful cases from men not altogether qualified by years and experience to issue them. From men, who, to speak figuratively— "Never set a squadron in the field, "Nor the division of a battle knows "More than a spinster; unless the bookish theorick," Now for a few words in my own defence. Mr. Knowles says, "It is much to be regretted that the consultation was deferred until eleven o'clock." I will just give him a little insight into the difficulties that beset a country practitioner. About nine p.m., on the night the woman was taken in labour, I sent to my friend Mr. Williams, of Guilsborough, five miles distant; he was not at home; thinking he might have gone to dinner at Northampton, I sent again, bidding my servant await his return, if expected, or, if Mr. Williams were at a case, to follow him. He was attending a lady four miles from home, and could not obey It was now between one and two my summons. o'clock a.m.; I then sent to Lutterworth, another eight miles distant, but fruitlessly. Mr. Colston felt diffident about acting without a third opinion, and so did I, for we did not arrogate to ourselves the belief that we were Nestors in age or wisdom; accordingly be successful with a pelvis one eighth of an inch larger Mr. Colston himself started to Harborough, another than Brooks's. I must must say this this seems to me, drawing eight miles, and returned with Mr. Francis. How had a very fine distinction, one that reads nicely, but canthe poor woman been all this time? Why, truly she not be of practical value, unless it were possible to had had pains all night, but of such a character that I define exactly to a line the size of the pelvis and the have seen many women bear the kind two or three child's head, neither of which can be done. As Mr. days in a first labour without anything like exhaustion, Knowles considers craniotoiny may sometimes be_sucand such as would not advance the child much, even in cessful with a pelvis of such a size, I contend every a capacious pelvis; and she had slept at intervals. Mr. woman should have the chance and benefit of the Francis thought the pelvis a little larger than I did, sometimes. and after much thinking and anxious speculation, we agreed to attempt delivery by embryotomy, as affording the best chance for the mother. And now for authorities to justify the attempt. The pelvis was from one inch and a half to one inch and five-eighths in the short, and as large as usual in the long diameter. Dr. Osborne did deliver a woman whose pelvis did not exceed one inch and a half in the short diameter, and she lived. Mr. Knowles suspects Dr. Osborne was wrong in his measurement; I do not see why the correctness of his judgment or veracity should be doubted, and must claim him as an authority on my side. The talented and accomplished Dr. Lee, in his recently published lectures says, (showing a pelvis to his class), “When you look at this distorted pelvis from malacosteon, which measures only one inch and three quarters from the last lumbar vertebra to the symphysis pubis, and know that two children, at the full period, were drawn through it, without destroying the mother, you may conclude that few cases of distortion can possibly occur, where you will not ultimately succeed in effecting the delivery with the crotchet." Now the pelvis, in this case, measured, when in the dissected state, one eighth of an inch more than in mine, and surely not more than mine in the living woman; and here let me observe, that the man who pretends to such exquisite sense of touch, that he can tell to the eighth of an inch the size of a pelvis, with the fingers necessarily cramped, possesses a treasure that I do not, nor many of my brethren lay claim to. Dr. Lee again says, "Wherever the presenting part can be reached, to apply the perforator and crotchet, an attempt should always be made to deliver, and the Cæsarian operation reserved for those cases in which the distortion is so great that the os uteri and presenting part are entirely beyond reach." Again, says the same high authority, "I would draw an entirely different conclusion, and in all cases, whatever the degree of distortion might be, either in the brim or outlet of the pelvis, attempt to deliver by embryotomy where the presenting part could be reached by the finger, and the crotchet applied." Mr. Barlow says, "where the pelvis is from two and a half inches to one and a half, delivery should be completed by embryotomy." I could quote other authorities to justify the practice, but I consider the opinion of so eminent an accoucheur as Dr. Lee, a host; while the fact of his having twice delivered a woman possessing a pelvis certainly not larger than in my case, at the full time, is a triumphant refutation of the assertion, that it is an impracticable proceeding. Mr. Knowles himself says, that "when the sacro-pubic diameter of the pelvis does not amount to one inch and three quarters, delivery can rarely be effected by craniotomy, with any probability of safety to the mother." We are to infer from this that he thinks it may somehow Dr. McEgan principally condemns "my practice, because he is an enemy to needless craniotomy. Why, no sane man would ever perform it, if he were certain it was needless; but, very few, perhaps none-unless fond of displaying and puffing great surgical deeds, would hesitate to adopt it in a case of doubt, and give the mother the benefit of the doubt. I must ever be an enemy to the Cæsarian section, from a conviction of the almost insurmountable changes attending it. I must honestly confess, that { do not believe Brooks would have recovered, had delivery by craniotomy not been attempted, because, although of course that operation tended to weaken her, neither my colleagues nor I considered her more than temporarily depressed by it-indeed, in half an hour, she was as cheerful, and her pulse as good, as ever. I firmly believe, had the operation been performed twelve hours earlier, she would have sunk just as rapidly, for the prostration following it is not one of degree, depending on the previous strength of the patient altogether, but the effect of a tremendous shock caused by an almost certainly fatal operation, which must be and has been felt, alike by the feeble and the strong, by the giant and the dwarf. I contend the Cæsarian section should never be resorted to while any reasonable chance remains of delivery by other means. I have proved,—at least I think so,→ that craniotomy holds out a reasonable chance of suécess; and in my case it was tried. Dr. Lee's case and statements put my mind at rest as to the correctness of the proceeding, and justify the deed to myself, and I hope, to many of my professional brethren. I am convinced the poor woman would have died under any circumstances, even had the Cæsarian operation alone been performed and performed earlier, and then I should have expected, and certainly should have metTM with a host of assailants, for not having given my patient the chance of delivery by embryotomy. This is just one of those cases of difficulty and nicety that, terminate as it will, is sure to be condemned, and I comfort myself with the conviction, that it is more consistent with human nature to censure and condemn doings of others in dangerous and difficult situations,“ Welford, Nov. 15, 1844. RESOLUTIONS OF THE DERBY MEETING. PROVINCIAL 545 limited to the qualified, licensed, and duly regis Medical & Surgical Journal.tered practitioner, and while it contends for this WEDNESDAY, NOVEMBER 27, 1844. It will be seen from the report of the proceedings at the important meeting of the Provincial Medical and Surgical Association, held at Derby, that the resolutions passed at that meeting, in common with those of many other influential meetings held in different parts of the kingdom, recognize the leading principles of reform hitherto advocated by the Association. While they give credit to such parts of the measure introduced into parliament by the Home Secretary, as are calculated to carry out these principles, they at the same time show wherein it falls short of, or fails to attain them, and record the dissent of the meeting from other parts, objectionable in themselves, and which, if passed into law, would unquestionably prove destructive to the profession, and injurious to the best interests of the community. Here, as elsewhere, we have seen the strong and decided protest against that false step in legislation, which disfigures the first clause of the bill, and which, if persisted in, must fatally vitiate the whole measure, rendering nugatory any good to be expected from other provisions of unquestionable value, and which if carried out with judgment, and modified so as to include within their scope every class of the profession, must materially tend to elevate the standing of the whole. The mischiefs which result from the practice of medicine, and from the dabbling in medication by unqualified and ignorant persons, can only be appreciated to their full extent by the medical profession, and when we perceive every grade, we might almost say every individual member, of that profession cordially uniting, and with one voice contending for that protection in the exercise of their calling, to which they are justly entitled by the requiremetits made from them, before they can be legally licensed to practice it,-when we see that this protection is sought as much for the welfare of the community as for the direct benefit of the profession, it is impossible but that a wise Government must yield to the desire so reasonably, so firmly, and so generally expressed. Equal right to practice without respect to local privileges, is unquestionably conceded under the bill, and indeed could not be withheld from any member of the profession, for, as far as the private and lucrative exercise of it is concerned, it is granted to every individual, man, woman, and child, throughout the kingdom. The resolution of the special general meeting of the Association, in reference to this point, while it acknowledges the principle, affirms that its operation should be equality of right among all the members of the profession, recognizes as the only ground on which such right should be exercised, uniform and suffimedicine. The resolutions of the meeting admit cient primary qualification in every branch of that the bill provides an approach to this uniformity of qualification, but at the same time affirm the necessity of still further carrying it out. Now these are two of the leading principles which have ever been contended for by the Associ ation, and together with the necessity for protection,' are clearly set forth in the statement circulated by the Council amongst the Members of the House of Commons during the last Session of Parliament. They are those which may be said to concern the individual and personal prosperity of every member of the profession, and ought to be conceded without reference to any public and corporate rights or privileges to which it may further be deemed fitting to admit him. It is to these corporate and public privileges that the third great principle contended for by the Association-a representative voice in the formation of the councils or governing bodies-bas relation, and ¦ accordingly we find a resolution of the meeting affirming the necessity of a further recognition of this principle in the Colleges of Physicians and Surgeons, In the statement to which we before alluded, it was shown that the general practitioners were entitled to be, in like manner, consolidated and incorporated together; and whether the Society of Apothecaries, to which body it must be admitted they are, as a class, greatly indebted, can be so far modified as to meet the occasion, or otherwise, the resolution of the Derby Meeting, advocating such an incorporation, is not only in accordance with the principles before set forth by the Association, and called for by the expressed wishes of this important branch of the profession, but its adoption by the Legislature is, under existing circumstances, absolutely essential to give due effect and consistency to much that is useful and beneficial in Sir James Graham's bill. The principle of representation has been recognized in the constitution of the Council of Health and Education, and such being the case, we contend that it should be carried out, so as to make it effective. Now this it cannot be, unless it represent not only the Government; not only the Universities and Schools of Medicine; not only the Collegiate Corporate bodies of the profession, at present under the bill limited to physicians and surgeons; not only the metropolitan towns-but also the widely extended country districts, and the provincial cities and towns, and especially the great |