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on a double inclined plane, so arranged that the leg lay horizontally. Leech*? were applied to the joint, and subsequently cold water irrigation.
Professor Williams said he would not detain the Society by reading the details of the progress of the case, which had been fully aud accurately taken b;> Mr Taylor. It would be enough to say, that the soft parts covering the displaced bone inflamed, and on the eighth day, when it was evident that their destruction was inevitable, they were divided by a crucial incision, which gave exit to a little sanious discharge, and exposed the bone, with its superior articular surface looking inwards. On the fourteenth day the bone was removed (some strong ligamentous attachments, which still held it, being divided with a probe-pointed bistoury guided by the forefinger), and it was then found tha: the astragalus had been fractured as well as dislocated, its head and a portioa of the inferior surface having been broken, or rather ground off, and a quantity of the resulting small fragments were removed. The limb was then replaced in its previous position. Nothing requiring to be particularly noticed occurres until a fortnight after the removal of the bone, when an abscess formed below and behind the external malleolus, and was opened. The discharge, both from this abscess and from the cavity from which the astragalus bad been removed, now rapidly diminished, and the parts presented a very healthy appearance Matters went on favourably till about 6th of May, when some trouble w*f occasioned by stripping of the integuments over the sacrum and os calcia. in spite of every precaution that had been taken to guard against both. This, however, was remedied by attention to position, and on the 7th of June the limb was replaced in its original posture. From this time he went on steadily, but very slowly, improving; and on the 10th of August the cavity whence the bone had been removed had cicatrized, leaving a deep impression.
The foot was in an exceedingly slight degree extended, but not permanently so, for he possessed some power of moving the ankle, and was able to brine the foot to a right angle with the leg. He now began to move about on crutches, and at first the foot, when allowed to depend for some time, became painful and oedematous, but that inconvenience was relieved by careful bandaging, and soon ceased. Towards the latter end of August he left the hospital to go to the country, and was then able to walk pretty well with the aid of a stick.
Nothing was seen or heard of the patient until ten months after he had left the hospital, when he returned and stated that he had resumed work, thongh not of so laborious a kind as before, but that the extension of the foot had gradually increased, so as to cause considerable inconvenience iu walking. The tendo-Achillis was now divided subcutaneously, and the foot was brought to about the same position it had been in when he first left the hospital. He was then provided with a high-heeled shoe, and left the hospital considerably improved, but using the help of a stick in walking.
Professor Williams said he was chiefly induced to bring this case before the Society, because it was rather curious so little attention has been directed to dislocation of the astragalus backward ; in fact it has been scarcely noticed by systematic writers on surgery. Benjamin Pell, indeed, says that the astragalus may be displaced backwards, but he apparently does so wholly ou theoretical grounds, and merely as contemplating the possibility of the occurrence; but Professor Williams could not then remember any other systematic writers who alluded to the subject, except Mr Lizars and Mr Liston, who have each very briefly mentioned a case that occurred in their own practice respectively, and Mr Liston observes tbat he never expected to see another. On the other hand, this dislocation was not noticed by Miller, Fergusson, Bransby Cooper, Skey, Pirie, or Erichsen, and it had even escaped the great experience and research of Mr South. The French systematic writers were quite silent on the subject. MM. Vidal de Casis and Nelaton, for example, the most recent of them, say nothing about it ; and yet it was scarcely necessary to say before that Society, tliat there are several cases of dislocation of the astragalus record. The accident, however, was undoubtedly a rare one, as only six ;9 of it, he believed, had hitherto been published; and the fact that so few s of the kind had yet been recorded had chiefly induced him to bring before Society the present case, which would make the published examples of ocatiou of the astragalus backwards amount to seven in number. There ■e, however, one or two points respecting which he would say a few words, .'he six cases already known are collected by Mr Turner in his valuable nograph on "Dislocations of the Astragalus" (together with a case inerteutly quoted from Boyer as an example of that accident) ; and in two those cases (Mr Philips') the bone appears to have been thrown directly kwards, as it is stated that in one the tendo-Achillis was forced back by bone, so as to form an angle of 45 degrees, and that the appearances in the ond case were exactly similar. In one case (Mr Turners) the displacent was backwards, outwards, and downwards; and in three (those of Mr ;irs, Mr Liston, and one recorded in the Lancet that was admitted to Unisity College Hospital), the astragalus was dislocated backwards and inrds. In the case read that eveuing, the displacement was also in the latter ection, so that in four of the seven cases now known, the astragalus has been ■kwards and inwards.
In only one of these seven cases (that recorded in the Lancet) was either ! tibia or the fibula fractured; and in that case both those bones were iken at the level of the ankle-joint. This case is also the only one of the •en in which reduction was effected; and as Mr Turner observes, the cxislce of fracture of the bones of the leg no doubt facilitated the reduction. In one case (Mr Turner's) the bone was removed, the dislocation having en compound, complete, aud irreducible; and in four (Messrs Philips', zars', aud Listou's) reduction being impossible, the bone was left in its new uation; in all these cases the patients did well, and had ultimately a use1 limb, without death of the bone, suppuration, ulceration, or sloughing of e integuments. In the case read that night the result was different, as had >peaTed from the report of the case. This, then, was the first case of discatiun of the astragalus backwards, in which the soft parts inflamed, and oughed, and exposed the bone.
It is stated in Mr Taylor's notes of the case that the attempts made to reduce le bone were not forcible, and were soon abandoned. The reasons for not iaking much or persevering effort at reduction were (Professor Williams said), hat as soon as he had satisfied himself the bone had sustained about a quarter f a complete revolution inwards on its antero-posterior axis, so that its superior rticulating surface looked directly inwards, he saw little prospect of effecting eduction, inasmuch as that deviation could scarcely be rectified by any force hat could have been brought to bear on the bone, and even if it were praeti;tble, it could not have been effected without inflicting an unjustifiable amount "f injury upon the soft parts covering the bone; the attempt at reduction, therefore, was very slight; so slight, indeed, as scarcely to be called an attempt at reduction; and, moreover, the history of previous caBes of the accident tended to show that, on the one hand, there was little hope of replacing the astragalus when the tibia and fibula were unbroken; and on the other, that in every instance in which the bone had been left in its new situation the issue bad been satisfactory. As to the rotation of the astragalus, that bone could be rotated either on its<antero-posterior or transverse axis. In Mr Liston's case, the astragalus was rotated in the latter direction; and in Mr Turner's it was rotated on its antero-posterior axis outwards, the superior articular surface presenting at the wound. In the case just read the bone had made a quarter of a revolution inwards. Professor Williams said he need not dwell upon the mechanism of the various rotations of the astragalus in dislocation; for whether the rotation was partial or complete; whether on the antero-posterior or transverse axis; or whether it occurred in dislocation forwards or backwards, the mode of its production was analogous in each case, and explicable on the same principles. But the recognition of the existence of such a rotation was of great importance, for when it existed to any considerable extent, Professor Williams thought it rendered reduction impracticable. Now, the outlines of the astragalus are so well marked and recognizable by the touch, and the exact position was so clearly made out in this case of dislocation backwards, where the soft parts covering the displaced bones are so much thicker than in dislocation forwards, that he could not but think the existence and extent or non existence of rotation could be easily determined, at all events in most cases, and especially in anterior dislocation; and thus an important guide aa to the treatment to be adopted would be obtained.
Mr Tufnell said— I met the patient the other day in the street when he was walking with one stick; he formerly required two, but latterly he said he had discontinued one of them. I asked him whether he was able to carry a basket on his arm and to work for his living, and he replied that he could not. Now, this is an important point to bear in mind. Three years ago, I visited the Curragh of Kildare to see a young soldier, whose horse fell on his side and dislocated the astragalus; I removed the latter and left the case to nature, and it ultimately did so far well that the man recovered, but with a pointed toe; and he afterwards wrote to me from England to know whether there was any contrivance which would enable him to support the weight of the body from tlx: kuee. 1 regretted that in that case 1 did not take away the foot by Syme's operation.
Mr Butcher—I do not think that under any circumstance the surgeon would be warranted in removing the ankle-joint in a case of this dislocation. The amputation of the ankle-joint is not so well established as Mr Syiue would lead us to suppose. I performed it myself on a woman, and although the stump was a beautiful one, she found it exceedingly difficult to walk on it. I since had to amputate in another case where Syme's operation had been performed some months before. I do not think the astragalus should be removed unless the symptoms were of a very urgent character. If an operation, however, must be performed, I would prefer to remove the astragalus, and also the extremities of the malleoli by bone forceps, so as to let the tibia down on the calcis. In London a considerable number of persons are walking about every day without the astragalus, and 1 think that on the whole, it is better to adhere to the rule of endeavouring to save parts as much as possible.
Mr Tufnell—When I spoke of Mr Syme's operation, 1 iutended to confine it to cases where accidents had occurred to a healthy structure; Mr Butcher seems to refer to amputation in cases of disease. There is a distinction to be drawn between a foot that is useful to a patient, and one that can be used. If a case occurred to a person who had to labour for his bread, I would remove the foot ; but on the other hand, if he belonged to the upper ranks of society, had no occasion to labour for his bread, and did not like the deformity, then 1 would endeavour to preserve the foot.
Professor Williams—I have no hesitation in saying that on several points the treatment of dislocation of the astragalus requires to be very carefully re- . viewed, and that Mr Turner's statistics are not sufficiently extended to justify some of the conclusions which have been drawn from them. 1 have myself collected a considerable number of cases in addition to those that are reported in his work, and I hope on some future occasion to bring the subject at greater length under the notice of this Society. As regards the question of leaving the bone in situ, this much is to be said, that if authority deserves to have any weight, we have in favour of doing so the great names of Sir Astley Cooper, Dupuy tren, and other surgeons of eminence, who did so even in some cases
STATEMENT Explanatory Of The Principles Of A Draft Of A Bill For Regulating The Medical Profession.
It is now twenty-two years since an attempt was made to introduce into Parliament a bill for regulating the Practice of Medicine. Repeated attempts hare been made since then, but all have failed, for one or more of the following reasons :—
1. Because too much was attempted at one time; viz., to regulate the practice of physicians, and surgeons, and general practitioners in one bill.
2. Because it was contemplated to suppress some existing medical institution or institutions, by withdrawing from them privileges long exercised, as they thought, for the public good.
3. By proposing to create a new medical incorporation; which would have certainly injured or destroyed one or more of those pre-existing.
4. By proposing for the executive medical head of the profession a representative council, chosen by the several medical institutions.
6. By attempting to define too precisely the requisite qualifications and the privileges of the three ranks of the profession, and to separate them in three distinct registers.
As the medical institutions, possessing, more or less, the right of practice, of one kind or another, in one part or another of the United Kingdom, are twenty in number, it is evident that no medical bill has any chance of success without avoiding these errors, unless it be pushed through Parliament in face of a considerable dissentient minority of these bodies, by the weight and influence of Government; which, whether rightly or wrongly, has been hitherto refused on such terms.
The accompanying draft of a bill is suggested, as being entirely free of all the preceding objections.
1. It proposes to confine legislation, in the first instance, only to the general practitioner, on the grounds—1. That this is the class in whose qualifications the public are most widely interested ; and, 2. That the regulation of the higher classes of the profession may be safely left, for the present, to the discretion and honourable rivalry of the bodies which now govern them.
2. It provides for a uniform system of qualification by education and examinations for general practice, as essential for entering any branch of professional practice in any part of the United Kingdom.
3. It proposes to confer a reciprocity of right of practice in all parts of the kingdom, by providing that any of the present medical titles, which now convey a right to practise any branch of medicine in some division, or some part of a division, of the United Kingdom, shall convey henceforth the privilege of practising medicine, in its several branches, in any part of the kingdom, provided the education required for the said title, and the examinations conducted by the said bodies, singly or conjunctly, shall comprise at least the education and examinations to be required by sect. 2 of this statement.
4. It proposes to place the nomination of the medical council of the nation, or general governing body, in the hands of the Crown, as the only way of at once limiting sufficiently the number of the council, and securing, as far as possible, an impartial nomination.
6. It contemplates the framing and publishing of a single register for the
KBW SERIES NO. V. MAT 1855. 2 K
United Kingdom, kept partly in each division thereof, presenting the mten. medical titles granted to each individual by the graduating' or licensing bodies recognized in this draft of a bill.
The bodies to be recognised are the several universities and chartered incorporations specified in the Appendix to the Draft. These are twenty ui number.
Strictly interpreted, there are certainly only three—probably, however, two more—of these bodies whose charters enable them to confer the privilege of practising every branch of the medical art; but by usage the greater numher of their charters have been allowed a much more liberal interpretation.
An attempt was lately made before Parliament to deny that the Scottish Universities could confer any right of practising any branch of the medieai profession in any part of the United Kingdom, even in Scotland. Without specifying the terms of royal charters, or of statutes of an early date, or going into any other detail on this subject, it is sufficient to notice that, in 1B40, when a second case between the University of Glasgow and the Faculty of Physicians and Surgeons of Glasgow was finally disposed of by the House of Lords, it was held by the Lord Chancellor Cottenham, and Lord Brougham, that the decision of the Court of Session, in a prior case between these corp-> rations, which had reference, among other things, to university degrees and diplomas held by various parties, had " found and established," that, in virtat thereof, "these parties are authorised to practise medicine;" and that th« unanimous opinion of the judges of the Court of Session bears, with regard » licenses for the practice of physic, that " a degree from a university, or a licenw from the royal physicians, was sufficient for that purpose."
At the same time an attempt was made to impress on Parliament the idea that universities were, in their own nature, intended to confer honours, not tc bestow privileges, on their graduates The example of other countries is a sufficient answer to this proposition; and, in point of fact, the legislature hare already repudiated it by the act in favour of the graduates of the London Uni.versity, passed at the close of last session.
The privileges of some of the bodies, which this draft of a bill proposes u> recognise, at present extend over a very limited district; but, nevertheless, in such a measure as the present, no sufficient reason can be shown for similarly restricting the range of their privilege, provided it be not exclusive, and if they maybe expected to do public good by sharing in the wider privilege. In fact, some of these bodies of limited privilege have done so much public good, that the title conferred by them has, by usage, been recognised as a qualification for practising medicine throughout almost the entire United Kingdom, as weO as the colonies.
Competent judges have doubted whether some of these institutions have hitherto existed for the public good. The advantage of the measure now proposed is, that this consideration does not require to be taken into account. While it excludes no such body from honourable competition, it compels all. without exception, to compete, on terms of fairness and equality, for public support.
It is not impossible that, under such competition, some of the bodies recognized in this draft of a bill may sustain injury, or even suffer gradual decay: but no existing institution will suffer, unless it ceases to enjoy the public confidence; and these are not the days for upholding monopolies by partial favour, when the objects of it have ceased to confer, and possibly never did confer, any commensurate public benefit.
The annexed draft of a bill does not contemplate the confounding of all ranks of the profession under one denomination, or the establishment of what has been called a one-faculty system. It leaves the several universities and royal colleges, which have hitherto fostered the higher branches, to continue to do so uncontrolled ; and there can be no doubt that their existence, their well-known desire and evident self-interest, together with the equally evident