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Z on record. The accident, however, was undoubtedly a rare one, as only six Home cases of it, he believed, had hitherto been published ; and the fact that so few
cases of the kind had yet been recorded had chiefly induced him to bring before the Society the present case, which would make the published examples of dislocation of the astragalus backwards amount to seven in number. There were, however, one or two points respecting which he would say a few words.
The six cases already known are collected by Mr Turner in his valuable monograph on “ Dislocations of the Astragalus” (together with a case inadvertently quoted from Boyer as an example of that accident); and in two of those cases (Mr Philips') the bone appears to have been thrown directly backwards, as it is stated that in one the tendo-Achillis was forced back by the bone, so as to form an angle of 45 degrees, and that the appearances in the second case were exactly similar. In one case (Mr Turner's) the displacement was backwards, outwards, and downwards; and in three (those of Mr Lizars, Mr Liston, and one recorded in the Luncet that was admitted to University College Hospital), the astragalus was dislocated backwards and inwards. In the case read that evening, the displacement was also in the latter direction, so that in four of the seven cases now known, the astragalus has been backwards and inwards.
In only one of these seven cases (that recorded in the Lancet) was either the tibia or the fibula fractured ; and in that case both those bones were broken at the level of the ankle-joint. This case is also the only one of the seven in which reduction was effected; and as Mr Turner observes, the existence 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 been compound, complete, and irreducible; and in four (Messrs Philips', Lizars', and Liston's) reduction being impossible, the bone was left in its new situation ; in all these cases the patients did well, and had ultimately a useful limb, without death of the bone, suppuration, ulceration, or sloughing of the integuments. In the case read that night the result was different, as had appeared from the report of the case. This, then, was the first case of dislocation of the astragalus backwards, in which the soft parts inflamed, and sloughed, and exposed the bone.
It is stated in Mr Taylor's notes of the case that the attempts made to reduce the bone were not forcible, and were soon abandoned. The reasons for not making much or persevering effort at reduction were (Professor Williams said), that as soon as he had satisfied himself the bone had sustained about a quarter of a complete revolution inwards on its antero-posterior axis, so that its superior articulating surface looked directly inwards, he saw little prospect of effecting reduction, inasmuch as that deviation could scarcely be rectified by any force that could have been brought to bear on the bone, and even if it were practicable, it could not have been effected without inflicting an unjustifiable amount of 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 cases 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 had 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 nonexistence of rotation could be easily determined, at all events in most cases, and especially in anterior dislocation; and thus an important guide as 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 luis 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 the knee. I regretted that in that case I 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 Syme 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 I 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, I intended 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 I 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 reviewed, and that Mr Turner's statistics are not sufficiently extended to justify some of the conclusions which have been drawn from them. I 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, Dupuytren, and other surgeons of eminence, who did so even in some cases where it was anticipated that the parts covering the bone were likely to slough. -Dublin Medical Press, April 1855.
VIATEMENT EXPLANATORY OF THE PRINCIPLES OF A DRAFT OF A BILL
FOR REGULATING THE MEDICAL PROFESSION. ! 18 now twenty-two years since an attempt was made to introduce into Par
pt a bill for regulating the Practice of Medicine. Repeated attempts e been made since then, but all have failed, for one or more of the following
• Because too much was attempted at one time ; viz., to regulate the pracof physicians, and surgeons, and general practitioners in one bill.
Because it was contemplated to suppress some existing medical instituon or institutions, by withdrawing from them privileges long exercised, as they thought, for the public good.
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.
... 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
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 influ. ence 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 grounds1. 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 NEW SERIES.-NO. V. MAY 1855.
United Kingdom, kept partly in each division thereof, presenting the several 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 in number.
Strictly interpreted, there are certainly only three-probably, howerer, 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 number 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 medical 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 1840, 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 corpo rations, which had reference, among other things, to university degrees and to diplomas held by various parties, had “ found and established," that, in virtue thereof, “ these parties are authorised to practise medicine;" and that the unanimous opinion of the judges of the Court of Session bears, with regard to licenses for the practice of physic, that “ a degree from a university, or a license 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 to 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 to 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 may be 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 well 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