82altered from the primitive state, and other portions whichhad undergone the cretaceous transformation ; whilst,near the surface of the lung, there were opake lines,considered by Dr. Williams as cicatrices. In the rightlung the mass was more uniformly of a chalky nature ;here, according to the views of the same writer, thetuberculous matter had advanced further before it beganto undergo those changes which were in operation at thetime of the patient’s death, and which would probablyhave terminated in the conversion of this plastery matterinto hard calcareous concretions.

(For several of the preceding observations the writer isindebted to the clinical lecture of Dr. Williams upon thecase, and in comments which may be made upon casesto be published hereafter he has availed himself of theclinical remarks and lectures of the respective physiciansunder whom the cases occurred.)

BRITISH MEDICAL ASSOCIATION,EXETER-HALL, March 19th.

Dr. WEBSTER, President, in the chair.

THE minutes of the last meeting having been con-lirmed, letters were read from the Glasgow and North ofEngland Medical Association, on the present state ofmedical affairs, and a poor-law committee was appointedto watch the proceedings of the committee of Lord

Ashleyon medical poor-law relief in the House of Com-mons, and render any assistance in its power. It wasafterwards resolved,-" That the annual oration, by Geo.Pilcher, Esq., be delivered on Tuesday, the 7th of May,at the London Tavern, after which the members of theassociation and their friends will dine together. Areport was then read, of which the following is an ampleabstract : -

REPORT OF A DEPUTATION OF THE BRITISH MEDICALASSOCIATION TO LORD ASHLEY, M.P., FEB. 19, 1844.

The deputation was appointed on the 30th of January,and consisted of Dr. George Webster, George Bottom-ley, Esq. (Croydon), R. L. Hooper, Esq., and thehonorary Secretary, who waited on Lord Ashley, at hisresidence, on the subjects of poor-law medical relief andmedical reform. In a lengthened interview they pointedout the numerous poor-law evils still existing, notwith-standing the medical inquiry of 1838, and the still later" order" of the poor-law commissioners of 1842, obtainedchiefly by the persevering efforts of the association. An

unexpected grievance of the " medical order" is theeffect it has had in curtailing orders for attendance inmidwifery cases, thereby acting most injuriously towardsthe poor, and lessening the salaries of the medical offi-cers by the very means intended to augment them, viz.,extra payment for such cases. The deputation showedhis lordship the different steps which the association andothers had taken in opposing the various poor-law evils,and laid before him the plans which they had drawn upas remedies for those evils, which they feared would con-tinue unless a proper system of medical superintendencewas adopted, and adequate remuneration awarded.

His lordship having listened attentively, confessedthat he had always considered that a great injustice hadbeen inflicted on medical officers by their dependency onthe whims and caprices of poor-law guardians and offi-cials, and that they never could be properly treatedunless they were rendered much more, if not entirely,independent of such authorities. He also said that heregarded the remuneration to medical officers as whollyinadequate to ensure proper attention and medicines tothe poor, as he understood that in general it was barelysufficient to cover even the cost price of the drugs. Headded, that he should be most happy to receive particu-lar instances of grievances to enable him to make out asufficient case to authorise the government to grant hima committee of the house, and if successful he would behappy to receive from the deputation all the aid theycould afford him to show how inefficiently the medicalportion of the Poor-law Amendment Act was carried out.The deputation then drew his attention to the injurious

effects to the poor which would result from some of the

proposed clauses of the medical bill about to be broughtinto Parliament by Sir James Graham, whereby it wassaid to be intended to remove the slight restrictions toillegal practice which already existed, by repealing theApothecaries’ Act, and throwing open the profession toignorant and unqualified adventurers. In reply to theargument which Sir J. Graham had formerly used to theassociation, namely, that it would be infringing on theliberty of the subject to prevent the public from consult-ing ignorant as well as highly qualified medical practi-tioners, the deputation now urged, as it had done to SirJames, that, for the general good, the liberty of thesubject might be, and was, occasionally, interfered with ; ;and that when the poor had no means of ascertaining thequalifications of medical men, they, at least, ought to beprotected by the legislature. As a case in point, the de-putation alluded to the efforts of his lordship to curtailI the excessive hours of female and youthful labour in thefactories,-a much greater interference with the liberty ofthe subject than the suppression of quacks and illegalpractitioners, though no one could doubt the benevolenceof the attempts. The deputation, therefore, confidentlyexpected to enlist his sympathy on behalf of the poor, ona question of such magnitude and importance.

His lordship, apparently much surprised, asked if SirJames Graham really contemplated free trade in medicine,so as to allow a class of medical practitioners to existwithout possessing medical qualifications? He acknow-ledged that he was ignorant of the subject, from its nothaving been before brought under his notice, but thatfrom what he had now heard he should give the questionhis serious attention.The deputation having thanked his lordship for his

courtesy and attention, withdrew.

MEDICAL SOCIETIES.ROYAL MEDICAL AND CHIRURGICAL SOCIETY.

March 26.—EDWARD STANLEY, F.R.S., President.

Notes of a Case of Vitiligo Infantilis. By GEORGE’ GREGORY, M.D., Physician to the Small-Pox and

Vaccination Hospitals.THE case was that of a child, eighteen months old. Atthe age of four months the mother first noticed about itsneck some smooth, white, shining elevations, which con-tinued to spread. At present these tubercular elevations,varying in size from that of a pea to a small nut, and ofirregular form, occupy the neck, back, and a largeportion of the abdomen. A few of them terminate byminute vesicles on the summit of the tubercle, and asmall scab succeeds. The child is in good general health,is at present cutting its teeth, and the process of dentitiongoes on favourably.The author observes, that it cannot be doubted but

that the vitiliginous state of the surface is connected withdentition. Like strophulous and other cutaneous diseases,it serves a very useful purpose in the infantile economy.The action of vessels which is here harmlessly expendedupon the surface, might, if transferred to an internal

organ, lead to serious results. While dentition continueshe considers it would be impossible to put a sudden checkto the disease, and unwise to do so if it were possible.The infant itself was shown to the fellows of the society,

and also a very beautiful and correct wax model, illus-trating the present appearance of the disease.

In answer to questions, Dr. GREGORY remarked that thecase before the society was the only one of the kind he hadseen, and having had confused notions respecting the natureof the affection he had not at first recognised its true nature.With respect to treatment, the disease seemed so decidedlyconnected with dentition that it was deemed advisable to

adopt no active means, but to pay attention simply to thegeneral health. As there was some debility in this case,mild doses of rhubarb and carbonate of iron were admi-nistered.

Dr. KERRISON had seen a case of the disease manyyears since. It was unaccompanied by constitutional dis-turbance, and little or no treatment was adopted.

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On Dislocations qf the Astragalus with the lower ends of the ’,Tibia and Fibula inwards, illustruted by cases. By HENRYHANCOCK, Esq., Surgeon to Charing-cross Hospital.

The object of this paper is to direct attention to an injuryof comparatively rare occurrence,—dislocation of the astra-galus from the os calcis and scaphoides, the ankle-joint re-maining entire.The writer, after alluding to numerous authors who con-

sidered that such an accident could not occur, gives an ac-count of the only four cases that he has met with in theworks of various writers ; two in the last edition of Sir A.Cooper’s work on Dislocations and Fractures, edited by Mr.B. Cooper; one related by Professor Harrison, in the" Dublin Journal," vol. xv., designated " displacement ofthe foot outwards with fracture of the fibula," and a fourth,described by Dupuytren in the " Lemons Orales," vol. i.,p. 225, as " a fracture of the fibula, with dislocation of thefoot inwards."Both these latter titles the author considers erroneous, for

it is very doubtful whether, in reality, the astragalus, withthe lower ends of the tibia and fibula, are not the parts dis-placed ; and even if this be not the case, it is only a portion,and not the whole, of the foot which is dislocated.The following cases were related by the author :-John Middleditch, a strong, healthy man, aged twenty-

four, was admitted into Charing-cross Hospital, under theauthor’s care, 5th December, 1840, with an injury to theright ankle, having fallen from the top of one of the vats ina brewery. Four days afterwards, when the swelling wasreduced, it was found that the fibula was fractured aboutthree inches above the ankle ; the axis of the tibia, insteadof falling on the centre of the foot, was thrown inwards andslightly forwards, giving the leg the appearance of beingtwisted in that direction. The position and direction of thefoot were not materially altered, further than by its pro-jecting considerably on its outer side, and the toes turningslightly outwards, but its dorsum looked upwards, as in thenatural condition. Upon carrying the finger along the outeredge of the heel, forwards, the anterior extremities of theos calcis, where it unites with the cuboid bone, could befelt distinctly, whilst above there was a considerable cavity,instead of the prominence formed by the astragalus and ex-ternal malleolus. By pressing the finger along the dorsumof the foot a depression could also be distinguished behindthe posterior margin of the scaphoid bone. On the innerside of the foot was a prominence, corresponding to the in-ternal malleolus, of which the inferior margin could bedistinctly defiued, and anteriorly and inferiorly another pro-jection, more prominent, and evidently caused by the head ofthe astragalus, over which the skin was tense, thin, andvesicated.The distance between the internal malleolus and promi-

nence of the os calcis was somewhat greater than in thesound foot, and that between the lower end of the innermalleolus and the sole of the foot diminished above aninch. The ankle-joint was still capable of flexion and ex-tension, and there was very considerable motion in thecentre of the foot, corresponding to the caleaneo-cuboidalarticulation, forming, as it were, a double joint.

It was concluded that the astragalus had been forced fromwithout inwards, off the upper articulating surfaces of theos calcis, carrying with it the lower ends of the tibia andfibula, most probably resting upon the lesser process of theos calcis. The various steps by which reduction waseffected are next described. The integuments over the pointof pressure sloughed away on the third day after the reduc-tion, leaving the anterior part of the astragalus exposed inits proper position ; and this was succeeded by considerabledischarge for several days, in the course of which the in-ternal calcaneo-caphoid ligament sloughed and came away.The astragalus now being no longer restrained in that direc-tion, gradually twisted round upon the calcis, until at lengtha hu’ge portion of its head protruded through the opening inthe integuments ; this prevented the wound from closing, asthe bone could not be kept in its proper position, but hadlost its articular cartilage, and was passing into a state ofnecrosis ; the author subsequently, with a small saw, re-moved its head, to the extent of above three-qnarters of aninch, after which the wound gradually healed, the partsbecame consolidated, and the man left the hospital cured, inJuly, just seven months after the accident. .

Ten months subsequently the following report was made :-He walks as well as he did before the accident, withoutstick or artificial support of any kind. The leg is largerthan the opposite one, and there is some thickening roundthe ankle, but the motion is good, and the direction of thefoot and the situation of the malleoli natural. He is able todo his work, which at times is heavy, as well as ever hedid, his leg being entirely free from pain.The particulars of the next case are taken from the sur-

gical notes of the late Mr. Howship, and relate to a prepa-ration in possession of the Royal College of Surgeons. It

appears from the position of the bones, that the same acci-dent had occurred as that described in the former case, butthat the dislocation had not been reduced ; the author entersinto a detailed account of the condition of the bones. Hethen concludes his paper with some observations on thetreatment to be pursued in these accidents, giving theopinions of various writers on dislocations of the astragalus.The PRESfDEKT referred to some points in the paper, and

dwelt particularly on the favourable termination of the

case, notwithstanding its untoward nature, and the lateperiod at which reduction was effected. He referred to a

paper by Mr. Turner, of Manchester, with which theauthor seemed unacquainted, in which that surgeon had,from the result of a number of cases, drawn the conclu-sion, that if dislocation of the astragalus were not at oncereduced it was the best practice not to attempt it at all.Mr. LLOYD said that when he was a dresser the plan

’

pursued in simple dislocation of the astragalus was an im-mediate attempt at its reduction ; if this failed the limb wasput in splints, and usually did well. In cases of compoundfracture it was the practice to attempt to save the limb,and this usually succeeded, unless there was very greatmischief. He recollected only one case in which amputa-tion was found necessary. He referred to the case of thelate Mr. Wontner, of Newgate, who had his leg amputatedfor compound fracture of the ankle-joint, in deprecation of,the practice, as after examination showed that the mischiefto the joint did not warrant the proceeding.Mr. ERICHSEN related a case of dislocation of the astra-

galus that occurred a few years ago at the University Col-lege Hospital, at the time that he was house-surgeonthere. A cabman, whilst driving furiously, was thrownfrom his box, and as he was rendered insensible by the fallhe did not know how he came to the ground. On admis-sion his right foot was found twisted outwards, the inneredge of the sole resting upon the ground; the astragalusand inner malleolus formed a considerable projection un theinner side. The astragalus, carrying with it the tibia, wasevidently thrown forwards and upwards upon the dorsumand inner aspect of the scaphoid bone; it also appeared tobe very slightly displaced from under the tibia; this was,however, uncertain. A piece of the outer malleolus, aboutthe size of the tip of the little finger, was broken otf. Re-duction was very readily effected by bending and fixing theknee. Extension was then made on the foot by graspingthe heel with one hand and the dorsum with the other,whilst an assistant pushed back the astragalus into its

situation, to which it returned with a very distinct snap.The limb was then placed on one of Macintyre’s splints,and the patient was cured in the usual time, without theleast deformity resulting. There was a Pott’s fracture ofthe left leg, which was treated in the usual manner. Mr.Erichsen’s object in mentioning this case to the society wasto show that the reduction of a simple dislocation of theastragalus (carrying with it the tibia) from the scaphoidbone was not so difficult in some instances as the author ofthe paper seemed to think. Mr. Erichsen adverted to thegreat difficulty in effecting the reduction in some cases ofdislocation of the astragalus, which he attributed partly tothe tonic spasm of the strong muscles of the calf of the leg,and thought that division of the tendo-Achilles, as practisedby Velpeau, Gerdy, and other French surgeons, might beuseful when the ordinary means failed.Mr. SHAW thought that the author had treated too lightly

of the difficulty of reducing a dislocated astragalus, whenit is displaced both from the tibia and fibula and from theos calcis and scaphoides. Such an injury is quite differentfrom the cases related in the paper, where the astragaluspreserved its relations to the bones of the leg. Severalyears ago, during the absence of his colleague, Mr. Arnott

84

under whose care the patient fell, he met with a case wherethe astragalus had been jerked between the lower heads ofthe tibia and fibula and the os calcis and scaphoides, so asto be displaced forwards and inwards, and the anteriorhead and neck projected through the skin. After repeatedtmsnccessful attempts at reduction, he excised the bone.Owing to the narrow space between the posterior tibialartery and nerve, which were seen at the inside of thewound, and the anterior tibial artery, both of which vesselsit was desirable to avoid wounding, he found considerabledifficulty in freeing the displaced bone from its ligamentousconnections. He, therefore, divided the bone with the saw,close to the skin, and with the bone-scissors cut through theremaining part lodged between the anterior edge of thetibia and os calcis, so as to remove the whole with com-parative ease. As regarded the wound, it healed favour-ably. The cure was prolonged by abscesses forming aboutthe hip, and caries of the sacrum ; but the patient left thehospital in six months with a useful foot.Mr. DAvis related a case of simple dislocation of the

astragalus which he had attended with Mr. Abernethy.The limb was put into splints, no attempt at reductionbeing made, and the patient did well.Mr. QUAIN and Mr. LLOYD contended that it was not

fair in the author of the paper to refer to the practice of oldsurgeons as evidence of that which obtained at the presentday, but Mr. HANCOCK soon settled this point by referringto the last edition of Cooper’s Dictionary, published twoyears since, in support of his assertion.Mr. HANCOCK, in reply to the observations of the presi-

dent, said he was acquainted with the paper of Mr. Turnerreferred to, but he did not see how the recommendation ofthat surgeon could have been taken in the present case, as

-

he (Mr. Hancock) did not see the patient until forty-eighthours after the accident, and then the swelling and inflam-mation were so great that there was no chance of successful ’,attempts at reduction, and, indeed, very few such attemptswere made until the day on which the pullies were applied.Mr. Wontner’s case, detailed by Mr. Lloyd, favoured his(Mr. Hancock’s) statement respecting amputation in thesecases; for here, after the operation, it was found that sucha step had not been necessary. He had noticed the diffi-culty alluded to by Mr. Shaw, and had related a case in thepaper in which, having found it impossible to retain thehead of the astragalus in its proper position, and that theprotrusion prevented the healing of the wound, he hadremoved the head of the bone with a small saw. He hadalluded to the same point, also, in his remarks on the im-portance of the calcaneo-scaphoid ligament.

Case of Obstruction in the Intestinal Canal, terminatingfavourably on the Ninth Day by Spontaneous Vo7niting.By Sir G. LEFEVRE, M.D.

The subject of the present case was a little girl, of twelveyears of age; of a very delicate constitution, strongly-marked scrofulous disposition, and with very feeble digestivepowers, so that she was unable to digest fruit or vegetables.She had been attacked by epidemic autumnal cholera, whichprevailed amongst children in the town where she was

residing, and which yielded to the usual mode of treatment.Soon after the termination of this she was attacked by adisease of an opposite nature, and became obstinately consti-pated, whilst the stomach rejected everything that was taken.Purgatives had been employed in every shape, but withouteffect; leeches had been applied to the abdomen, which hadbeen fomented freely. Such was the history of the case

which I received from the two medical men in attend-ance, previous to my seeing her on the 27th of August,in the afternoon. She was much flushed in the face, had ananxious countenance, a small, quick, compressible pulse, acold, moist surface, the extremities being colder than na-tural. She suffered from distention of the abdomen, with-out complaining of much pain, and she vomited continuallya green bilious fluid. As no inflammation was apparent,and as more depletion was not, under the existing circum-stances, indicated, soothing measures were employed. Thevomiting was the most annoying symptom, from its frequencyrather than from any distress which it occasioned, for thisdark-green fluid was thrown up without much effort. Asmall blister was applied to the pit of the stomach, and

small doses of prussic acid administered in almond milk.This treatment seemed to check the vomiting for many hourssuccessively. She passed a tranquil night, but no relief tothe bowels had been obtained by stool, and the abdomen wasmuch more swollen. Croton oil was given internally and byclyster during the day, and as warm applications seemed tohave no effect, bladders filled with ice were applied over thebelly. The patient was restless and uneasy, continuallychanging her place in bed, but this arose from distentionrather than from any acute pain. About midnight of the28th, she complained of twisting and severe pain in thebowels of a colicky nature, there was also more pain upon)pressure than previously, and, as opiates were administeredwithout benefit, I applied a dozen leeches to the abdomenwith immediate relief to the distressing symptoms, which,subsided soon afterwards. She got some sleep, and wasfree from pain when awake. I was obliged to return to

London, and did not see her again till the afternoon of thefollowing day. I learned from the physician in attendancethat she had passed the day on which I left her pretty well,but that, at midnight, the same symptoms recurred as onthe night previous, and, notwithstanding her great state ofexhaustion, he had again applied leeches with benefit. Heinformed me that the vomiting had returned, and that thematter brought up was evidently from the ileum, and theseat of stricture seemed to be about the caput caeci. Therewas no question, upon minute examination, that the mattervomited up proceeded from the small bowels. The disten.tion was now very great, respiration was much impeded,and the little patient suffered severely. A long elastic tubewas introduced into the rectum and carried up into thecolon, through this water was forced by a pumping syringe.The operation was productive of great distress to the pa-tient, and was ineffectual as to relief. The night wasrestless, and the following day the little sufferer was muchexhausted. The face was colourless, the countenance

anxious, the body covered with a cold clammy sweat, andshe expressed herself as if about to die. The bed-room

having a southern aspect, and the weather being sultry, Idesired that she might be removed into a cooler room. Shewas carried in the arms to her bed, and, as she was muchfatigued by the operation, I gave her a glass of Madeirawine, which she drank with pleasure, but hardly had sheswallowed it when she made signs for the basin, lifted her-self in bed, and threw up a dark green fluid to the amountof three pints. She experienced immediate relief andbreathed more freely, and the upper part of the body be-came more loose and compressible. I gave her some morewine, which remained on her stomach ; she had no morenausea. Constant friction was maintained over the abdo-men, and injections of vinegar and water were repeatedevery hour. The first was returned without being accom-panied by any solid matter, but had a foetid smell. Thesecond was accompanied by pieces of flocculent matter, ofa membranous appearance, and the fluid returned washorribly foetid, like putrid water in which flesh had beenmacerated. She was enabled to compress the abdominalmuscles and make an effort to go to stool, which the pre-vious great distention, paralysing the action of the muscles,had prevented her from doing. Much of this membranousmatter came away after each injection. The smell was mostoffensive. About four hours after the spontaneous vomiting sheasked to go to the chair, when the bowels gave way and a

large quantity of solid excrement was voided. She passedmore stools in the course of the evening, and then slept train-quilly. The following morning I gave her a dose of castoroil, which produced its desired effect without creatingnausea,and I left her convalescent. I learned, subsequently,from my colleagues, that she had a good deal of coustitu-tional fever for four or five days. She recovered in a short

time, and her digestive powers are now better than previousto her illness. The obstruction was relieved only en theninth day of the disease.

Sir G. LEFEVRE observed that the case was interestingfrom the diagnosis formed and the difficulty of arriving ata correct one in these cases. Some symptoms favoured theopinion that the obstruction depended on intussusception;other symptoms were against it. The periodic character ofthe affection was remarkable. Had an emetic been admi-nistered early in the attack might not the termination of the.case have been bitstened ?