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Pectoral muscle. What will this do ? Why,if the arm is lifted up, unquestionably itwill depress the arm on the side. Whenthe arm is depressed on the side, it willbring the arm forward; and the ridge beingin front, or external to the bicipital groove,it will roll the arm in. All this is said

upon the presumption of the trunk beingthe fixed part, but the arm may be the fixedpart. Have you never seen a little boyclimb up a tree ? If you have, you will haveobserved that he catches hold of a boughwith his arm, and draws up his body, whichis done with this muscle ; sometimes, also, helays hold of a branch with his legs.

This muscle is well known to every artist,and gentlemen having a taste in that way,and it would be most unpardonable for amedicalman not thoroughly to understand thepectoral muscle. And to show you of howmuch consequence it is to know the at-

tachment of muscles, I mention this : Sup-pose a muscle to be burst, and subsequentlyinflamed, what are you to do ? What! to

approximate the different attachments as

much as you can, and to let the fibres be asloose as possible, for then the inflammationwill go down, and the parts will unite ; butif you let the attachments be separated, andthe fibres stretched, God knows when theinflammation will go down, or the parts ofthe muscle unite. But suppose the muscleto be divided ; if you cut it, it gapes, it re-tracts by the living power, and you maybring the parts of the skin together by ad-hesive plasters, but how do you close thewound in the muscle ? There is no other

way but by compression ; and if you ap-proximate the fibres, then they will unitetogether, and the wound will be closed.There is no other way of closing muscularwounds. You may think as you please, butI am sure that no one is fit for his pro-fession who does not understand the at-

tachment of the muscles, neither can helearn the rest of anatomy, without under-standing the muscles : don’t, therefore,suffer your minds to repose, or be con-

tented, without acquiring this knowledge.They say when you take off a diseasedbreast, you should put the pectoral muscleon the stretch : 1 remember the time when

they used to sit a patient down in a chair,when that operation was going to be per-formed, and put a plane under the arm to

keep it stretched. They don’t do the ope-ration so now; but, of course, they put thepectoral muscle on the stretch still.

Deltoid muscle. If there is any part thatsurgeons should be acquainted with, it is thegap between the deltoid, and the claviculaiportion of the pectoral muscles. I put myfinger into that gap in my own person, and Istop the beating of the pulse at the wrist

Suppose a man has got a bleeding in hisarm, which there is a difficulty in stopping,how are you, as a surgeon, to stop it 1 Bypassing your finger over the first and secondribs, pressing the artery, and you stop it atonce. When I talk about this sort of thing,and hear a medical man say he can’t do it, Ialways say, there are others that can. And Itell this story of a lady who was examinedby a great number of learned doctors; theycould not tell what was the matter with her;they had never met with such an intermaittentpulse in the whole course of their lives, norany thing at all to equal it, and they pro.nounced their opinion that she could notlive a moment, and left the room ; and,egad, all this time she was tweedling with thisartery at the shoulder. (Laughter.)Now I will only just say, with respect tosystem, that there is a great deal in that, In

acquiring a knowledge of any science, systemis almost indispensably necessary ; but it isespecially so in the medical profession.With this view, the abdomen is divided into?’egions; and from want of attending to this,I have known something of this nature occurelsewhere : the examiner has asked a younggentleman who presented himself for exami.nation, " What do you see upon opening theabdomen 1" The chap has stared, looked

) aghast, and stuttered out, " wh—wh—wh;what-what do I see, Sir?" " Aye ’’" Why, th-there’s, there’s the liver, Sir:’" Well ?" " An-an-and there’s the

stomach, Sir. An — an - an-and - andthere’s, there’s the spleen, Sir. And there’sthe cœcum, Sir." (Roars of laughter.) Now,then, just let me tell you, that you willdo well to proceed systematically, and to packup your knowledge as you go along, in suchorder, that, when you are asked for it, youwill at once know where to find it.

LECTURES

ON THE

Diseases of the Nervous System.BY

DR. CLUTTERBUCK.

LECTURE VI.

Of Phrenitis.Gentlemen,HAVING treated of membranous inflamma-

tion of the brain, we come now to inflamma-tions of the organ itself; and first those atthe acute kind, or such as are attended withpyrexia, or a febrile state of system. Nowthe disease may be general or partial. One

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might even conceive inflammation to occupythe whole organ at once, although the divi-sion and separation of parts that are foundhere, make’ it improbable that such shouldoften, if ever, be the case : nor has the ac-tual existence of any such case, I believe,been proved by dissection. Indeed it is difficult to imagine the entire mass of brain tobe at once the subject of inflammation, con-sistently with life. It is very probable,however, that one hemisphere of the brainmay be inflamed, without the opposite one ,just as happens with regard to the lungs.We have, indeed, a tolerable proof of this incases of hemiplegia, where the disease isconfined to one side of the brain, as shownboth by the symptoms and by the appear-ances after death. It is reasonable also tobelieve, that the different lobes of whichthe hemispheres are composed, may be se-parately affected, and give rise to peculiarsymptoms, as they have no doubt differentfunctions to perform. It is certain, like-wise, that the cerebellum is very distinct inits uses from the cerebrum ; and it is hardlyto be questioned that the different struc-tures found at the basis, under the deno-mination of corpora quadrigemina, pons varolii,medulla oblongata, &c. (made up as these

parts are of processes from the cerebrum anccerebellum) have each their peculiar affices,and give rise to peculiar symptoms, whendiseased. Anatomv as well as observationhave gone some way toward proving thesepositions. But our knowledge of the sub-ject is still far from precise or satisfactory.Experiment itself is extremely fallacious inmatters of this kind, and has furnished re-sults in many respects contradictory. Muchyet remains to be done upon this interest-ing subject, before the pathology of thebrain can make any considerable advances.Happily, however, such minute distinctionsas I have just alluded to, are by no meansessential to successful practice ; for we actupon general indications, which are not

much influenced by the particular seat ofthe disease. It is enough, in general, thatwe can assign the nature of the diseasepresent, especially as founded in inflamma-tion or otherwise ; a point that may in mostcases ble determined without much difficulty,and with sufficient certainty for practice.And in all doubtful cases, you should makeit a rule to act as if inflammation were ac-

tually present ; but, of course, with thegreater caution, in proportion as the case isuncertain.Now without attempting to make a divi-

sion of the different inflammations of thebrain upon strict anatomical principles, (forwhich, as I have shown you, there is as yetno proper foundation), I shall confine mysel:to the varieties that authors have principall,)noticed, and which are founded chiefly upor

the apparent disorder of functions. Thoseof the acute or febrile kind may all be in-cluded under the terms phrenitis and idiopathicfever - for I shall assume for the present,that the latter, as well as the former, is

merely a variety of inflammation of thebrain ; leaving the proofs of this opinion,to a future occasion.

1. Of Phrenitis.

This term has been applied by authors tothat variety of cerebral inflammation, whichis characterised by great and active disorderof the mental functions. Accordingly, Dr .Cul-len, following the generality of authors, givesus, as a part of the definition, " furious deli-rium ;" as if this were a necessary symp-tom of inflamed brain. He mentions, how-ever, as an alternative, tt)pho-ma?!M ; bywhich is to be understood, delirium with a

degree of stupor. But neither one nor theother of these is necessary to constitute thedisease ; as you will presently see when.

the symptoms have been fully described.This form of inflammation of the brain, hasbeen sometimes called phrenismus, cephalitis,

sphacelismits, &c.

Symptoms of Phrenitis. In pointing outthe characters of this disease, you must callto mind the distinction I formerly made ofsymptoms in general, into common and proper.Now the common signs or symptoms, viz.heat, redness, pain, and swelling, by which weascertain the presence of inflammation, willnot always avail us here, as you will pre-sently perceive when we have examinedthose signs individually. Nor is pyrexia moreto be relied upon. We are obliged to resort,therefore, to the proper or special symptoms,in order to form our diagnosis, and whichconsist chiefly in a disturbed state of thesensorial functions.I Now as to the common symptoms of in-flammation :-

Heat fit head is a frequent sign of inflam-mation going on in the brain, and which isobservable in all the varieties of the disease,and when present, it may be much reliedupon. But slight affections of the sort maybe unattended with this effect, at least, inany perceptible degree. Redness can only beinferred to exist, from its extending, as it

occasionly does, to the eyes and face. Thisredness or suffusion of the face and eyes,though only occasional, makes, however, apart of Dr. Cullen’s definition of phrenitis.Pain in the head is another frequent attendanton phrenitis, especially at the outset of thedisease, that is, while feeling and con-sciousness remain. At a later period ofthe disease, it is seldom complained of. Thepain is often of a throbbing kind. The de-gree and danger of the disease, however,

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bear, but very little proportion to the pain 2. The voluntary povner is not alwaysthe patient experiences ; which, on the affected in phrenitis. the disease, in its

contrary, is often the greatest where the strictest and simplest form, being an affectiondanger is the least ; and vice versa. There of the mental function only. It is seldomare, you will recollect, two causes of this however so simple as this: not only serzin.

anomaly; one is, the natural insensibility of tion being disturbed, as I have just de.the brain ; the other, the loss of conscious- scribed, but the voluntary power also, andness which is so common an attendant of that very variously. In some cases it is in.brain-affections. As to swelling, this, it is creased in energy, enabling the patient toplain, cannot take place with regard to the make the most extraordinary muscularentire organ, except in the individual case efforts; in others, the reverse state, prosti-a.of infants, where the bones are not yet firmly tion of strength, occurs ; and this is generallyunited; in these, a protuberance at the the case towards the end. At other times,fontanel is very observable, when inflamma- there are feeble and tremulous movements;tion is going on in the interior of the skull. and, occasionally, epilepsy or general con-

Pyrexia, again, which is one of the common vulsions take place.signs of inflammation, wherever seated, is 3. 7lementalftinctions. Inflammation may,not always present in this, more than in and very often does, exist in the brain with-others. Indeed, in some of the worst cases, out any disturbance of the mental powers:where the brain is in a state of oppression but in the variety of the disease we are nowwith regard to its functions, the general vas- considering, such disturbance is the charac.cular action of the system appears to be teristic mark of the disease. The mental dis-

kept down by this very circumstance, the order shows itself in various ways. It often

pulse deviating but little from the natural commences with an unusual flow of spirits,state. On many occasions, the general cir- with great loquacity ; which is succeeded

culation is greatly though variously dis- by confusion of thought, incoherent speech.turbed : the pulse being sometimes ex- and irrational conduct, up to the pitch oftremely hurried, sometimes preternaturally fury at times ; and generally, then, is ac-

slow ; and not unfrequently irregular also. companied with high febrile action, so as toWe must in general, therefore, look be- agree pretty well with the definition given

yond the common signs, of inflammation, in by writers. Or, the ideas may be of aorder to discover the existence of phrenitis, gloomy and melancholy- cast, leading fre.and inquire into the state of the sensorial quently to despondency ; or there may befunctions, where the unequivocal signs of the stupor, or abolition of the mental faculties,disease will be found. Now the manner in whence the term typho-munia, which Dr.which those functions are disturbed, will of Cullen introduces into his definition ofcourse depend upon the degree of the dis- phrenitis. These varieties in the state of theease, and the particular seat it occupies in mind and feelings of the patient, indicate

the brain; and will therefore be extremely nothing certain with respect to the cor-

various. poreal state of the brain, and afford hardly1. Sensation. This function of the brain any guide in regard to practice ; as I shall

is very generally, though not always, dis- presently have occasion to observe to you.turbed in phrenitis; and the disturbance In addition to the symptoms now men-shows itself in different ways, and in the tioned, there are often others that assist usdifferent organs of sense. Thus the eye is in forming the diagnosis such as heat ofoften too acutely sensible of light, and the head, throbbing of arteries, redness of theear of sound. Sometimes those senses are eyes, and a peculiar and generally quick ex-impaired, or wholly lost. And sometimes pression of countenance, depending partlyfalse perceptions arise, not produced by any upon a contracted state of the pupils, andexternal cause, but by a disordered condition partly upon a sharpness of features, the

ofthe origin of those senses in the brain. Thus effect of muscular contraction. The sleep,it is that imaginary objects are seen ; flashes likewise, is hardly ever natural; in mostof light are complained of; or every thing cases there is extreme watchfulness, andaround the patient appears to him to be on that continued often for many days.fire ; the colours of objects are changed to You will find it stated by authors, thathis imagination : and the same may be the true or idiopathic phrenitis, (phrenitis vera,) is acase with regard to the organ of hearing. very rare disease, while the symptomatic isThe other senses of taste, smell, and touch, exceedingly common. Now you might ima-are liable to be equally deranged: thus gine from this, that two different diseasesthere are fancied tastes and odours: while a were here spoken of; and that the latter,sense of creeping on the skin, or a feeling of in fact, was hardly to be considered as in-cold, or heat; or an extreme degree of sensi- flammation of the brain. This, however,bility to the tmteh, and often actual and acute is a mistaken view of the subject. Thepain; are among the occasional symptoms of term idiopathic phrenitis has been appliedthis affection. when the disease arises primarily, and that

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either spontaneously or from some evidentexternal cause : such- as exposure to cold, in-sofatima &c. ; while the disease has beencalled symptomatic, when it comes on second-arily in the course of other diseases, as fever,or any other. This distinction, however, isa frivolous one. The disease is not the lessinflammation of the brain, because it occursin the course of another disease, which maybe then considered as its occasional or ex-

citing cause. Undoubtedly, the treatmentcalled for in such cases, may sometimes re-

‘ quiremodification; not because the diseasein itself is different, but because it arises ina different state of system, and under dif-ferent circumstances.

The progress and termination of phrenitisare various, according to its violence, andthe greater or less disposition there may beto disease in the brain. Many cases termi-nate speedily, and favourably ; others pro-ceed rapidly to a fatal termination, by inter-ruption of functions. Or it may go on to

stippuration; though this is only likely to

happen in the milder and protracted formsof the disease. It may end also in a ruptureof blood-vessels in the brain, and thus giverise to apoplexy, from extravasation of blood.Or, lastly, it may terminate in insanity, orpermanent derangement of intellect, fromthe alteration of structure induced by theinflammation.

For the causes of phrenitis, I must refer you to a former lecture, where I pointedout the causes of inflammation of the brainaltogether ; for they are not peculiar in thiscase. Nor are the appearances on dissec-tion such, as to enable us to discriminatebetween this and the other forms of inflam-mation of the brain, whether acute hydroce-phalus, or idiopathic fever. The most speedilyfatal cases, in all the varieties of the disease,are those which leave the fewest and faint-est traces behind them.

Treatment of phrenitis.—The treatment ofthis disease is to be conducted upon thecommon principles that govern our practicein other inflammations : that is, accordingto the degree and stage of the complaint,and the habit of the patient ; with an atten-tion to such points as experience may havetaught us, arising from the peculiar natureof the organ affected. And I must here re-peat to you what I formerly remarked, thatyou are not to form your indications of cure,as is often done, from the state of mind ofthe patient, but from the ordinary bodilysigns, as in other inflammations. You arenot called upon, for example, to bleed to anextreme degree, every case that is attendedwith active or even furious delirium; normust you stimulate, merely because the

spirits are low and depressed: but first en-

deavour to ascertain the bodily strength, bythe ordinary means.In the treatment of phrenitis, your first

attention should be paid to the causes of thedisease ; in order to attempt their removal,if they should be still acting. This beingaccomplished as far as possible, the usualremedies for inflammation are to be applied.If the case is recent, and the patient strong,large and repeated bloodletting will be ge-nerally required: in weak subjects, the

quantity of blood to be taken must be go-verned by the bodily strength, and not bythe violence of the delirium. You are notto consider opening the temporal artery, as

having any peculiar advantage over venesec-tion - but rather the contrary, as I beforestated. Cathartics, and the digitalis in mi-nute doses, are equally indicated as in otherinflammations. Blistering, where the pulseis much hurried, appears a doubtful remedy;as is the application of a blister to the scalp.It is generally better to apply continued coldto the head, the good effect of which I havesometimes thought was enhanced, by theoccasional use of warm fomentations.

There is a period when opium appears tobe extremely useful ; but its too early ap-plication, for the mere purpose of procuringsleep, is injurious and even dangerous. Whenbloodletting has been as largely used as thecircumstances of the case appear to warrant,then and not till then is opium proper. Un-der this limitation, it often produces thebest effect, by conciliating sleep, duringwhich there is often a gradual and sometimesan entire subsidence of all the symptoms ;so that the patient, after a sleep of severalhours duration, awakes free from delirium,and becomes immediately convalescent.Whether these good effects are most likelyto be produced by small and repeated dosesof the remedy, or by a single large dose, it isdifficult to determine. I am rather inclinedto prefer the latter mode ; giving, for exam-ple, two or three grains of the solid opium,or 40 or 50 drops of the tinctrre, at a dose :but I have also seen equally good effectsfrom the quantity of five or six drops, givenrepeatedly at intervals of a few hours. Thecombination of opium with ipecacuanha, in theform of Dover’s powder, appears well adapted to the case.There is one variety of phrenitis that has

of late been much talked of, under the noveldesignation of delirium tremeus; as if it werea new or nondescript disease ; wearing thesemblance only of inflammation of the brain,but not actually such. And accordingly apeculiar mode of treatment has been sug-gested, in a great measure, the reverse ofthat which is usually employed in phrenitis ;namely, large and repeated doses of opium;bloodletting being altogether reprobated inthese cases.

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Now I think it right to guard you againstan indiscriminate admission of these opi-nions, though I must allow they come froma respectable quarter. The chief peculiari-ties of the disease are, the muscular tremorof the hands that attends the delirium, andits taking place mostly in habitual drunkards.But the disease itself is nevertheless in-flammation in the brain, though its charac-ter may be modified by the nature of the ex-citing cause, and the habit of the patient.In many of these cases, undoubtedly, thegeneral strength is much impaired, so as notto call for evacuations, especially of blood.But this rule is far from being general.Delirium, with muscular tremors, is oftenmet with, where the habit is still strong,and where there are sufficient marks of a

very active state of disease going on in thebrain. In such cases, though produced byfrequent intoxication, bloodletting is as neces-sary, though not perhaps to the same ex-tent, as in ordinary cases of phtenitis. Afterthe abstraction of blood, opium may be safelyresorted to ; though I believe it is less ne-

cessary than is commonly imagined. I haveseveral times had to regret the neglect ofbleeding in these cases; and have been

compelled to resort to it, from the failure ofother means.

’ The last form of acitte inflammation ofthe brain, which I shall have to notice, isthat termed idiopathicfever, a subject that willrequire a good deal of attention, both fromits extent, and from the diversity of opinionthat exists with regard to its intrinsic nature.This I shall resume at our next meeting.

FOREIGN DEPARTMENT.

Clinical Report of the Practice in La Charité,during the Winter of 1825-6.

IT is the bounden duty, of every HospitalSurgeon and Physician to publish, fromtime to time, detailed statements of the re-sults of his practice, and thus give the pub-lic and the profession the benefit of his ex-perience. The truth is so obvious, that itrequires no argument to enforce it. Sometime since, when looking over a work on thediseases of the brain, our attention was ar-rested by a note at the bottom of one of thepages, in which the author said that he hadconsulted (on some of the points treated ofin his book) his friend Mr. -, who hadgreat opportunities of observation ; that hehad dissected the brains of some hundredsof lunatics and idiots; and that he had

found-no matter what he found-he hadopportunities, or rather they were thrownaway on him, for 116 does not appear to have,even taken a note of the examinations, orto have inquired into the histories of thecases, and but for a casual note in the bookof his " confrere," the world would havebeen ignorant that such a mass of apathyand negligence had ever existed. But weshould not, probably,, comment hardly uponthis gentleman; his case and his conductare by no means singular; they are in strictconformity with that of many, nay, most of £the hospital practitioners of the country,more especially those who complained mostloudly of the invasion of their private rightsby the publication of reports of cases whichare treated in the public hospitals. Whereare we to find the results of the practice ofour leading physicians and surgeons ? In the

pages of THE LANCET; and but for its ex-

ertions they would have been consigned toutter oblivion. About 70,000 patients an-nually pass in review before the medical °staff of the great hospitals of London, andwhen we come to inquire what new facts

are elicited? what difficulties are solved! ’)what improvements are made ? in a word,when we ask, what are these gentlemendoing ?-we are obliged to pause for a reply;and in the end, most probably, receive none,or next to none-for it can scarcely be calleda reply to say that certain purists (bothsurgeons and physicians) have lately gotinto the practice of sending reports of casesto the Yellow Journal—as they are drawn npin such a way as to render them unavailablefor any useful purpose, and the practicepursued in several of them is such, that wedevoutly hope it may never be drawn intoa precedent for the guidance of others.We want in our hospitals a regular system

of clinical instruction, in order to renderstudents fitted for the active duties of their

profession, and that they may learn its

principles and practice at the bed-side ofthe patient, and not by books, or by meteroutine courses of lectures delivered at a

distance from the hospitals, and without anyreference to the cases which they contain.We want to see a system of discipline esta-blished, which may teach young men how toobserve, to think, to investigate ; and thiscan only be done by directing their attention to cases, pointing out the leading ha-racters of different diseases, indicating themethods of distinguishing them, and, finally,by marking those methods of treatmentwhich have been sanctioned by experience.This, or some such plan, should be carried

into execution ; students require it as anessential requisite for completing their edu-cation. We believe they are usually, on

; admission into the hospitals, required to paya pretty large fee, for which they receive no