[No. 128 [Feb. 11, 1826.]

LECTURESON THE

THEORY AND PRACTICE OF PHYSIC,

BY DR. CLUTTERBUCK.

Theatre, General Dispensary, Aldersgate-street.

LECTURE XIV.

On Inflammation in general.

Gentlemen,You will find, in authors, diseases

divided into general or universal, that is,those that are supposed to affect thewhole system at once ; and local, or suchas are confined to individual parts or or-gans. The chief example of the formerthat has been adduced, is fever, whichhas almost universally been consideredas a disease of the whole system : of thelatter, may be mentioned pneumonia, gas-tritis, hepatitis, or any other of the dis-eases called topical, where a single organonlv is Drimarilv affected.Now there ate good grounds for ques-

tioning the justice of this arrangement,and for doubting whether there be any i

universal diseases, in the sense here allud-ed to; that is, in which the whole bodyis at once,-and from the first, affected.This is a point of no small practical im-portance ; for if, as I suppose, diseasesare always, at their outset, affections ofindividual parts, and not of the wholebody, (however general they may after-wards become, by sympathy of one partwith another,) there will be an advantagein practice in always looking to the pri-mary affection, as the first cause of thegeneral disorder existing in the systemat large. It leads us to what may betermed a radical mode of cure. Whereas,the considering disease as a universalaffection, in which no one part suffersessentially or exclusively, more thanothers, leads us to palliatives merely ; for

supposing these to be only secondary,may leave the primary one unsubdued;while the means employed may even beinjurious to the primary disease. To illus-trate this, I may refer you to the case ofwhat is called idiopathic fever, which, asI shall endeavour to prove to you here-after, is primarily a topical affection ofthe brain, and consists in actual inflam-mation of the cerebral substance. Nowadmitting, for the present, this to be ajust view of the matter, our great objecttluoughout the disease win be, to relievethe organ nrincinallv and Drimarilv affect-ed, by such means as the nature of theaffection suggests, and which experience,at the same time, may have confirmedthe utility of: that is, by antiphlogisticmeasures of all kinds, adapted and pro-portioned to the circumstances of thecase, such as the stage of the disease, thehabit of the patient, and the like ; disre.

L garding, or, at all events, considering assecondary in point of importance, the

general weakness and other symptoms- that arise out of the topical affection of- the brain, which constitutes the reali disease.

The chief reason that the topical natureof fever has been denied, appears to bethat the disease, in many Instances, makesits approaches so mildly and insidiousty,that the topical symptoms are overlooked,or do notcome under the cognizance of thepractitioner. The disease is not seen, tillit is fully formed, and has affected thewhole system. Another is, that when theattack of fever is sudden and violent, theinfluence of the brain is such as to disturb,almost instantaneously, the whole sys-tem, mind as well as body ; leaving hardlya distinguishable interval, between thetopical, and the general affection.Another ground for questioning theexistence of universal diseases, is the dif-

terent susceptibilities of different partsof the body ; so that an application orcause which powerfully influences oneput, will make little 01 no impressionupon others. I hardly know a singleagent, which is capable of impressing inthe same manner every part of the body ;

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or, if it were capable, which conld be ap-plied so as to affect all at once. Whereas,there is no difficulty in conceiving gene-ral disorder of system to be produced bydisease of an individual part, especiallya part of such paramount intluence asthe brain.

Discarding, therefore, the notion ofuniversal disease, I shall call your atten-tion to a division of diseases into generaland local, though in a different sense tothat I have just mentioned.The different organs of which the body

is composed, are all made np of the sampsimple or primitive textures ; namely,blood vessels, absorbents, and nerves, unitedtogether by cellular or connectmg mem-brane. Now these simple or primitivetextures, being cssentia!)y the same everywhere, are consequently, liable to thesame forms of disease. Thus diseases ofblood vessels, of absorb,72- vessels, and ofne1’ves, are general diseases, since theymay occur any where in the body, andare the same in their nature and treat-

ment, so as to admit of a general doc-trine being laid down with regard to

them. As an example of such generaldisease, in the sense here intended, maybe mentioned inflammation more parti-cularly, which is clearly an affection ofall these primitive textures at once,blood vessets, nerves, and absorbents ;and may arise any where in the body ;60 that, in this sense, inflammation is ageneral disease, one that may affect anypart, though not all parts at the sametime. Hæmorrhage again is an affectionchiefly of the blood vessels, and may takeplace in various parts of the sanguiferoussystem, (though not so extensively as in-flammation ;) while it is the same as toits general nature, wherever seated.-Lastly, dropsy, in which both blood vesselsand absorbirag vessels are concerned, ranksamong general diseases, upon the groundsah cadv stated. The affections of nerves.which constitute one of the simple or pri-mitive textures, cannot be sufficientlyunderstood, without reference to thebrain and nervous system altogether.We are now, therefore, to enter upon

the consideration of General Diseases,according to the order just laid down;namely, inflammation, hæmorrhage, anddropsy : beginning with inflammation, asthe most extensive, as well as, in all re-spects, the most impoitant.

General Doctrine of Inflammation.This is a snbject of paramount import-

ance ; for inflammation is unquestionablythe most frequent, often the most painful,and, upon the whole, the most daugerousef diseases. It produces the must strik-

ing changes in parts ; it alters the ap.pem’ance, the feelings, the functions,and, nltimately, the structure of the partwhich it affects. It so changes the natu-ral actions, as, in many cases, to cause itto form, or, as we express it, to secretepoisonous matter, as in the instances ofthe variolous, the venereal inflammation,and many others. And when to this Iadd, that the consideration of inflamma.tion involves in it the doctrines and treat-ment of most other diseases, such, at

least, as are really important and dan.gei-otis, I need say no more to exciteyour closest attention to the subject. In.rlammation, in short, constitutes the es.sence of nearly all acute diseases, whileit lays the foundation of all our chronicones, I feel no hesitation in saying, thatwhen you have once made yourselves

thoroughly acquainted with the nature

and character of inflammation, in all itsbearings, and have learned to treat it,properly in all its forms and varieties,,yon will have little more to learn. The

subject, however, is one of great extent,and a perfect knowledge of it is difficultof attainment. We shall find it requisite,therefore, to devote no inconsiderableportion of our time and attention to itsinvestigation.

In order to treat the subject usefully orsatisfactorily, we must proceed with itin a methodical way; first pointing outthe signs or characters of the disease,both local and general, by which we maybe enabled to detect it, even when hid.den from our view ; its remote or occasionalcauses must be inquired into, as well asthose which give a predisposition to it-its intrinsic nature, or essence, investi-gated, as far as can be done, both ky rea-soning upon the phenomena, and with theaid which dissection can atford us—itscourse and terminations described-itsdifferent forms and varieties pointed outand explained-and, lastly, the mode oftreatment it requires, according to thedifferent circumstances under which ittakes place. Not one of these points canbe safely neglected, or even hastily orsuperficially passed over.There are certain oh-vions appearances

in inflammation, which have at all timesattracted the notice of practitioners,evenfrom the earliest ages, and have beenconsidered, indeed, as characterizing thedisease; these are chiefly four, namely,

heat, redness, pain, and swelling. Nowthese, taken together, nndonbtedly serveto prove the presence of the disease;but, individually taken, they are not tobe relied upon; siuce either of themsingly may be present, without inflamma-lioll, as either may be wanting, and yet

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the disease exist. There are many cases,likewise, in which, though these charac-ters may exist, we have no sufficientmeans of discovering them. It becomes

necessary, therefore, to inquire, how farwe may rely upon them, individually orcollectively, and what other means wehave of forming our diagnosis, where thesefail us.When inflammation is seated in an ex-

ternal part, such as the skin, it commonlypresents all the characters I have justmentioned; the disease then cannot bemistaken. But how far these are essen-tial, and consequently always present,will appear from the consideration ofeach separately, which we now thereforeproceed to.1. Heat. The very term inflammation,serves to point out the most obvious clia-ractrs of the disease, and has allusion tothe burning heat, as well as the fiery red-ness, which so commonly present them-selves. I hardlv need remind you, thatthe appellation is derived from the Latinword inflammatio, signifying burning.The Greeks used the term p.lzlog-osis, aword of the same import. And the dis-tasehax been similarly expresse,l in otherlanguages.

Increase of hent is so general a charac-ter of inflammation, that were we able tomeasure it correctly in all cases, it wouldprobably be fonud to be univer,al1y pre-sent. In very minn1e inflammations, andin the slyhter degrees of the disease, it ishowever, obv:onsly difficult, if not impos-sible, to do this. The heat of an in-flamed part varies, from two or three, toeight or ten degrees above the ordinarystandard, according to the degree of inflammation present, and the nature of thepart affected. The natural heat of thecentral parts of the body, is from 960 to98 ; but in the extremities, it is com-

monlv 5° or 6° less than in the centre.

hence, when inflammation is seated inthe extremities, the heat of the part maybe actitally below that of the centre ofthe body; yet it will be above the healthystandard of the part affected. It is thiscircumstance which has led some to say,that increase of heat is not essential toinflammation. The heat of an inflamedpart is, at times, greater than that whichtakes place in a fever, or any other dis-ease.

This character, increase of heat, is notof itself sufficient to prove the existenceof inflammation, though it is always asuspicious circumstance ; but must betaken in conjunction with others, beforewe can venture to rely upon it. Increaseof heat may be produced by friction, ex-ercise, or any cause that increases the

circulation of blood in a part, without in-flammation being present. On the otherhand, a part may be actually hotter thannatural, and that arising from intlamma-tion, yet from being deeply seated, wemay be unable to detect the change. Butalthough increase of heat is not alwaysdecisive in showing the presence of in-flammation, it is a sign of great use to nsin practice, as it often leads to a furtherinvestigation, which may determine thepoint ; and, in doubtful cases, it may bepretty safety relied upon. Thus, ill in-fants, when, upon grasping the head be-tween the hands, we find a considerableincrease of heat within, it is a strongground for believing inflammation to be

going on in the brain or its membranes ;and the same with regard to the thoracicand abdominal cavities.

i -2.Redness. This is by no means a ne-cessary character of inflammation, sinceit is not always present ; nor, on the otherhand is it, when present, always a sign ofexisting inflammation; for parts mayturn vividly red hy heat or friction, with-out being actually inflamed. Mere red-ness is consistent with healthy action ;but, in inflammation, the vascular actionis morbidly changed, as well as increased.Redness, again, takes place in many partsafter death, from gravitation of the blood,into the most depending vessels; and theparts so reddened, have been often saidto be irflamed. Many errors of this kind

have been fallen into, which you oughtto be aware of.Inflammation only reddens parts, whosevessels are sufficiently large to admit red

blood, such as the skin and many others.Some parts which do not carry red blood

in health, may nevertheless become red

under inflammation, the vessels becominglarger under this disease. Such is thecase with the serous membranes. Red-ness in these, therefore, is to a certain

extent, characteristic of inflammation.Rut there are several structures, the ves-sels of which are so extremely minute, asnot to admit red blood into them, evenunder inflammation. This is the casemtli regard to the ligamentous structure,the cornea liicid-a, the arachnoid mem.brane, and the ineiltillary substance of thebrain. The existence of inflammation inthe-e parts, therefore, is not to be deter-mined by redness, but by other signs,which I shall have occasion to mention.Again, parts may have been actually

red from inflammation during life, but theredness may have disappeared afterdeath. This is the case in persons whohave suffered ophthalmia at the time ofdeath ; the redness of the tunica conjunc-tiva disappears. I have seen the skin ot

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the abdomen intensely reki from inflam-ruation during fife, where the redness haswholly disappeared after death, so as toafford no evidence of inflammation havingexisted in the part. This is easilyunderstood. In the last act of life, theblood is generally expelled from the ca-pillaries back into the larger trunks ; andthe surfaces of parts, in consequence,become pale and colourless. Inflamma-mation must have existed for some con-siderable time, before it produces so

permanent an enlargement of vessels, asto allow of their retainng a conspicuousonantitv of red blood after death.I may remark further, that when inter-nal parts are the seat of the inflammation,we are unable to judge of their colour.Upon the whole, therefore, redness is avery equivocal sign of inflammation andis only to be relied upon in conjunctionwith other signs.

3. Pain. This is perhaps the least tobe relied npon, of a’1 the symptoms ofinflammation, though it is a very frequentattendant of the disease, and thereforeshould excite our suspicions. It maytake place in all degrees, from the trouble-some sensation termed itching, tip to themost acute pain. The degree or danger ofinflammation is,however, not always to bejudged of, by the pain which the patientis suffering. For, in the first place, itdepends upon the sensibility of the partaffected, whether the disease will be

accompanied with more or less pain.Violent inflammation of the substance ofthe lungs, and of the cerebral substance,often take place, with little pain. Andthe same is the case with the liver,which is not a very sensible organ.But when membranes are actively inflam-ed, they generally give rise to veryacute pain, though the danger is not pro-portionate. The nature of the disease,a180, may incapacitate a patient trom

describing his sensations ; as when thebrain is the organ affected. And thesame inability may occnr from the nato-ral imbecility of the patient, his age, orother circumstances. That pain is notessential to inflammation, is proved byanother fact, which is, that parts aresometimes rendered completelv insensibleby paralysis ; yet they are still susceptibleof inflammation, as from the applicationof blisters, &c.

Pain is produced by other causes, as

spasm ,- and it is of consequence to dis.tinguish inflammatory from spasmodicpain, because the treatment is differentln the two cases. Pain arising from in-flammation, is pretty constant, yet notabsolutely uniform in degree. Spasmodicpain, on the contrary, is always accom-

panied with marked remissions. Tutkind of pain, also, serves in some measure Ito distinguish it, though it is not easy to

describe the difference. Pain proceedingfrom inflammation, is in general accom.

panied with heat, and is, therefore, oftencalled a burning- pain; on the contrary, ’

I the pain arising from spasm, is of a more :cold nature. The pain of colic is verydifferent from that of enteritis, But thestrongest ground of distinction between

inflammatory and spasmodic paiti, is, that Ii the former is increased upon pressure,whereas the latter is diminished by thesame cause. The pain of an inflamedpart is otten of a throbbing kind, that is,

it is increased at every pnlsstion of the .

arteries ; but this takes place only wherethere are tolerably large arteries in the

part. Now as in this case the pain arisesfrom distention, we find that every in-crease of distention aggravates it; as Ipressure made upon the parts, and the ,ledependent posture.

4. Swelling. This is one of the mostgeneral effects of inflammation, and in.

deed may be said to be universal. Themost delicate membranes acquire addi-tiollal thickness, when inflamed, althongh

they are not at the same time reddened.The degree of swelling, depends chieflyupon the texture of the part. If thetettnrebe loose, as in cellular membrane, theswelling will be considerable. We liavean example of this in the eeltuhr snb-stance of the eyelid, where a slirlu de.dree of inflammation will occasion so

much swelling, as to close the eye alto-gether. In more deuse structures, as theligaments and bone,;, the swelling will bemuch less. Yet even these parts are notexempt from this effect; though, m ith res-pect to bones, it takes place much moreslowlv.Although parts in general become

swelled under inflammation, this cannot

happen with respect to the entire brain;for this organ being enclosed in an un-

yielding case of bone, cannot increase inbulk altogether. The effect here, there-fore, must be different. If any of itsvessels are enlarged in their diameters, ereffusion of any kind takes place into its ca-vities or interstices, other parts must suffercompression. In this way, inflammationin one part of the brain, may have theeffect of compressing the blood-vessels ofthe neighbouring, or even the most dis’tant part; so as to impede or interruptthe circulation there ; and conseqnentlydisturb, if not suspend, its functions.And thus disease in one part of the brainmay not only derange the functions of thepart immediately affected, but likewisethose of other parts of the same organ,

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and, subsequently, those parts of the

general system which are connected withthem; rendering the symptoms of inflam-mation in the brain far more numerousand complicated than those of other or-gans. In children, however, where thesutures are open, we often observe thebrain swelling from inflammation, andagain subside as the inflammation de-clines.These are the obvious, or externalcharacters of inflammation ; but theywill go but a little way, in enabling us todetect internal inflammation. Thus, forexample, in inflammation of the brain,neither redness, nor swelling, could availus much, if at all. It is true that in someeases, the conjunctiva of the eye becomesred, when inflammation is going on in thebram or its membranes;. but this is notessential. Again, pain could not suffice; ,as the brain is a very insensible part. In-crease of heat, however, may sometimeshe detected, not only in inflammation ofthe brain, but in other internal inflamma-tions ; and when we do feel it, we mayplace great reliance upon it. In inflam-mation of the thoracic and abdominalviscera, likewise, these obvious charactersare of very little service to us. It is,therefore, proper that we should becomeacquainted with the other signs, by whichinflammation may be known, whereverseated.

Other effects of Inflammation.1. Induration. When inflamed parts

swell, they generally become at the sametime harder in their texture. This is

particnlarly observable in the cellularmembrane every where. By this sign,we are often enabled to detect inflamma-tion in the abdomen whatever viscus beaffected. It may take place withoutswelling, and even where the bulk of thepart is reduced ; as in the liver, which,in some chronic states of inflammation,shrinks in size, but may nevertheless befelt up!!n examination to be greatly in-durated, In the brain, likewise, inilam-mation hardens the cerebral substance,so as, after death, to show the previousfxistpnce of indammation, as satisfactorilyas redness in other parts. Membranes,also, at the same time that they become.thickened, acquire additional firmness oftexture; as is seen paiticularly in thearachnoid membrane.

2. Loss of Transparency in parts thatare naturally transparent, is 2nother ofthp sins ot’ inflammation having existedin them. This is observed in regard tothe cor?iea lucida, the crystalline lens,and vitreous humour of the eye; and in.the tunica arachnoidca of the brain. Opa-

city therefore, is one of the signs by whichinflammation is known to have existed inthese structures. Parts that thus losetheir transparency by inflammation, donot usually become red, and not untilthe structure is entirely changed.

3. Increased Sensibility. Inflamed partsare generally tender to the touch, provingthat they have acquired increased sen-sibility. Even parts that are naturallyinsensihle, often become highly sensibleunder inflammation; as the bones andligaments. Tenderness to the touch, these-fore, becomes a sign of great importance.By pressure, and the pain which this pro-dnces, we are often enabled to detectinflammation in parts that are out ofsight. And it enables us to distinguishinflammatory from spasmodic pain, as Iobserved before; we have examples ofthis in colic-and enteritis, which by thissign albne may often be distinguished.But we should be aware that spasm may

induce, or be followed by, inflammation,and thus the two diseases may exist toge-ther. In some cases, the part acquiresso high a degree of sensibility, that the

I action of the arteries may. readily be feltby the patient; which is not the case inhealth. In the whitlow we have a strik-

ing example of this ; and in inflammationof the brain, the pulsation of the arteriesin the head is often bitterly complainedof. But although the common sensibilityor feeling, is increased under inflamma-tion, the peculiar sensibility is ratherdiminished, or rendered inaccurate; as

in the organs of sense, the distinctnessof perception is lost.

4. Increased .Irritability and Contracti-lity of parts also take place in inflam.mation. This is seen in the intestinalcanal, and other moving parts. Thuscarditis is attended with great frequencyof pulse, the heart being rendered tooirritable by the inflammation, to allowmuch blood to accumulate in it. Thesame thing is observed in the urinarybladder, which, when inflamed, has itscontractility increased, so that it will notbear the usual degree of distention. Inshort, whatever organ be inflamed, itssensibility, irritability, and contractility,will all be increased. It is thus that.inmany brain affections the mind becomesirritable, while, at the same time, thegeneral sensibility is heightened, and themuscular power increased, or renderedmore active and often irregular.

5. Disordered Function is an invariableconsequence of inflammation. The func-tion may, however, be very variouslydisturbed. In violent inflammations itmay be altogether suppressed, as is seenin Mephntts, and in inflammation of the

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mucous membrane. In these cases, thenatural secretion may be totally put astop to. In milder cases, the functionwill be variously altered. And in stillmilder ones it may even be increased.We have a good example of all this va riety of effect, in inflammation of themembrane lining the nostrils. If the in-flammation be violent, as it commonly isat first, the secretion will be wholly puta stop to. If, however, it be less violent,or, from continuance has become so, thesecretion, at the same time that it is in.creased is also of an altered nature.-When other signs of inflammation arewanting, or are not to be relied upon, anexamination of the function of a partwill generally enable us to detect thedisease. Hence you learn the absolutenecessity of physiological knowledge.-Whenever the function of a part is dis-ordered you may be sure the organ itselfis not in a sound or healthy state of ac-tion. Thus, for example, if you find anyone of the cerebral functions imperfectlyor improperlv performed you may takeit for granted, that the brain is in some

way disordered. Whether this disorderbe inflammation or not, must be jndged ofby the other symptoms. If a blood ves-sel be inflamed, its action will be moreor less altered, according to the degreeof the inflammation. If a nerve, its sen-sibility is excited in the highest degree,and that of the parts also to which it goes;as in inflammation of the great sciaticnerve. If an absorbing vessel is affectedwith inflammation it thickens, contracts,and the passage of the lymph through Itis more or less obstructed; and if iianyabsorbents are thus affected, it occasionsan anasarcons state of the parts below.This is often observed in lying-in women :as in the disease called by some phleg-masta dolens. If a mnscle is inflamed, it I

loses in a great measure the power ofacting, and does not readily obey thewill; as in some cases of rheumatism, andin strains and bruises of these parts. Inthe compound organs, the effects vary ineach; but the function always is de-ranged, and that according to the degreeof inflammation present. If it be a se-cretory organ, the secretion is alwayschanged, either in quantity or quality, orboth; and, in some cases, it is even ren-dered poisonous.

6. Change of Structure. As inflamma-tion is principally an affection of the iblood vessel; and as these are chieflyconcerned in the growth of the body,it is natural to suppose that, when inflam-mation occurs, this structure of a partwill in time be altered ; inflammation, infact, always has this tendency, more or

less, according to the nature of the part;and sooner or later, according to the de.gree of the disease, the age of the pa.tient, and other circumstances. Changeof structure induced by inflammation willcontinue after the inflammation is reo

moved. If the change the part has un.dergone be but trifling, it may graduallydisappear. Thus the swelling of partssubsides ; the natural transparency is reostored, and the blood vessels return totheir former dimensions: but when thestructure is changed in a greater degree,it commonly continues through life, andthe part is rendered incapable of per.forming its healthy actions. Thus it isthat mania succeeds to phrenitis andsometimes to ordinary fever-sometimesdisappearing after a few months, and atothers continuing through life. Thistendency of inflammation, even when

slight, to change the structure of parts,shows us the necessity of putting stopto the disease, particularly if the organaffected be essential to life. Slight in.flammation of a part is often overlookedor neglected not only by the patient, linteven by the practitioner; and this goeson till the structure of the part is altered;we have then little power over it. Wehave an example of this in the lungs, inwhich slight degrees of inflammation areoften overlooked, and pulmonary con.sumption is frequently the consequence.It behoves praetitioners therefore, to bevery much upon their guard, against this,and to endeavour as quickly and com-pletely as possible to put a stop to thedisease. Most of our chronic diseasesmay be traced to the neglect of inflam-mation in the beginning.There is no end to the variety ofstruc.

ture, that inflammation is capable of pro-ducing: increase of bulk, of hardness, ofvascularity; sti ppu ration, ulceration, schir.rns, and carcinoma, all are but conse-

quences of inflammation of different kindsand degrees; with correspondingchangesin the state of functions and often de-strnction to life itself.

It may be remarked of inflammationaltogether, that it always tends to theproduction of new matters, either solidor fluid ; and thus tumours and excre-scences are formed, on the one hand; orincreased discharges, on the other; ac-cording to the nature of the part affected,and the degree and duration of the dis-ease.

Effects of Inflammation on tie Systertz.Inflammation is essentially a local dis-

ease, and not necessarily attended withgeneral disorder of system: as when

slight in degree; of small extent; not

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attended with much pain ; aud in habits iof little or moderate irritability. But,when extensive or severe, even withoutbeing attended with pain, it occasions Imore or less of general disorder, differingaccording to the state of system at thetime, and other circumstances. As the

leading symptom of this general disturb-ance, is increased heat, this state altoge-ther has been called, in general language,fever; and as it is the consequence of aprevious disease (inflammation), it hasbeen called symptomatic fever (pyrexia:)it being supposed that fever might takeplace independent of inflammation ; whenit was called idiopathic or original fever :this however, I shall endeavour to show,is not the case. It has been also calledconstitutional disorder, or, the constitutionsympathizing with the part, general in.flammation—or symploms of irritation.-(This subject will be resumed in our nextlecture.)

LECTURESON SOME

PRACTICAL POINTS OF SURGERY

DELIVERED TO THE

Students of the late Borough Dispensary,

BY MR. ALCOCK.

LECTURE X.

Of Fractures.Gentlemen,fractures of the shoulder blade are less

frequent than, from its exposed situation,might be expected ; but when it is consi-dered that the bone moves freely and ex-tensively upon the chest, and that theonly point of firm resistance is that form-ed by its union with the clavicle, you maytrace, in the yielding nature of the con-nexion of the scapula with the chest, thecause of the rarity of fracture of the sca-ptila.

The acromion, the most exposed pointof the scapula, sometimes is fractured bya direct blow upon it, as by the falling ofa heavy body. The thin covering at thispart, consisting of little beyond the inte.guments, admits of the easy and effectualexamination of the acromion, and if frac-ture exist, it can scarcely be overlookedor mistaken. The raising of the arm by the

action ofitsmuscles is impracticable, whilstthe fractured portion of the acromion isdrawn downwards by that part of thedeltoid muscle attached to it. The treatiiietit consists in pressing the humeruupwards, so as to prevent the fragmentfrom falling below its natural situation,and by bandages and compresses (or otherapparatus) fixing the upper extremity tothe chest, so as to prevent the motion of £the parts upon each other.

Fracture of the neck of the scapula isalso of very rare occurrence, so much so,that a hospital surgeon of great expe-rience, and one of the Court of Exami-ners, has stated that he had only met withone instance of it during a period of 45

years. It is occasioned either by a di..

rect blow upon the shoulder, in a di4rection downwards and inwards, or by afall upon the shoulder, the shock beingcommunicated through the head of thehumerns to the neck of the scapula. Thefalling down of the head of the humerusso nearly resembles the displacement bydislocation, that it has happened even ina metropolitan hospital, that the pullieshave been used to reduce the supposeddislocation, several weeks after the acci.-dent, when, on further inquiry, it wasfound that the fracture of the neck of theseanula had been ascertained bv othersurgeons at a comparatively recent pe.riod after the accident. The stifferingattendant on forcible extension undersuch circumstances, may be conceived;but cannot be described! When thefracture is recent, it is not difficult torestore the limb to its natural position,and the retaining it by compresses andbandage, so as to fix immoveably for thetime the upper extremity to the chest,requires no more skill than what is ne-

cessary in the treatment of fractures ofthe clavicle, or other accidents, whichrequire perfect rest and apposition of in-jured parts.

Fractures of the humerus, if transverseand lower than the insertion of the del-toid muscle, are the most simple in treat-ment, and generally successful in resultof any of the fractures of the limbs ; onthe other hand, oblique fractures at theupper part of the bone have been mis.taken, and permanent lameness has beenthe consequence of inefficient treatment.There is often, accompanying such acci-dents, considerable swelling ; but still thediagnosis is sufficiently distinct on carefulexamination, if the natural relation of theparts be well known, and the deviationfrom that natural condition of the partsbe carefully observed. Perhaps a point