-No. 4.] LONDON, SATURDAY, JULY 24, 1824.

SURGICAL LECTURES.

Theatre, St. Thomas’s Hospital. WEDNESDAY EVENING,

MAY 19, 1824.

_ LECTURE 67.

Having given you, in the last.lecture, a general description ofscrofula, we shall now proceedo treat of the several parts

attacked by this disease, andfirst of the absorbent glands

most commonly affected.

Scrofulous affection of the glands f the neck.

Of the° : different absorbent

glands, those of the neck are

most frequently - affected with-serofulous disease. Now, when,

you are consulted in a case of

this kind, the symptoms you findare as- follow: - In the nrst

place, you learn from the child’smother, that she at first observ- ed a. swelling-in the neck whichwas small, hard, ’not painful, norin any way discoloured, buttender to the touch. Thus the

inflammatory process does not

go on to the rapid - destruction ofthe part, for the swelling willfrequently remain in this stateof indolence during weeks,months, and -sometimes_, years.Sometimes, however owing toaccidental circumstances, or

changes in the weather,. or thestate of the child’s constitution,the complaint .proceeds withgreater -rapidity. If the com-plaint occurs in a person of anirritable habit, it, will advance

with rapidity; if on the contrarythe person be of an indolent

habit, it will be slow in its -pro-gress. When you examine bydissection, the state ,of the partsaffected with scrofulous disease

you find extravasated into thegland a great quantity Qf blood,and the blood-vessels enlarged.The interior of the gland is com-,posed of rather a firm substance,which is of a yellowish-whitecolour. If you inject the sub-

ject first, you will -see that theblood-vessels do -not, pass intothe substance effused—in fact,that the adhesive matter is notorganized. As the vessels do

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not shoot into this substance, it

does not undergo the same

changes as the adhesive matterthrown out in common chronic

disease. In common chronic in-

flammation; the adhesive mattereffused may be injected, whichshews that it is in some degreeorganized. Remember, then,that during the’ adhesive stage,the inflammation may be in-

creased from change of seasons,climate, or any particularity of

constitution, and proceed to the

suppurative. This disease pro-duces little pus. These are the

common symptoms of suppura-tion, -but in a much niilder de-

gree than are usually met with.The suppurative process is weakand languid, and it is a longtime before matter forms. The

suppuration is very imperfect,"the pus has not the true charac-

ter of purulent secretion ; it is composed of a curd-like matterand resembies -pus mixed with

serum. These, then-, are the ap-pearances of the suppurative.stage. Suppuration proceedsvery slowly. The skin at first

has a blush of inflammation onit, then becomes of a - livid or

purple hue. It frequently hap-pens, that when the skin is in

this state, a long time elapsesbefore it gives way. When the

sldn, however, breaks, it gene-

rally separates to a considerableextent. The reason :why scarsin the neck are so large is, thatthe vitality of a large portion ofthe skin has been destroyedfrom the pressure of the pus; it

then assumes a livid appearance,and when it gives, way, sloughsto a considerable extent. The

ulcerative process proceedsslow-ly, compared with uleeration inother complaints. The interiorof a suppurative gland, very

rarely sloughs ; but the matterthat is effused, separates with the

pus. Such is the- history of anenlarged absorbent gland, af-

fected with scrofialous disease,the various changes which it

undergoes, and the appearanceswhich those changes present intheir different stages.

Death is sometimes producedby enlargement of the absor-

bent glands of the neck. I will

relate to you three instances

which more particularly strike

my mind. In one case the

glands covered the jugular vein.I attended the case with a re-

spectable practitioner in the city.’ The patient had frequent rigors,and a great deal of constitll-

tional irritation at the time I, saw him ; his life was evi-

dently in imminent danger, and

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in a few days after he died We found on dissection that theabsorbent glands were adheringto the jugular vein, and that thematter had escaped into it, whichwas the cause of the great con-stitutional irritation under whichhe laboured, a short time pre-vious to his death. The secondway in which .an enlargement

of the glands of the neck may givense to death, is by pressure onthe veins producing apoplexy.Isaw a case of this kind in a lad

’

of 16 or 17 years of age. The

glands were enlarged so as topress on the veins of the neck,.andthe boy died apoplectic. Thethird case which I shall men-tion is one where an enlarged.gland suppurated into the larynx,

and produced suffocation. It

occurred in a boy who had re-ceived an injury of the head, which was followed by enlarge-,ment .of the absorbent glands of .the neck. They went into a .suppurative state, and the pusdischarg’ed itself into the trachea,and produced death by suffoca-tion. But it generally happensthat when these cases terminatefatally there also is present con-siderable disease of the lungs,and bronchial glands. If I were asked why the ab-sorbent glands. of the neck are

more frequently affected withscrofulous disease than the otherglands, I should answer that’it was owing to their being somuch exposed and consquentlyso much influenced by thechanges of weather and sea-sons. A child exposed to thecold with the ears half frozen,the cheeks and head also. cold,is suddenly brought into a stateof excessive heat, which ypro-duces a slight degree of inflam-mation in the parts ; that irrita-tion, also produces inflammation of the absorbents ; and thus thereason why the glands of theneck are so frequently enlarged.Scrofulous enlargement glands of the neck, is more frequentthan of those in the axilla; andenlargement of those in the ax-illa, more common than of the glands of the groin ; becausethe lower parts are better pro-the lower parts are better pro-tected from the atmosphericchanges. But it sometimes hap--pens that a peculiar secretiontakes place in the gland, andthat earthy matter is effused in!it.- it is not at all an uncommonoccurrence for a substance like

chalk, and composed of carbo-nate of lirne to be deposited in-an enlarged gland. Here is a

specimen (exbibitin- it to the

class) of earthy natter, that was

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deposited in a gland. I removedit after death. These depositsare usually composed of carbo-nate of lime. , ’

Treatment of enlarged absor-bent glands of the neck. When a child with scro-

fulous -enlargement -,of , an- ab-

sorbent gland of the .nec:k, isbrought to you for advice,you will treat it, -if the com-

plaint’ be of recent occurrence,like a case of common inflamma-tion. You will give rhubarb andcalomel internally, and you re-commend evaporation lotions,’for local app.lications: The bestlotion you can use, is the liquorplumbisuperacetatiwith spiritsOf wine and water. In this waythe inflammation will be gra-

dually subdued. But theseglands are apt sometimes, not-withstanding’ all the means youemploy, and all the care that maybe taken of the child, to go intothe suppurative stage. In this

case you must give the rhubarband carbonate of soda, twice aday, tog-ether with a small

quantity of the hydrargyruscum creld (one grain) three orfour times in the twenty-fourhours. You must next consider

-what local treatment to employif the gland suppurates. When

you find that there is a disposi-

tion to suppurate, evaporatinglotions will not succeed, andtherefore must be discontinued.You should feel if there be

any fluctuation; for the moment,that there is the. slightest blushon the part and sense of fluctua-tion, indicating the presence ofpus, you should make a smallopening with a lancet, as in acommon abscess ; you shouldnot wait for the skin to assumea livid hue; for then you willnever be able to prevent scars.A scar in the neck of a’boy isnot of much consequence, butin the neck of a female, it,

is quite a different case. In boys,the neck is covered by the dress;whereas in females, it is gene-’rally exposed, and a scar in-thatpart might be the means of des-troying the happiness of the indi-vidual, whose misfortune it wasto have it. Nothing,gentlemen,is so revoltin to the mind, or atleast the minds of those who

possess fine feelings, and are.fined taste, as the appearanèe ofany thing on the female figurewhich calls to the recollection,that the person you behold is

’tainted by a disease of a scrofu-lous nature ; and therefore it is

your duty, if you have any re-

gard for your own reputationand the happiness of. others, to

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prevent the occurrence of scars on the neck, a circumstance whichmay be easily effected. I will

tell you why scars on the neckare so frequently met with ; thesurgeon waits, too often, till theskin has become livid, and

then makes a puncture. Butin this case, he gains nothingby making an opening into thegland ; in fact, if the skin be ofa livid colour, I advise you then-.not to make an opening.-Apply poultices, and let na-

ture effect the opening ; for the scar will not be so great then as if you were to make

it. But I seriously advise ’youto make a puncture before theskin assumes the appearance I

have just been describing to you.The instrument with which I

open these abscesses is a cataract

knife, and I make the incision

transversely, and just in the di-rection of the creases of the

neck, so that when the wound- heals, no scar is to be perceived.When the matter is dischargedby the puncture, apply your fin-ger, to the side of the swellingand squeeze out all the solid mat-

ter that may be contained in thegland. If the sac be not carefullyemptied of all the solid matter,this substance will keep up considerable irritation and prevent the

healing of the wound, thereforeI wish to press on your attentionthe necessity of attending to this:point. I have frequently seanseriousinconvenience occasioned

by its being neglected. Remem-ber first, the time at which youare to make the puncture, andthe direction in which it is to be

made ; and secondly do not omit in all these cases to squeeze outall the solid matter that may be

within the gland. If the woundbe indolent afterwards, you hadbetter inject into it a solution ofsulphate of zinc, containing aboat °

a scruple of the zinc to a pint ofwater. Throw a small quantityof this into the wound, it willsoon produce healthy ’ranpla-tions, and lessen the dischargeifit be copiousr Such, then, gen-tlemen, is the treatment to be

adopted after the gland has pro-ceeded to the suppurative state.What I advise you to do, is tomake an opening into the -glandas soon as fluctuation can be de-

tected, and before any discolora-tion of the skin takes place ; inorder to prevent a scarhereafter:

, Thus you see by a little atten-tion the cause of much unhappi-

,

ness may be kept off. At this’ time you should give rhubarb and

carbonate of iron, about two

grains of the former, and five of

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the latter twice a day. The dietshould be nutritious, but not inthe slighest degree stimulating.With respect to the ulcerativeprocess, there is nothing particu-lar to remark; fomentations, poultiees, and the ordinarymeans must be had recourse to.

Your object, however,should beto prevent ulceration by the modeof treatment I have laid dovvn;and it is only when it cannot beprevented that these means are

to be employed.

Affection of the MesentericGlands.

The glands which are affected with scrofulous disease next in

frequency to those of the neck,are the mesenteric glands. In

young persons, they arw most, commonly affected at the age of six or eight months. This com- plaint is known by the belly be- ing tumid,and from the tender-

, ness on pressure ; attenuation of the skin, voraciousness of appe-tite ; the limbs of the child atthe; same time wasting. The in-’testines are equally irregular, being sometimes purged at otherscostive. In the motions are oc-

casionnally observed earthy mat-ter (a specimen of which I nowsend . yon round) , composed of-carbonate of lime. The causes

which produce enlargement ofthe mesenteric glands arise fromdisease of the secreting- gla;ndof the intestinal canal, such as

irritating food ; which irritatesthe mouths of the absorbentvessels of the intestines leadingto the mesentery. With respectto the effects of mesenteric dis-eases, they consist at first in aninterruption of the process ofabsorption. The chyle travelsthrough the. absorbents to themesenteric glands,and whensome of these are enlarged the chyle is interrupted in its course.Although the child generallyeats so voraciously, is it wonder-ful that there should be suchemaciation independent of the ir-ritation, produced by,the systembeing deprived of nourishment ?

Treatment of Diseased Mesen-teric Glands.

As to the treatment, I advise

you to. direct . that- the .-Pbildshould take animal food, prepared so that it maybe easily-digested. Vegetable food isvery improper.. A little arrqw-root may be taken, and nutri-tious broths. Animal food willgenerally best agree with thechild, if it be prepared in themanner by which it may bemost easily digested. The prin-

103

ciple on, which you act, is, thatthe child may take the most

nutritious food, and why ? Be-cause absorption being to a greatdegree prevented, it is impor-tantthat nothing but highly nu-tritious food should be, taken,so that nutriment may be con-veyed to the system. Animal

’

food is more nutritious than ve-

getable food, therefore you giveit in, preference to the last. To

assist the digestive process, it is

desirable to give some wine andwater, to stimulate the stomach

to secrete the gastric juice, andto excite the action of the in-testines ; in exciting- the intes-

tines, you have a two-fold objectin view :, stimulating the absor-bents, and producing the peris-taltic motion of the intestines.The best medicines in this disr

ease with which I am acquaintedis the oxymuriate of mercurygiven in small doses, and in

combination with the tincture

of bark. One grain of the oxy-muriate in two ounces of tinc-

ture of bark, or should the bowelsbe costive, in the same quantityof tincture of rhubarb.. Thehydrargyrus cum creta and

rhubarb, given so as to pro-duce an aperient effect, are

good medicines. The oxymu-riate of mercury should be given

with no other view than to im-

prove the secretion from the

liver and intestines, and thus.

produce one stoola day. Theabdomen should be covered witha stimulating plaster, or fre-quently rubbed with the hand,in order to produce a gentleaction in the part, and excitethe absorbents. This is thetreatment of enlarged mesentericglands.

,

..Dropsy is sometimes connected

withthis disease. Then paracen-tesis should be performed; whenthe patient generally recovers.Now and then a mesenteric

gland suppurates, opens at thenavel, and frequently com-

municates with the intestines,and thus an artificial anus is

produced. In these cases,wherethere is an artificial anus, a large proportion recovers. Poultices

should be applied over the

opening ; and when the inflam-mation is subdued, strips of ad-hesive plaster shouldbe applied,so as to bring the edges of thewound together, but not untilyou think that all the matter

has been discharged from thegland.

Diseases of Joints.The diseases of joints vary

in their character; according to

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the stage of the complaint. It

generally happens ’that after achild of a strumous habit haswalked a considerable distance,that it complains of pain in thejoints, which is accompaniedwith stiffness of the joint, andinability to move it . The parenttakes alarm; and I may say thatthis disease can never be too

early attended to. The com-plaint may generally be re-

moved, if it be attacked earlybut if six weeks or two months‘elapse before the person applies,he will never recover. A great

deal, therefore, depends, in thiscomplaint, on early treatment.To prevent mischief is infinitelybetter than to effect a cure;and in these complaints a cure

is not so easily effected. Thereis little tenderness at first, andthe swelling is very slight Ifthe synovial membrane be in-flamed, there will be a grittingbetween the bones under the

patella on each side, and so in I different parts according to thejoints affected. The joint willremain in ’this state for sometime, possess the same appear-ance as in health and the con-

stitutiori suffer little. But whereit has existed a long time, thesuppurative process will at lastbe set up, and the joints will as-

sume the character common toinflammation of all joints. Whenthe suppurative process com-

mences, a great quantity of pusis secreted, if there be much con-stitutionalirritation.Indeed theremay be at first a copious secretion and slight constitutional de-rangement ; for the suppurativerangement; for the suppurativeprocess is not attended with thesame constitutional effects as inother parts of the body. Whenthe abscess breaks (which islong time from the commence-merit of the disease-) the ulcera- ,tion is often at a little distancefrom the joint; and there aregenerally sinuses extendingfrom the point of ulceration, for2 or 3 inches up to the joint,and thus in scrofulous enlarge-ments of the knee, the abscess

generally breaks above or belowthe patella. We generally letthese by them-selves, as there is little constitu-tional irritation at first, and theopening cannot be delayed toolong. The abscess generallyopens in more parts than one,and the suppurative process takesplace at a distance rom thejoint; the ulcerative process isslow and excites little constitu-tional irritation. When youdissect a joint affected with

scrofulous disease, you find,

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after having cut through the in-teguments, that there is a greatdeal of adeps between the liga-ments and interstices of the skin.Next you will see the capsularligament thickened, and that

the thickening has taken placeon its interior surface. The sy-

noyiai membrane will be alsofound highly vascular. You nowexamine the cartilages, whenyou will find that they have uii-dergone more or-less ulceration,and covered by processes of ad-hesive matter ; and, lastly; thebones themselves will now andthen be in a state of ulceration;sometimes there are earthydepo-sits on them; but they are more

frequently lessened in size.---

With respect to the nature of

the oomplaint, I believe that it

is the result .of exercise, whichhas produced inflammation of

the internal lining of the joints,and frequently the synovialmembrane. The action of the

jbints leads to the inflammation;for you find that a child- after

walking’, for taken- as it fre-

quently is to a distance from itsplace of residence, the parentforgetting that it has to make

two or three steps to her one,and its attention being kept upby the prospect of amusement,I say, that in these cases you

will find the -child on the fol-lowing day complaining of painin the

joints.—

A medical man isconsulted, who finds swellingand signs of inflammation of thejoint; inflammation of the syno-vial membrane comes on,whichleads to the absorption of thecartilages, and sometimes bone ;for my own part, I believe thatit is the internal lining of thejoints originally affected. Mr.BRODiE.whom I am proud

to call my- friend, has written awork on diseases of the joints,which cannot be too carefullyperused by those who wish tobecome acquainted with, theseaffections ; and he is more dis-

posed than I am to think thatthe disease commences in the

cartilages. I am of opinion thatthe synovial membrane is at firstattacked, and then. that the

complaint gradually extends tothe other parts. It howevermatters little, for the same treat-ment is to be pursued, whetherthe disease originates in the car-tilage or the internal lining ofthe joint.. :.. - .

Treatment of Scrofulous Affec-, tions of the Joints. _

The treatment required in thesecompl aints is as follows :the greatobject is to preserve the limb in

106

a state of rest. This is so obvi-

ously necessary for an inflamed

part,that every man will see thereasons for attending to it. If

I had inflammation of the hand,should I expect that inflamma-

.’ tionwould cease unless I kept mylimb quiet and in a state of rest ? and is it not equally absurd to

imagine that an inflammation ofthe joint will be subdued, unlessthat joint be kept in a state of

perfect rest ? I will not say that

the body should always be keptat rest, but only the limb affec-ted. This may be often secured,so that it shall remain quiet,although the body is in exercise.Next in importance to rest is thereducing the heat of the part.-

Evaporatinglotions of water andspirits of wine, or the liquorplumbisuperacetatisdilutus with

spirits of wine and water, shouldbe employed. Rhubarb and the

submuriate of mercury ought tobe given once a day or every se-cond day. Suppose, however,that the disease advances, and is

. not subdued, it will be necessaryto employ some local counter ir-ritation. Blisters, tartar emeticointment, vinegar poultices, is-

.. sues and setons, are the various

means used for. this.purpose. If thejoint suppurates, it will be bestnot to apply issues or setons close

to the joint. Mr. CLINE tried

once to investigate this point,and the result of his observation

was that.if setons and blisters

were employed, they should beemployed at some little distancefrom the joint. Blisters may be

applied over the joint, but theyshould not be so large as to pro-duce considerable irritation; theyshould be kept open by the un-guentum sabinae. Depend on it,this is the best treatment; thetartar emetic ointment is a useful

irritant, in the proportion of adram of the tartarized antimonyto an ounce of spermaceti oint-ment. When the irritation has,

by evaporating lotions, and othermeans, been lessened, no motion

being at all employed, it will be

necessary to put a splintunderthelimb, extending from the ham tothe heel, and then to use friction,so that the joint may in time

be restored to use. If nofriction or passive motion be

employed, there will be no useof the limb any more. This

was the great advantage ofthe -late Mr. GROSVENOR’S plan ofOxford. I will not say that fric-tion, when the inflammation isgoing on, is not injudicious, butI mean that if the int1ammatiol1be subdued, you are not toleave the joint in a’ state ofrest, but to use friction. Letme put you on your guard, with

107

respect to cases of common in-flammation; in them you mayemploy motion earlier than inscrofulous disease ;there is such a disposition to a return of theselast affections, that you shouldnever give any pain in themotion you use the exerciseshould be so employed, as notto excite the least uneasiness intaking it.The next circumstance to be

considered is when does ampu-tation become necessary ?—For-merly limbs used to be ampu-tated for scrofulous affections,much more frequently than atthe present day, and the reasonof it is, that the affected limbmay, with care and manage-ment, be often made more use-ful than an artificial one. In

enlargements of the knee andaincle, it may be necessary nowand then to amputate, but itought never to be done unlessthe patient is labouring under

great constitutonal irritation,Which threatens destruction tohis life, or the limb has undergonesuch changes that it is not likelyto be useful hereafter. For in-stance, in cases of scrofulous af-fections of the ancle joint, thefoot often remains extended,and the patient is only able; towalk on the toes. Here an arti-ficial foot would be much: bet=ter than the natural one. Inscrofulous diseases of the knee-joint, the tibia is often dislo-cated forwards. You saw a caselately,over the way, of this de-scription; the deformity willalways remain and the limb beof little use. Amputation ofthe fingers and wrist is occa-sionally performed ; that of theelbow very rarely.

CHEMISTRY.

We concluded our remarks onelectricity last week by shew-ing that that the division ofsubstances into electrics andnon-electrics, is perfectly unne-cessary and incorrect, sinceevery substance in nature is elec-tric under certain circumstances;and hence non electric bodies,cannot extst.

We have somewhere previ-ousty remarked, that " whena body is electrically excited, itwill attract other bodies;" thisfact is observed to obtain only toa certain extent; for we find, insome cases, that electricity willproduce just the opposite effect,namely, it will repel other bo-dies which happen to be placedwithin the sphere of its influence..The circumstances necessary

for ’both these phenomena are,that the bodies them selves shallbe either in different states ofelecticity, or that they shall besimilarly electrified: in differentstates where they attract eachother, and in similar states wherethey repel each other. The first ofthese phenomena may be shewnby rubbing a wine glass,sealingwax, or glass rod, with a piece offlannel, as previously noticed,and bringing it near light bodieswhich have not been excited, such as are in a different state of electricity, for instance.as small bits of cork or fea-thers, under ordinary circum-stances. The second phenome-non — repulsion, and which isthe most important one of thetwo, may be shewn by bringingbodies which have been simi-larly excited, or charged withelectricity, near each other.—