Chapter VI: Part 6

“The hazard of the operation, and the little chance he had of its proving successful, being explained to him, the unfortunate man earnestly begged to be relieved from so hideous a load, even though he should die under the operation. I therefore yielded to his entreaties, and took off the hand a little above the wrist, in November 1782, although there was a small indurated gland above the elbow. On dissecting the hand immediately after I had taken it off, the fungus, on being cut, appeared to be extremely similar to the substance of the brain, and to arise from the metacarpal bones of the middle and fore-finger. These bones were in part dissolved, and the other bones of the hand were also in a morbid state.

“No accident occurred during the amputation; but soon after it, a colliquative diarrhœa came on, which seemed to be increased by opiates and astringents, but was at length checked with draughts of fixed alkaline salt and lemon juice, swallowed in the act of effervescence. He afterwards took the bark, drank seltzer water, and was allowed a liberal use of wine. The suppuration for some time was ichorous and bad, but he gained strength daily. At the end of seven weeks, the stump was completely cicatrized, and the indurated gland above the elbow had disappeared. He went into the country, drank goat’s whey, bathed in the sea, became very corpulent, and seemed to be in perfect health, but had somewhat of a sallow bloated appearance. He continued well till July 1783, when he began to complain of pains in his back, attended with rigidity. These pains, as they increased, extended down his thighs and legs, and occasioned him to sleep ill at night. He grew feverish, his pulse beat extremely quick, and his countenance acquired a shining yellowish red colour, an appearance which I have remarked to be characteristic of a cancerous habit. He now began to walk with difficulty. I took a small quantity of blood from him, and found the texture of the crassamentum extremely loose, and the serum in too great quantity. He was very difficult to purge, and unfortunately was under a constant necessity of taking medicines to procure the necessary discharges. Antimonials in a variety of forms were given, and the bark was again tried, as were all the medicines that are usually prescribed in rheumatic cases. Blisters were applied, and issues cut in his thighs, but all to no purpose. He was obliged to take to his bed in August, and never after quitted it.

“It is difficult to form an idea of the constant and excruciating pain this poor man suffered. Opium, though given in large doses, afforded him but little relief, and at last none at all. He generally lay on his back, fixed as it were to the bed, the least motion occasioning the most intense pain. As the disease advanced, he complained of a difficulty of passing his urine, which was loaded with a viscid mucus, and he once discharged an oblong calculus; but at last he voided his urine involuntarily, and sometimes even his fœces, but the latter only rarely, when he had taken a purgative, which, as I have already mentioned, was required to be of the most active kind, otherwise it produced no effect.

“During the whole course of the disease, his pulse was rapid, but his tongue was remarkably soft and florid. He was never delirious. Latterly, he spit blood once or twice; his lower extremities became very œdematous, and his back was covered with eschars; but these dropped off, and the sores suppurated and healed kindly. Two months before his death, his pains abated considerably. He died without pain, March 4 1784, which was about two years and nine months from the time the seton was passed, and a year and four months from the time he underwent the amputation.

“His body was opened a few hours after his death. The abdominal viscera appeared to be perfectly sound, and of their natural colour, except the liver, which had a small steatoma on its convex surface, but was in other respects healthy. The gall bladder was rather fuller of yellow bile than it is generally found to be. The left kidney was enlarged, and on dividing it longitudinally, much red gravel was found in its pelvis, and the ureter seemed much lessened. The urinary bladder was contracted, and its coats uncommonly thickened, but no sabulous concretions were observed in it.

“On each side of the vertebræ lumborum, the lumbar regions were rendered convex by a large cancerous deposition, which elevated the psoæ muscles; and when the cellular investitures, which were condensed into a cyst, were opened, the cancerous matter appeared in a large quantity, in colour and consistence exactly resembling the fungus of the hand, and not unlike the substance of the brain. The whole weighed about five pounds; and when this was removed, the last vertebra of the back, and the three first of the loins, were found to be in a softened, eroded, and in some parts a totally dissolved state. There appeared not the least mark of ichor, sanies, inflammation, or hardness of the soft parts; nor were the mesenteric glands at all affected. The matter seemed to have been really a cancerous exudation, and to be formed chiefly of coagulable lymph. This cancerous mass seemed to possess a remarkable dissolving power, which was exerted wholly on the bones, and did not, as usual in cases of this sort, cause any schirrous hardness of the surrounding soft parts.”

CASE V.

A woman, some time after receiving a blow on the leg, perceived a small moveable tumor. It was soft, elastic, and seated on the outside of the leg, about half way betwixt the knee and ankle joint. I made a small incision through the skin down to the tumor, and dissected it off to its base. I then dissected the substance off from the facia of the muscle, and brought the skin together with adhesive plaster. It united readily, and the patient was cured. The tumor was soft, like brain, of a greyish colour, and greasy consistence.

DISSERTATION V.

_On the Scrophulous Inflammation._

Scrophula is a morbid condition, which has been called the opprobrium of surgery, much more justly perhaps than any other disease, cancer itself not excepted, for even this most dreadful disorder may be removed by an early operation; but the nature of scrophula admits of no treatment equally successful.

From the obscurity in which its causes are involved, and from no certain method of cure being known, I can only make a few unconnected remarks on this disease.

A scrophulous system is generally marked by a fine skin, delicate complexion, light blue eyes, with opake sclerotica, and frequently a swelling of the upper lip. At other times, especially in those who belong to what has been called the melancholic temperament, the complexion is darker, and the skin coarser; but in these, at least when young, the face is generally tumid, and the look unhealthy.

In these systems, as will presently be observed, almost every disease is different, in some points, from the same disease when it occurs in a healthy person; but the action which more decidedly manifests this modification, is the inflammatory, insomuch, that, by some, scrophula and scrophulous inflammation have been confounded; and this disease has been described only in so far as it has appeared conjoined with inflammation. We have therefore almost always in the description of scrophula a swelling of the glands, and subsequent ulceration, or inflammatory affections of other parts of the body, detailed as necessary and essential symptoms.

The scrophulous inflammation is marked by a soft swelling of the affected part, which very frequently is one of the lymphatic glands. The covering, or coat of the gland, becomes slightly thickened, and its substance more porous and doughy[84]. The swelling increases, and the doughy feel changes by degrees into that of elasticity, or fluctuation, and a firm stool, or circumscribed hardened margin, can be felt round the base of the tumor. The skin is slightly red. If, at this time, an incision or puncture be made, either no matter, or very little, is evacuated, the lips of the wound inflame and open, displaying a sloughy-looking substance within, and betwixt this and the skin a probe can often be introduced for some way all round. If, however, the disease have been farther advanced, then there is very little elasticity in the tumor, it is quite soft, rather flaccid, and fluctuates freely; the skin becomes of a light purple colour, and small veins may be seen ramifying on its surface. In some time after these appearances are observed, the skin may be felt becoming thinner at one particular part, and here it also generally becomes of a darker colour, then it bursts, and discharges a thin fluid like whey, mixed with a curdy matter, or thick white flocculi. The redness of the skin still continues, but the aperture enlarges in proportion as the tumor subsides, forming the scrophulous ulcer. The margins are smooth, obtuse, and overlap the ulcer; they are of a purple colour, and rather hard and tumid. The surface of the sore is of a light red colour; the granulations are flabby and indistinct; and the aspect is of a peculiar kind, which cannot be described. The discharge is thin, slightly ropy, and copious, with curdy-looking flakes. The pain is inconsiderable.

[84] When the conglomerate glands are affected, the tumor is generally hard and firm until matter forms.

When this ulcer has continued for some time, it either begins slowly to cicatrize, or more frequently the discharge diminishes, and becomes thicker; it then hardens into an elevated scab, of a dirty white, or yellowish colour. This continues for a considerable time, and then crumbles off, leaving the part covered with a smooth purple cicatrix. This description corresponds to the mild scrophula, or the struma mansueta of the older writers; but occasionally, especially if a bone be diseased below the ulcer, the sore has a more fiery appearance, the surface is dark coloured, the margins soft, elevated, and inflamed, and sometimes retorted. The discharge is watery, the pain very considerable, and the surrounding skin inflamed. This has been called the struma maligna, and was said to be marked by the greater degree of hardness and inequality in the tumor, varicose veins, and pulsatory pain: It was likewise said to be contagious. But although occasionally this state of the scrophulous ulcer be preceded by a hard and painful tumor, yet it is not necessarily so, but rather seems to depend upon a disease of the parts below, which generally are bones, cartilages, or tendons in a morbid state; and hence this overacting scrophulous sore is most frequent over the smaller joints, particularly the toes.

Sometimes the scrophulous abscess, after bursting, forms a sinus, the mouth of which ulcerates, and assumes the appearance of the specific ulcer; but the track of the sinus remains in a suppurating state. This not unfrequently is connected with a diseased bone, or cartilage, or tendon.

Scrophulous tumors and ulcers more readily disappear during the winter, and return again on the approach of summer; but this is by no means an universal law of the disease.

It is likewise observable, that swellings of the glands are very apt to subside pretty rapidly in one place, and appear equally quickly in some other glands, in the vicinity of these originally affected. Ulcers likewise frequently heal upon the appearance of the disease in other parts.

When the joints become affected, the cartilages swell, and the quantity of the lubricating matter is increased; the tendons are surrounded with a glairy matter, like the white of egg; and, lastly, the bone becomes enlarged. These effects are attended with stiffness and pain in the joint, which is sometimes intolerable, especially during the night, and confined to a single spot, from the disease residing chiefly there. In some time after this, small abscesses form in different parts of the inflamed joint, which gives it a spongy elastic feel. These bursting into one another, form a larger cavity, which communicates with the articulating surface of the bones, and reaches to the skin, through which a fluctuation may be felt. This abscess at last bursts, and discharges a curdy matter. Long before this happens, the bone generally ulcerates, and becomes rough. This disease is uniformly attended with hectic, which terminates the patient’s misery.

Not unfrequently, in scrophulous people, eruptions appear on different parts of the body, especially on the face, which is covered with pustules of a dark red colour, suppurating slowly, and sometimes never.

At other times, we find incysted tumors on different parts of the body. These may appear in any habit; but when they occur in scrophulous people, they assume the specific action of the constitution; in which case, instead of containing an uniform fluid, like thin jelly, of a yellowish colour, as the simple incysted tumor does, they are filled with a thick curdy purulent-looking matter, or with serum, containing white flakes, little lumps, of a white substance.

All the causes capable of inducing simple inflammation will of consequence induce the scrophulous inflammation, provided that the inflammation be not induced in such a way, and in such organs as make it heal rapidly, as will be afterwards noticed. Specific inflammation is likewise modified when it takes place in a scrophulous constitution, and is much more tedious in its cure. This is evidently seen in the small pox and venereal disease.

Although the effects of a scrophulous constitution, in modifying action, be most distinctly observed in the inflammatory action, yet it does not operate exclusively on this; on the contrary, we find, that typhus fever, and some other actions, which may exist without any perfect local inflammation, are, cæteris paribus, more violent in scrophulous habits than in others.

This constitution is more easily acted on by certain agents, particularly such as tend to induce inflammation, than healthy constitutions in the same circumstances. It would likewise appear, that, on the contrary, there are other agents which operate with more difficulty. It is in general observable, that scrophulous people are less easily affected with mercury. On a few, indeed, it operates readily; but, when we attend to the general habitude of these people, we must consider the aptitude of some individuals to assume the mercurial action to depend on some peculiarity of constitution, unconnected with the scrophulous condition.

By the ancients, and many of the moderns, the pituita was considered as the cause of scrophula, producing tumefaction, by stagnating in the glands. When any of the bile became mixed with the pituita, then the inflammation was more violent, and the ulceration deeper. Some latter writers, convinced that a simple redundancy of any particular humour could not produce scrophula, had recourse to the supposition of an acrimony, which was productive of swelling and ulceration, and which might “taint the whole fluids of the body[85].”

[85] Cullen’s First Lines, Vol. IV.

Others attempted to explain this disease, upon the principle of debility existing in the whole body, but particularly in the lymphatic system[86]. This is an idea still more puerile than the doctrine of morbid humours, which, however unfounded, had several plausible arguments to support it, and which was incontrovertible until the laws of the animal economy were better understood. Simple debility never can give rise to the marks of the scrophulous constitution; it cannot produce ulcers of a nature and appearance so peculiar; neither can it explain why particular parts are more apt to be affected than others; because, if debility exist equally in every part of the absorbent system, then every part ought to be alike diseased; and if it exist only in particular parts, then it is necessary to point out some cause of this partial debility. We likewise frequently observe very great debility in this system, owing to general weakness, and yet no symptoms of scrophula appear in consequence.

[86] Bell’s Treatise on Ulcers, p. 424.

Scrophulous people possess a peculiar constitution, and may therefore be said to constitute, in one respect, a distinct variety of the human race. This state is produced by a peculiar condition of the semen (owing to the peculiarity of the system which forms it), or of the female organs of generation, which possess the same general nature with the body, of which they form a part. When the organs of generation in both sexes are healthy, that is to say, similar in nature to what may be considered as the proper nature of the human race, taken as a distinct class of animals, then the semen stimulates the ovarium to the formation of a healthy child, or one which possesses a constitution, or susceptibility of performing, and having actions induced in it, similar to that of the majority of mankind. In this process, the ovarium is to be considered as a gland, and the semen as its peculiar stimulus. If, however, either the nature of the gland, or of its stimulus be changed, it is evident that the action induced must be more or less modified, and the secretion or product changed to a greater or less degree in its nature and properties. Were it possible for a progeny to be produced by an intercourse betwixt the human and the brute creation, they would possess a nature different from both, or perform actions of a mixed kind. This may be observed with regard to mules amongst brutes. In the same way, a healthy and scrophulous person must produce a child which differs from a healthy one, in having a certain peculiarity of constitution.

Agents produce different effects in different animals; thus the matter of cow-pox applied to the cow and to man produce very different appearances. Agents likewise, in the same genus of animals, produce different effects, according to the peculiar constitution of the individual. Thus, the matter of small-pox in some men produces only a slight local sore, whilst in the generality it produces a general disease, and eruption. The same disease affords an instance of changes taking place in the constitution after birth, by the establishment of certain actions; for it is rendered unsusceptible of the same action being induced afterwards; and, in this respect, is brought to resemble the constitution of a different genus of animals, with regard to that disease. There are some constitutions, such as those called irritable, in which certain symptoms of febrile, and other actions, are much more violent than in people of a different description. In them, for instance, typhus fever is attended with a very frequent pulse, and yet the other effects of this action are not violent in the same proportion.

Peculiarity of constitution is often manifested by no evident sign, and the modifications of actions induced are often marked by no perceptible diseased phenomena, which may be considered as belonging exclusively to that constitution. But, in the scrophulous constitution, there are, in almost every instance, perceptible modifications of the formative action[87], producing a peculiar appearance of the eye, countenance, &c. as has already been mentioned; and although some diseased actions, which receive modifications from this peculiarity of constitution, may not be attended with obvious alterations, yet others, especially such as are attended with an inflammatory condition, are distinctly changed. It is these changes which constitute what in common language has been called scrophula, which is merely a peculiarity of a common action (namely, inflammation), which is dependent, not upon any particular nature of the agent or exciting cause, but upon the peculiarity of constitution, which is susceptible, by these agents, of such an action.

[87] The morbid condition of the formative action is very frequently manifested in the bones, which are less perfect, that is to say, softer, containing less calcareous earth, and later of being formed. Thus, the teeth are longer of appearing; the bones of the head are soft and yielding, and hence the head is large; the long bones bend and lose their shape, or their extremities swell, and, from being more vascular than their nature is fitted for, inflammation is very apt to be induced. The yielding and increasing of the bones of the cranium is likewise attended with a similar effect, for the brain becomes too large in proportion to the rest of the body, and is very apt to inflame, and have effusions formed into it. At other times, the diseased state of the formative action appears most distinctly at the surface, the skin being rough, and very apt to desquamate.

From what has been said, it will appear, that I consider the scrophulous inflammation, or what has in common language been called scrophula, merely as an accidental circumstance, occurring in a scrophulous constitution; but it is by much the most dangerous and troublesome effect of the peculiarity of constitution. It has likewise a very evident effect in increasing this condition of the system; for we find, that the probability of scrophula appearing in a child is, cæteris paribus, correspondent to the presence or absence of scrophulous inflammation in the parent; or, in other words, that those who have either at the time of marriage, or before it, had scrophulous inflammation, are more likely to have their children strongly scrophulous, than others of the same family, who have not had inflammation. It is likewise certain, that if, by any cure, we can, for one or two generations, prevent the appearance of scrophulous inflammation, the children will become less and less diseased, or have less peculiarity of constitution; but if, by any accident, scrophulous inflammation be in one of the descendents excited, even in a slight degree, his immediate progeny will be more diseased than he himself before the induction of the inflammation[88].

[88] Some gentlemen have denied that scrophula was a hereditary disease; but it is unnecessary to offer any argument on this subject.

With regard to the exciting causes of scrophulous inflammation, I may remark, that they are similar in kind to those capable of inducing simple inflammation; but they frequently operate more powerfully; that is to say, causes which would scarcely induce inflammation in a healthy person, may induce a local disease, and inflammation, in a scrophulous habit; because the different parts of the body perform their functions less healthily in a strongly scrophulous person, and are more easily deranged. In every system, those parts which are most delicate, or require the greatest perfection of action in order to keep them right, are most easily deranged. Now, in scrophulous people, the natural action being modified, the body becomes more delicate, and is more susceptible of derangement, especially those parts which naturally are delicate[89], or require a perfection of action. The glands seem to be amongst the most delicate organs; for they have not only to perform the formative, or nutritive function, in common with every other part, but they have also to perform a separate and distinct function, or change the nature of certain fluids which are brought to them. It is on account of the natural delicacy of the glandular system being increased by the diseased condition of the general system, and of the exposure of the lymphatic glands to the action of stimulating matter, taken up by the absorbents on the surface, as, for instance, matter from scabs on the head of children, that this species of inflammation most commonly appears in the lymphatic system; but this system does not seem to be the peculiar seat of the diseased condition, as some suppose, nor to be otherwise predisposed to scrophulous inflammation, except in so far as its natural delicacy is increased by the diseased condition which it possessed, ab initio, in common with the rest of the body; and consequently it is rendered less able to perform its functions properly, the effect of which is, the induction of a new local diseased action, or slow inflammatory action, by the slightest cause.

[89] This term is used here in a different sense from its common one, which signifies sensibility, or delicacy with regard to sensation, and capability of being acted on.

Besides the common exciting causes of inflammation, the particular formation of organs may induce this disease, or at least make very slight causes produce it. Thus, for instance, in people with a very small narrow chest, the circulation of the blood must be performed with greater action than in other circumstances, and thus may tend to induce an inflammatory state. When the bones are very vascular, and imperfectly formed, they are apt to have a morbid degree of action excited in them by very slight causes; and the same holds true with regard to any other part of the body which is imperfectly formed, or which is not exactly fitted for the support and performance of its requisite action[90].

[90] Parts which are improperly organised, or which are not in every respect similar, both in their structure and constitution (by which I mean, mode of acting in general), to what naturally they ought to be, are not only less capable of performing their actions aright, but likewise are to be considered as in some respect extraneous to the human body, or, as it were, insulated, and do not correspond exactly to other parts. They therefore receive less support from the neighbouring parts, and, consequently, have their power diminished. The imperfection of action consequent to these causes is proportioned to the morbid condition of the part.

Scrophulous inflammation is in general dangerous and tedious, in a degree proportioned to the effects and duration of simple inflammation upon the same parts. Thus, simple inflammation of one of the conglobate glands of the neck, is tedious, but not dangerous; and the same holds true of scrophulous inflammation; but the duration of this is much longer. Simple inflammation of the lungs, again, is dangerous; and scrophulous inflammation is infinitely more so. Such parts as heal easiest, when affected with simple inflammation, or ulceration, recover soonest from scrophulous inflammation; and the same causes which retard the one will retard the other also. Thus, the same cause which renders a superficial simple ulcer unhealthy and chronic, will prevent a superficial scrophulous ulcer from healing: But, if none of these causes operate, then scrophulous inflammation, or ulceration, will heal pretty readily, provided that simple inflammation, or ulceration of the same parts, would do so; but, for this purpose, it must be quickly induced; for all inflammation, or ulceration, which is slowly induced, is slowly removed. As a confirmation of these positions, we find, that a blister on a scrophulous person will heal readily, because the inflammation is induced acutely, or with a certain degree of quickness, and has, when the affection is simple, a promptitude to heal, which manifests itself also in scrophulous people. In this instance, the difference in the time required to heal the inflammation in a sound and a scrophulous person is not perceptible; because the affection, if simple, has a tendency to heal immediately. But, in a deep wound, especially if contused, we find the difference more marked; because here, although the constitution be healthy, the duration of the disease is considerable; and, in a scrophulous person, the cure is protracted still longer, and the sore assumes a specific appearance. In diseases of the glands, the difference is still more perceptible; because the disease, although simple, is longer in duration. In affections of the bones and cartilages, the same is observed. When a bone is fractured in a healthy person, it unites without inflaming; and, in a scrophulous person, unless the diathesis be exceedingly strong, it likewise does so, but the union is longer of taking place; but, if a bone inflames in a sound person, the disease is very tedious; and, in a scrophulous habit, it is infinitely more so. The same holds true with regard to tendons and cartilages; and hence the greater danger of a sprain in a scrophulous than a healthy person. From these, and other facts, which it is altogether unnecessary to mention, it fully appears, that scrophulous inflammation is tedious and dangerous, in proportion to the progress and effects of simple inflammation and its consequences, when it attacks the same parts; but this proportion is not regular and uniform; but the duration increases, in a higher ratio, in proportion as the simple inflammation and ulceration of the same parts, and in the same circumstances, is tedious. Thus, a deep wound in a healthy person is pretty long of healing; but, in a scrophulous person, it is much more so. Simple inflammation of a gland is still more tedious than the same extent of inflammation in cellular substance; and scrophulous inflammation is still longer of running its progress; but the proportion betwixt the duration of the scrophulous inflammation, in these two cases, is not exactly as the duration of the simple inflammation of the two, compared with each other, but is in an increased ratio.

When scrophulous inflammation is excited in the vicinity of a part already possessing this action, it occasionally removes the action from that part, in the same way as inducing simple inflammation by a blister in one part cures the same disease in another part in the vicinity. It was an observation of this fact which made it be considered as part of the description of scrophulous tumors and ulcers, that they not unfrequently disappear in one place, whilst they show themselves in another; but, in every instance, this disappearance is an effect, and not a cause; for we uniformly observe, that, before it takes place, the new part has begun to inflame or swell.

With regard to the diagnosis of scrophula, it is impossible to say any thing satisfactory; because, as long as the inflammation remains trifling, and the skin sound, it is very difficult, if not impossible, to distinguish a scrophulous swelling from any other of a different kind. Much assistance has been supposed to be derived from the situation of the tumors, most of those which appear in the neck being considered as scrophulous; but this is certainly a false principle. From the same method of reasoning, most swellings in the groin have been considered as venereal, whilst many are of a very different nature, and not a few scrophulous. The best plan is to attend to the appearance of the body in general, and to the presence or absence of the sign of a scrophulous system; next, whether any ulceration be present, by the absorption of matter, from which these swellings may have been produced. If these be present in a system not possessing the marks of scrophula, the probability of the tumor being scrophulous is less; but, if the system be evidently scrophulous, then we must consider, whether the glands, originally swelled by the absorption of matter, have assumed the slow inflammation of a scrophulous nature, or have assumed a different species of inflammation, dependent upon the peculiarity of the matter; for they can scarcely be supposed to be simply inflamed. Scrophulous swellings of the lymphatic glands are generally soft and doughy, and frequently give the feel of containing a fluid long before suppuration has taken place. They are at first free from pain, and, in mild cases, even toward the end, the pain is inconsiderable. When matter is formed, the skin generally becomes purple, and then gives way in a small spot. Swellings of the secreting glands are to be distinguished from schiro-cancer, by the hardness being less, the pain very inconsiderable, the presence of a scrophulous habit, and by the feel of fluctuation much earlier than takes place in cancer. Upon the whole, the presumption of any affection being scrophulous, is to be formed by the presence of the marks of a scrophulous diathesis, and the absence of such symptoms and appearances, whether antecedent or present, which characterise inflammation of a different species, or make us suppose it to have taken place, whether this be simple or specific. Scrophulous ulceration is distinguished by its peculiar aspect, joined with the marks of a scrophulous habit.

_Of the Treatment of the Scrophulous Inflammation._

If the foregoing reasoning be just, it will appear, that, in scrophulous habits, our great attention ought to be directed to the prevention of the scrophulous inflammation, which is to be done by avoiding, as far as lies in our power, the operation of any agent tending to excite inflammation. It has been observed, that, in scrophulous systems, very slight causes were sufficient to produce disease; because the parts on which they act possess a peculiar constitution, and are less capable of performing their natural and healthy functions properly, and therefore are sooner rendered diseased. Inflammation may also be induced by the structure of the part being such as to prevent it from carrying on its functions properly, and therefore the same effect is produced as in the former case, where the constitution, or mode of action, and not the evident structure or mechanism of the part, was affected.

The lungs are to be prevented from assuming the scrophulous inflammation, by avoiding, in the first place, all the common exciting causes of pneumonia, such as cold, damp, &c. It is, in the next place, to be prevented, by avoiding such causes as tend to increase the circulation in the chest, or affect the function of respiration. Hence, violent exercise, climbing ascents, intoxication, thick hazy atmosphere, are to be guarded against.

The lymphatic glands are to be prevented from inflaming, by avoiding exposure to cold, and to the other common causes of inflammation, but especially by preventing the absorption of irritating matter, such as matter from sores, and the like. A neglect of this is perhaps one of the most frequent causes of scrophulous inflammation; for swellings of the glands of the neck can very often be distinctly traced to scald head, to ulcerations about the ears, little sores in the mouth, caries of the teeth, or to the absorption of particles of food allowed to remain and undergo fermentation in the mouth. The greatest attention ought therefore to be paid to cleanliness. The head ought, in scrophulous children, to be washed daily, and the sweat removed from behind the ears; vermin ought to be diligently removed; but mercurial, and acrid preparations, frequently used with that intention, ought to be avoided.

The mesenteric glands are to be prevented from inflaming, by supporting the action of the bowels, and preventing the formation of irritating matter, which, when absorbed, may swell these glands. Nourishing digestible diet, conjoined with rhubarb, and such remedies as act as tonics, at the same time that they keep the belly easy, are of use in this view; for the whole process of digestion is thus supported, and neither the feculent part of the food, nor the mucus of the intestines, become morbidly irritating.

The other parts of the body are to be prevented from inflaming, by avoiding the usual causes of inflammation, and the action of whatever may injure the healthy condition of the part, or impede the natural action. Thus, the knee and ankle joint occasionally become affected with scrophulous inflammation after fatigue, which injures the healthy condition of the parts.

Besides these precautions, which are necessary in those of an evidently scrophulous constitution, with regard to particular parts, it is likewise useful to preserve as vigorous and perfect a performance of the natural actions of the system, considered in the aggregate, as possible, by which we lessen the risk of any one part becoming diseased; for, whatever impedes or diminishes the performance of the natural and healthy action of a part (and, in this case, the whole body is to be considered as made up of parts), renders that part more susceptible of disease, or derangement of its actions. Cleanliness, pure air, warm and sufficient clothing, nourishing and digestible diet, invigorating exercise, and a due proportion of sleep, are therefore very powerful preventatives of this species of inflammation, insomuch, that Dionis remarks, that seventy-five out of the hundred, who came to be touched by the king, were children of the poor peasants.

When scrophulous inflammation does take place, then this invigorating plan is had recourse to as a cure, whilst, in truth, it is most useful as a prophylactic. The invigorating plan, which consists in the use of good diet, moderate exercise, sea bathing, &c. is indeed useful at this period, both because it tends to make the disease more easily overcome, and prevents other parts from being injured; but its utility is still greater as a prophylactic; and it does not appear to have any certain efficacy in promoting the resolution of scrophulous tumors, because these have naturally a strong disposition to advance slowly to suppuration, and therefore are not readily affected by such means as tend simply to strengthen the system, or support its actions, because these do not change its peculiarity, or morbid modification, which existed, ab origine. But, when the tumors have proceeded the length of ulceration, then they have gone a step farther to a natural termination; and, although the means which strengthen the system cannot remove the scrophulous diathesis of the system, they may nevertheless accelerate the cure of a chronic tedious ulcer, which is slowly tending of itself to a termination.

The remedies called agentes similes operate more directly on the scrophulous mode of action than those means which tend simply to strengthen the system, and may be usefully conjoined with them, because these agents tend to induce an action different from the scrophulous one, at the same time that it possesses a certain coincidence with, or general resemblance to the natural or healthy action. Hence, the bark has been frequently found to be useful in the cure of scrophulous inflammation, but oftener of ulceration than tumefaction of the glands, for the reason mentioned above. It does not appear, however, to possess, by any means, that certain power of curing scrophulous affections which is attributed to it by Dr. Fothergill, and several other authors; nor are we to suppose that it shall infallibly cure scrophulous inflammation, or ulceration of parts, which, even when affected with simple inflammation, are very difficult to be cured. If we find it difficult to cure a simple inflammation, or ulceration of a tendon, cartilage, or bone, we must not be disappointed if even a specific remedy for scrophula (granting such a one ever to be discovered) were to prove ineffectual in procuring a speedy restoration to health. The bark is likewise often ineffectual, because it is improperly administered. Given in small quantities, once or twice a-day, as is frequently done, it may prove a stomachic, and increase, like other tonic bitters, the power of the stomach, or the functions dependent on it; but we never can thus obtain the benefits of the specific action of the bark on the system. For this purpose, it must be given liberally, in as great doses, and as frequently repeated as can be done without producing continued sickness, or vomiting; and this must be continued regularly, late and early, not for days, but perhaps for weeks, at the same time that we prevent the action of such causes as would counteract the effects of the bark, such as poor diet, bad air, confinement[91], &c. Administered in this way, the bark may be rendered really useful, not only in the cure of scrophulous ulceration, but perhaps of many other diseases, whilst, in the common way of prescribing it, little or no benefit is derived from it.

[91] See what has been said on this subject when treating of the cure of mortification.

The muriated barytes has been recommended by Dr. Crawford[92], and has of late been tried in France by M. Pinel[93] and others. It does not appear to have any influence on tumid glands, or scrophulous tumors; but occasionally it is serviceable in scrophulous ulceration. It is, however, a medicine on which very little dependence can be placed, and which fails in a great majority of instances[94].

[92] See the second volume of Medical Communications.

[93] Nosographie Philosophique, Vol. II. p. 238.

[94] When it is wished to prescribe it, the following is a very good formula:

R. Terræ Ponder. Salit. Chryst. gr. x.
Aq. Font.
Aq. Cassiæ utriusque uncias iii
Syrupi Aurent. uncias ii.

Half an ounce of this may be given at first, twice or three times a-day, and gradually increased to such quantity as the stomach can bear without sickness.

The muriat of lime has been proposed by M. de Fourcroy; it is given more liberally than the muriated barytes, but it is not more efficacious.

Iron by itself, or mixed with the fixed or volatile alkalis, has also been frequently employed, but with very little benefit[95].

[95] This metal was one of the principal ingredients in a remedy used by the Marischal de Rougeres, which consisted of filings of iron, sal ammoniac, salt of tartar, &c. Journal de Med. Tom. XL. p. 219.

Burnt sponge, millipedes, vitriolated tartar, and many other trifling remedies, which were at one time in repute, are now deservedly neglected.

Cicuta has been greatly recommended by Dr. Fothergill and others[96]. It has very little effect on scrophulous tumors, or mild ulcers; but, when administered freely, it is sometimes of service in the irritable fiery ulcer, which was by the older writers called struma maligna.

[96] This is highly recommended by M. Martcau. Journ. de Med. Tom. IV. p. 121.

Mercury is another remedy, which at one time was much employed in this disease; but few expect any benefit from it now. Gentle, or what has been called alterative courses, are, however, still recommended by many, with a view to satisfy the patient. Various preparations have been used. Some exhibited the corrosive sublimate, others the calomel, whilst the acetite of mercury, mixed with the powder of vipers and earthworm, with the rust of iron, was much employed on the continent[97]. Antimony has frequently been conjoined with this, but without much benefit.

[97] Practique Moderne de Chirurger, par Ravaton, Tom. II. p. 3.

Nitrous acid has, I believe, in some cases, a considerable power over scrophulous ulcers. From the trials which I have made with it, I am inclined to attribute some effect to it in promoting the suppuration of scrophulous glands, or tumors, and in disposing ulcers to heal. Two or three drachms may be given daily, and continued for a fortnight, provided no bad effect be produced by it, such as pulmonic affections, &c. If, within this time, no melioration appear, we may give up this medicine.

The hepatised ammonia, in the dose of eight or ten drops, three times a-day, is sometimes useful in abating the pain, and changing the fiery appearance of the irritable ulcer, or struma maligna.

The breathing of oxygene has been proposed as a cure for this species of inflammation; but it will be extremely difficult for the advocates of pneumatic medicine to point out any authentic case in which it was really of benefit.

Much has been written concerning the local treatment of scrophulous tumors and ulcers; but we are still very much in the dark with respect to any efficacious method. Formerly, the extirpation of the gland, or tumor, was advised by all; but, more lately, doubts have been started concerning the propriety of the practice; and, by most practitioners, it is now deemed unnecessary, if not dangerous.

In the writings of the ancients, as well as many of the older writers on surgery in our own country, particularly in the works of Mr. Wiseman, this practice is freely inculcated; and many cases are detailed in which the tumor was extirpated with success. Even in the present day, no surgeon dreads the consequence of removing scrophulous joints, which, with regard to the present question, are to be considered in the same light with the glands.

It is supposed, that, by extirpating superficial tumors, the disease may be transferred to some of the more noble parts, and produce a more fatal complaint. But, if it be admitted that these tumors do not appear as necessary parts of scrophula, as the eruption of measles does of the rubeolous fever, but only as accidental circumstances, or fortuitous inflammations, rendered tedious and specific by the peculiarity of the constitution, this supposition will appear to be groundless. Even granting that scrophulous tumors did appear without any local exciting cause, and were, in every respect, similar to the eruption of exanthematous fevers, it will not thence follow, that removing the local disease, after it has appeared, will make another part become diseased; unless it be said that scrophula depends upon a particular morbid humour, which, if denied an outlet in one place, must accumulate in another, which is a supposition I will not trouble myself to refute.

The arguments, then, against the excision, are not to be drawn from its danger, but from the pain which it produces, and from the number of glands which must frequently be removed, and which might perhaps be resolved without coming to suppuration. It is likewise at times dangerous to extirpate these tumors, on account of their situation.

On the other hand, when only one gland is affected, when it is superficial, and has continued so long, in spite of our remedies, that there is little probability of resolving it, then, by extirpation, we procure a speedy cure, and avoid a tedious disagreeable ulcer, and unseemly cicatrix. The existence of the scrophulous inflammation, and particularly the ulceration, has a tendency to increase the scrophulous diathesis, or peculiar mode of action of the system. By cutting this short, therefore, we prevent that evil, and render the system less susceptible of the scrophulous inflammation, and the chance of communicating the disease to the progeny less.

It may also be said, that the wound, after the extirpation, might not heal readily; but the testimony of many writers, as well as what I have observed myself, convince me that this is not the case; for the readiness with which the skin unites and heals, when not previously diseased, produces a speedy cure; whereas, had the diseased gland remained below, and the specific inflammation been propagated to the skin, the ulceration must have been tedious.

Upon the whole, then, in determining on the propriety of extirpation, we must consider whether there be only one gland affected, or an incipient disease in a chain of glands; and, if only one, whether there be a probability of this one suppurating; and whether the advantage of an early removal of the affected part will not be counterbalanced by our losing the chance of restoring the part, and of preserving its functions and utility, as, for instance, in scrophulous inflammation of the breasts, testicle, joints, &c.

Caustics have been proposed with the same view as the incision; but they are more tedious, produce extensive ulceration, greater pain, and are much less certain than the operation.

Issues are recommended as a general remedy, to act as a drain to the constitution, and to render the drying up of the ulcer safe. In this point of view, they appear to be altogether useless and unnecessary; but, when employed as part of the local treatment, they are much more useful. The benefit arising from the use of issues, in the cure of scrophulous inflammation of the bones and joints, is now so fully established, by the practice of every surgeon, that it is useless to insist upon it here. In these cases, it is necessary to insert the issue, which is generally made with caustic, as directly over the affected part as possible; and the size of this issue ought in general to be correspondent to the extent of the disease. There are two circumstances which greatly tend to render this practice efficacious, and which ought to be fully attended to: First, that the disease be allowed to gain as little ground as possible before the insertion of the issue, or that the issue be inserted as early after the disease is observed as the patient will permit. Second, that, during the continuance of the issue, every circumstance be avoided which may counteract its use, such as much use of the joint, or other species of irritation. In diseases of the lower extremities, therefore, whatever exercise produces pain must be carefully avoided; and, for the same reason, in diseases of the spine, proper contrivances to relieve the diseased bone from pressure are necessary to be conjoined with the issue. It sometimes happens, that matter has either formed before the insertion of the peas, or some time afterward. In this case, it either comes to be discharged by an opening through the ulcerated surface, or issue, or it bursts at a more dependent part. In the first situation, no change of treatment is necessary; in the second, it is of service to insert a pea over the mouth of the aperture, which has a tendency to heal the part below, and prevent the formation of a tedious sinus. When the part becomes free from pain, and the soft parts have subsided in their swelling, and matter does not appear to be forming, or does not continue to be formed, if it had already been secreted, we may consider that the effect of the issue is now produced, and may begin gradually to diminish its size.

Issues, employed as a local remedy, have hitherto been chiefly used in diseases of the bones and joints, and sometimes in scrophulous affections of the liver, or lungs; but it is reasonable to suppose that they ought likewise to be useful in the cure of enlargements of the glands, and other scrophulous tumors, if inserted in the immediate vicinity of the part. The only objection to their use is the cicatrix which they leave, and which, in certain situations, we would wish to avoid. When the tumor is thickly covered with the integuments, the issue may be made directly over it, by means of a blister, kept open by savine ointment[98], or any other irritating preparation; but, when the tumor is thinly covered, this will not succeed, as the inflammation consequent to the insertion of the issue will be communicated to the gland which is in immediate contact with the ulcerated surface. In this case, a small pea issue, or seton, may be inserted by the side of the tumor. In scrophulous inflammation of the glands of the neck, this remedy is not adviseable, owing to the scar which it leaves; but, in affections of the mammæ, and some other parts, it may be useful.

[98] This ointment may be prepared by macerating one part of recent savine leaves bruised, in four parts of ung. resinos.; it is then to be strained.

Blisters, frequently repeated, are sometimes, in slighter cases of affections of the joints, used in place of issues.

Preparations of lead are frequently employed, and, where the tumor is painful, are often of service. When the lymphatic glands are inflamed, a saturnine solution[99], applied cold to the part, by means of a compress of linen, and frequently renewed, has a tendency to abate the pain and resolve the inflammation. These solutions are sometimes employed warm, particularly in affections of the bones or joints; but they do not, in these cases, seem to have any considerable superiority over fomentations with warm water.

[99] The following may be used for this purpose:

R. Ceruss. Acetat. drachmam unam.
Aq. Rosar. uncias octo. Solve, dein cola.

Cloths dipped in cold water, sea water, or weak vegetable acids, have also been used, and have a tendency to abate pain, but are inferior to the saturnine solution.

Ether, applied with a pencil to the part, is also sometimes of service.

Sea salt, mixed with bile, has been recommended, but has very little effect.

Camphorated liniment is very frequently used, in which case the part is generally kept warm with flannel. It does not, however, appear to possess any very great power of discussing these tumors; but the friction which is made use of with these sometimes hastens the removal of these tumors, and may be usefully alternated with the use of the saturnine lotion. A mixture of ether and linimentum opiatum may be employed for the same purpose.

Hemlock poultices were at one time in repute, but they have now lost their character.

By these means, even after a small quantity of matter is formed in the gland or tumor, we may discuss the tumor, or make it less; but, if the quantity of matter should continue to augment, we may consider resolution as out of the question. Our object must then be to bring the part to suppuration as quickly as possible; because we not only thus shorten a process which must be completed before the parts can be healed, but also render the ulcerative action more healthy, and easier induced; for the more quickly that the suppurative action is performed, the sooner does the ulcerative action take place, and the more vigorous is it, provided that no new cause render it unhealthy, as has formerly been mentioned.

This advice, however, must not be adopted without some exceptions, and must be chiefly confined to affections of the glands and cellular substance, and ought not to be extended to the joints. In these cases, even although a small quantity of matter form, we ought still to endeavour to prevent general suppuration, and the bursting of an abscess; because this would, instead of accelerating the cure, as is frequently the effect in the other case, be attended with dangerous consequences; we must therefore rather continue the use of the issues, and endeavour to procure the absorption of what matter is already formed.