_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.
The means employed for promoting suppuration were formerly poultices
of lily roots, honey, &c. alternated with fomentations prepared from
pomegranate seeds, and myrrh, and cypress leaves, or, occasionally,
stimulating plasters; but now the common bread and milk poultice is
advantageously substituted in place of these remedies. When the
process is very tedious, electricity is useful along with the poultices.
When these tumors have suppurated freely, and an abscess occupies
the whole of the gland, it is useful to evacuate the matter by a
small opening with a lancet, if there be no appearance of the abscess
bursting quickly, and the sooner this is done the better. When this is
done, a poultice should be applied until next day, the part is then to
be wiped clean and dry, and a small bit of lint, spread with simple
ointment, applied on the orifice. The surrounding red skin is to be
dulled with powdered cerussa[100], and then covered with dry lint. A
compress is to be laid over the whole, and moderate pressure employed.
These applications are to be renewed every day, or twice a-day,
according to the quantity of the discharge, and other circumstances;
and, at each dressing, the parts may be bathed with spirit of wine.
If this mode of dressing does not produce a cure, but the opening
enlarges, and the surface ulcerates, we must then employ the dressings
for a scrophulous sore.
[100] Keeping this skin dry has a tendency to prevent ulceration,
and abate the redness and inflammation. The cerussa may sometimes be
advantageously mixed with an eighth part of powdered camphire, which
promotes the removal of the superficial inflammation.
When, notwithstanding the use of issues, matter is formed in joints,
or, when these fail to procure the absorption of what was formed before
they were introduced, then one of two things must happen; either the
abscess must be punctured, or it must be allowed to burst of its own
accord. In general, I believe, it is most advantageous to allow the
abscess to burst, without any interference, except the continuance of
the issue, or the establishment of such new ones as circumstances,
particularly the situation of the pain, may point out. If, however, it
were at any time deemed proper to evacuate the matter, this ought to be
done with a small trocar, at different times, in the manner recommended
by Mr. Abernethy for the cure of lumber abscess. This is infinitely
preferable to the barbarous practice which even some surgeons high in
reputation advise and make use of, I mean the insertion of a seton
through the abscess of the joint[101].
[101] Bell on Ulcers, p. 471.
When the scrophulous suppuration ends in the ulcerative action, the
cure is generally tedious. It is even doubted by some how far it is
safe to attempt a speedy termination to the ulcer, as it is supposed,
that, in this case, the disease may be driven to some other part: And
so fearful are they of this dreadful event, that they are careful, by
issues and new artificial sores, to continue the discharge after the
original ulcer is healed.
If I have been right in my view of this disease, it will appear, that
this reasoning is false, and that the practice is both useless and
troublesome. Even those who propose and defend the practice, do so not
upon the principles of reason and judgment, or from logical deductions
from the theory which they give of the disease, but upon imaginary
apprehensions. We find, for instance, Mr. Bell saying, that, “till the
disease is eradicated from the habit, all that should in general be
done to the sores, is, to give as free and open vent to the matter as
possible[102].” From this, we should, without doubt, expect, that he
considered scrophula as dependent upon some peculiar humour which was
to be expelled; but just before we are told, that this disease depends
upon debility, particularly of the lymphatic system; a condition
which it is not customary to talk of eradicating, or rooting out, or
expelling. Upon the common principles of reasoning, Mr. Bell ought only
to have forbid healing the sores, until the system was strengthened,
otherwise the weakness would be driven or determined to some other part.
[102] Bell on Ulcers, p. 427.
Moderate pressure, by means of adhesive plaster, conjoined with the
application of cold water, is one of the best remedies for the mild
scrophulous ulcer, when it is situated so, that this can be used. When
it is not, then dusting the part thickly with cerussa, containing a
sixth part of powdered alum, may be had recourse to. A piece of dry
lint is next to be applied, and a compress bound down, with such
pressure as can be used. It is sometimes useful to dip the compress in
cold water, and renew it frequently.
The ceratum e lapide calaminari forms a very good dressing for this
sore, when it is intended to leave it to follow its own course.
As a stimulant, the unguentum resinorum, either alone, or mixed with
red precipitate, is often used; but it seldom is of service, and
often makes the sore irritable. If, however, the ulcer become very
indolent, this, or the citrine ointment, properly diluted[103], may
be of service. The same may be said of the other common stimulating
applications.
[103] This application forms a very useful remedy for the scrophulous
ulceration of the eye-lids, which we so frequently meet with.
Poultices made of bread and sea water have been recommended, but seem
to possess little power of accelerating the cure.
Solutions of alum, of blue vitriol, corrosive sublimate[104], of the
nitrites of copper, bismuth, and silver, are sometimes useful to wash
the sore with.
[104] This substance is the basis of a celebrated lotion for the face,
which is sometimes useful in chronic pustules, which are frequently of
a scrophulous nature. It promotes suppuration, the pustule then scabs,
and, when this falls off, the part is sometimes found sound below. It
is made by dissolving corrosive sublimate in an emulsion of bitter
almonds.
The recent leaves of the wood sorrel bruised, and applied raw to the
sore, is sometimes useful. The same may be said of cloths dipped in
lemon juice, or vinegar and water.
Saturnine ointment is much employed by some, for abating heat and pain;
but is inferior to compresses dipped in cold water.
Sometimes only the anterior part of a scrophulous tumor suppurates and
ulcerates, and the deeper part of it remains swelled and hard. In this
case, the bottom is generally covered with a slough, which comes slowly
away piecemeal, and is renewed for some time, until the tumor subsides,
partly by sloughing, partly by absorption, and partly by the subsidence
of the remaining inflammatory action. In this case, sprinkling the
surface lightly with precipitate, or blue vitriol, is of service; and
this may be alternated with the common warm poultice. When the surface
becomes cleaner, dry lint forms a very good dressing; and this may be
covered with a pledget of linen spread with cerate. Afterwards pressure
is useful.
The irritable overacting sore, or what has been called the struma
maligna, is very difficult to manage, especially as it is frequently
connected with a diseased state of the bones or tendons below.
The hepatized ammonia, diluted in the manner formerly mentioned, or
simple ointment, mixed with opium, are sometimes of use.
Poultices of bitter almonds, beat up with a little olive oil into a
fine pulp, and then warmed, occasionally relieve the pain, and make the
ulcer more healthy.
Carrot poultices, or warm poultices made of bread and strong decoction
of camomile flowers, are also sometimes of use.
Carbonic acid gas, or carbonated hydrogene, are sometimes of temporary,
rarely of permanent advantage.
Anodynes, internally, are useful here, as in other painful sores.
In all cases of scrophulous inflammation or ulceration, it is useful
to exhibit, alongst with the proper local treatment, such internal
medicines, and to attend to the constitution, in such respects as
may be deemed proper. Upon these points I have already made some
observations.
When the local disease cannot be cured, and has induced the scrophulous
hectic; when this cannot be removed by the means commonly employed, and
which have been mentioned in the dissertation on simple inflammation,
then the diseased part must be removed, if its situation permit.
This must not, however, be rashly done, but must be delayed until
we ascertain, that our remedies, general and local, (which must be
used with assiduity and care), are of no avail. It is not sufficient
that the hectic continues, and that other appearances are almost
stationary; they ought to be augmenting, in order to justify amputation
of a useful and important part; because every practitioner must have
observed the recoveries which take place, even after the hectic fever
has made considerable progress. On the other hand, we must not allow
the constitution to suffer too much, but must interfere, whenever
we perceive that our labours are fruitless, and that the hectic is
regularly and progressively increasing, and the strength sinking. When
this is observed, the only chance for life is an operation; and every
day this is delayed adds to the risk attending it; for there is a
degree of injury, more than which the constitution cannot sustain, and
which will prove fatal, even although the exciting cause be removed.
To fix the proper period requires judgment in the surgeon; but he
may be enabled to do so, by attending carefully to the state of all
the symptoms; for whenever these continue progressively to become
worse, and have reduced the patient already to a state of weakness,
which cannot be much increased without danger, he may consider it as
impossible to delay amputation longer with any hopes of success.
Having made these observations on this species of scrophula, I shall
now conclude, by shortly mentioning the mode of treatment adopted by
the older practitioners.
Bleeding, which at first was made use of according to the custom of
the day, was soon laid aside, on observing, that, in many cases, it
was manifestly hurtful, and in every instance useless. But although
the plan of general depletion was given up, yet local evacuations
were much insisted on; for they held it as absolutely requisite,
that the brain should be purged of its pituita, (the redundancy of
which produced the disease), by errhines, fomentations to the ears,
and the application of issues and sinapisms to the head. The stomach
was cleared of viscosities, by emetics of mustard or broom-seed;
the bowels, by aloes; and the skin and kidneys, by sudorifics and
diaphoretics.
Having thus procured a sufficient evacuation, the patient was desired
to smell a pomum odoratum, composed of styrax, amber, myrrh, aloes,
and many other ingredients; the vapours of which were supposed to get
up to the anterior ventricles of the brain, and dry them. Hunger and
thirst, by drying the juices, were decreed to be salutary. Every thing
was rendered nauseous with medicine. The bread was seasoned with anise
and fœnugrek seeds, and the drink consisted of decoctions of guaiac and
mastic wood, which last was “a friend to the brain and viscera[105].”
As a condiment to these medicated meals, Arnoldus de Villa Nova treated
his patients to the burnt sponge, mixed with salt and pepper.
[105] Laurent. de Strum. Nat. p. 67.
But these, and indeed all the medicines yielded by the materia medica,
were considered as trifling, and of no avail, when compared to the
miraculous power possessed by the king, who, with one touch of his
hand, could banish this dreadful disorder, and dry up all the sores. So
valuable did this royal prerogative appear in the eyes of many, that
it became a national controversy, whether it belonged to the French
or English; whilst the Romish and Protestant churches reciprocally
urged this prerogative of the king of the country where they were
established, as a manifestation from heaven of the justice of their
cause.
In France, the king touched publicly, at four dated feasts in the
year, preparing himself the day before by prayer and fasting; then
entering the apartment where the sick were arranged, the patients
were individually presented by the chief physician to his majesty,
who placed his hand upon their head, pronouncing these words, “Le Roy
te touch, et Dieu te guarit.” The sick then retire, and soon find a
manifest amendment. “In some the ulcers dry up; in others the swellings
diminish; and, wonderful to relate, in a few days, more than 500 out of
1000 are perfectly cured!”--“Hic hœrant philosophi, cœcutiunt medici,
stupet prophanum vulgus.”
Upon reading these accounts, we smile at the credulity of mankind; but
we pity them, when we learn, that near a thousand every year made weary
and expensive pilgrimages, from very distant countries, to purchase
this imaginary benefit.